2003 CAEP/ACMU Scientific Abstracts: 61-80
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
061 Quality of Life Outcomes for Respiratory Distress Patients Treated by EMS.
Nichol G, Stiell IG, Blackburn J, Luciano T, Nesbitt L, Wells GA, Huszti E, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Little is known about the outcomes of respiratory distress patients treated by EMS. We followed a group of these patients to measure their health-related quality of life (HQRL). METHODS: The Ontario Prehospital Advanced Life Support (OPALS) Study is a large multicenter initiative to evaluate the impact and cost-effectiveness of EMS programs on 40,000 critically ill and injured patients. As part of the ongoing OPALS Study economic evaluation, we conducted a prospective cohort study and included consecutive adult respiratory distress patients treated in the BLS-D/ALS EMS system of one OPALS Study city over a 5-month period. Patients were interviewed every 3 months for up to one year after discharge by a study nurse using the Health Utilities Index Mark 3 (HUI3) HQRL tool. HUI3 consists of 8 attributes (vision, hearing, speech, mobility, dexterity, emotion, cognition, and pain), and is scored from 0 (equal to dead) to 1 (perfect health). Results were evaluated by using descriptive and regression analyses. Secondary analyses will compare these scores to those after cardiac arrest and correlated HUI3 scores with process measures. RESULTS: Of 169 eligible patients, 152 were interviewed at least once and had these characteristics: mean age 67.7 (SD 18.3), female 54.4%, EMS status severe or life threatening 42.6%, length of stay in days median 6.0 (IQR 2.5-10.5) and survival to discharge 85.7%. During the follow up period, 70 patients died (41% of eligible). HUI3 scores at 3, 6, 9 and 12 months post discharge were median (IQR): 0.47 (0.17-0.78); 0.51 (0.21-0.80); 0.41 (0.11-0.70); and 0.54 (0.26-0.81), P value for trend >0.05. CONCLUSIONS: This is the first longitudinal study of HRQL of patients with respiratory distress transported by EMS. HRQL is stable in this population but the scores are much lower than those for cardiac arrest patients (median 0.80). These data are critical inputs to analyses of whether ALS EMS care for respiratory distress patients is cost-effectiveness. Key words: respiratory distress, emergency medical services
062 A Novel Surveillance System to Measure the Burden and Acuity of Illness in the Community.
Deedo RJ, Travers AH, Panylyk A. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: The Public Access Defibrillation Trial (PAD) trial is an international clinical trial of a community approach to victims of OOHCA. The primary objective of this study is to determine if a PAD Surveillance Net (PSN) can be established to reflect the complete burden of illness (cardiac and noncardiac) for local PAD units. The secondary objective is to evaluate the sensitivity (undertriage) and specificity (overtriage) of the PAD volunteer/911 Dispatcher Interface (PVDI) for determining the acuity of the emergency request. METHODS: Demographic data from the 51 community PAD units was collected and a 900 volunteer responder pool was maintained. The Emergency Medical Services (EMS) Records Management System (RMS) was modified to collect the types of calls to PAD sites: [I] 'Events' (any EMS call), [II] 'Episodes' (any unconsciousness or collapse; any CPR or AED attempted; and/or any death), and [III] OOHCA. Hospital outcome data was collected for both Episodes and OOHCA. RESULTS: From January 2002 to January 2003, a novel 'real-time' PSN platform has recorded over 1446 Events, with 240 subsequent Episodes, and 11 OOHCA. The types of dispatch calls and types of illnesses varied by individual site (2 casinos, 2 office towers, 4 recreation centres, 6 hotels, 6 malls, 6 senior complexes, 7 entertainment complexes, 9 grocery stores, and 11 pools). The sensitivity and specificity of the PVDI for Events, Episodes and OOHCA was determined to be 85.0% and 42.4% respectively. This trial is ongoing and will close in September 2003. CONCLUSION: For the first time a novel PSN has been created to accurately reflect the burden of illness in selected PAD sites. Analysis of the EMS data coupled with the site demographic data and outcome data will serve to facilitate the PAD site's risk management and emergency response specific to the burden of illness that they encounter. Key words: public access defibrillation
063 A Location-Specific Utility Measure to Guide the Distribution of Public Access Defibrillation (PAD) Programs within the Community.
De Maio VJ, Stiell IG, Vaillancourt C, Wells GA, Spaite DW, Nesbitt L, Cousineau D, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: There is little published data regarding the strategic placement of PAD programs. We identified a location-specific utility measure to guide the implementation of PAD. METHODS: This prospective cohort included all adult, out-of-hospital cardiac arrests occurring before EMS arrival in the multicenter, Ontario Prehospital Advanced Life Support (OPALS) Study. EMS response included firefighter defibrillation, BLS-D and ALS. The provincial property assessment roll identified the specific property type for each cardiac arrest address and the total number of sites, per location type, within the study boundary. Analyses included frequencies, incidence rates, and utility scores: i.e., the number of PAD programs needed to treat one witnessed VF/VT cardiac arrest (NPNT) during a 5-year period. We estimated the effect of PAD in those sites with the highest utility using a prior model that predicts 18% survival to hospital discharge for cases with a defibrillation response interval of ? 3 minutes. RESULTS: From 1995-2000, there were 7,707 cardiac arrests. Higher utility locations included (cardiac arrests, sites, incidence rate, NPNT): casinos (28, 2, 14, 0.1); non-acute hospitals (42, 42, 1, 5); shopping malls (77, 394, 0.2, 9); nursing/retirement homes (457, 460, 1, 10); hotels (65, 604, 0.1, 19); penal institutions (6, 21, 0.3, 21); golf courses (9, 156, 0.06, 26); recreation/community halls (165, 3206, 0.05, 27); air/rail/bus terminals (4, 83, 0.05, 42); restaurants/bars (48, 1410, 0.03, 47). The placement of 1502 PAD programs to treat the 669 cardiac arrests that occurred in the top 5 locations would have yielded an estimated 87 additional survivors during the study period. CONCLUSIONS: Strategic placement of PAD programs within those locations with only the highest utility may lead to clinically important survival benefits. Location-specific utility measures should be used to guide the initial placement of PAD programs and the redistribution of public AEDs already within the community. Key words: public access defibrillation, cardiac arrest
064 The Direction of Electronic Patient Care Reporting in Alberta Emergency Medical Systems.
Singleton B, Abrams T, Travers AH. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Technology is playing a larger role in collection, manipulation, and storage of medical data. Software companies are currently offering a variety of products to assist in the prehospital patient care report (PCR). We surveyed Alberta prehospital services to determine the direction they are moving in implementing this technology. METHODS: Cross-sectional survey of Provincial Emergency Medical Services (EMS) in September 2002 by e-mail. The main outcomes were the plans to use electronic patient care report (e-PCR) software. RESULTS: Of the 12 services contacted 9 (75%) responded to the first e-mail survey and 3 (25%) responded to a reminder e-mail for a total of 100% response. All services stated they had done some type of investigation into e-PCR software and 5 (42%) state they had participated in some form of trial using e-PCR software. 4 (33%) indicate they have bought or developed an e-PCR solution, of these only 1 (8%) is fully implemented. 11 (92%) indicate they have or are planning to implement an e-PCR solution within the next 3 years. All services reported currently using a variety of technologies that may impact or be impacted by the use of e-PCR technology (Table I). 8 (67%) reported having money budgeted for e-PCR software. The top 3 critical success factors identified by respondents were user friendliness, scalability/ customization, and ability to interface with existing software.
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CONCLUSION: Most prehospital services have identified e-PCR as a technology that they will implement within the next 3 years. There is a wide variety of steps being taken by prehospital services to move toward the implementation of e-PCRs. Key words: emergency medical services, information systems
065 Alberta PCR: Alberta Prehospital Consortium on Research.
Travers AH, Panylyk A, Sookram A, Sosnowski T. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Research in the prehospital environment has been in evolution and continues to grow with large scale clinical trials. Many of these studies occur in isolation and occur with non-emergency groups who want to conduct research in the prehospital domain. Objective: Phase I: To inventory and establish a communication network amongst the provincial EMS systems. Phase II: To determine the need and feasibility of a prehospital research platform and consortium amongst emergency medical services within Alberta. METHODS: Phase I: An inventory of EMS services was completed using Health databases for the 17 Albertan Health Districts. Phase II: A cross-sectional survey was sent to 18 of the larger EMS agencies. RESULTS: Phase I: Amongst 17 Albertan Health Districts and a population of 2,302,389, ninety-five hospitals are currently serviced by 47 Advanced Life Support services (240 ambulances) and 59 Basic Life Support services (156 ambulances). Phase II: 93% (13/14) stated that research is feasible and 93% (13/14) that research important in the prehospital setting. The top three barriers to EMS research were listed as funding (13/14), EMS operational issues (6/14) and physician barriers (5/14). 86% (12/14) felt that prehospital research would provide novel results, and 100% (14/14) ranked the body of evidence for prehospital care as "Fair or poor evidence to support". 64% (9/14) stated that paramedics are able to obtain informed consent in the prehospital setting. 50% (7/14) felt that a "waiver of informed consent" (WOIC) is appropriate in the prehospital setting, but only 36% (5/14) had an infrastructure in place to deal with WOIC. There was broad interest in the types of studies and patients for potential prehospital research. CONCLUSION: An Alberta PCR is feasible with substantive interest in the implementation and maintenance of such an infrastructure. Key words: emergency medical services, research
066 EAR: Edmonton Airway Registry.
Travers AH, Panylyk P, McLelland K, Sookram S. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Despite previous research, the determinants of airway intubation success remain elusive and are affected by a number of interactions and confounders. A statistical construct termed a 'causal pathway' was created in this study to allow multivariate analyses of predictor variables on airway success. This causal pathway is as follows:
Medic --> Environment --> Patient --> Airway --> Medications ===> Airway Success
We propose that the individual predictors in each domain incrementally affect the next domain, ultimately affecting the outcome measure of airway intubation success. The objective of this study is to evaluate the determinants of intubation success or failure using a novel causal pathway model. METHODS: Prospective observational cohort for invasive airway management in an Emergency Medical Service (EMS) using an intubation registry completed concurrent to patient prehospital care. There are no 'Rapid Sequence Protocols' utilized in this EMS service staffed by 300 EMS personnel and 24 ambulances. RESULTS: The EAR encompasses comprehensive evaluation of invasive airway management between November 2001 and December 2002 and is ongoing. In total there were 589 cases requiring invasive airway management with 83% (488/589) being intubated with a median number of attempts of 1 (Range 1 to 4). Of the remaining 101 cases: 50 had insertion of a combitube; 17 failed combitube and required simple Bag-Valve-Mask (BVM) maneuvers till Emergency Department (ED) arrival; and 34 had BVM until ED arrival. No surgical airways performed in this cohort. Multivariate analysis with the causal pathway model is currently under data interrogation. CONCLUSION: Our endotracheal intubation (ETI) success rate of 83%, and a combitube success rate of 75% for those failing ETI. Further multivariate modeling using a causal pathway paradigm will serve to determine the key predictors for the airway success. Key words: airway management
067 Use of a Combitube in the Prehospital setting.
McLelland K, Travers A, Sookram S. Edmonton Emergency Response Department, City of Edmonton, Division of Emergency Medicine, University of Alberta, Edmonton, AB.
BACKGROUND: Although endotracheal intubation is the definitive technique for airway management, many alternative airway devices have been developed for use in difficult airway situations and in Emergency Medical Services (EMS) systems whose policies restrict endotracheal intubation. The Combitube is an esophageal tracheal double lumen tube designed for emergency intubation and has recently been introduced to Edmonton_s EMS system. This study proposes to evaluate the insertion success and complication rate after the implementation of this new airway device. METHODS: The Combitube was placed on all ambulances in November 2001 after didactic and hands-on training was provided to EMT-As and EMT-Ps. The Combitube was to be inserted when three attempts at intubation have been unsuccessful. EMS crews recorded study results on a Patient Care Report (PCR) form and an intubation log form. A consecutive sampling of all intubations and combitube insertions was completed for success rates and frequency of complications on all patients requiring intubation in the field. A chart review of the inpatient records was completed to look for complications from Combitube use. RESULTS: Between Nov.10, 2001 and Jan.20, 2002 the Combitube was attempted as an airway device in 19 patients with a success rate of 89% (17/19). In 53% (10/19) cases the EMS crews described difficulty in inserting the combitube, and 37% (7/19) required multiple attempts at insertion. In 11% (2/19) of cases there were clinical and radiographic diagnoses of pneumomediastinum. 48 additional cases are currently under evaluation under the Edmonton Airway Registry. CONCLUSIONS: In the first year after the education and implementation of a new airway device, for patients who failed intubation a combitube insertion success rate of 89% was seen with a 11% reported complication rate. Potential interactions and confounders by patient and prehospital variables is currently under interrogation under a cumulative series of 67 cases in total. Key words: airway management, emergency medical services
TOPIC: RESPIRATORY/PEDIATRICS
068 Changing Patterns of Pneumonia Presentations to Emergency Departments in Alberta.
Barton AC, Marrie TJ, Yiannakoulias N, Holroyd BR, Bullard M, Spooner CH, Rosychuk R, Svenson L, Schopflocher D, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: This study examines emergency department (ED) presentations of pneumonia with regards to epidemiology, disposition and trends over time. 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 (2000/01) with a diagnostic code of pneumonia, both bacterial (481, 482.x, 483.x, 484.x, 485, 486) and viral (480, 487). 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, crude and adjusted rates and trends over time are reported. RESULTS: Overall, 1.7 million ED visits were recorded in the fiscal year of 2000/2001 and of these, 26,975 visits were made by 15,707 people for pneumonia (crude ED visit rate: 15.9/1000 visits). Males and female proportions and rates were similar in all age groups, except over the age of 75 years where men experienced higher rates. There was a bimodal distribution in age, with peaks at 1-4 years and >75 years. There was significant seasonal variation, with 33% of pneumonia visits occurring during the months of December (16.6%) and January (16.4%). Most visits resulted in discharge home (74.4%), but 25% (6788) of visits resulted in admission to hospital, compared to a 9% admission rate for all ED visits. Current age and gender-adjusted rates (9.84/1000) are lower than 1998/99 (11.1/1000) and admissions have decreased (36% vs. 25%) over the same period. CONCLUSIONS: Pneumonia is a common presentation to the ED, however, changes in ED epidemiology are being observed. Moreover, decreased admissions suggest changes in diagnostic and treatment approaches in this setting. Reasons for these changing patterns warrant further investigation. Key words: pneumonia, pediatrics
069 Anti-inflammatory Treatment of Asthma in Canadian Emergency Departments.
Rowe BH, Colman I, Diner B, Stiell IG, Grafstein E. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Current patterns of emergency department (ED) treatment for airway inflammation are unknown; this study examines ED management of asthma using anti-inflammatories. METHODS: Multicenter, web-based survey was completed by ED physicians affiliated with a national research network between 07/02-10/02; contact was made by the local network representative. Data collection focused on MD respondent approach to three cases of acute asthma using inhaled (ICS) and systemic corticosteroids (SCS). E-mail contact was made by each site leader and two reminders were sent to staff to access a secure website. RESULTS: A total of 242 (52%) physicians from 19 community and academic EDs in 6 provinces completed the survey. Respondents were more commonly male (75%), less commonly fellowship trained (36%), and often had < 10 years of clinical experience (58%). In severe acute asthma, most MDs would use SCS (95%) via the oral route (66%), and less would use ICS (32%); few would use IV MgSO4 (13%). In discharged patients, MD less commonly would prescribe SCS for episodic asthma than chronic asthma (76% vs 88%; p = 0.0004). Almost all would prescribe corticosteroids as a fixed dose (74%) of prednisone (96%; 50mg/day) for 7 days or less (93%). Physicians reported they would commonly add ICS after discharge for acute asthma (87%) if patients were not on ICS at the time of their exacerbation. Physicians were unclear if they should maintain (59%), increase (37%), or stop (4%) agents in patients already on ICS. CONCLUSIONS: Overall, there is practice variation among ED physicians in Canada with respect to the in-ED and post-ED treatment of acute asthma, which appears more pronounced with ICS than with SCS. Further primary research is required to determine the most effective treatment to prevent admission and reduce relapses using ICS agents and also the most effective method to disseminate results to busy clinicians. Key words: asthma, corticosteroids
070 Multicenter Study of Emergency Department Visits for Pneumonia.
Rowe BH, Hohrmann JL, Emond JA, Colman I, Camargo CA Jr, for the CAEP/MARC-16 Investigators. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Current patterns of emergency department (ED) diagnosis and treatment for pneumonia are unknown. The objectives of this study were to define the epidemiology of ED visits for pneumonia, including pneumonia type, antibiotic selection, and ED disposition. METHODS: Multicenter, retrospective chart review over a consecutive 4-week period between 12/01-04/02. Using standardized protocols, 23 EDs abstracted data for patients, age 18+, with a physician-diagnosis of pneumonia. Data collection focused on patient characteristics, diagnostic testing, and treatment. Pneumonia severity index (PSI) was calculated for patients where data were complete. Proportions are presented with 95% confidence intervals (CI). RESULTS: A total of 1,268 charts were reviewed. Patients had a mean age of 62 years; 51% were female (95% CI: 49-54%); and 57% were white, 20% black, 6% Hispanic, and 17% other race/ethnicity. Community acquired pneumonia (75%) was more common than institutional (11%) and aspiration (2%) pneumonia; 12% of pneumonia cases were unclassified. Admissions were common (61%), even for low PSI scores (Table). Overall, median length-of-stay was 5.3 hours in the ED and 10 days for those hospitalized. Three in four (74%) patients received antibiotics during their ED stay. Although antibiotic selection varied by PSI group, many ED patients were given a quinolone.
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CONCLUSIONS: ED patients with pneumonia are a heterogeneous population. Antibiotic selection and ED disposition vary by PSI score, and appear suboptimal. Key words: pneumonia
071 Variation in Management of Acute Allergic Reactions.
Woo MY, Stiell IG. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: There is little high-quality evidence to guide the emergency department (ED) management of acute allergic reactions. This study determined the variation in therapies administered to patients with acute allergic reactions. METHODS: A formal health records review was performed for the period January 1, 1997 to December 31, 2000 in a university tertiary referral center. Inclusion criteria included patients of any age who presented to the ED with a diagnosis of an allergic reaction of less than 4 hours duration. A single reviewer identified cases using discharge diagnoses of allergic reaction, anaphylaxis, and angioedema and abstracted data into a standardized electronic database. Patients were then categorized according to a modified Ring classification: Grade I: dermatological manifestations only; Grade II: dermatological and/or gastrointestinal, and respiratory involvement; Grade III: any of Group I and/or II and hypotensive; Descriptive and chi-square statistics were used. RESULTS: 139 patients met the inclusion criteria with a mean age of 40 (Range 4-100). 35% were male. 11% were categorized to Group I, 83% to group II and, 6% to group III. Patients were kept in hospital for less than 4 hours 83%, 60% and 66% of the time for Grade I, II, and III patients, respectively. Epinephrine was given to 40%, 59%, and 88% of Grade I, II, and III patients, respectively (p=0.09). H1-blockers were given to 53%, 95%, and 100% of Grade I, II, and III patients, respectively (p<0.01). Salbutamol was given to 0%, 12%, 38% of Grade I, II, and III patients (p<0.05). Fluid bolus was given to 0%, 5%, 50% of Grade I, II, and III patients, respectively (p<0.01). Steroids were given to 20%, 42%, and 38% of Grade I, II, and III patients. CONCLUSIONS: Although epinephrine is recommended as a first-line treatment it was used much less than H1-Blockers in Grade II and III patients. Further research needs to be conducted to determine which patients would benefit from epinephrine and other therapies. Key words: allergic reaction
072 Peritonsillar Abscess in the Paediatric Population.
Millar K, Tingley R, Drummond D, Johnson DW, Kellner JD. Division of Emergency Medicine, Alberta Children's Hospital, Calgary, AB.
INTRODUCTION: Peritonsillar abscess (PTA) in the paediatric population has not been well described. Outpatient therapy and steroid use have become increasingly popular despite lack of evidence to support these practices. Objectives: 1) To determine the incidence of PTA in children 2) To conduct an analysis to examine factors associated with i) corticosteroid use and ii) outpatient management of PTA. METHODS: We conducted a retrospective chart review of patients <18 years who resided in the Calgary Health Region (CHR) who were diagnosed with PTA in the CHR between Mar/94-Dec/02. RESULTS: We identified 220 children who presented with 240 episodes of PTA. The incidence for PTA among children in the CHR was 13 per 100,000 person-years. The incidence was highest among adolescents (40 per 100,000 person-years). The incidence was stable over time. Medical management was received by 62% and surgical intervention by 38% (8% needle aspiration, 28% incision and drainage, 2% quincy tonsillectomy). IV antibiotics were given to 85% at presentation and 68% were discharged home at the time of diagnosis. Among those initially discharged, 7% failed outpatient therapy. All of these patients had received IV antibiotics, 6 developed progressive uvular deviation and 3 developed dehydration. Factors associated with initial inpatient management included uvular deviation (OR 2.74), decreased oral intake (OR 2.51), dehydration (OR 1.86), white count > 15 x 10 9 /L (OR 5.54), and IV antibiotics (OR 3.32). Steroid therapy was received by 36%. Factors associated with the use of steroids included IV antibiotics (OR 2.54) and dehydration (OR 1.46). CONCLUSIONS: PTA is primarily a problem of adolescence. Outpatient management was successful for two thirds of patients. Among those admitted, there were several important clinical features including uvular deviation and decreased oral intake. Corticosteroid use was common although no clear patterns of usage emerged. Further research on the role of steroids is necessary. Key words: peritonsillar abscess
073 Playground Safety: Attitudes and Practices of Parents and Guardians.
Bruder EA, Ouellette D, Joubert GI. Faculty of Medicine and Dentistry, University of Western Ontario, London, ON.
INTRODUCTION: In 1998 the Canadian Standards Association (CSA) implemented new construction standards for playgrounds. Despite the improvements children continue to sustain injury. How parental attitudes about playground risk contribute to childhood injury is unknown. We sought to assess parents / guardians (PG) supervision, attitudes, and knowledge regarding playground safety. METHODS: PG were observed by the research assistant (RA) in municipal playgrounds in London, Ontario, Canada for 5 minutes recording: the number of children supervised, the distances to each child, and PG behaviors. After disclosure and consent the RA surveyed the PG assessing knowledge of playground injuries and need for medical treatment, supervising practices, and attitudes regarding playground safety. Data was analyzed using SPSS 6.1. RESULTS: Fifty PG (92% female, 8% male) agreed to participate. 42% of the PG were observed interacting with other adults and 16% of PG ignored their children. PG were noted to interact (44%) or play (32%) with their children. On average 2.6 (+/- 0.9 SD) children were supervised per adult. The average distance to the nearest and farthest child was 8.2 +/- 12 m and 19.3 +/- 15 m, respectively. PG implicated climbers (67%), swings (15.6%) and slides (17.8%) as causes of injury. PG reported that children using the playground were supervised 96.6 +/- 7.5% of the time. PG felt that children should be supervised until 10.7 +/- 1.7 years of age. Using a 10 point agreement scale PG attitudes about playground safety were: "Playgrounds are safe" (7.0 +/- 2.1)> "Playgrounds could be made safer" (7.7 +/- 2.2), "Playgrounds are safer than in the past" (8.2 +/- 2.6), "Falls are the most common cause of injury" (8.8 +/- 1.5). CONCLUSIONS: PG feel that Canadian playgrounds are safe, and safer than in the past. PG thought they supervise their children most of the time but spend less than 50% of the time involved with them. Despite PG knowledge about the risk, they did not modify their behavior. Key words: injury prevention
074 Factors Influencing Parental Decision in Seeking Emergency Services for Non Urgent Visits.
Bergeron S, Leduc N, Champagne F, Ste-Marie G, Lafrance M. Division of Emergency Medicine, Hopital Sainte-Justine, University of Montreal, Montréal, Quebec.
INTRODUCTION: To determine which factors are involved in parental decision making when seeking care for unscheduled visits that are judged non urgent by triage in a paediatric emergency department (PED) and parental perception of the severity of their child's illness. METHODS: Pre-tested questionnaire during 3 consecutive weeks in March 2002 in a PED. If assigned a non urgent triage level (Paediatric CTAS), parents were asked to participate; a researcher then either completed a standardized questionnaire or helped the parents do it when consent was obtained. RESULTS: A total of 135 of the 160 (84%) eligible families participated; A total of 49 (36%) phoned a medical information line before and 17 of those were told to consult. The mean age of the patient was 5.6 years +/- 4.0. The mean number of any medical visits in the past 6 months was 4.5 +/- 6.2 SD. 70% had a primary care physicians (79% a paediatrician and 20% a family physician). However, only 16% mentioned that their primary care physician was the usual source for unscheduled visits; they consulted instead the PED (42%), community clinics (29%), or other hospital ED (4%). The most common reasons for PED visits were: PED are specialized in children care (41%), previous good PED experience (11%), and nearby location (6%). 61% said that if a paediatrician could see their child, they would use other hospital EDs or community clinics. Waiting time was not a determinant in their decision. 78% felt that their child's illness was urgent and 49% were afraid of complications if not seen right away. CONCLUSION: A large number of parents feel that their child's illness is serious even if classified as non urgent by the triage protocol. Neither the location nor the waiting time seemed to be important in their decision. The notion of a paediatrician seen as the child's specialist seems extremely important for parents. These issues must be addressed before a reduction in the number of non urgent visits in our overcrowded PED can be realized. Key words: utilization
075 Aerosolized Magnesium Sulfate in the Treatment of Acute Asthma.
Blitz M, Diner B, Hughes R, Knopp J, Beasely R, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
OBJECTIVE: Acute asthma is a common emergency department (ED) presentation which is initially treated with cortico steroids and inhaled agents (beta-agonist and anticholinergics). The objective of this review was to determine the effect(s) of inhaled magnesium sulfate (MgSO4) in acute asthma. METHODS: A comprehensive search for trials was conducted using the "Asthma and Wheez* RCT" register, a comprehensive search of EMBASE, MEDLINE, and CINAHL maintained by the Cochrane Airways Group. In addition, hand searching of the top 20 respiratory care journals was completed. Studies were included if patients with acute asthma were randomized to receive inhaled MgSO4 versus beta-agonists or control. Two reviewers performed selection, methodological quality, and data extraction independently. For dichotomous variables, relative risk (RR) with 95% confidence intervals (CI) were calculated; for continuous variables weighted (WMD) and standardized mean differences (SMD) with 95% CI were calculated. RESULTS: More than 200 articles were reviewed and from 31 potentially relevant citations, 5 papers met the inclusion criteria. These trials were produced in the past 10 years and represent moderate methodological quality. Overall, inhaled MgSO4 reduced admission to hospital (RR = 0.61; 95% CI: 0.38 to0.98). Changes in peak expiratory flow rate (PEFR) measures over the short term (< 2 hours) demonstrate a non-significant trend in favor of inhaled magnesium (%PEFR WMD: -7.77; 95% CI: -27.5 to 11.94; SMD = -0.13; 95% CI: -0.66 to 0.4) effect favoring inhaled magnesium. This agent is well tolerated, easy to administer and free of serious adverse events. CONCLUSIONS: Inhaled MgSO4 appears to be an efficacious agent for the treatment of acute asthma in the ED. Despite its minimal short-term benefit on airway caliber, compared to control use results in a fewer admissions. Given its ease of administration and low cost, further research into the use of this agent seems warranted. Key words: asthma, magnesium
TOPIC: INFECTIOUS DISEASE/INFORMATICS/ METHODOLOGY
076 Emergency Department Presentations of Cerebral Malaria.
Rehmani, R. Section of Emergency Medicine, Aga Khan University, Karachi, Pakistan.
INTRODUCTION: Malaria continues to be a major problem in tropical countries. Cerebral malaria, a diffuse encephalopathy caused by Plasmodium falciparum is characterized by fever, altered state of consciousness, and a convulsion. METHODS: This study was a prospective review of all patients with presumed Cerebral Malaria for one year to the Emergency Department (ED). All patients fulfilling inclusion criteria were enrolled and were entered on specially designed proforma. Their peripheral smear was studied based on which the diagnosis was classified as definite cerebral malaria and probable cerebral malaria. All patients were treated by intravenous quinine and specific syndromes were managed according to standard guidelines. RESULTS: The review revealed 107 cases over 1-year period. There were 82 males and 35 females. Average age was 34.2 years (range 6 - 70 years). The average duration of symptoms was 1.0 days (range 0 - 12 days) before presentation to the ED. All patients presented with fever and CNS involvement, 72% had convulsion, 12 developed coma, anemia was seen in 60%, but only 25% required blood transfusion. Initial ED WBC counts was normal in 64 patients, elevated in 14, and low in 29 patients. 66 out of 107 patients with jaundice had indirect hyperbilirubinemia and elevated liver enzymes suggesting hemolysis and the hepatocellular damage while thrombocytopenia was found in 76 patients. Smear was positive in 90% of patients, while others responded to quinine infusion given empirically. Complications like respiratory failure, renal dysfunction, hypoglycemia, bleeding diathesis, and severe anemia developed, and three patients died. The important observations of this study were stormy presentation, increased incidence of haemoglobinuria and jaundice, and the presence of neck rigidity. CONCLUSIONS: Presumed Cerebral Malaria is an entity which should be kept in mind when treating fever without definite focus in tropical countries, because timely and specific therapy is lifesaving. Key words: malaria
077 Is Individual Emergency Physician Efficiency a Significant Determinant of ED Overcrowding?
Campbell SG, Maxwell DM, Sinclair DE. Department of Emergency Medicine, Dalhousie University, Halifax NS.
INTRODUCTION: Overcrowding in emergency departments (ED) has become widespread worldwide. ED overcrowding has been found to correlate with increased patient mortality rates and increased patient dissatisfaction. Patients frequently perceive that delays to treatment are due to poor ED management rather than problems in the health care system, and emergency physicians often believe that the problem is out of their sphere of influence because it stems from extra-ED issues. As yet, the sensitive topic of contribution of individual physician emergency physician (EP) efficiency to ED overcrowding has been neglected in the literature. METHODS: We collected data on the number of patients seen per hour (Pt/Hr) by each physician (n=22) and average times from triage to EP, nurse to EP and EP to discharge, from July 1, 2001 to June 30, 2002, at the ED of the QEII Health Sciences Centre in Halifax, Nova Scotia, a 975 bed hospital with 72,000 adults ED visits annually. RESULTS: The variation between physicians in Pt/Hr was found to be considerable, (average 3.0/hr, range 2.3 - 4.8), and variation was consistent when times were compared for 'fast-track' and 'acute' patient areas, with 'faster' physicians seeing over double the number of patients than 'slower'. There were trends to shorter times in each time category with increased Pt/Hr. CONCLUSION: Significant variations exist among emergency physicians with regard to the Pt/Hr. Rapid transit of patients through the ED should not be achieved at the cost of good, appropriate patient care, and an ideal standard should be developed for training and quality management purposes. Wait times correspond weakly with Pt/Hr, and should not be used in isolation to evaluate emergency physician efficiency. Key words: overcrowding, quality
078 Clinical Practice Guideline Utilization by Emergency Medicine Staff with Varying Access.
Bullard MJ, Meurer D, Holroyd BR, Diner B, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
OBJECTIVES: Access to clinical practice guideline (CPG) information in emergency medicine (EM) has the potential to improve practice efficiency and patient care. This study examines the perceptions of EM staff using a computer-based system focussed on CPG applications. METHODS: A desktop computerized tracking system was accessible to all staff of two linked EDs. This was supplemented with EM-specific desktop CPG materials including decision tools, order sets, full care maps, and discharge instructions using an intranet website (eCPG); access was provided to 38 full-time EM staff at two major teaching hospitals. Staff completed a questionnaire after 12-18 months of eCPG access. Users were classified as control (CON; Peds EM = 12), regular adult users (REG; n = 16) and expert users (EXP; n =10) who were exposed to a supplemental laptop research study. Analyses were completed using ANOVA. RESULTS: Groups were similar in age, years of practice, home use of computers and access to the internet; more female physicians practiced in the CON group (p = 0.01). REG and EXP users rated the eCPG decision tools and order sets as equally easy to find and useful (p > 0.05). Compared to CON and REG users, EXP users prefer the order sets and decision tools more than patient information sheets (p = 0.004). EXP users also more commonly used the eCPG sites as a first-line resource for accessing CPG information than the CON and REG users (p = 0.046). EXP would more often seek CPG from the website than REG users (p = 0.02); CON staff employed a wide variety of alternatives to access CPG resources. CONCLUSIONS: An intranet based EM-specific eCPG site is used widely by all users; however, users with more exposure appear to find it easier to use and a preferred resource. Knowledge developers should consider ease of access and incorporate training into dissemination to enhance the future use of electronic resources. Electronic interventions to improve use of CPG resources appear warranted. Key words: clinical practice guideline, quality
079 A Review of the Limitations of the Number Needed to Treat.
Harris DR, Levy A. Department of Emergency Medicine, St. Paul Hospital, Vancouver, BC
INTRODUCTION: The results from randomized trials in the emergency medicine literature can be difficult to apply in a clinical setting and the number needed to treat (NNT) has been advocated as the most clinically relevant measure of effect. However, the number needed to treat is not without limitations. The purpose of this study was to systematically review the published literature to identify limitations of the number needed to treat. METHODS: Design: Systematic review. Search strategy: A MEDLINE search was performed using 'number needed to treat' as keyword (.mp). Reference lists from relevant articles were handsearched and applicable book chapters were also accessed. Study inclusion: Eligibility criteria were applied to select articles that were focused on methodologic and statistical properties of the NNT. Blinded eligibility was checked by more than one observer with disagreements resolved by consensus. This resulted in 425 relevant articles. Data extraction: A data extraction form was used and extraction performed by more than one observer. RESULTS: Ten limitations were identified - five specific to NNT and five common to all measures of effect. Specific to NNT are: 1. Underestimates benefit of therapy; 2. Undesirable mathematical and statistical properties; 3. Not applicable to all patient subgroups; 4. Not valuable as a tool to compare therapies, and; 5. Problematic in meta-analyses. Common to all effect measures, but important, are: 1. Does not incorporate costs; 2. Does not consider adverse outcomes of therapy; 3. Not appropriate to extrapolate NNT values beyond the period of the trial; 4. Not relevant for decisions at a population level, and; 5. No consideration of patient expectations and preferences. CONCLUSIONS: NNT should not be applied as a definitive measure, but rather examined in conjunction with other measures of effect. Awareness of these limitations will allow more educated interpretation of trial results and, hopefully, enhance evidence-based emergency care. Key words: number needed to treat, critical appraisal
080 Pitfalls of Email Survey Research.
Harris DR, Connolly H, Christenson J, Innes G. Department of Emergency Medicine, St. Paul Hospital, Vancouver, BC
INTRODUCTION: Surveys are widely administered in health research. Electronic mail (email) is a relatively new, convenient, cost-efficient method to conduct survey research. However, email survey research has significant obstacles that require consideration. The purpose of this study is to present the methodology of email survey research and outline its numerous pitfalls. METHODS: Design: Qualitative Study. Data: The authors were involved in a national survey of emergency physicians conducted by email in 2002, sponsored by a Canadian Association of Emergency Medicine (CAEP) Research Grant. Recipients were randomly selected from the CAEP membership roster. Response rate was poor at 96/340 (28%) after three emailings. Through participant observation and analysis of comments from survey respondents, hypotheses for the marginal response rate were identified. An iterative process was performed to identify categories. RESULTS: Three major categories of pitfalls were identified specific to email survey research: A. Sampling issues - out-of-date or invalid addresses, mailbox limits, and unable to capture intended sampling frame; B. Process issues - respondent computer skills, heterogeneity among computer hardware and software, document formatting, and incentives, and; C. Questionnaire issues - questionnaire completion and complex survey design issues. These are examined in detail and methods to avoid these problems are discussed. This is contrasted to traditional mail-out surveys. CONCLUSION: Although email survey research is a convenient and cost-efficient method to conduct questionnaires, it may not achieve response rates comparable to traditional methods. Awareness of the pitfalls in conducting email survey research will allow Investigators to obtain high response rates and valid results from future surveys. Key words: survey research, methodology
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