2003 CAEP/ACMU Scientific Abstracts: 41-60
CAEP Abstracts
CJEM 2003;5(3):179-209
Disclaimer: The large number of abstracts submitted and the short time interval between submission and publication did not permit communication with authors, abstract revision of CJEM editorial review. The following abstracts are presented, unedited, as they were submitted to the CAEP Research Committee. Abstract authors are from the department or division of emergency medicine of their respective universities unless otherwise specified.
abstracts : 001-020 : 021-040 : 041-060 : 061-080 : 081-100
041 Emergency Department Gridlock and Pre-Hospital Delays for Cardiac Patients.
Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Dept of Emergency Services, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.
OBJECTIVE: To determine the effect of simultaneous ambulance diversion at multiple emergency departments (gridlock) on transport delays for patients with chest pain. METHODS: Retrospective data on consecutive ambulance patients with chest pain and the diversion status of emergency departments in Toronto were obtained from January 1998 to December 1999. Gridlock was calculated separately for the four city quadrants as the daily duration of episodes where all EDs in the quadrant were simultaneously diverting ambulances. The primary outcome was 90th percentile ambulance Transport Interval (scene departure to hospital arrival). RESULTS: 11400 patients were included (mean age 67 years; female 51%; severity of illness moderate to life-threatening 89%). Ambulance diversion resulting in gridlock was associated with prehospital delays. Gridlock occurred an average 1.1 hour/day, and 3060 patients were transported on days when it occurred. 90th percentile Transport Interval was 15.5 min (95% CI 15.3-15.9) for patients not exposed to gridlock vs. 17.4 min (95% CI 16.8-17.8) for patients who were exposed to gridlock. In multivariate analyses, both Transport and Total Prehospital Interval delays were associated with ambulance diversion, but only when it resulted in gridlock (0.2 min/hour, 95% CI 0.1-0.4 and 0.2 min/hour, 95% CI 0.04-0.4 respectively). Delays were similar regardless of patient severity of illness (p = 0.5). Age (0.8 min/10 years, 95% CI 0.5-1), female sex (1.9 min, 95% CI 1.3-2.6), and advanced care paramedics (5.3 min, 95% CI 4.4-6.3). CONCLUSIONS: Ambulance diversion was associated with delays in prehospital ambulance transport for chest pain patients, but only when it resulted in gridlock. The magnitude of the delay was the same regardless of patient severity of illness. Key words: overcrowding, emergency medical services
042 Clinical Scaphoid Fracture: Over-Treatment of a Common Injury?
Stenstrom R. Department of Emergency Medicine, St. Paul's Hospital and University of BC, Vancouver, BC..
INTRODUCTION: Clinical scaphoid fracture [CSF] (tender scaphoid and negative x-rays [XR]) is commonly managed with thumb spica cast and repeat imaging, despite little evidence for this approach. METHODS: Objectives: 1. Estimate the proportion of CSFs that are true fractures 2. Identify risk factors for 'poor outcome' of scaphoid fracture (AVN, non-union, malunion). 3. Identify side-effects of treatment of CSF. A separate study was conducted for each objective. 1. Cohort study. 186 consecutive patients, diagnosed with CSF in the ED over 2 years were followed to establish the proportion of true fractures. 2. Case-control study. 27 cases of 'poor outcome' of scaphoid fracture were identified from operative records from 3 hospitals. 2 matched controls per case were chosen randomly from 285 consecutive patients diagnosed with clinical and true scaphoid fracture. Blind assessment of records for the following variables was conducted: age, gender, initial treatment, initial x-rays + or -, location of fracture, and imaging modality 3. A telephone survey of 50 randomly selected patients with CSF assessed satisfaction with and side effects of treatment, and disability. RESULTS: 1. 176/186 (94.6%) of patients initially diagnosed with CSF had repeat imaging (XR, bone scan, MRI or CT) 10-42 days after initial injury. 7/176 patients (3.9%) had a true scaphoid fracture (95% CI 2.1-5.7%). Over 3 years of follow-up, no patient with CSF had a 'poor outcome' (95% CI 0-1.7%). 2. Conditional logistic regression identified these risk factors for poor outcome: initial XR positive (odds ratio [OR] infinite), age > 60 years (OR 4.1, 95% CI 1.5-12.9), and initial treatment (non-operative) (OR 3.6, 95% CI 1.7-8.8). 3. 41/50 of CSF patients telephoned were casted. 3/50 had returned to the ED for a tight cast. 1/50 patients had true fracture. 465 days of work were missed in casted patients. CONCLUSIONS: This common injury is over-treated and there is significant morbidity associated with treatment. Key words: scaphoid fracture
043 Measuring Trauma Care Performance in Ontario Emergency Departments.
Lindsay MP, Schull MJ, Anderson GM. Institute of Clinical Evaluative Sciences, University of Toronto, Toronto, ON.
INTRODUCTION: The care of traumatic injuries accounts for the greatest proportion of the overall caseload in emergency departments (EDs), yet existing measures of ED quality of care may not capture important aspects of trauma care. The purpose of our study was to develop and test a set of specific clinical quality indicators for ED trauma care that could be applied across a range of settings. METHODS/RESULTS: Using a previously validated modified Delphi panel process, an advisory panel was convened to select appropriate injuries and indicators for measuring trauma care in EDs. Based on a literature review and formalized expert consultations, a set of 7 important outcomes were chosen and panelists were asked to identify which of these outcomes were linked to quality of care for each of 15 injuries that are either common or where ED care may have significant impact on outcome. For 9 injuries (minor head trauma, moderate head trauma, ankle injury, neck injury, open fractures of upper limb, hip fractures, thoracic injury, spinal cord injury, multisystem trauma), the panelists identified at least one outcome linked to quality of ED care (e.g., neck injury -diagnostic tests, open limb fracture - morbidity, thoracic injury - mortality) for a total of 31 injury-outcome pairs. Next, 45 specific clinical indicators for 31 injury-outcome pairs were identified (e.g., time to operating room for hip fracture, antibiotics for open fractures). The panel highly ranked 33/45 specific indicators for the 9 injuries (e.g., CT scan rates in minor head injury, trauma leader response time for multisystem trauma, length of time on back board for neck injury). These indicators were subjected to feasibility and validity studies using an administrative dataset containing over 1.1 million trauma cases treated in 166 EDs in the province of Ontario over one year. CONCLUSIONS: The study shows that it is possible to systematically develop and apply clinical quality of care indicators to ED trauma cases. Key words: trauma, quality
044 The Bedside Investigation of Pulmonary Embolism Diagnosis (BIOPED) Study.
Rodger M, Wells P, Makropoulos D, Stiell IG, Jones G, Rasuli P, Raymond F, Clement AM, Karovitch A, Djunaedi H, Bredeson CN, Reardon M. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Bedside methods to exclude pulmonary embolism (PE) include the Wells Clinical Model, non-ELISA D-Dimers and alveolar dead space analysis. We sought to test whether using combinations of bedside tests was as safe as a standard strategy of diagnostic imaging. METHODS: This triple blind randomized controlled trial enrolled adults with suspected PE in a tertiary care hospital. Patients were randomized to initial bedside tests or initial V/Q scan without bedside tests. All patients had a Wells Clinical Model score, a non-ELISA D-Dimer and alveolar dead space analysis but these data were only used in management in the bedside test group. Patients assigned to the bedside test group had a sham V/Q performed if 2 of 3 of the bedside tests were negative; otherwise they had a real V/Q scan. Further diagnostic testing and management were dictated by a blinded physician. The primary outcome was recurrent Venous Thromboembolic (VTE) disease over 90 days in patients not anticoagulated. Chi-square and logistic regression analyses were performed. RESULTS: Of the 399 patients, 64.4% were ED cases, 65 were anticoagulated after the initial work-up, and the total VTE rate was 18%. Among the 334 patients not anticoagulated, the VTE rate was 2.4% (95% CI 0.6-6.1%) in the bedside test group vs. 3.0% (1.0-6.8%) in the V/Q scan group (P=0.76). 5.3% patients with 2/3 bedside tests negative had VTE vs. 24.1% with 2/3 bedside tests positive (p<0.0001). 9.9% patients with <4 points on Wells Model had VTE vs. 21.6% with >4 points (p=0.004). 6.2% patients with negative D-Dimer had VTE vs. 26.5% with positive D-dimer (p<0.0001). 12.4% patients with alveolar dead space fraction <0.15 had VTE vs. 32.1% with >0.15 (p<0.0001). LR analysis demonstrated all 3 bedside tests were independent predictors of VTE. CONCLUSIONS: Using a strategy that 2 out of 3 negative bedside tests excludes PE is as safe as an initial V/Q scan approach and eliminates the need for diagnostic imaging in 1/3 of suspected PE patients. Key words: pulmonary embolism
045 Streptococcal Pneumonia Culture and Resistance in Low Risk Patients with Pneumonia.
Rowe BH, Campbell S, Hohrmann JA, Emond J, Spooner CH, Camargo CA Jr for the CAEP/MARC-16 Investigators. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Limited information exists on the presence and resistance of Streptococcal pneumonia (SP) in patients with pneumonia discharged from the emergency department (ED). This ED study examined the utility of a standardized collection of sputum for patients with a physician-diagnosis of pneumonia. METHODS: Multicenter, prospective cohort study in Canadian and US EDs between 12/01-10/02. Using a standardized method for sputum sample collection, 22 EDs enrolled pts, age 18+, discharged with community acquired pneumonia (CAP). Patients with a pneumonia severity index (PSI) of >III were excluded. All patients were treated with clarithromycin for 7 days and followed for by telephone (2 wks) and in person (4 wks) to ascertain outcomes. Cultures were completed on "culturable sputum" and SP resistance to macrolides and penicillin was determined by local and central laboratories. RESULTS: A total of 270 patients have been enrolled in this interim analysis, 141 (52%) had sputum samples that qualified for culture and 59 (22%) grew an identifiable organism. Overall, 35 (13%) were positive for non-SP organisms, and 24 (9%) grew SP. No penicillin and 3 macrolide resistant organisms were identified in the SP+ cases; 4-wk cure rates were similar in all SP+ and SP- groups. CONCLUSIONS: Out-patient treatment of CAP is common in the ED, and empirical treatment is recommended with macrolides. SP resistance appeared low and patients did well in this setting, although < 25% of sputum samples grew pathogens in PSI Class I-III patients. In these low risk PSI groups, sputum cultures should be reserved for surveillance purposes only. Key words: pneumonia, sputum culture
046 Prospective Assessment of the Accuracy and Reliability of the Eight Clinical Criteria in the Canadian C-Spine Rule.
Stiell IG, Dreyer J, McKnight RD, MacPhail I, Bandiera G, Clement C, Lee J, Cass D, Rowe B, Brison R, Schull M, Lesiuk H, for the CCC Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: We recently prospectively validated the accuracy, reliability, and acceptability of the Canadian C-Spine Rule (CCR) in a cohort of 8,283 patients. In this study, we sought to evaluate the accuracy and reliability, separately, of each of the 8 high-risk and low-risk clinical criteria within 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. Physicians performed standardized clinical assessments and completed data forms for patients who then underwent radiography to determine the outcome, clinically important c-spine injury. 130 patients were independently examined by a 2nd MD. Patients were followed by a 14-day telephone interview. We conducted chi-square, odds ratio, and kappa coefficient analyses. RESULTS: Among the 8,283 patients, the mean age was 37.6 (range 16-100), 52.3% were male, 67.2% were injured in a MVC, and 2.0% had clinically important cervical spine injury. This table shows % of injury and non-injury patients with findings, P-value, unadjusted odds ratio, and kappa coefficient:
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CONCLUSIONS: The 3 high-risk and 5 low-risk CCR criteria showed very good interobserver agreement and very strong association with c-spine injury. The excellent accuracy and reliability of the CCR is based upon the strength of its clinical components. Key words: clinical prediction rule, diagnostic imaging, cervical spine injury
047 Establishing a Predictive Model for Physician Clinical Workload.
Stenstrom R, Innes G, Grafstein E, Christenson J. Department of Emergency Medicine, St. Paul's Hospital and the University of BC, Vancouver, BC.
INTRODUCTION: Emergency department (ED) physician staffing requirements should be based on clinical workload. Factors predicting physician time necessary to care for patients are poorly described. METHODS: Objectives: To develop and validate a multivariable linear regression (MLR) model to establish which clinical, demographic and setting variables have the strongest association with time needed to treat patients. A research assistant (RA) followed 20 emergency physicians (EP) for 31 day, evening and night shifts at a busy inner city ED. The RA recorded EP time spent performing clinical, teaching, departmental and communication functions for 585 consecutive patient visits. The RA also recorded candidate predictor variables: gender, age, mode of arrival, CTAS level (Canadian Triage and Acuity Scale), language, housing, vital signs, GCS, co-morbidity, prior visits, need for a procedure, and whether a resident or student was involved in care. Association between predictors and total EP time per patient (dependent variable) was assessed with MLR. The model was then validated on 234 subsequent patient visits. RESULTS: Assumptions underlying MLR were valid for these data. Colinearity between variables was minimal. The regression equation for total physician time per pt (TFT) was derived using a forward stepwise selection procedure (F-to-enter 0.05): TFT = 49.8 + 10.9(procedure required [Y/N]) - 4.0(CTAS level [1-5]) + 3.1(ambulance arrival) ' 2.3(GCS [3-15]) + 3.4(age > 70 years]) + 3.4 (female gender) + 2.5 (English not first language) + 1.5 (# of comorbid conditions) + .32(age x CTAS interaction). This model predicted 29.2% (R2 = .292) of the variance in physician time per patient (F [8, 331] = 17.4; P <.0001). The cross-validation R2 for the second sample (N = 241) was .239 (shrinkage R2 = .053).
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CONCLUSIONS: This study describes a predictive MLR model for physician workload that has been validated in our institution. After validation in other settings, these data will help predict ED manpower needs. Key words: emergency workload
048 Predictors of Survival for Out-of-Hospital Respiratory Distress Patients in the OPALS Study.
Stiell IG, De Maio VJ, Nesbitt L, Wells GA, Brisson D, Beaudoin T, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: We previously demonstrated that the addition of an ALS EMS program led to a large mortality reduction for respiratory distress patients. In this study, we sought to determine which specific factors are associated with better survival. METHODS: The Ontario Prehospital Advanced Life Support (OPALS) Study evaluates EMS programs for critically ill and injured patients. The respiratory component was a multicenter before-after controlled trial that enrolled adult patients with a primary complaint of shortness of breath. During the before phase, care was provided at the BLS-D level and during the after phase, ALS providers performed endotracheal intubation and administered IV drugs. We conducted stepwise logistic regression analyses to identify independent predictors of survival. RESULTS: The 7,478 patients enrolled during the two 6-month phases had these characteristics: mean age 70.6 (16-107), female 53.3%, survival rate 86.7%. This table compares survivors and non-survivors and gives the adjusted odds ratios for predictors associated with survival: CONCLUSIONS: We believe this to be the largest dataset of out-of-hospital respiratory distress patients. After adjustment for demographic, clinical, and EMS factors, the only interventions associated with better survival were salbutamol and NTG. Key words: emergency medical services, respiratory distress
049 Nonurgent Emergency Department (ED) visits: Patient Characteristics and Barriers to Primary Care
Afilalo J, Marinovich A, Afilalo M, Colacone A, Leger R, Unger B, Giguere C. Emergency Department, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, Quebec
OBJECTIVE: ED overcrowding is at the forefront of the medical and political agendas and diversion of nonurgent (NU) patients (pts) has been entertained as a management strategy. Prior to policy changes a clear understanding of the reasons why these pts are not seeking care at a primary care provider (PCP) before presenting to the ED is essential. This study compares NU pts to urgent and semi-urgent (USU) and describes the NU pt reasons for not seeking care at a PCP before presenting to the ED. Methods: Cross- sectional study with sequential sampling in 5 tertiary care hospitals EDs (Oct. 19 1999 to May 26 2000). Data on past medical history, social support, awareness and utilization of healthcare, ED visit, referral, Activities of Daily Living (ADL),socio-demographics, were obtained. The NU group were pts triaged as code 5 while USU were pts coded 2,3,4 using the Canadian Triage & Acuity Scale. Pts reasons for visiting the ED were structured into the Andersen Behavioral Model (ABM) for health care utilization. Only comparison producing P-value <0.05 are shown. RESULTS: Of 2348 pts approached 1804(76%) accepted to participate. NU (n=454) were younger than USU (n=1329) (mean age 43 vs. 49 years). NU pts had better health (number of prior conditions;(3.1 vs 2.87) and functioning (ADLs; 1.92 vs 1.87), were less likely to arrive by ambulance (4% vs 22 %), reported less specialist care (38% vs 48%)and were less often admitted from the ED (4% vs 24%). While 70%of NU pts compared to 75%USU pts were followed by a PCP, only 22% of NU pts and 27%USU pts sought PCP care before presenting to the ED. The reasons given by NU pts for not seeking PCP care were: accessibility (34%), referral/follow-up to the ED (19%), familiarity with (19%), perception of need (16%), and trust of the ED (10%). CONCLUSION: The reasons NU pts seek ED care before presenting to their PCP include practicality, perceptions of need, professional advice, and accessibility. Planning strategies for diversion of this group should consider and address such matters. Key words: overcrowding
050 Prospective Evaluation of the Classification Performance Accuracy of Neck Rotation and Flexion in Potential C-Spine Injury Patients
Stiell IG, Eisenhauer M, Reardon M, Worthington JR, Holroyd B, Clement C, Cass D, Greenberg G, Schull M, Brison R, Rowe B, Battram E, for the CCC Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON
INTRODUCTION: We recently validated The Canadian C-Spine Rule (CCR) for radiography in alert and stable trauma 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 substudy prospectively evaluated the accuracy of rotation and flexion for ruling out c- spine injury. 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 standardized examinations for active rotation and flexion and recorded their findings on data forms. Patients underwent radiography to determine the outcome, clinically important c-spine injury. Analyses included sensitivity, specificity, and descriptive statistics, with 95% CIs. RESULTS: 5,442 patients were enrolled over 30 months and had these characteristics: age range 16-100, male 50.6%, ambulance arrival 51.9%, important c-spine injury 0.6%, unimportant injury 0.2%, CCR low-risk 68.8%, medium-risk 4.0%, high-risk 27.2%. For patients capable of rotation or flexion, the accuracy and probability of injury, stratified by risk category, were:
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CONCLUSIONS: Both rotation and flexion demonstrate 100% negative predictive value and can be considered accurate techniques for evaluating cervical spine injury in alert and stable patients. For patients classified as low-risk by the CCR and capable of neck rotation, the probability of injury is 0.03%. Key words: clinical prediction rule, diagnostic imaging, cervical spine injury
TOPIC: ADMINISTRATION/OTHER
051 Development and Application of an Abbreviated Tool to Estimate Length of Stay for the Emergency Department Clientele
Afilalo M, Unger B, Colacone A, Giguere C, Boivin JF, Leger R, Stiell I, Vandal A, Xue X. Emergency Department, Sir Mortimer B. Davis-Jewish General Hospita, McGill University, Montréal, Quebec.
OBJECTIVE: To develop an abbreviated tool which will allow for the estimation of the length of stay (LOS) for the emergency clientele using intrinsic patient characteristics. METHOD: The project included several phases, beginning with the collection of data from about 3 000 patients recruited in 6 participating hospitals. A first series of in-depth statistical analysis on the data collected had identified 12 patient characteristics which influenced LOS. A second series of analysis was performed to estimate the pertinence of only keeping two of these variables, i.e. ? age ? and ? transportation ? (using ambulance or not), to predict LOS. Both variables are currently available in existing administrative database as opposed to the other characteristics previously identified. The LOS was modelled as a mixture of two distinct distributions by evidence from a descriptive analysis and clinical appropriateness. Estimations of the maximum likelihood are obtained via the EM algorithm. RESULTS: Coefficients to estimate the LOS attributable to each combination of age categories (<25, 25-44, 45-64, 65-74, >or = 75) and transportation categories (using ambulance or not) vary from 4.276 to 11.911. These coefficients are used to obtain a predicted LOS according to the clientele's prevalence for each of the 10 combined categories. CONCLUSIONS: Using both age and means of transport, an estimation of the ED clientele LOS can be calculated. This estimate can be used to evaluate the burden that a clientele poses on the ED. Moreover, an internal performance index of the ED (IPI) can be calculated for different hospitals. Therefore, despite variations in clienteles between EDs, the IPI would allow for comparisons between and within EDs over time, facilitating the evaluation and understanding of the overcrowding phenomenon. Key words: overcrowding, length of stay
052 Impact of Ambulance Transportation on the use of Resources in the Emergency Department
Marinovitch A, Afilalo J, Afilalo M, Unger B, Colacone A, Giguere C, Leger R, Xue X, Boivin JF, MacNamara E. Emergency Department, Sir Mortimer B Davis-Jewish General Hospital, McGill University, Montréal, Quebec.
OBJECTIVE: Ambulance diversion is sometimes used to manage emergency department (ED) overcrowding. Our objective was to determine how ambulance transportation is associated with the use of various resources in the ED. METHODS: Retrospective administrative database review of visits to a Montréal tertiary care hospital ED over one year, from April 2000 through March 2001. Resource-use measures: consults and radiology/imaging tests (excluding plain-film X-rays) ordered from the ED, ED length of stay, and admission to the hospital from the ED. RESULTS: During the study interval, 39,674 patients made 59,142 visits to the ED. Of all visits, 15.6% were by ambulance. Ambulance visits were more likely than non-ambulance visits to be made by older patients (68 years old [95% CI: 67.7-68.6] vs. 47 [46.8-47.2]), by female patients (59% female vs. 55%) [odds ratio (OR): 1.18 (95% CI: 1.13-1.23)], to be triaged more urgently (2% non-urgent vs. 44%) [OR: 0.021 (0.0183-0.025)], and to occur during off-hours (47% between 5pm and 9am vs. 43%) [OR: 1.19 (1.14-1.25)]. Ambulance visits were more likely than non-ambulance visits to result in consults (56% with consults vs. 20%) [OR: 5.15 (4.92-5.40)] and imaging tests (20% with tests vs. 12%) [OR: 1.90 (1.79-2.01)], to have a longer length of stay [13.2 hours (13.0-13.5) vs. 5.9 (5.9-6.0)], and to result in hospital admission (40% admitted vs. 10%) [OR: 6.01 (5.71-6.32)]. In multivariate models that accounted for the effects of age, sex, home origin of visit, triage level and ED stretcher use, ambulance transportation had independent associations with greater use of consults, longer length of stay, and more hospital admissions, but was not independently associated with use of imaging tests. CONCLUSIONS: This preliminary study indicates that patients transported by ambulance generally use more resources in the ED. Key words: utilization
053 Documentation of Substance Abuse in a Canadian Tertiary Care Emergency Department Patient Population.
Brubacher JR, Mabie A, Ngo M, Buchanan J, Abu-Laban RB, Shenton T, Dickson B, Purssell R. Vancouver General Hospital and the University of British Columbia, Vancouver, BC.
INTRODUCTION: For many patients with substance related issues, the ED is the sole provider of medical care and an ED visit may present an opportunity for intervention. This needs assessment sought to determine the prevalence and characteristics of substance related medical problems in ED patients, as defined by documentation in the medical record. METHODS: Trained evaluators using explicit criteria reviewed sequential ED charts from 25/06/02 to 6/08/02 at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance related issues. RESULTS: Of 6040 visits, 6026 charts (99.8%) representing 5229 patients were captured for review. 673 visits (11.2%: 95%CI 10.4%-12.0%) by 599 patients had documentation of problematic substance use and 521 visits (8.6%: 95%CI 7.9%-9.4%) by 469 patients were due to substance related medical problems. The mean age of patients with substance related visits was 38.4 years (standard deviation 37.4, median 36) compared with 48.6 years (standard deviation 20.5, median 45) for other visits (p<0.0001). The mean/SD/median duration of visits due to substance related problems was 323/324/232 minutes compared with 252/405/164 minutes for other visits (p<0.0008). During this 6 week period there was no significant difference in the proportion of revisits between patients with and without substance related medical issues (12.4% and 13.5% respectively, p=0.43). CONCLUSIONS: Substance abuse contributes significantly to tertiary ED visits and duration of ED stay. Our methodology likely underestimates the scope of the problem and with universal screening the prevalence would probably be found to be even higher. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance related issues. Further research and efforts of this nature are being pursued at our institution. Key words: substance misuse
054 Wide Complex Tachcardia and Severe Hypotension Following Low Dose Propafenone: Response to Bicarbonate.
Brubacher JR. Vancouver General Hospital, University of British Columbia, Vancouver, BC
INTRODUCTION: Propafenone is an orally available antidysrhythmic frequently used in the management of atrial fibrillation (Afib). We report a case of significant toxicity following the ingestion of only 450 mg of propafenone. Case Report: A healthy 73-year-old female presented with acute Afib. Her pulse was 120/min and BP was 118/80 mm Hg. Rate was controlled with diltiazem and propranolol. She received 1200 mg of procainamide IV but remained in Afib. She was then given 300 mg of propafenone PO and discharged with a prescription for propafenone and propranolol. On discharge, her pulse was 90/min and BP 125/82 mmHg. Six hours later she took 150 mg of propafenone as prescribed. Within 1 hour she became dyspneic and vomited. On arrival in hospital she was unconscious and in wide complex tachycardia with femoral pulses but no obtainable blood pressure. With defibrillation and lidocaine she converted to sinus rhythm with a QRS width of 158 msec. For the next 20 min she remained in sinus rhythm but had no obtainable BP despite receiving 3.6 mg of epinephrine and a dopamine infusion at 25 mg/kg/min. After 100 mEq of hypertonic sodium bicarbonate (HCO3-) her BP was 72/40 mmHg and QRS width narrowed to 136 msec, after another 100 mEq of HCO3- her BP was 94/40 mmHg and the QRS was 104 msec. A pill count revealed that one tablet of propafenone and no propranolol tablets had been taken. Troponin and CKMB remained normal, as were potassium, magnesium, and calcium. Procainamide and N - acetyl procainamide were not detected. The patient had an uneventful recovery. CONCLUSION: We report a case of severe cardiac toxicity with response to bicarbonate following 450 mg of propafenone. Key words: propafenone, toxicity
055 Are Injection Drug Users at Higher Risk of Adverse Outcomes During Procedural Sedation?
Manoocha A, Innes G, Grafstein E. St. Paul's Hospital; The University of British Columbia; Vancouver, BC
INTRODUCTION: Because of tolerance to opioid and sedative medications, injection drug users (IDU) require different drugs and doses for procedural sedation, which may put them at higher risk of adverse events (AE). Our objective was to compare drugs used, dosing variability and AE rates in IDU vs. non-IDU patients undergoing procedural sedation. METHODS: This review of prospectively-gathered PS data was performed at St. Paul's Hospital, an inner city teaching centre that cares for most of Vancouver's IDU population. The primary outcome was the combined rate of hypoxia (O2 saturation <90%), hypotension (systolic BP <90 mmHg) and bradycardia (pulse <50) in the 2 groups. RESULTS: Between Jan.1997 and Sept. 2002, 843 patients were studied, including 516 non-IDU, 247 IDU, and 80 unknown status. IDU patients were more likely to be sedated for abscess drainage and non-IDUs for orthopedic reductions. The primary sedation regimen in non-IDUs vs. IDUs, respectively, was fentanyl/midazolam in 95% vs. 73%, ketamine in 2.5% vs 26%, and propofol in 2.5% vs. 1%. In non-IDUs vs. IDUs respectively, the mean midazolam dose was 3.4 vs. 4.7 mg; the mean fentanyl dose was 201 vs. 313 mg; the mean ketamine dose was 75 vs. 87 mg; and the mean propofol dose was 120 vs. 140 mg. No mortality or significant morbidity occurred in this series, and the primary composite endpoint (AE rate) was similar between groups.
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CONCLUSION: IDUs require higher medication doses during procedural sedation, but are no more likely to suffer significant adverse events. Key words: procedural sedation, injection drug user
056 Length of Stay in the Emergency Department for Women with First Trimester Problems
Carpenter JL, Howes DW, Caudle JM, Pickett W. Department of Emergency Medicine, Queen's University, Kingston, Ontario
INTRODUCTION: Abdominal pain and bleeding in the first trimester of pregnancy are very common presenting complaints to the emergency department (ED). The first priority in evaluating these patients is to rule out ectopic pregnancy (EP). It has become clear that history and physical exam are not effective and therefore ultrasound scan (USS) is recommended. This observational study was performed in an ED without a dedicated ultrasound machine to document (1) the disposition patterns and (2) the length of stay (LOS) in the emergency department, for patients with first trimester problems requiring USS. METHODS: This retrospective chart review was performed in a tertiary care academic centre using a standardized data collection form. Computer searches of two separate databases identified women presenting with (a) a positive b-HCG or (b) a discharge diagnosis of a first trimester complication. Exclusion criteria included: previous ultrasound confirming intrauterine pregnancy (IUP), not first trimester, missing data and patients seen directly by gynecology. RESULTS: 158 charts were identified. 66 were excluded. 92 were therefore included in the analysis. Disposition: 31 (33.7%) patients had their ultrasound performed during the presenting visit, while 34 (37%) had a scan planned for another day. 24 (26.1%) had no mention of planned USS.LOS: Those who had their USS during the primary visit had an average LOS of 387 minutes while those sent home had LOSs of 142 minutes at the primary visit and 116 minutes when returning for results. Interrater agreement was very high. CONCLUSIONS: This review suggests that at our centre, almost one third of patients are being sent home without mention of follow-up USS. Furthermore, it demonstrates that LOS for women awaiting USS during their index visit is substantial. This suggests that if emergency physician-performed ultrasound were able to demonstrate an IUP as part of the physical exam, 63% of the ED time might be avoided in this common ED presentation. Key words: ectopic pregnancy, ultrasound
057 An Evaluation of the Effectiveness of Intravenous Ethanol in the Treatment of Ethylene Glycol and Methanol Poisonings
Lister D, Tierney M, Dickinson G. Department of Pharmacy, The Ottawa Hospital, Ottawa ON
INTRODUCTION: Management of methanol and ethylene glycol poisoning includes inhibition of alcohol dehydrogenase with either intravenous ethanol or fomepizole. There is a lack of contemporary data on intravenous ethanol to allow comparison of outcomes with fomepizole. OBJECTIVE: To evaluate the effectiveness of intravenous ethanol for the treatment of ethylene glycol and methanol poisonings. DESIGN AND SETTING: Retrospective chart review of patients with ethylene glycol or methanol poisoning treated with at least 6 hours of intravenous ethanol in a tertiary care hospital. PATIENTS: Patients had initial serum methanol or ethylene glycol concentrations of at least 3.1 mmol/L or 6.2 mmol/L respectively or laboratory findings consistent with poisoning. MAIN OUTCOMES: In-hospital mortality, incidence of renal dysfunction secondary to ethylene glycol, incidence of visual disturbances secondary to methanol, incidence of hypoglycemia secondary to intravenous ethanol, success in achieving target ethanol concentration of > 22 mmol/L. RESULTS: Twenty-seven patients met eligibility criteria and 25 of these patients survived. Twenty-six of 27 patients received concurrent hemodialysis. Renal dysfunction occurred in two of 11 patients with ethylene glycol poisoning, with only one requiring long-term dialysis upon hospital discharge. No incidence of visual disturbance could be attributed to methanol in patients admitted for methanol poisoning. There were no episodes of hypoglycemia in any patient during ethanol infusions. Forty-four percent of all ethanol levels were < 22 mmol/L during ethanol treatment. CONCLUSION: Intravenous ethanol, combined with hemodialysis, is effective and safe therapy for the management of patients with methanol and ethylene glycol poisoning. Clinical outcomes appear to be similar to those achieved with fomepizole despite inconsistency in achieving recommended ethanol serum levels. Key words: methanol, ethylene glycol, ethanol
058 Trends in the Use of Diagnostic Imaging for Acute Appendicitis
Jimenez T, Theakston KD. Division of Emergency Medicine, University of Western Ontario, London, ON
INTRODUCTION: The accurate diagnosis of acute appendicitis remains a clinical challenge for emergency physicians and surgeons. Numerous published studies have reported the high diagnostic accuracy of ultrasound (US) and computed tomography (CT) for the diagnosis ofacute appendicitis. The routine use of CT for suspected appendicitis has been recommended to both decrease the negative laparotomy rate and reduce total cost. We sought to examinethe recent local experience with diagnostic imaging for appendicitis compared withhistorical controls. METHODS: For 1995 and 2001, adult cases of appendicitis managed at LHSC were identified from the surgical pathology database. 221 cases were identified; 206 were available for review. A retrospective chart review using a structured data extraction tool wasconducted. The use of imaging modalities and clinically important outcomes such asnegative laparotomy rate, perforation rate, time to surgery and hospital length of stay(LOS) were analyzed. RESULTS: The baseline patient demographics were the same between the two study periods. In 2001 as compared to 1995, the use of plain radiographs dropped (18.6% vs. 34.9%, p<0.01), the use of ultrasound increased (45.7% vs. 31.8%, p<0.05), and the use of CT significantly increased (10% vs. 0.01%, p<0.01). There were no significant differences in the negative laparotomy rate (14.7% vs. 11.9%, p=0.29), perforation rate (18.6% vs. 19%, p=0.5), or time to surgery (10.3 hrs vs. 9.75 hrs., p=0.32). The LOS was significantlyreduced (77.5 hrs. vs. 102.7 hrs., p=0.005). CONCLUSIONS: This retrospective study at a single institution demonstrated increase use of US and CT for suspected appendicitis from 1995 to 2001. Despite the increased use of advanced imaging the negative laparotomy rate and perforation rate did not change. Further research is needed to identify the appropriate and cost-effective diagnostic role of US and CT for patients with suspected acute appendicitis. Key words: computed tomography, appendicitis
TOPIC: EMS
059 How are Pediatric Patients Managed by EMS and what are their Outcomes?
Richard J, Stiell IG, Osmond M, Nesbitt L, Beaudoin T, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: There has been little research describing the effectiveness of prehospital care and the outcomes of children managed by EMS. We evaluated the prehospital interventions and outcomes of pediatric cases within the Ontario Prehospital Advanced Life Support (OPALS) Study, which is a large multicenter initiative to evaluate the impact of EMS programs on 40,000 critically ill and injured patients. METHODS: We conducted a prospective cohort study in a single city with a 2-tiered BLS-D/ALS EMS system. Enrolled were all children <16 years managed by EMS over a 6-month period. Data were collected from ambulance reports, centralized dispatch data, ED records, and in-hospital records. We performed descriptive statistics with 95% CIs. RESULTS: The 1,368 study patients had these characteristics: Mean Age 8.0 (range 0-15); Male 57.5%; EMS Case Severity: life-threatening 2.4%, severe 14.3%, moderate 39.5%, minor 34.6%; EMS Return Priority urgent 8.1%; Primary Problem: minor trauma 44.7%, seizure 11.0%, respiratory distress 8.5%, overdose 4.4%, allergic 2.7%, psychiatric 2.7%, major trauma 1.0%, cardiac arrest 0.1%; Pick-Up Location: residence 52.0%, street 16.9%, public place 15.6%, school 9.6%. 28.0% of patients were not transported (parental transport 24%, monitoring at home 17%). BLS interventions were oxygen 19.6%, glucose measurement 16.8%, immobilization 12.0%, salbutamol 3.4%, SC epinephrine 0.7%. ALS interventions were cardiac monitor 21.0%, IV insertion 8.5% (mean volume 98.1 ml), IV diazepam 0.9%, IV morphine, 0.8%, intubation 0.1%. Disposition from ED was home 94.5%, ward 3.5%, ICU 0.9%, death 0.5%. CONCLUSIONS: This is the most comprehensive review of EMS pediatric management and reveals that most children are not severely ill, most do not receive ALS interventions, there is a high rate of non-transport, and the vast majority are discharged home from the ED. Future research should evaluate the effectiveness of ALS interventions and the efficiency of EMS care for children. Key words: emergency medical services, pediatrics
060 Use and Yield of Investigations for Alert Patients with Possible Subarachnoid Hemorrhage.
Perry JJ, Stiell IG, Wells GA, Mortensen M, Lesiuk H, Wallace G, Sivilotti M, Kapur A. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: 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 computed tomography (CT) and lumbar puncture (LP) in ED patients with possible SAH. METHODS: This prospective cohort study was conducted at 3 university tertiary care EDs. Adult patients with normal neurological examination, GCS score of 15, and a complaint of a non-traumatic acute headache were enrolled over 2 years. Exclusion criteria included: history of recurrent headache of similar quality/intensity, referral with confirmed SAH, papilledema, previous SAH or known brain neoplasm. The outcome criterion was SAH on CT, xanthochromia in the CSF or the presence of red blood cells in the final tube of CSF with positive cerebral angiography. Analysis included descriptive statistics including 95% confidence intervals and ANOVA for length of stay. Positive cases were excluded in the length of stay calculations, so that the sickest patients did not bias testing. RESULTS: The 589 patients had the following characteristics: mean age 42.9 years, 60.6% female, 78.2% worst headache of life, 31.0% vomiting, 4.8% transient loss of consciousness, 80.5% CT, 44.7% LP (85.0% with either CT or LP) and 6.8% SAH. Only 8.4% CT and 0.8% LPs were positive for SAH. There were no missed cases with CT. All positive LPs had positive CT scans. 176 (42.1%) patients underwent a normal CT without subsequent LP. The mean length-of-stay for patients without SAH was as follows: 3.6 hours (2.9-4.2) without testing, 6.1 hours (5.8-6.4) with CT, 7.1 hours (6.7-7.5) with LP; (P<0.001). CONCLUSIONS: This study demonstrated that headache patients who underwent testing spent much more time in the ED. CT scans were often not followed by LP, which when performed, provided no additional information. CT and LP had very low yield suggesting the need for a clinical decision rule for the investigation of acute headache to rule out SAH. Key words: subarachnoid hemorrhage, clinical prediction rule
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