2003 CAEP/ACMU Scientific Abstracts: 81-100
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
TOPIC: GERIATRICS/EDUCATION/CARDIOVASCULAR
081 Attracting Top CaRMS Candidates: A Survey of Important Program Attributes.
Millington SJ, Ball I, McCauley W. Faculty of Medicine, University of Western Ontario, London, ON.
INTRODUCTION: FRCP Emergency Medicine residents work intimately with staff in the department, and many will become staff at the institution that trains them. As such, it is in the best interest of each site to attract the best candidates to their respective centers. The goal of this study was to determine those factors that were most important in the decision-making process for medical students applying to FRCP Emergency Medicine Programs. METHODS: Seventeen out of eighteen University of Western Ontario 2003 Emergency Medicine candidates completed a paper survey on the day of their interview in London. Respondents ranked various factors that went into their decision-making process in selecting a residency program on a scale of 1 (least important) to 5 (most important). The surveys were kept completely anonymous. The mean and median responses for each category were calculated. RESULTS: The twenty-one surveyed factors were broken down into 4 broad categories. The following tables illustrate the calculated mean for each category.
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CONCLUSIONS: Based on this survey, those factors relating to previous interactions with a program and those relating to the characteristics of the program itself are most important in the minds of the FRCP Emergency Medicine interviewees. The items that make up these two categories are largely within a program's control. By tailoring certain variables relating to their program, interview days, and electives offered to medical students, a residency program will be more capable of attracting the strongest CaRMS candidates. Key words: medical education
082 Mathematical Model Predicting the Potential Impact of Various Community Bystander CPR Rates on Overall Survival from Cardiac Arrest.
Vaillancourt C, Stiell IG, Wells GA, De Maio VJ, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Survival from cardiac arrest remains low. Bystander CPR is a crucial yet weak link of the chain of survival for cardiac arrest. We sought to determine the potential impact of various community bystander CPR rates on overall survival from cardiac arrest. METHODS: We used descriptive analysis and mathematical modeling of data prospectively collected within the Ontario Prehospital Advanced Life Support Study. This study has the largest population-based cohort of adult out-of-hospital cardiac arrests in 20 communities with BLS-D and ALS paramedics. We used the following assumptions from the literature for our mathematical model: 1) bystander CPR is well-performed in 50% of cases; 2) the odds of survival with well-performed CPR compared to technically incorrect CPR is 3.4; 3) increasing CPR teaching in the community will increase bystander CPR rates; and 4) improved bystander CPR rates will be in the well-performed CPR group. We determined baseline bystander CPR and survival rates for witnessed and un-witnessed cardiac arrest cases. Victims receiving bystander CPR were divided in two equal groups and assigned a 3.4 differential survival rate. We varied bystander CPR rate between 20% and 60%. RESULTS: From 1995 to 2000, there were 7,707 consecutive cardiac arrest cases: mean age 68.9, 67% male, 37% VF/VT. Bystander CPR and survival to discharge were: 49% witnessed (23%, 6.8%), and 51% un-witnessed (11%, 1.3%). Estimated overall survival and additional number of lives saved with various bystander CPR rates are: 20%(4.1%, 2), 25%(4.6%, 9), 30%(5.1%, 17), 35%(5.6%, 24), 40%(6.1%, 32), 45%(6.5%, 39), 50%(7.0%, 47), 55%(7.5%, 54), and 60%(8.0%, 62). CONCLUSION: We used the largest known multicenter cardiac arrest database to model the potential impact of various bystander CPR rates. Community interventions designed to improve bystander CPR rates could have a significant impact on survival from cardiac arrest. These results may be used for sample size calculation in cardiac arrest research. Key words: cardiac arrest, resuscitation
083 Patient Satisfaction with an Emergency Department-Based Outpatient Deep Vein Thrombosis Treatment Program.
Zed PJ, Filiatrault L, Busser JR. CSU Pharmaceutical Sciences, Vancouver General Hospital & Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC.
INTRODUCTION: The purpose of this survey was to evaluate patient satisfaction with the emergency department (ED)-based outpatient deep vein thrombosis (DVT) treatment program at Vancouver General Hospital (VGH). METHODS: An 18-question patient satisfaction survey was mailed to all patients enrolled in the VGH outpatient DVT program following discharge from the program from June/99-Dec/02. In addition to overall satisfaction with the outpatient program, the survey was designed to evaluate specific aspects of the program which included comfort/convenience of having condition treated at home, knowledge and care provided by hospital staff, education provided and efficiency of hospital visits. Finally, questions were asked to assess future expansion of the program such as willingness to be treated again if a recurrence occurred and willingness to self-inject low-molecular-weight heparin (LMWH), if taught, and be treated at home. RESULTS: 134 patients were mailed a survey following discharge from the program of which 112 were returned resulting in an 83.6% response. Overall, 96.4% of patients were comfortable having their condition treated as an outpatient while 82.1% felt it was more convenient to return to hospital daily for medications and assessment than to be admitted to hospital. Most respondents (97.3%) felt that the nursing staff was courteous and understanding as well as very satisfied/satisfied (97.3%) with the education provided by the clinical pharmacist. 76.8% of patients were very satisfied/satisfied with the efficiency of treatment at each return visit to the ED. Overall, 97.3% of respondents were very satisfied/satisfied with the treatment received in the outpatient program and 92.9% would enroll again if future treatment was indicated. If taught, 51.8% of patients were willing to self-inject LMWH at home if future treatment was indicated. CONCLUSIONS: The VGH ED-based outpatient DVT treatment program appears to be achieving a high level of patient satisfaction. Key words: deep vein thrombosis, low-molecular-weight heparin
084 Fibrinolytic Administration for Acute Myocardial Infarction in a Tertiary Emergency Department: A Retrospective Review and Analysis of Factors Associated with an Increased Door-to-Needle Time.
Zed PJ, Abu-Laban RB, Cadieu T, Purssell RA, Filiatrault L. CSU Pharmaceutical Sciences, Vancouver General Hospital & Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC.
INTRODUCTION: The purpose of this study was to evaluate door-to-needle time for fibrinolytic administration for AMI at Vancouver General Hospital (VGH) and identify factors associated with time prolongation. METHODS: A retrospective chart review of all patients fibrinolysed for AMI in the emergency department (ED) at VGH was performed from January 1/98 to December 31/99 to determine door-to-needle time. A mixed-effects linear regression model was fit to the fibrinolytic data with the door-to-needle time to identify factors associated with prolonged times. RESULTS: 140 patients were included in the final analysis. The mean and median door-to-needle times were 58 and 43 minutes, respectively. A door-to-needle time of under 30 minutes was achieved in 24.3% of patients; 30-40 minutes in 24.3%; 40-60 minutes in 22.1%; and over 60 minutes in 29.3%. The strongest predictors of prolonged door-to-needle time were prescriber specialty, mode of arrival, time of arrival and time between chest pain onset and ED arrival. Emergency physician prescriber without prior cardiologist consultation resulted in a significantly shorter door-to needle time compared to requesting a cardiology consult prior to administration (mean [median] 41 [35] minutes versus 108 [90] minutes respectively, p<0.001). Patients who arrived by ambulance had shorter door-to-needle times than those who did not (mean [median] 50 [38] minutes versus 71 [57] minutes respectively, p=0.008). Patients who arrived during the night shift (2300-0700h) had significantly shorter door-to-needle times than those patients who arrived during the day (0700-1500h) or afternoon (1500-2300) shifts (p=0.0481); and patients who had a longer time from chest pain onset to ED arrival also had longer door-to-needle times (p=0.0233). CONCLUSIONS A significant number of AMI patients fibrinolysed at VGH do not meet the national guideline for door-to-needle time less than 30 minutes. Factors associated with this should be addressed to improve the care of patients with AMI. Key words: myocardial infarction, fibrinolysis
085 Practice Patterns in the Care of Patients with ST Elevation Myocardial Infarction.
Price L, Eisenhauer M, Massel D, Keller J. Division of Emergency Medicine, University of Western Ontario, London, ON.
INTRODUCTION: Improper care of patients with acute coronary syndromes can lead to significant morbidity and mortality. METHODS: This retrospective chart review describes the care of adult patients diagnosed with ST elevation myocardial infarction (MI) admitted through the emergency department at London Health Sciences Centre, South Street Campus (LHSC-SSC) during the year of 2000. The purpose of the study was to compare and contrast the standard of care at our institution with the 1999 American Heart Association (AHA) guidelines. The secondary party of the study involved a blinded analysis of all included patients' electrocardiograms (ECG's) by an emergency physician and a cardiologist to determine agreement for the decision to thrombolyse. RESULTS: There were 66 patients and 67 admissions. 64.2% of the population were male and the mean age was 65 years. The proportion of patients who received aspirin in the emergency department or en route was 88.1%, which is in fair agreement with the AHA guidelines. The mean time to first ECG was 16 minutes and the mean door-to-needle time for thrombolysis was 47 minutes. These both exceed the recommended 10 and 30 minutes respectively. 94.7% of those who received Tissue Plasminogin Activator (TPA) did not receive the recommended 60 U/kg or maximum of 4000U bolus of IV heparin. Of those who received lytics, 3.3% had a documented major contraindication, and 21.7% had a documented minor contraindication as described by the guidelines. 16.4% of all patients died, 20.9% suffered a bleeding complication, and 16.7% failed lytics requiring urgent percutaneous transluminal coronary angioplasty (PTCA). The kappa for ECG analysis by the emergency physician and the cardiologist in the decision to thrombolyse was 0.58, which shows moderate agreement. CONCLUSIONS: It is apparent that the care of patients with ST elevation MI at LHSC-SSC falls short of the AHA guidelines in several important areas. Key words: myocardial infarction, fibrinolysis
TOPIC: INJURY/TRAUMA
086 Multicenter Comparison of the Predictive Value of the Revised Trauma Score and the Glasgow Coma Scale
Al-Salamah M, McDowell I, Stiell IG, Wells GA, Nesbitt L. Department of Emergency Medicine, University of Ottawa, Ottawa, ON
INTRODUCTION: Identifying risk of mortality is an important aspect of ED care of multiple trauma patients. This study compared the predictive accuracy of the Revised Trauma Score (RTS) and Glasgow Coma Scale (GCS) and their components. METHODS: This multicenter prospective cohort study was conducted in 20 communities as part of the Ontario Prehospital Advanced Life Support (OPALS) Study. Included were adult trauma patients with ISS >12 and who were treated at 12 regional Level 1 trauma hospitals. Physician trauma team leaders assessed each patient for the RTS and GCS. For the RTS, GCS and their subscales we analyzed: 1) Receiver Operating Characteristic (ROC) curve areas and Kendal_s Tau c correlation coefficient (Tc) for survival to hospital discharge, 2) Mann-Whitney U-test for ICU admission, 3) Spearman_s Correlation Coefficient for the disability measures, Glasgow Outcome Scale (GOS) and Functional Independence Measure (FIM). RESULTS: We enrolled 912 patients with these characteristics: median age 39, male 71.3%, blunt trauma 90.1% and mortality 20.3%. This table shows ROC curve area and Tau c for survival, Spearman_s for GOS and FIM, and P-value for ICU admission:
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CONCLUSIONS: The GCS score and its Motor and Verbal components predicted survival and ICU admission. The Motor and Eye components predicted disability better than either GCS or RTS. The RTS failed to show an advantage over the GCS in our study population, which was mostly blunt trauma patients. These findings validate the use of GCS for triage of trauma patients, and the use of the Motor component where the GCS may be unobtainable, as for intubated patients. Key words: trauma, emergency medical services
087 Survey of Canadian Emergency Physicians' Management of Traumatic Corneal Abrasions.
Calder LA, Stiell IG, Balasubramanian S. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Current literature on the ED management of traumatic corneal abrasions(TCA) lacks evidence and consensus. We sought to determine the practice patterns of Canadian emergency physicians for TCA management. METHODS: Using a modified Dillman technique, we conducted a formal mail survey of a random sample of emergency physicians from the CAEP membership list. We used a web-based survey for members with an email address (400) and a postal survey for those without (70). We distributed a pre-notification letter, a survey of 15 multiple choice questions, and follow-up surveys to non-responders. The survey focused on the indications and utilization of 3 therapeutic modalities: patching, topical antibiotics and analgesia (oral and topical). Demographic information was also gathered. We performed descriptive analyses with 95% CIs. We obtained REB approval. RESULTS: The 275 respondents had these characteristics: median age 39, male 78.2%, fulltime emergency physician 71.6%, certified in EM 85.6%, practice in a teaching hospital 65.0%. Patching was uncommonly used(78.8% never/rarely patched) with the most common indications being large size 38.6%, severe pain 34.9% and photophobia 30.2%. Topical antibiotics were used for TCA by 70.6%; particularly for contact lens wearers 74.1%, and FB 70.7%. The topical antibiotics of first choice were: sodium sulfacetamide 36.7%, bacitracin/polymyxin 13.8%, erythromycin 12.0%, and ciprofloxacin 6.6%. The following were offered for pain management: oral analgesics 81.4%, cycloplegics 62.0% and topical NSAIDs 52.2%. Tetanus immunization was offered by 65.1% for TCA with FB and only 45.5% for those without FB. Routine follow-up was arranged by only 11.6%. CONCLUSIONS: To our knowledge, this is the largest formal mail survey of emergency physician TCA management and demonstrates considerable variation in practice. Much research is required regarding the best ED management of TCA, especially regarding use of antibiotics, cycloplegics, and topical NSAIDs. Key words: corneal abrasion
088 Secondary Falls Prevention in the Emergency Department - A Pilot Study.
Ackroyd-Stolarz S, Sinclair D, McKean K. Department of Emergency Medicine, Dalhousie University, Halifax, NS.
INTRODUCTION: Fall-related injuries in older adults comprise a significant proportion of the total burden of injury in Canada. This results in loss of independence, increased risk of fractures, and early admission to nursing homes. In addition, many seniors present to the Emergency Department (ED) as a result of a fall, placing significant strain on the health care system and dollars. By educating individuals on preventing falls these consequences can be decreased. The purpose of this pilot study is to determine the feasibility of delivering a community based, multidisciplinary falls prevention program from the ED. METHODS: Patients, over 65 years, that presented to the ED after falling were randomized to an intervention or control group. The control group received a social visit unrelated to falls prevention. The intervention group received an initial home assessment from HomeCare. A physiotherapist (PT), occupational therapist (OT) or nurse conducted a maximum of three subsequent home visits, including standardized and individualized falls prevention education. Patients recorded falls for a 2-month follow-up period. RESULTS: Fifteen patients (m=3,f=12) were recruited into the study (77yrs,SD=6.7). HomeCare identified the need for home visits from OT and PT in 63% (5/8) of patients in the intervention group. For one patient OT was the only area of need identified. Only 25% (2/8) of patients were recommended no further intervention. Nursing was not identified as a need for any of these patients. Follow-up assessment of falls was 100% for both groups. CONCLUSIONS: This pilot study shows evidence that an ED randomized control trial is a feasible way to deliver falls prevention education. This multidisciplinary approach is necessary to identify modifiable hazards within the home that may otherwise go unrecognized. A large multi-centered study is underway to further evaluate this intervention. Key words: injury prevention
089 The Epidemiology of Parasuicide Presentations to the Emergency Department.
Colman I, Yiannakoulias N, Schopflocher D, Svenson L, Holroyd BR, Bullard M, Klassen T, Johnson D, Craig W, Rosychuk R, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Parasuicide (attempted but not completed suicide including overdose and self-inflicted injury) is a common presentation to the emergency department (ED) and is often a pre-cursor to death by suicide. The objective of the present study was to examine the epidemiology of parasuicide presentations to EDs in Alberta. METHODS: Self-poisoning/self-injury records for the fiscal years 1998/1999, 1999/2000, and 2000/2001 were accessed from the Ambulatory Care Classification System, a database that captures all emergency department encounters in the province of Alberta. Available data for each case included demographic details, location and time of visit, diagnoses and procedures with 1998/99 serving as the index year. RESULTS: There were 22,396 parasuicides presenting to Alberta EDs over the three year period. Parasuicide rates were highest among females (219 per 100,000 compared to 159/100,000 for males in 1998/99) and those younger in age (228/100,000 for under 45 years vs. 99/100,000 for 45 years plus). Rates were particularly high among those on social services (1,296/100,000) and those with Aboriginal treaty status (849/100,000). Rates of return visits to the ED in the year following the parasuicide were also high (66% returned to ED, 18% returned for parasuicide after an initial 1998/99 visit). There was marked regional variation in the data; particularly notable was that of the two major urban centers, the city of Edmonton consistently had significantly higher parasuicide rates than the city of Calgary. Finally, clear trends could be seen in the timing of parasuicide presentations by hour of day, day of week, and month of year. CONCLUSIONS: Parasuicide is common in the ED, with particularly high rates demonstrated among marginalized populations (Aboriginal and impoverished). This study provides comprehensive data on those who present with parasuicide, and can be used to guide further treatment, research and evaluation in order to serve this population more effectively. Key words: suicide
090 Parenteral Corticosteroids for Acute Migraine: A Systematic Review of the Literature
Colman I, Innes G, Brown MD, Roberts T, Grafstein E, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB
INTRODUCTION: Corticosteroids may be beneficial in relief of acute migraine headache and in the prevention of relapse of the attack. This systematic review was designed to evaluate the effectiveness of parenteral corticosteroids in the treatment of episodes of acute migraine. METHODS: Randomized controlled trials were identified using MEDLINE, EMBASE, other computerized databases, hand searching, bibliographies, and contact with pharmaceutical companies and authors. Studies in which a corticosteroid was compared to placebo or any other standard migraine therapy were considered. Relevance, inclusion, and study quality were assessed independently by two reviewers. RESULTS: 1,246 potentially relevant abstracts were reviewed, but only 2 studies met the inclusion criteria. One study was of high quality and included 98 patients; the other was of low quality and included 21 patients. No significant differences were noted between corticosteroid groups and comparison groups with regards to pain reduction or improvement in functional ability. However, corticosteroids (specifically dexamethasone) reduced the likelihood of relapse of acute migraine within 48 hours (odds ratio = 0.28, 95% confidence interval: 0.11, 0.69). CONCLUSIONS: Although corticosteroids are widely used in the treatment of acute episodes of migraine headache, there is little evidence to support this practice. One high quality study suggests that dexamethasone may reduce relapses of migraine after emergency department discharge. Further research in this important area should be encouraged. Key words: migraine, corticosteroids
TOPIC: ADMINISTRATION
091 Feasibility of Emergency Department Based Daily Random Patient Satisfaction Surveys.
Innes G, Boychuk B, Barker C, Grafstein E. St. Paul's Hospital; The University of British Columbia; Vancouver, BC.
INTRODUCTION: Patient satisfaction is a key quality measure. Commercial (CM) satisfaction surveys are often telephone or mail surveys, which may be conducted well after the ED visit and have poor response rates. Sampling and recall bias may lead to invalid results. For cost reasons, our last ED satisfaction survey was conducted in 1995, having a 32% response rate. Our hypothesis was that internal daily (ID) random exit surveys are feasible and will provide higher response rates and more valid results than previously conducted CM surveys. METHODS: On a daily basis, 5 random clock times were generated. The first patient registering after each clock time was identified as the survey patient. Patients were excluded if they were comatose, confused, violent, psychotic, intoxicated, critically ill, or had a language barrier and no translator. Research assistants obtained consent and instructed patients how to complete the survey. Those who failed to return completed surveys after their ED visit were surveyed by telephone within a week. Our sample size for this study was 300 patients, based on that of the 1995 commercial survey. RESULTS: Response rates were 139/300 (43%) and 95/300 (32%) for the internal and CM surveys respectively (p=0.007). Response rates for specific survey items ranged from 37.3-42.0% in the internal survey and 19.7-31% in the CM survey. Internal survey respondents more closely matched actual ED patients than did CM survey respondents (table). The proportion of patients who rated care as good to excellent was similar in the ED survey (88%; 95%CI, 83-93) and CM survey (92%; 95% CI, 87-98).
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CONCLUSIONS: Internal daily random exit surveys are feasible and may provide more valid patient satisfaction data, but response rates for both survey methods fall below levels generally acceptable in survey research. Key words: quality, patient satisfaction
092 Emergency Department Overcrowding: Impact of Hospital Occupancy on Length of Stay in Emergency.
Curry G, Hall CA, Schorn R. University of Calgary, Department of Emergency Medicine, Calgary, AB.
INTRODUCTION: Tertiary emergency departments (ED) struggle with ED overcrowding. The ED relies on inpatient beds to enable ED outflow of admitted patients. The number of occupied inpatient beds is intuitively associated with the ability to clear admitted patients from the ED. No direct relationship has previously been described between hospital occupancy and average ED length of stay (ALOS). METHODS: The Calgary Health Region ED is a multi-site, singly administered tertiary care system serving ~900,000 citizens through 3 adult ED's. Data from all sites are prospectively collected regarding inpatient and ED visits. (hospital occupancy = number of admitted pts/number of inpatient beds). Data are presented from April 1997 - June 2002 from a representative adult site. RESULTS: ED ALOS increased disproportionately to ED visits.
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For admitted ED pts, hospital occupancy has a predictable effect on ALOS. Above 90% occupancy, each 1% rise increased ED ALOS for admitted pts by 20 min, without a significant effect on ALOS for discharged pts. (see below) This relationship between ALOS and occupancy has not been previously described.
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CONCLUSIONS: There is a predictable increase in ALOS for admitted ED patients as hospital occupancy increases. The current trend toward operating hospitals near full inpatient capacity, therefore, contributes significantly to a decrease in functional capacity for the ED. The resultant risks to patients inherent in ED overcrowding are significant and must be considered by health care planners. Key words: overcrowding
093 Patients Who Leave the Pediatric Emergency Department without Being Seen: Why Don't They Stay and Where Do They Go?
Goldman RD, MacPherson A, Schuh S, Mulligan C, Pirie JR. Division of Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON.
INTRODUCTION: Numerous children visiting Pediatric Emergency Departments (EDs) leave prior to being seen by a physician (LWBS). Of potential concern is the inability to provide them with a timely assessment and treatment. The objective of this study was to examine the acuity (triage score) of children who LWBS compared to children who have stayed to be seen in the ED. METHODS: We conducted a prospective cohort study during a 3 month period in the ED of a tertiary pediatric hospital in Toronto, Canada. All families who LWBS were contacted and asked questions about their child's condition, use of follow-up health services, and socio-demographic variables. Logistic regression analysis was used to compare LWBS children with controls matched for age and gender. RESULTS: During the study period, 289 (2.6%) families left the ED, of whom 180 (62%) consented to participate in the study. The study and control groups consisted of 158 and 316 children respectively. Waiting for too long and improved symptoms accounted for 58% and 37% of premature leaving. Of the LWBS, 15% were triaged as "urgent" and two-thirds of them sought further medical care, of whom one child was admitted. Multivariable analysis showed that patients who left had a lower acuity, compared to those who left (OR 4.95, 95% CI:2.6-9.4). Most of them sought further medical attention after leaving (OR 4.63, 95% CI: 2.8-7.8), and were more likely to register in the ED between midnight and 4 am (OR 4.86, 95% CI: 2.2-10.5). CONCLUSIONS: Children who LWBS have a lower acuity level, seek follow-up care elsewhere, and usually leave because they get better or the wait is too long. Sizable proportions are "urgent" but their outcome is favorable. Key words: quality, outcomes
094 Emergency Section and Overcrowding in a Teaching University Hospital of Karachi, Pakistan.
Rehmani R. Section of Emergency Medicine, Aga Khan University, Karachi, Pakistan
INTRODUCTION: Emergency section (ES) overcrowding is a serious and growing global problem. Ideally, ES provides key access to acute care services. The initial evaluation and stabilization of patients can take 1 to 2 hours. Patients without major problems are discharged promptly, and those who require further evaluation and treatment are admitted to inpatient services. Overcrowding occurs when the patients needing admission are delayed in ES because of the unavailability of inpatient beds. The objective of this study was to quantify the extent of Emergency Section (ES) overcrowding at our hospital and to identify possible solutions. METHODS: The ES log was reviewed for all patients who presented to the Aga Khan University Hospital's ES from January 2001 through March 2001. The ES information system has an automatic patient log and generates daily report for patients who stay longer than 6 hours. All charts of patients who stay longer than 6 hours are pulled and reviewed as a quality assurance process. RESULTS: Among 9360 patients, 1669 (17.84%) were held in the ES for more than 6 hours. Of those 134 (8%) were discharged from the ES, while 1535 were admitted to the hospital. Of 1535 patients, the delay in 982 (64%) was because of the unavailability of bed, in 276 (18%) because of financial constraints, 123 (8%) because more than one specialty were involved, and 92 (6%) patients were delayed because the admitting residents wanted to investigate the patients more thoroughly. 62 (4%) had the miscellaneous reasons. CONCLUSIONS: Significant overcrowding exists in ES at our hospital. Four solutions are proposed: (1) early discharges of in-patients, (2) creation of a holding unit, (3) flexible ward assignment, (4) active inter-facility transfer. These efforts will lead to an optimal care in our ES in rising patient demand. Key words: overcrowding
095 Development of an Activity Based Costing Tool for Trauma Care.
Farooki N, Guy P, Gowing M. Division of Orthopedic Surgery, McGill University, Montréal, Quebec.
INTRODUCTION: Repeated budgetary cutbacks increasingly force physicians to economically justify clinical decisions, yet traditional costing methods are inadequate in providing relevant cost information for funding decisions. Activity Based Costing (ABC) is an accounting method that defines costs in term of an organization's activities (e.g. medical services). The purpose of this project was to develop a cost-tracking tool to measure the costs of interventions performed on trauma patients. METHODS: Clinical observations, established treatment protocols (the ATLS, Advanced Trauma Life Support) and recognized care delivery databases (the GRASP collection of nursing interventions) were used to create lists of activities for the Emergency Department (E.D.), the Operating Room (O.R.), the Intensive Care Unit (ICU), and the ward. Each activity was then assigned either an intensity (number used) or a duration (time spent) value. The activities were then grouped and the lists were combined into a single user-friendly database using Palm-based and bar code scanner technology. RESULTS: The Palm-based data collected by the ABC tool was exported to statistical analysis software to combine the financial data and the clinical information from the trauma registry. We validated the data collection process by tracking the costs incurred during two videotaped events. Two independent cost-trackers recorded no differences on 30 entries in an E.D. case and 2 differences in 44 entries in an ICU case. CONCLUSIONS: We offer practitioners and administrators a validated method to track resource consumption, and to improve economically justifiable treatment decisions. Key words: utilization, trauma
096 Interpretation of Plain Radiographs by Pediatric Emergency Physicians: Do we Need Routine Review by a Radiologist?
Gouin S, Trieu TV, Bergeron S, Patel H, Guerin R. Division of Pediatric Emergency Medicine, University of Montreal, Montréal, Quebec.
INTRODUCTION: To evaluate the accuracy of diagnostic interpretation of plain radiographs by Pediatric Emergency Physicians (PEPs) and pediatric radiologists. To determine the effect of incorrect radiologic interpretation by PEPs on patient management. METHODS: Series of all consecutive patients (0-18 years) who underwent plain radiographs while they presented to a pediatric Emergency Department (ED) during September 2001, were reviewed. The radiologic interpretation of the PEP, documented at the time of the ED visit, was compared to the pediatric radiologist's report, documented within 72 hours. Data were obtained via the ED Hospital Information System, the Radiological Information System and the medical records. RESULTS: Data were available from 1644 of the 1651 sets of plain radiographs ordered by the PEPs during the study period: chest (42%), abdomen (19%), upper extremities (17%), lower extremities (7%), sinus (4%), skull (3%), clavicle (3%), spine (2%), pelvis (2%) and others (1%). The prevalence of positive radiological studies as per the radiologists was 32.2% (529/1644). Overall the PEP's accuracy (range) was 98.1% (1613/1644) (94.6-100%), sensitivity 96.4% (33.3-100%), specificity 98.9% (98.5-100%), NPV 98.3% (88.9-100%) and PPV 97.7% (90.6-100%). The proportion of false negatives (FN) was 1.2% (19/1644) and of false positives was 0.7% (12/1644). Of the 19 FN, 1 required immediate follow-up, 2 required follow-up in 1-2 days, 2 required follow-up in several days, 13 had a missed abnormality but no change in therapy was required and 1 had a questionable diagnosis. CONCLUSIONS: Plain radiographs interpretations by PEPs were extremely accurate. Infrequently, a severe diagnosis (1/1644) was missed by the PEPs. The routine review by a radiologist must be further evaluated. A selective approach may be more cost-efficient. Key words: diagnostic imaging,
097 Decision Analysis of Computed Tomography for Suspected Appendicitis.
Theakston KD. Division of Emergency Medicine, University of Western Ontario, London, ON.
INTRODUCTION: While the use of computed tomography (CT) to increase the accuracy of clinical examination has been studied, the most cost-effective strategy for the diagnosis of acute appendicitis remains unresolved. CT has been demonstrated to be highly accurate for the diagnosis of acute appendicitis and several researchers have recommended the routine use of CT for all patients with suspected appendicitis as a cost-effective diagnostic strategy. No Canadian economic analysis has been published on the use of CT for suspected appendicitis. METHODS: A decision analysis model was constructed (DATA 3.5, TreeAge Software, Boston, MA) to compare a clinical diagnostic strategy to a CT strategy. The baseline values for the model variables and probabilities were estimated from the published literature and from a Canadian hospital cost-accounting database. A cost-minimization methodology was used and separate analyses were conducted from both a governmental and societal perspective. Sensitivity analysis and Monte Carlo simulation were employed to test the robustness of the model. RESULTS: For the reference case, the use of a CT strategy for all patients with suspected appendicitis was less costly ($231, governmental; $425, societal) than the clinical strategy. From the governmental perspective, this result was sensitive to the cost of the CT and the prevalence of appendicitis in the study population. From the societal perspective, the dominance of CT over the clinical strategy was not sensitive to changes in any variable over their plausible ranges. CONCLUSIONS: This decision analysis, using Canadian cost data, suggests that the routine use of CT for patients with suspected appendicitis is less costly than relying on clinical diagnosis alone. Reduced cost arises from less admissions for observation and a reduced negative laparotomy rate. Further prospective Canadian cost-effectiveness studies are needed to determine the most cost-effective diagnostic strategy for emergency department patients with possible appendicitis. Key words: computed tomography, appendicitis
098 Nontraumatic Chest Pain in the Emergency Department: Need for Chest Radiography?
Nemeth J. Dept. of Emergency Medicine, McGill University Health Center, Montréal, Quebec.
INTRODUCTION: Patients presenting with non-traumatic chest pain (NTCP) is a frequent occurrence in the emergency department and more often than not these patients end up undergoing plain chest radiography (CXR). There currently exists no evidence-based, standardized criteria by which emergency department physicians order this investigation. Using a standard questionnaire sent to physicians certified in emergency medicine I sought to determine the variation of physician practices in ordering CXR in patients with NTCP. METHODS: A standardized questionnaire compromised of 6 questions was sent out to a random sample of 150 members of the Canadian Association of Emergency Physicians. Questions were formulated to assess practices of emergency department physicians in ordering CXR in patients presenting with NTCP. RESULTS: A total of 72 responses were gathered and analyzed. The majority of the respondents (46/72, 64%) had >10 years of experience in emergency medicine. Furthermore, most of the respondents had emergency medicine training in the CCFP program (41/72, 57%) versus RCPS program (19/72, 26%). The majority of the respondents listed suspicion of spontaneous pneumothorax (70/72, 97%), pneumonia (64/72, 88%), congestive heart failure (40/72, 55%), pulmonary embolus work-up (39/72,54%) and thoracic aortic dissection (37/72, 51%) as their main reasons for ordering a CXR. The following unexpected findings on CXR, which could change initial management were listed as pneumothorax (50/72, 69%), consolidation (39/72, 54%), signs of thoracic aortic dissection (35/72, 49%), significant pleural effusion (23/72, 32%). The number of times in the last 10 shifts that initial management was changed because of initial CXR findings were 0 (39/72, 54%), 1 (12/72, 17%), 2 (10/72, 14%), 3 (4/72:5%). CONCLUSIONS: Physicians did not vary greatly in their practice of ordering CXR for patients presenting with NTCP. It was however rare for management to be changed based on initial CXR findings. Furthermore, it could be argued that for most of the suspected diagnosis for which a CXR was ordered is either mainly a clinical diagnosis or for which CXR is neither specific nor sensitive. These findings underlie the need for the development of clinical guidelines by which one can identify those patients presenting with NTCP for whom a CXR is needed in their work-up. Key words: diagnostic imaging, chest pain
099 Economic Evaluation of the Potential Impact of the Canadian CT Head Rule.
Coyle D, Stiell IG, Wells GA, Clement C, for the CCC Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: The Canadian CT Head Rule (CCHR) is designed to improve the efficiency of ED management of minor head injury patients. This economic analysis estimated the potential cost savings to the Canadian health care system with widespread use of the CCHR. METHODS: This economic analysis used a probabilistic-based decision analytic model comparing current clinical practice to that assuming 100% uptake of the CCHR. Costs savings were assessed from a Canadian health care system perspective. The sensitivity and specificity of the rule was estimated by combining data from the derivation (N=3,121) and validation (N=2,588) studies. For our base analysis, current CT ordering rate was estimated to be 80.2%. Sensitivity analyses assumed rates of 90% and 100%. Cost data were obtained from provincial health care fee schedules, hospital cost accounting systems and the literature. The probabilistic model employed Monte Carlo simulation that was based on 5,000 replications. We estimated the expected values for potential cost savings and reduction in CT rates. RESULTS: In our base analysis, based upon the high-risk criteria and an absolute reduction in CT use of 44.5% (from 80.2% to 35.7%), the expected cost savings per patient was $27.52 (95% credibility interval $6.75-$44.34). For analysis based on the medium risk criteria and an absolute reduction in CT use of 17.8 %, the expected cost savings per patient was $17.56. Total annual cost savings, assuming 200,000 minor head injury cases per year, would be $5.5 million based on the high risk strategy and $3.5 million based on medium risk. Results were sensitive to the rate of use of CT in current practice. Assuming CT rates of 90 and 100%, the expected annual cost savings were $7.3 million and $9.5 million, respectively. CONCLUSIONS: Widespread use of the CCHR is expected to lead to cost savings as low as $3.5 million per year or as high as $9.5 million. Future studies should evaluate the potential economic impact of the CCR in other countries. Key words: diagnostic imaging, clinical prediction rule, computed tomography
100 Do Co-intoxicants Increase Adverse Event Rates In Patients With Opioid Overdose?
Mirakbari SM, Innes GD, Christenson J, Tilley J, Wong H. St. Paul's Hospital; The University of British Columbia; Vancouver, BC
INTRODUCTION: Patients frequently arrive in emergency departments after being resuscitated from opioid overdose. Autopsy studies suggest that multi-drug intoxication is a major risk factor for adverse outcomes after overdose. If this is true, there may be high-risk drug combinations that identify patients who require more intensive monitoring and observation. Our objective was to determine the impact of co-intoxication with alcohol, cocaine or CNS depressant drugs on adverse event rates in patients resuscitated from acute opioid overdose. METHODS: Data were extracted from the database of a prospective opioid overdose cohort study. Patients who received naloxone for presumed opioid overdose and were treated at this inner city ED between May 1997 and May 1999 were prospectively enrolled. Investigators gathered clinical, demographic and other predictor variables, including co-intoxicants used. Patients were followed to identify pre-specified adverse outcome events occurring within 24 hours, and multiple logistic regression was used to determine the association of concomitant drug use with adverse event rates. RESULTS: Of 1155 patients studied, 58 (5%) had pure opioid overdose and 922 (80%) reported co-intoxicants, including alcohol, cocaine and CNS depressants. Overall, there were 123 major adverse events (11.6%) and 194 minor adverse events (18.4%). After adjustment for age, gender, HIV status, cardiovascular disease, pulmonary disease and diabetes, we found that co-administration of alcohol, cocaine or CNS depressants, alone or in combination, was not associated with increased risk of death or adverse events during the 24-hour follow-up period. CONCLUSION: Most opioid overdoses involve mixed ingestions. In patients resuscitated from acute opioid overdose, outcomes are similar for patients with pure opioid overdose and multi-drug intoxications. A history of co-intoxication cannot be used to identify high-risk patients who require more intensive monitoring and prolonged observation. Key words: opioid overdose
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