CAEP/ACMU 2002 Scientific Abstracts: 75-89

2003 Scientific Abstracts

CJEM 2002;4(2):124-154

075 Emergency Department Treatment of Stable Acute Paroxysmal Atrial Fibrillation.
Kapur AK, Stiell IG, Wells GA, Brison RJ, Mortensen M. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: The optimal management of acute paroxysmal atrial fibrillation (PAF), a common ED presenting complaint, remains undetermined. This study's purpose was to compare immediate and short-term outcomes of aggressive (AGG) and conservative (CON) ED treatment of clinically stable PAF. METHODS: This 6-month prospective cohort study, conducted at 3 university-affiliated hospital EDs, enrolled all adult patients with <48 hours of clinically stable PAF. CON patients received no treatment or only rate control agents. AGG patients had pharmacologic and/or electrical cardioversion attempted. Patients were telephoned at 4 weeks to determine PAF recurrence, complications, and quality of life using the SF-36 scale. Proportions of the AGG and CON groups in sinus rhythm at ED discharge and at follow-up, as well as complications in the ED and at 4 weeks, were compared using chi-square. Quality of life was compared using t-test. RESULTS: We enrolled 169 patients, 32 in the CON group and 137 in the AGG group. The CON group was slightly older (mean 70.3 vs 61.9 yrs, p = 0.001) and more had coronary artery disease (78.9% vs 42.6%, p < 0.01). More AGG patients cardioverted to sinus rhythm in the ED (82.5% vs 34.4%, p < 0.001) and fewer were admitted (8.0% vs 37.5%, p < 0.001). Fifteen (8.9%) patients, all AGG, had complications in the ED; 2 (1.2%) required admission. 97.0% of patients were followed up. More AGG patients cardioverted and stayed in sinus rhythm for 4 weeks (52.3% vs 30.0%, p = 0.03). AGG patients had higher physical summary scores on the SF-36 at 4 weeks (47.1 vs 41.2, p = 0.01). No thromboembolisms occurred by four-week follow-up. CONCLUSIONS: This is the first study to prospectively follow PAF patients treated in the ED. Aggressive treatment for PAF is as safe as conservative and more successful for restoring sinus rhythm in the ED and should be considered the optimal ED management of PAF.

076 A Descriptive Review of a Canadian Chest Pain Evaluation Unit.
Martin D, Sinclair D. Dalhousie University. Halifax, NS.

INTRODUCTION: Many North American centres have addressed the problem of evaluating non-diagnostic chest pain by developing dedicated units for rapid assessment and risk-stratification. The QEII Health Sciences Centre opened its Chest Pain Evaluation Unit (CPEU) in 1999. In order to present some initial data on the operation of such a unit in the Canadian setting, we conducted a review of its operation over a 6 month period. METHODS: The sample consisted of all 136 patients observed in the CPEU from April to October, 2000. Data were collected retrospectively from an admissions log and patient charts. RESULTS: There was 21% utilization of theoretically available patient-hours in the CPEU. Mean length-of-stay in the CPEU was 13.6 hours. 68.2% of patients underwent exercise stress testing (EST), 2.3% underwent coronary angiography, and 0.8% underwent perfusion scintigraphy, while 28.0% underwent no other investigation while in the unit. Of those undergoing EST, 16.7% had positive tests, 44.4% had negative tests, and 38.9% had non-diagnostic tests. 5% of patients with negative EST results were admitted to the Cardiology service. 33.3% of patients with positive EST results were discharged home. Of all CPEU patients, 75.7% were discharged home, and 24.3% were admitted to the Cardiology service. No deaths occurred in the CPEU. Rationale for admission was based on a positive EST result in 31.2%, EKG and cardiac marker evidence in 18.8%, isolated cardiac marker evidence in 18.8%, and isolated EKG evidence in 12.5%, while 15.9% of admissions involved subjective rationale. 9.8% of patients observed in the CPEU ultimately received an acute coronary diagnosis. CONCLUSIONS: These results identify a number of topics requiring further investigation. The effect of Canadian CPEUs on admission rate and length-of-stay, and the role of specific technologies in the admit/discharge decision are among those areas in which important questions remain.

077 Institutional Variation in the Emergency Department Management of Paroxysmal Atrial Fibrillation: A Comparison of Two Canadian Centres.
Ip J, Cadieu T, McKnight D, Abu-Laban RB, Zed JP. Vancouver General Hospital. Vancouver, BC.

INTRODUCTION: Paroxysmal atrial fibrillation (PAF) is the most common ED dysrhythmia. A recent paper described the ED management of 289 PAF patient encounters at Ottawa Civic Hospital (OCH) (Ann Emerg Med 1999:04). Our suspicion was the ED management and disposition of PAF at Vancouver General Hospital (VGH) varies significantly from OCH. The purpose of this study was to evaluate this hypothesis. METHODS: PAF patients presenting between Jan/01/1999 and Jun/01/2000 were retrospectively identified from the VGH ED database and their records reviewed. Inclusion/exclusion criteria identical to the OCH study were employed. Institutional variance was evaluated using appropriate comparative two-tailed statistics. RESULTS: 88 patient encounters of stable PAF were identified: 74 (84%) were treated in the ED and 14 (16%) received no ED interventions. Demographic and baseline characteristics were similar between VGH and OCH patients, with the exception of previous PAF (42% vs 72% respectively). Twenty-six encounters (30%) were treated only with rate controlling medications. The majority of cardioversion attempts were chemical (43/88: 49%), 53% with prior rate control. Of those in whom chemical cardioversion was attempted, 16 (37%) went on to electrical cardioversion. Only 5 encounters (6%) were treated with primary electrical cardioversion. Comparison between VGH and OCH respectively, showed no statistically significant difference in overall and primary electrical cardioversion proportions (24% vs 28% and 5.7% vs 4.5%), or success rate (91% vs 89%), but significant variation in chemical cardioversion proportion (49% vs 62%, p = 0.025); chemical cardioversion success rate (26% vs 50%, p = 0.004); mean ED length of stay (5.9 vs 5.0 hr, p = 0.040); consultation proportion (59% vs 13%, p < 0.001); admission proportion (34% vs 3%, p < 0.001); and ED return within 7 days proportion (7% vs 14%, p = 0.006). CONCLUSIONS: There is significant variation in the ED management of PAF between VGH and OCH. We suspect this finding is reflective of a general wide variability in the ED management of PAF. Development of a practice guideline may improve management of PAF and resource utilization.

078 A Survey of Emergency Physicians' Attitudes Towards Primary Electrical Cardioversion for Stable Paroxysmal Atrial Fibrillation of Less Than 48 Hours Duration.
Ip J, Sandhu M, McKnight D, Abu-Laban R, Zed PU, Pharm D. Vancouver General Hospital. Vancouver, BC.

INTRODUCTION: Recent studies of the emergency department management of stable paroxysmal atrial fibrillation (sPAF) at Vancouver General Hospital and Ottawa Civic Hospital demonstrate that electrical cardioversion (EC) for sPAF of <48 h duration (sPAF <48 h) is safe and effective (conversion proportion 89-91%). Approximately 5% of patients in these studies underwent primary EC. Primary EC of sPAF <48 h is neither common nor well studied; however, there are reasons to believe it may be preferable to primary chemical cardioversion. Further research would be useful to define the role of primary EC for sPAF <48 h. The purpose of this study was to determine emergency physicians' (EPs) current usage of and attitudes towards primary EC for treatment of sPAF <48 h, and their hypothetical willingness to participate in a future clinical trial of this modality. METHODS: A 12-question survey was distributed to all board-certified EPs and emergency residents in 4 British Columbia university-affiliated hospitals between Aug/01/2001 and Oct/15/2001. Reminder follow-ups were utilized to encourage responses and anonymity was maintained. RESULTS: Seventy-six percent (51/67) of surveys were completed. Seventy-eight percent of respondents (range by institution: 67%-92%) use EC for sPAF <48 h and 67% felt it was safe and effective. No respondents felt EC was unethical or dangerous and 75% deemed EC as safe or safer than chemical cardioversion. Approximately 70% of respondents felt primary EC could improve patient comfort and/or expedite ED disposition. Forty-three percent felt EC was easy to use, could reduce consultation frequency, and prevent confusion in choice of chemical cardioversion agents. Ninety percent of respondents (range by institution: 83%-93%) indicated a willingness to participate in a clinical trial on primary EC for treatment of sPAF <48 h (46/51, 95% CI: 79%-97%). CONCLUSIONS: The results of this study indicate that a clinical trial of primary EC for the treatment of sPAF <48 h would be supported by most emergency physicians and appears warranted.

079 Development of a Tool for Predicting Length of Stay (LOS) for the Emergency Department Clientele.
Afilalo M, Unger B, Colacone A, Giguère C, Boivin JF, Vandal A, Léger R, Stiell I, Xue X. Sir Mortimer B. Davis-Jewish General Hospital, McGill University. Montreal, QC.

OBJECTIVE: To develop a tool that will quantify the predicted length of stay (LOS) of ED patients. The "LOURDEUR TOOL" will be based on patients' intrinsic characteristics (PICs) and not factors related to the organization or functioning of EDs. METHODS: An in depth review of the literature and numerous discussions with emergency physicians (EPs) permitted the development of a conceptual model of factors which affect ED LOS. This model was subsequently used in an expert consultative process with other EPs and nurses from across Quebec. The goal of the consultative process, in the form of focus groups, was to produce a list of PICs, measurable early on arrival to the ED, that could potentially be associated with LOS. The list produced was the source for the development of a questionnaire focusing on the PICs. The next phase of the study included a prospective sampling of visits (n = 2841) in 6 EDs (Quebec n = 5; Ontario n = 1). Using a sample size of 2146 patients and 110 variables from the questionnaire, a multivariable logistic regression analysis and mixed linear modeling methods were employed to identify the most important PICs associated to the LOS. RESULTS: Through a backward and stepwise model selection, the following variables were found to have an impact on LOS: Age, reason for ED visit, number of hospital admissions in the last 3 years, triage code, perception of severity of illness, autonomy, mode of transport, presence of endocrine or memory problems, ED referral, having a family physician and employment status. CONCLUSIONS: The "LOURDEUR TOOL" permits the estimation in LOS that is based on the PICs. It will bring new insights on ED congestion and will enable comparisons both within and between EDs irrespective of their functioning. It can also be used to evaluate the impact of the various health system transformations on specific patient populations and thus adjustments can be made more efficaciously.

080 Recent Increases in Left Without Being Seen in the Emergency Department.
Bullard M, Rowe BH, Yiannakoulias N, Spooner CA, Holroyd B, Craig W, Klassen T, Johnson D, Rosychuk R, Svenson L, Schopflocher D. University of Alberta, Edmonton, AB.

OBJECTIVES: Patients who leave emergency departments (EDs) without being seen (LWBS) constitute have the potential for increased morbidity and dissatisfaction. This study examines LWBS trends over a three-year period. METHODS: All patients presenting to provincial EDs were eligible for inclusion. Data were derived from a sample of ED patients treated in 17 health regions over 3 years (98/99, 99/00, 00/01) with a disposition code of LWBS or a disposition code of left against medical advice in conjunction with a refusal of service (V642). Data were extracted from the Ambulatory Care Classification System (ACCS) database, computerized abstracts coded similarly by medical record nosologists across all regions. Descriptive statistics and crude presentation rates are reported. RESULTS: Overall, approximately 1.5 million ED visits were recorded per year across the province. The number of patients LWBS has risen every year; 98/99: 21,195, 99/00: 25,865; and 00/01: 32,375. Young children (ages <5; 14%) and adults (ages: 20-29; 23%) represent the largest percentage of cases overall. The elderly (>64 years) represent <5% of the overall LWBS sample. Wide seasonal variation (34%) was observed and December rates were highest (9.7%). The rate of LWBS is increasing in all areas of the province, but rates increased most in rural EDs over the time period (59% increase). For the 2 major urban centres, rates per 1000 ED visits were higher in Calgary than in Edmonton for all 3 years; increases over time were greater in Calgary (39%) than Edmonton (25%). CONCLUSIONS: Despite the most rapid population growth of any province in Canada, in-patient capacity was not increased over the study period. These results indicate that LWBS cases across a large population are increasing steadily and can be considered a proxy marker for ED overcrowding. Further detailed evaluation of LWBS should identify other reasons for premature departure.

081 Adventure and Adversity: Injury Patterns in an Extreme Sport.
Denny CJ, Schull MJ. Division of Emergency Medicine, University of Toronto. Toronto, ON.

INTRODUCTION: Adventure racing is a wilderness multisport endurance activity. These events challenge teams with days of continuous travel through environmental extremes of temperature and terrain. Despite increasing popularity, there is a paucity of literature examining patterns and predictors of injury in this sport. Our purpose was to estimate the prevalence of adverse incidents in adventure racing. METHODS: Prospective, cross-sectional survey of all athletes at the Canadian Adventure Racing Championships. During a three-day race in September 2001, 15 teams of 4 athletes trekked, mountain biked, and canoed a 234 kilometre course in northern Ontario. Trained interviewers administered a questionnaire to consenting team captains at the finish line, or at basecamp if teams did not finish. An incident was defined as any injury or illness of sufficient severity to impede team progress. Analyses included descriptive statistics with 95% confidence intervals, and logistic regression to determine the association of adverse incidents with age, gender, team, and level of adventure racing experience. RESULTS: All 15 team captains agreed to participate. Of 60 athletes, 44 (73%) were male, with an a mean age of 31.5 years. Nine teams (60%; 95% CI 32-84) failed to finish the race; 7 due to an incident (47%; 95% CI 21-73). Of the 60 athletes, 29 (48%; 95% CI 35-62) suffered an incident. Fifteen incidents occurred while trekking, 10 while biking and 4 while canoeing. The most common adverse incident was musculoskeletal injury (52%; 95% CI 32-71). There were no deaths and only 1 incident required hospital care. In multivariate analysis, least experienced athletes (<1 year of adventure racing) were more likely to have an adverse incident (OR 7.6 p = .02). CONCLUSIONS: Incidents affect nearly half of adventure racers. Less than half of teams finish the race. Injury prevention initiatives may be more effective if focused on least experienced athletes.

082 Treatment Strategies for Early Presenting Acetaminophen Overdose - A Survey of Medical Directors of Poison Centres in North America and Europe.
Kozer E, McGuigan M. Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, and the Ontario Regional Poison Control Centre. Toronto, ON.

BACKGROUND: Acetaminophen is frequently used in self-poisoning in Western countries. Although treatment with N-acetylcysteine (NAC) reduces liver injury, no consensus exists on the preferred management of acetaminophen toxicity. OBJECTIVES: To describe the approach taken by toxicologists in North America and Europe toward the management of acetaminophen toxicity. METHODS: Medical directors of poison centres in the United States, Canada, and Europe were surveyed by means of a questionnaire presenting 2 clinical scenarios of acetaminophen overdose: a healthy adolescent with no risk factors who had an acute ingestion of acetaminophen, and an adult with both acute ingestion and possible risk factors. For each case several questions about the management of these patients were asked. RESULTS: Questionnaires were sent to medical directors of 76 poison centres in North America and 48 in Europe, with response rates of 62% and 44% respectively. Forty percent of responders suggested using charcoal 4 hours after ingestion of a potential toxic dose of acetaminophen, and 90% recommended treatment with NAC when levels were above 150 mg/mL but below 200 mg/mL 4 hours after ingestion. Duration of treatment with oral NAC ranged from 24 to 96 hours; 38 responders suggested a duration of 72 hours. Of 49 centres recommending oral NAC, 18 (36.7%) said they might consider treatment for less than 72 hours. Eleven of 29 (37.9%) responders suggested treatment with intravenous NAC for more than 20 hours as their usual protocol or a protocol for specific circumstances. CONCLUSIONS: Our study showed large variability in the management of acetaminophen overdose. Variations in treatment protocols should be addressed in clinical trials to optimize the treatment for this common problem.

083 Shiftwork and Emergency Medical Practice: Systematic Narrative Review.
Frank JR, Ovens H. University of Toronto Division of Emergency Medicine, Toronto, ON.

INTRODUCTION: Shiftwork is an essential component of the demanding 24/7 practice of emergency medicine. Unfortunately, shiftwork schedules are also known to have numerous negative effects on shiftworkers. To our knowledge, no systematic narrative overview of the shiftwork literature exists. METHODS: We sought to answer the question, "What are the effects of shiftwork on emergency medical practice?" We conducted a systematic literature search using multiple databases, including Ovid Medline (1966-2000), Psyc Info (1984-2000), and Emergency Medical Abstracts (1995-2001) using a defined search strategy. We also searched the Web sites of the American College of Emergency Physicians (www.acep.org), the American Academy of Emergency Medicine (www.aaem.org), and the Canadian Association of Emergency Physicians (www.caep.ca) for documents containing "shiftwork". We searched the internet for shiftwork information using the Google (www.google.com) meta-engine. We also searched the University of Toronto electronic library resources site for relevant journals and references (www.utoronto.ca). Bibliographies were hand-searched for further references. Finally, we consulted experts in the fields of chronobiology and emergency physician wellness. RESULTS: Thirty-two initial references met all of our database inclusion criteria and 15 Web sites were incorporated. Additional sources added a further 65 relevant references. Shiftwork has negative effects on sleep, performance, mental, social, and physical health. Strategies for ameliorating these effects exist in 5 categories. CONCLUSIONS: Shiftwork is essential to EM practice, but has numerous negative effects on EM physicians. Our review identified 5 strategies for minimizing the impact of shiftwork on EM practice.

084 First Aid Kit Availability and Content Among Trekkers in Nepal.
Fedder S, Abu-Laban RB, Fefer J. Department of Emergency Medicine, Langley Memorial Hospital. Langley, BC.

OBJECTIVES: Adventure travel has increased the incidence of medical problems in isolated areas. We sought to determine the preparedness of trekkers in Nepal as manifested by whether they carried a first aid kit and, if carried, by the kits contents. Our primary objectives were to determine the proportions of trekkers who: (1) carried first aid kits; (2) carried antibiotics from each of 3 a priori-defined categories; and (3) carried prophylactic medications for altitude illness. METHODS: A convenience sample of trekkers who attended free daily information lectures on altitude illness from 01/October/1998 to 05/December/1998 in Manang, a village midway along a 3 week trek (altitude 3540 m, maximum trek altitude 5416 m) were invited to participate. Subjects were asked a series of standardized questions during a brief interview by 1 of 2 researchers with multilingual abilities. RESULTS: 121 trekkers were enrolled, the majority of whom were from Europe (44%), the USA (23%), Australia/New Zealand (20%) or Canada (7%). The mean age of those studied was 32 years and 63% were male. 97% of subjects carried a first aid kit (117/121, 95% CI: 91.8%-99.1%), 73% carried at least 1 antibiotic (88/121, 95% CI: 63.9%-80.4%), and 40% carried prophylactic medication for altitude illness (48/121, 95% CI: 30.9%-50.0%). Thirty percent of subjects carried an antibiotic agent from 1 category only; 33% from 2 categories; and 10% from all 3 categories. Logistic regression models, fit for secondary purposes, indicated that carrying a complete or near-complete selection of antibiotic categories and carrying prophylactic medications for altitude illness were both independent of trekker age, sex, region of origin, days trekking and total days travelling. CONCLUSIONS: Although the majority of trekkers in the Nepalese Himalayan carry first aid kits, a significant proportion of these kits lack agents from important antibiotic categories and/or lack prophylactic medications for high altitude illness. Measures to improve the preparedness of trekkers for medical problems appear warranted.

085 A Surveillance of Soccer Injury in Canadian Children: A Five Year Canadian Hospitals Injury Report and Prevention Program (CHIRPP) Perspective.
Shore BJ, Joubert GI. Department of Pediatrics - Emergency Medicine, Children's Hospital of Western Ontario, London, ON.

INTRODUCTION: In 2000, the Canadian Soccer Association reported that there are 644,028 children under the age of 19 playing organized soccer. The objective of this study was to examine the relative frequency of soccer injury in children using the CHIRPP. METHODS: A retrospective study was conducted using the CHIRPP database, incorporating data from 10 pediatric hospitals and 6 general hospitals since 1990. Soccer injury reports between September 1, 1994 and August 31, 1999 were analyzed. Age ranged from >1 to <19 years of age. Over the five-year period injuries were analyzed to describe age, gender, context of the injury, body part injured, and severity of injury. RESULTS: Total data pool consisted of 10,647 records. The greatest number of inuries was in the 10-14 age group (n = 6281, 62% male, 38% female). The rank order of injuries were sprains (31.5%), fractures (29.4%) and superficial lacerations (25.5%). Significantly more injuries resulted from non-competitive (64%) versus (36%) for competitive play (p > 0.01). 97.3% of all injuries were minor. Using hospital admissions as an indicator for injury severity, only 2.7% required admission. Fractures (73%) and head injuries (11%) were the 2 most common diagnoses requiring hospital admission. Males had an overall higher admission rate (Odds Ratio = 1.37). Male competitive play resulted in higher rates of severe head injuries (Odds Ratio = 7.47) compared to male non-competitive play (Odds Ratio = 1.21). CONCLUSIONS: Using the CHIRPP surveillance tool, soccer injuries in Canadian children occur at a greater rate in non competitive compared to competitive play. The majority of soccer injuries in children are minor in severity. Males are at an increased risk for soccer injuries in general, in particular for those requiring hospitalizations, and especially head injuries.

086 Patterns of Injury of Canadian Children in Non-Competitive Soccer: A Five Year Canadian Hospitals Injury and Report Prevention Program (CHIRPP) Perspective.
Shore BJ, Joubert GI. Pediatric Emergency Medicine, Children's Hospital of Western Ontario, London, ON.

INTRODUCTION: The Canadian Soccer Association reports that in 2000 there were 644,028 children under the age of 19 playing competitive (C) soccer. The objective was to examine the relative frequency of injury in non-competitive (NC) soccer play using CHIRPP. METHODS: A retrospective study was conducted using the CHIRPP database, incorporating data from 10 pediatric hospitals and 6 general hospitals. Soccer injury reports between September 1, 1994 and August 31, 1999 were analyzed. Age ranged from >1 to <19 years of age. Over the five-year period injuries were analyzed to describe age, gender, the context of the injury, the mechanism of injury, and the severity of injury. RESULTS: Analysis was done on 8,424 completed records. A significantly larger proportion of soccer injuries were as a result of NC 64% (n = 5361) play versus 36% for C play (p > 0.01). Males were twice as likely to be injured in NC group (67.4%) versus females (32.6%). The 10-14 age group had the greatest number of injuries (3084). Contact accounted for 84% of all NC injuries. Majority of injuries were minor (96.3%). Using hospital admission as an indicator of injury severity, only 3.3% required admission. Fractures (71.9%) and head injuries (10.7%) were the 2 most common diagnoses requiring hospital admission. Males had an overall higher admission rate (OR = 1.16) and more frequent severe head injuries (OR = 1.21). CONCLUSIONS: Using the CHIRPP surveillance tool, soccer injuries in Canadian children occur at a greater rate in non-competitive play. This data shows that the majority of soccer injuries in children are minor in severity and associated with contact. Males are at an increased risk for soccer injuries in general, and in particular for those requiring hospitalizations, especially head injuries.

087 Practice Variation Among Pediatric Emergentologists and Pediatric Orthopaedic Surgeons in the Management of Wrist Buckle Fractures.
Plint A, Clifford T, Perry J, Bulloch B, Nguyen BH, Miller K, Pusic M, Joubert G, Lalani A, Ali S. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: Buckle fractures are the most common wrist fractures in children and frequent cause of ED visits but there is few studies regarding their management. The purpose of this study was to examine practice patterns and attitudes of pediatric emergency physicians (EP) and pediatric orthopedic surgeons. METHODS: A standardized survey assessing management of wrist buckle fractures and attitudes for immobilization was mailed to all pediatric orthopedic surgeons and EPs at 9 children hospitals. A modified Dillman's method was used for follow-up. RESULTS: 82% of physicians surveyed responded (31/39 orthopedic surgeons and 79/96 EPs). 63% of EPs and 68% of orthopedic surgeons believed wrist buckle fractures need to be immobilized (p = 0.28). There was variation among orthopedic surgeons on the length of immobilization recommended, 71% recommended 2 to 3 weeks and 10% treated only until pain free. EPs showed great diversity on length of immobilization needed (until pain free [17%], 2 to 3 weeks [35%], and 1-2 weeks [13%]). 52% of orthopedic surgeons preferred a below elbow cast, 30% preferred a combination of splint and cast (30%), and 10% preferred a splint. EPs "usually or always" used a cast (60%) or splint (31%). Among physicians who believed all fractures should be immobilized, pain control was the most frequently cited reason (95% orthopedic surgeons, 90% EPs, p NS). Orthopedic surgeons were more concerned about refracture than EPs (76% vs 55%, p = 0.10). The remaining physicians did not believe all buckle fractures needed immobilization, cited buckle fractures are stable (67% orthopedic surgeons, 79% EPs, p = 0.46) and have a low risk of refracture (33% orthopedic surgeons, 67% EPs, p = 0.09). CONCLUSIONS: Although many physicians believe wrist buckle fractures need immobilization, a significant number disagree. There is variation in the type and length of immobilization used. Given this practice variation, the optimal management of wrist buckle fractures needs further study.

088 Croup Presentations to the Emergency Department: Description and Outcome.
Rowe BH, Yiannakoulias N, Johnson D, Klassen TP, Bullard M, Spooner CH, Holroyd BR, Svenson L, Rosychuk R, Schopflocher D. University of Alberta, Edmonton, AB.

OBJECTIVES: This study examines ED presentations of croup and subsequent visits for the same problem within the year using a large administrative database. METHODS: All patients <20 years of age 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 (1998/99) with a diagnostic code of croup (464.4). 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: During the year, there were 4706 unique croup-related visits to the emergency department by 3933 individuals under 20 years of age. These visits made up roughly 0.3% of the 1.5 million total visits to the emergency department. Overall, 2702 (66%) of patients were between 1-4 years of age; males presented more commonly than females. Impressive daily and seasonal variation exists; weekends (35%) and December-February (38%) numbers were highest. Most visits resulted in discharges from the emergency department (4209; 90%). There were 464 admissions (9.9%), including 10 to critical care areas. The 2 urban health regions had lower or significantly lower than average rates of croup presentation. Repeat visits to the ED for croup were not uncommon; 16.5% of the cases made at least 1 additional visit to the ED for croup within a year of the first visit. CONCLUSIONS: These results indicate that croup is a relatively common presentation to the ED. Repeat presentations and variation in rates of presentation suggest that further evaluation of croup patients is required to determine the treatment variation for this ED problem.

089 Patients with Community-Acquired Pneumonia Discharged from the Emergency Department According to a Clinical Practice Guideline - A 2 Year Observational Study.
Campbell SG, Patrick W, Varley-Doyle S, Els M, Murray D, Urquhart D, Maxwell D, Hawass A, McIvor RA, Hernandez P, McParland C, Haase D. Dalhousie University Department of Emergency Medicine. Halifax, NS.

INTRODUCTION: Clinical practice guidelines (CPG) decrease admission rates for CAP, although the safety of decreased admissions in a non-study setting remains unclear. According to the CPG at our institution, patients with a pneumonia severity score (PSS) of <90, (Fine groups I to III) and who met each of 4 additional discharge criteria, are discharged, with referral for telephone follow-up in 24-48 hours. OBJECTIVES: Primary objective: To assess the safety of discharging patients with CAP according to a CPG based on a pneumonia severity scoring system. Secondary objective: To assess the utility of a 24-48 hour follow-up call. METHODS: A retrospective chart audit of all patients identified in the ED database as having been discharged with a diagnosis of pneumonia during the period 3 Jan 1999-3 Jan 2001. Readmission or death rates within 2 weeks of the emergency visit were evaluated, using data from all local hospitals and from the provincial coroner. RESULTS: 867 patients were identified. The average age was 55.5 years. (range 16-98), and the mean PSI score was 69.2 (range 6-187). 26 (3%) were readmitted within 2 weeks, 15 (1.7%) died within 2 weeks. Of 148 (17.1%) patients referred for follow-up, average age (58.8 vs. 54.9) and PSI scores (67.2 vs. 69.6) were similar to patients not referred. Referred patients were twice as likely to be readmitted within 2 weeks (4.7% vs. 2.5%). There was no difference in deaths within 2 weeks between the groups (1.4% vs. 1.8%). CONCLUSION: The use of a CPG to guide the discharge of patients from the ED appears to be safe. Patient follow up referrals are infrequently made, and the chance a referral does not appear to be linked to the PSI or age of the patient, but does appear to be associated with a higher subsequent admission rate.