2004 CAEP/ACMU Scientific Abstracts - Poster Presentations (#112 to #132)

CAEP Abstracts

CJEM 2004;6(3):173-212

abstracts:  001-016 | 017-032 | 033-052 | 053-075 | 076-092 | 093-111 | 112-132

112 Impact on admission rates of evidence-based (EB) guidelines in the real life of the emergency department (ED).

McGillivray DL, Chalut DS, Plotnick LH, Savdie CR, Ducharme FM. Division of Pediatric Emergency Medicine, McGill University, Montreal, PQ

INTRODUCTION: EB pediatric guidelines have the potential to reduce asthma admissions rates. Previous RCTs have shown that admission rates may be reduced up to 40% with the early use of systemic steroids and 20% with ipratropium. The objective of this study was to evaluate the effectiveness of asthma guidelines in the real-life setting of the ED. METHODS: Prospective cohort study of all children 2-17 years of age, presenting with acute asthma over a 16 week period. Asthma severity was assessed by the PRAM (Preschool Respiratory Assessment Score), a validated clinical score. The following EB recommendations were put into a guideline format for use in the ED: within the first hour of arrival, patients with moderate asthma received inhaled beta-agonists and systemic steroids and severe asthmatics patients received inhaled beta-agonists, ipratropium and systemic steroids. The cohort was analyzed with respect to adherence or non-adherence. Adherence was defined as strict adherence to ALL components of the guideline and non-adherence as any guideline deviation. The primary outcome measure was a comparison of admission rates between the adherent and non-adherent groups for moderate and severe asthma. RESULTS:1039 patients were studied, 37.7% (393) mild, 38% (395) moderate, 6.4% (67) severe, and 17.8% (185) severity not measured. The admission rate for the adherent moderate asthma group (n = 42) was 19.0% (95% CI: 7.2, 30.9) versus 29.5% (24.7, 34.2) in the non-adherent group (n = 353), P value 0.16. The admission rate for the adherent severe asthma group (n = 30) was 53.3% (35.5, 71.2) versus 64.9% in the non-adherent severe group (n = 37), P = 0.34. CONCLUSION: Adherence to guidelines was associated with a reduction in absolute admission rates by 10.5% and 11.6% for moderate and severe asthma. In this real-life setting of the ED, the reduction of admission rates with adherence to EB guidelines is consistent with, but not as significant as, previously published RCTs.

Key words: asthma, pediatric, clinical practice guideline

113 Management of alcohol withdrawal: a chart audit of two urban emergency departments

Borgundvaag B, Kahan M, Midmer D, Borsoi D, Edwards C, Ladhani N. Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON

INTRODUCTION: Evidence suggests that symptom-triggered benzodiazepine treatment reduces complication rates and length of stay in the emergency department (ED), and brief advice by ED physicians improves treatment outcome. We sought to describe the management of alcohol withdrawal in two urban EDs. METHODS: Following approval from hospital ethics review boards, a chart audit form was developed to document details of patient demographics, chief complaint, symptoms of withdrawal (tremor, seizures), blood alcohol level (BAL), treatment provided, patient disposition (social services involvement, discharge medications, referral to detox) and length of stay. We audited random ED charts with a diagnosis of alcohol withdrawal, alcoholism or alcohol-related problems from 1999-2001. RESULTS: A total of 209 ED charts were audited. Patients in both hospitals were similar in demographic and clinical characteristics. A BAL was obtained on 67% of patients, and 50% of these had a BAL of 0. Twenty patients received an initial dose of diazepam with a calculated BAL > 35 mmol/L. Tremor and past seizures were frequently not documented (18.6% & 51.6% respectively). Thirty of 48 patients with no or, no documented, tremor received diazepam anyway. Of seventy-three patients with a history of withdrawal seizures, only 60 received diazepam. No patient was assessed using the CIWA scale. Patients at one hospital received a substantially higher dose of diazepam than the other (64 mg vs. 26 mg, p<.001). Nine percent of the low-dose hospital patients had seizures in the ED, compared to less than 1% in the high-dose hospital (p = .012). The average length of stay in the ED was 9 hours and 40 minutes. Most patients did not receive documented advice or referral back to their family doctor. CONCLUSION: Patients in alcohol withdrawal spend considerable time in the ED. In our series, clinical information, which could be used to guide therapy, was frequently not obtained, not documented or ignored, and management was not optimal.

Key words: alcoholism, alcohol withdrawal

114 Emergency physicians: their considerations of pain recognition and management strategies.

Pulfrey SM, Meadows L. Division of Emergency Medicine, University of Calgary, Calgary, AB

INTRODUCTION: Pain could be the principal bane of human existence. It is also the most common reason patients seek medical care in the emergency department. Alarmingly, recent studies indicate that pain continues to be underestimated and under-treated by emergency physicians. The question of why this is so remains unanswered. Similarly, the specific elements that determine an emergency physician's ability to recognize, acknowledge, and actively manage a patient's pain have never been explored from a qualitative perspective. METHODS: Eleven full-time emergency physicians working in a tertiary care emergency department were recruited as key informants by convenience sampling. During recorded individual face-to-face interviews, their experiences in regards to pain recognition and management issues in the emergency department were explored in a qualitative fashion. Interviews were then completely transcribed and analyzed via thematic analysis using the techniques of immersion and crystallization. RESULTS: Pain recognition and management problems from an emergency physician's perspective were multi-factorial and focused on difficulties arising with the following: 1. Subjectivity of pain. 2. Bias secondary to physician education and experience with pain. 3. End point variation in emergency physician's perceived responsibility of patient care. 4. Creating or nurturing an addiction. 5. Coercing consent with analgesia. CONCLUSIONS: These preliminary observations highlight some basic barriers and challenges associated with the recognition and management of pain in the emergency department. Furthermore, these rudimentary observations have potential importance towards devising strategies to improve the care received by the emergency department patient in pain.

Key words: pain management

115 How often should indwelling IV catheters in ambulatory patients be flushed?

Trojanowski T, Campbell SG, Ackroyd-Stolarz S. Emergency Department QE II HSC, Dalhousie University, Halifax, NS

INTRODUCTION: Ambulatory intravenous treatment has been advocated for several conditions that present to the emergency department (ED). Although regimens that involve administration of antibiotics every 24 hours are commonly employed, institutional protocols commonly indicate 8 hourly flushes of indwelling IV catheters to maintain patency. We sought to identify if there was any benefit to flushing more often than Q24. METHODS: A retrospective review of both HCNS/VON (Home Care Nova Scotia/Victorian Order of Nurses) and MDU (Medical Day Unit) records of patients receiving IV therapy between May 1, 2002 and June 30, 2003. We compared complication rates of different IV flushing intervals. Complications were defined as suspicion of infection, blockage, leakage, pain/discomfort at the current site, or "other". RESULTS: One hundred and eleven courses of treatment were studied from 63 different patients, 86% (95/111) cases were from the MDU and 14% (16/111) from the HCNS/VON health records. In 50.5% (56/111) of cases, the patients were female. In 57% (63/111) of cases, the catheters remained in situ for the duration of the treatment without complication. 43% (48/111) had complications during the treatment period necessitating catheter removal and reinsertion at another site. 89% (99/111) of cases used Q24h, 2.7% (3/111) Q12h, and 8% (9/111) Q8h flushing intervals. A statistically significant difference was found between flushing Q24h (39/99 (39.4%) complication rate) versus Q<24h (9/12 (75%) complication rate) (p = 0.021). There was no statistically significant difference in complications between males and females (Pearson C2, p = 0.106). CONCLUSIONS: Q24h flushing interval for indwelling peripheral IV catheters appears to have lower complication rates than Q12h and Q8h. The inconvenience to patients, and the use of hospital resources, especially unneeded ED visits, involved in more frequent than Q24 flush appears to be unwarranted.

Key words: outpatient IV therapy

116 The use of propofol for procedural sedation in a rural community hospital.

Reid DK, Mensour M. Attending Emergency Physician, Ross Memorial Hospital, Lindsay, ON

INTRODUCTION: To determine the safety of propofol used for procedural sedation of emergency department patients undergoing painful procedures, we conducted a prospective study in a rural community hospital with 30,000 visits/year, staffed by CCFP (Family Medicine), CCFP-EM (Emergency Medicine), and CCFP-ANAES (Anesthesiology) physicians. METHODS: A prospective study was conducted between July 1,2001 and March 31, 2002. Patients presenting to the emergency department requiring painful procedures were given procedural sedation at the discretion of the treating physician. All patients were given oxygen by non-rebreather mask. An attempt was made to give a 12 ml/kg bolus of crystalloid prior to propofol administration. Propofol was given initially at 1 mg/kg and then titrated to effect. End tital carbon dioxide levels were not measured. Inclusion criteria were fracture reduction, dislocation reduction, abscess I & D, cardioversion, chest tube, or complex lacerations in patients with an American Society of Anesthesiologists (ASA) classification IE or IIE. Exclusion criteria were ASA classification III or IV and sedation occuring outside of the emergency department. The primary outcome measures were complication rates: desaturation; hypotension; apnea; inadequate sedation, bradycardia. Secondary outcome measures included time to sedation; time to recovery; and time to discharge. A subgroup analysis of the usage rate and complication rate by training of the physician was performed. RESULTS: Of 134 charts, 105 met inclusion criteria. The overall complication rate was 4.8%. [Hypotension 2.9% (3/105); Desaturation 1.0% (1/105); Inadequate sedation 1.0% (1/105)]. Demographics were similar in each group. Complication rates listed by age group, procedure type, and training level are presented. Mean time to recovery was 9.5 minutes and mean time to discharge was 99 minutes. CONCLUSIONS: Emergency Department use of Propofol is safe for procedural sedation and has comparable complication rates to those sedation agents already in use.

Key words: procedural sedation, propofol

117 Use of comparison views for pediatric elbow injuries in Canadian non-pediatric emergency departments: a survey of physician practices.

Dowling SK, Farion KJ, Clifford TJ. Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON

INTRODUCTION: Pediatric elbow injuries are a common presenting complaint to the Emergency Department (ED). Although the pediatric elbow radiograph is a valuable diagnostic tool, it is inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended for all elbow injuries to provide an anatomically "normal" radiograph. Recent studies have questioned the utility of comparison views in the Pediatric ED. To our knowledge, no study has ever assessed the current practices or the usefulness of comparison views in the non-pediatric ED. The primary objective of this study is to determine what the current physician practices are for use of comparison views in pediatric elbow injuries at non-pediatric ED's in Canada. METHODS: A self-administered mail survey was sent to 300 randomly selected emergency physicians (EP's) across Canada, using the Canadian Association of Emergency Physicians (CAEP) database. RESULTS: Of the 300 EP's surveyed, 236 responded (79%). Pre-defined criteria excluded 24 respondents. Of the 212 eligible respondents, 96% ordered comparison views selectively, and 64% of these EP's ordered these views only 0-24% of the time. The most common reason cited for ordering comparison views was confirmation of normal anatomy (44%). Most EP's (93%) found the views to be "Never", "Rarely" or only "Sometimes" useful. Many EP's (54%) lack confidence interpreting elbow x-rays ("Not", "Minimally" or "Somewhat Confident"). CONCLUSIONS: The results from this survey demonstrate that non-pediatric EP's order comparison views selectively for elbow injuries, despite being only "Somewhat" confident in interpreting the x-rays. There is little variation in frequency that comparison views are used and their usefulness. These results, combined with the literature, suggest that comparison views should be used selectively, dependent on findings from the radiographs of the injured elbow. Future initiatives to improve EP skill and confidence in interpreting these x-rays may be warranted.

Key words: elbow injuries, pediatric, diagnosis

118 Analysis of scoring trends and reviewer agreement from three years of abstract submissions to the CAEP annual meeting.

Strome TL, Spooner C, Colman I, Morrison L, Grafstein E, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: The purpose of this study is to determine the extent of agreement between independent reviewers on the quality of submissions to the last three CAEP annual meetings. This is to identify factors that might result in low agreement, and to suggest improvements for future abstract scoring systems. METHODS: Submitters used an on-line system to submit abstracts to the CAEP annual meetings from 2001-2003. Each submission was assigned three volunteer CAEP reviewers with provisions that reviewers were not placed in a position of conflict. Reviewers used an on-line form to score abstracts and were blinded as to the abstracts' source (i.e., author(s), institution). Scoring was based on nine criteria, each contributing between two and six points toward the total (maximum 24). An abstract's final score was the mean of the three reviewers' scores. RESULTS: Ninety-five abstracts were submitted in 2001, 121 in 2002, and 115 in 2003. Mean scores were 14.40 in 2001, 14.16 in 2002, and 14.06 in 2003, with no significant difference over the three years (ANOVA p = 0.626). Pearson correlation coefficients on reviewer score were calculated comparing the three reviewers pair-wise for each of the three years. All correlations were significant at the 0.01 level (two tailed), ranging between 0.263 and 0.655. Agreement between each pair of reviewers on each criteria (for each of the three years) was calculated using the "weighted kappa" technique. All kappa scores were unimpressive, ranging between 0.0251 and 0.5223. There is a statistically significant increase in reviewer agreement (ANOVA p = 0.005) from 2000 to 2003. CONCLUSIONS: The correlation between reviewers' total scores suggests general recognition of "good" and "bad" abstracts. Clear and definite criteria descriptions resulted in better kappas than the more opinion-based criteria. In future abstract competitions, ensuring that criteria are more objective and based on concise requirements may further improve inter-rater agreement.

Key words: reliability, research

119 A description of abstract submission trends to the past four CAEP Annual Meetings.

Strome TL, Spooner C, Grafstein E, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: Scientific abstracts to the Canadian Association of Emergency Physicians (CAEP) Annual Scientific Meetings have been submitted electronically for the past four years and stored in administrative databases. This descriptive study uses this database to explore the trends in submissions of scientific abstracts over the past 4 years. METHODS: Abstract authors used a web-based system to submit scientific abstracts to the CAEP annual meetings for 2001-2004. For each abstract submitted, the author specified the category, investigation type, and preferred presentation type by choosing from the appropriate list. Each abstract was scored using a 9-criteria scoring system based on the study methodology. Each abstract was reviewed by 3 CAEP reviewers with a total score range from 07-24 each year. RESULTS: A total of 490 abstracts were received over 4 years; 95 in 2001, 121 in 2002, 115 in 2003, and 160 in 2004. The mean score for abstracts over the 2001-2004 period was 14.39; there was not a difference in scores based on the year of submission (ANOVA, df = 3; F = 1.476, p = 0.219). No Preference was the most popular presentation choice over the study. The top four chosen categories were Other (14.6), Clinical Practice (14.2%), EMS (13.6%), and Cardiovascular (10.9%). The leading four investigation types were Prospective Cohort (30.4%), Administrative Database (19.1%), Retrospective Chart Review (14.7%), and RCT and Survey (tied at 8.7% each). A total of 53.9% of abstract presenters were Emergency Physicians, 13.9% were Royal College residents, and 11.2% were in the "other" category. The remainder were Medical Students (10.9%), Fellows (9.1%), and CCFP(EM) Residents (0.9%). CONCLUSIONS: The pattern of submissions over the four years appear to be similar. Understanding submission trends will assist conference planners to better understand the research interests of the CAEP research community and to organize session tracks and time allotments to reflect these interests.

Key words: research

120 Emergency Department triage: evaluating the validity of a computerized triage tool.

Dong SL, Bullard MJ, Meurer DP, Blitz S, Colman I, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: Emergency department (ED) triage needs to be reliable, reproducible and accurate. A web-based triage decision tool (eTRIAGE) based on CTAS produced poor agreement, when compared to paper triage. This study employed an expert triage panel to determine whether the paper or eTRIAGE cohort scores most accurately agreed with CTAS criteria. METHODS: A random sample of 100 patients enrolled in a prospective triage study comparing paper-based triage to eTRIAGE in a tertiary care ED of a large urban centre were selected for study. A trained extractor reviewed the ED charts compiling the triage information used by both the standard (paper) triage nurse (TN) and the eTRIAGE nurse. Information was used by the expert panel, blinded to both triage scores, to derive the CTAS reference standard score. This score was then compared to the paper and eTRIAGE scores to determine sensitivity (Sn) and specificity (Sp). RESULTS: Complete data was available from 97 charts. The mean age was 45 and 48% of the patients were men. The distribution of patients by CTAS score is shown in the following Table. When compared to the reference standard, the sensitivity and specificity of paper-based triage and eTRIAGE, respectively were: level 1 (Sn 100, Sp 100; vs Sn 100, Sp 100), level 2 (Sn 4.2, Sp 100; vs Sn 66.7, Sp 94.5), level 3 (Sn 60, Sp 58.2; vs Sn 53.3, Sp 76.1), level 4 (Sn 74.2, Sp 68.2; Sn 64.5, Sp 75.8) and level 5 (Sn 36.4, Sp 98.8; vs Sn 36.4, Sp 95.4). CONCLUSIONS: Triage scores generated by nurses using eTRIAGE achieved a similar distribution to the expert panel. The major differences were paper-based TNs under-triaging level 2 patients while slightly over-triaging level 3 and 4 patients. When compared to an expert panel eTRIAGE achieved greater congruity than triage nurses without decision support.

Key words: triage, reliability

121 Distance learning in Emergency Medicine: lessons learned in the creation and implementation of an online disaster medicine curriculum.

Parks P, Singleton B, Lund A. Division of Emergency Medicine, University of Alberta, Edmonton, AB

OBJECTIVE: To examine the feasibility of an online distance learning (DL) curriculum for the delivery of disaster medicine (DM) education to health care providers across Canada. METHODS: Disaster Medicine Online (DMO) was created as a DL curriculum designed to provide emergency medicine health care providers with an introductory understanding of DM. From March 2002 to April 2003, the initial DMO module (DMO 101) was provided on five separate occasions to 102 health care providers. DMO 101 consisted of one week of preparatory online learning skills followed by two weeks of introductory disaster medicine instruction. Through the use of Computer Mediated Conferencing (CMC) boards, active interaction amongst students and facilitators was established as one of the key educational components of the course. The CMC boards allowed for asynchronous communication between the course participants and facilitators obviating the need for everyone to be online at the same time. Prospective objectives were built into all lessons, and students had to complete an examination at the end of the course to demonstrate that the learning objectives were indeed met. RESULTS: Overall the feedback from the five iterations of the course was extremely positive, with the most common criticism being a desire for further modules and a need for more detail on the covered topics. 73% found the CMC boards to be a useful learning adjunct, and 87% found facilitator input useful for achieving the learning objectives. The major obstacle in providing the course was in establishing and maintaining a proper infrastructure to ensure uninterrupted delivery. CONCLUSIONS: DL was favorably received as a method of delivering DM education to Canadian health care providers, and the lessons learned in the provision of DMO may possibly facilitate future online curriculums.

Key words: distance learning, medical education

122 Emergency department management of low back pain: a review of changes in treatment following the implementation of an electronic clinical practice guideline.

Bullard MJ, Lari H, Holroyd BR, Meurer D, Blitz S, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: The majority of ED low back pain (LBP) presentations are benign; however, there are a number of red flag conditions, which if missed can lead to significant morbidity. This study reviewed the adequacy of chart documentation and adherence to recommended LBP guidelines for emergency care and examined the impact of a point-of-care electronic CPG (eCPG) using a wireless mobile computer. METHODS: Two LBP documentation approaches at a tertiary referral ED were compared: paper charts (P) and eCPG during 2002. Demographics, documentation, management, and disposition were collected using a standard form, and the groups were compared and referenced to a historical chart audit. Groups were compared using chi-square, ANOVA and K-W tests. RESULTS: 483 charts were included (449 PRE, 22 P, 12 eCPG). Most patients were diagnosed as having mechanical or non-specific back pain and patient demographics were similar except for the P-group, which had a higher mean age (64 vs PRE 44.8 and eCPG 41) and a higher female to male ratio (2:1 vs 1:1 for the other groups). In higher risk patients, over 50, a history of cancer was recorded 9.3%, 21%, and 100% of the time (PRE, P, eCPG, respectively; p < 0.0001); consideration of an abdominal aortic aneurysm was noted in 3%, 15% and 100% of cases (p < 0.0001); and motor strength was recorded in 40.7%, 33.3%, and 100% of cases (p = 0.0002). Investigation rates were similarly low for all groups with discharge on NSAIDs +/- acetaminophen compounds the final disposition for most patients. CONCLUSION: Recommended standards of care for LBP (limiting radiography, admissions and narcotic use) were being followed at the study ED; however, documentation was poor. While introduction of a LBP eCPG emphasizing the need to exclude all red flag diagnoses did not change management appreciably, it did significantly improved charting. For this eCPG to be widely implemented, an electronic computing device that is robust and easily portable will be required.

Key words: clinical practice guideline, back pain

123 Effect of anticholinergic drugs on the efficacy of activated charcoal.

Green RS, Sitar DS,Tenenbein M. Department of Emergency Medicine, Dalhousie University, Halifax, NS

INTRODUCTION: Although it is a commonly held that the ingestion of drugs with an anticholinergic action would prolong the duration of time after drug ingestion for effective gastrointestinal decontamination, data are lacking to support this belief. The purpose of this study is to determine whether activated charcoal is more effective in the presence of concurrent anticholinergic activity. METHODS: A three-limbed randomized crossover study in 10 healthy volunteers was completed to determine the ability of a 50 g dose of activated charcoal to reduce the bioavailability of a simulated overdose of acetaminophen (12 x 325 mg tablets) in the presence and absence of a concurrently present anticholinergic drug, atropine (0.01 mg/kg I. M. administered 15 minutes prior to the acetaminophen ingestion). RESULTS: After the acetaminophen ingestion, median Cmax occurred at 1 hour for all three exposures, but was lower in the atropine-treated study arm (31 + 19 mg/L) than in the control or charcoal alone intervention arms (49 + 13 and 51 + 16 mg/L respectively) (P < 0.05). Compared to the control area under the serum concentration versus time curve, a single dose of activated charcoal one hour after drug ingestion reduced acetaminophen bioavailability by 20% ( 95% CI 4 - 36%) and by 47% (95% CI 35 - 59%) in the presence of atropine (P < 0.05 atropine plus charcoal versus charcoal alone). CONCLUSIONS: Our data support the belief that activated charcoal is more effective in the presence of anticholinergic activity. Additional study is required to determine whether in patients with anticholinergic drug overdose, activated charcoal is effective at times beyond the recommendation for overdoses of drugs without this pharmacodynamic effect.

Key words: activated charcoal, decontamination

124 Emergency department revisit rates in patients with substance problems in a Canadian tertiary care hospital population.

Brubacher JR, Mabie A, Abu-Laban RB, Buchanan J, Shenton T, Dickson B, Purssell R. Vancouver General Hospital and the University of British Columbia. Vancouver, BC

INTRODUCTION: Previous research by our group demonstrated that 11.6% of tertiary care Emergency Department (ED) patients abuse substances. The purpose of this descriptive study was to further characterize the impact of substance related problems by comparing ED revisit rates in patients with and without substance problems. Our primary hypothesis was that the population of patients with problematic substance use would have a higher proportion of ED revisits. METHODS: In our prior study, trained evaluators using explicit criteria reviewed 6026 sequential ED charts representing 5188 patients at a Canadian tertiary care teaching centre and recorded documentation of problematic substance use and whether the ED visit was due to substance related issues. For the current study, our ED database was queried to identify revisits from 1/09/02 to 31/08/03 for this same population. Descriptive statistics with 95% confidence intervals were generated. The primary comparison was done with a T-test at a significance level of 0.05. RESULTS: Revisits per patient ranged from 0 to 29. Of 4588 patients without identified substance abuse, 975 (21.3%: 95% CI 20.1% to 22.5%) made a total of 2150 revisits. (0.47 per patient). Of 600 patients identified as having a substance problem, 161 (26.8%: 95% CI 23.3% to 30.6%, p = 0.002) made a total of 466 revisits (0.78 revisits per patient). Among the 469 patients with a substance related visit, the revisit rates ranged from a low of 0.67 per patient in the alcohol user group (409 total, 272 revisits in 104 patients) to a high of 0.89 per patient in the intravenous drug user group (188 total, 167 revisits in 54 patients). CONCLUSIONS: Patients with substance problems are more likely to revisit the ED than those without substance problems. There appears to be variability in the revisit rate for different types of substance problems. The magnitude of this problem supports the need for further research and an interdisciplinary identification/intervention program.

Key words: emergency health services, substance abuse, alcoholism

125 Factors associated with the use of psychoactive substances before or after a night shift by Canadian emergency physicians.

Bailey B, Alexandrov L. Section of Emergency Medicine and section of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hôpital Ste-Justine, Montreal, PQ

INTRODUCTION: To describe factors associated with the use of hypnotics, sedatives, alternative medications, alcohol and illicit drugs by emergency physicians before or after a night shift. METHODS: All members of the Canadian Association of Emergency Physicians with a mailing address in Canada were mailed a copy of the survey asking them to reveal their use of psychotropic substances to help sleep before or after a night shift. Inclusion criteria were staff working at least 50% of the time or more in emergency medicine in Canada with at least 1 night shift per month. Information on family, medical practice and sleep practice was requested. A stepwise logistic regression model was constructed, using significant variables identified through univariate analyses, in order to select a subset of characteristics most predictive of using substances before or after a night shift. RESULTS: Of the 1621 surveys presumed received, 805 were returned completed for a response rate of 49.6%. Of those that responded, 628 met the inclusion criteria. The use of psychoactive substances as sleep aids before a night shift was associated with the use of psychoactive substances after a night shift (OR 3.8 95% CI 2.4, 5.9), and the use of psychoactive substances at other time (OR 3.8 95% CI 2.1, 6.6). The use of psychoactive substances as sleep aids after a night shift was associated with the use of a technique to help sleep before a night shift (OR 2.1 95% CI 1.3, 3.3), the use of psychoactive substances before a night shift (OR 4.0 95% CI 2.4, 6.4), the use of psychoactive substances at other time (OR 4.7 95% CI 2.6, 8.4), and the success of a nap before the night shift (OR 0.46 95% CI 0.25, 0.83). CONCLUSIONS: Emergency physicians that use psychoactive substances to sleep before or after a night shift are more likely to use them to sleep at other times. Successful sleep before a night shift decreases the use of psychoactive substances after the night shift.

Key words: shiftwork

126 Compliance with American Geriatrics Society care guidelines for elderly fallers in a tertiary emergency department.

Salter AE, Davis J, Donaldson MG, Buchanan J, Abu-Laban RB, Janssen PA, Robinovitch SN, McKay HA, Khan KM. School of Human Kinetics, University of British Columbia, Vancouver, BC

INTRODUCTION: Falls among the elderly account for 86% of injury-related admissions to Canadian hospitals. Retrospective data suggest that care meeting guideline recommendations is infrequent after fallers present to the emergency department (ED). The purpose of this study was to prospectively compare care after an ED fall presentation to guidelines published by the American Geriatrics Society (AGS). Our primary hypothesis was that 30% or less of patients would receive care compliant with the AGS guidelines. Secondarily, we sought to produce a detailed physiological description of elderly presenting with a fall to a Canadian ED. METHODS: All community-dwelling men and women, aged 70-years or older presenting to a single tertiary care ED with a fall-related complaint and discharged to outpatient care were eligible. Baseline and 6-month post-fall measurements described patients' medical care and subsequent referrals. Information gathered included 6-month change in physiological fall-risk factors, depressive state, balance confidence, physical activity, functional status, living arrangements and subsequent falls. RESULTS: Fifty-eight patients were enrolled with the following characteristics: mean age 78.5 (± 5.5); female 63.7%; fallen once or more in the prior year 51.7%; referred to family physician 29.3%; and, received AGS guideline care 0% (95% CI 0% to 6.2%). Baseline physiological fall-risk scores classified the cohort at 1 SD higher risk than age-matched norms (range -0.1 to 3.7, mean 1.5) with 6-month changes showing a mean 8% increase in fall-risk. CONCLUSIONS: ED care of elderly fallers not admitted to hospital is inconsistent with the AGS guidelines. "Care gaps", remediable at both the physician and patient level, exist in treatment and prevention pathways. As the ED is a potentially ideal place to identify this high-risk population, our study highlights the need for further research and the development of innovative approaches to address this issue.

Key words: injury prevention, falls

127 Emergency Physician recognition of adverse drug related events in elderly patients presenting to an emergency department.

Hohl CM, Robitaille C, Lord V, Dankoff J, Colacone A, Pham L, Bérard A, Pépin J, Afilalo M. McGill University, Montréal, PQ

OBJECTIVE: We examined the ability of Emergency Physicians (EPs) to recognize adverse drug related events (ADREs) in elderly patients presenting to the ED. METHODS: Prospective observational study of patients > 65 years of age who presented to the ED. ADREs were identified using a validated, standardized scoring system. EP recognition of ADREs was assessed through physician interview and subsequent chart review. RESULTS: One hundred and sixty-one patients were enrolled for participation in the study. Thirty-seven ADREs were identified which occurred in 26 patients (16.2%; 95% CI 10.5-22.0%). The treating EPs recognized 51.2% (95% CI 35.2-67.4%) of all ADREs. There was better recognition of those ADREs related to the patient's chief complaint 91% (95% CI 74.1-100%), as compared to recognition of only 32.1% (95% CI 14.8-49%) of ADREs which were not associated with the chief complaint. EPs recognized six of seven severe ADREs (85.7%; 95% CI 59.8-100%), 13 of 23 moderate (56.5%; 95% CI 36.8-77%) and none of the mild ADREs. ADRE recognition varied with medication class. CONCLUSION: EP performance was superior at identifying severe ADREs relating to patients' chief complaints. However, EP performance was sub-optimal with respect to spotting ADREs of lower severity, having missed a significant number of ADREs of moderate severity as well as ones unrelated to the patients' chief complaints. ADRE detection methods need to be developed for the ED to aid EPs in ADRE detection.

Key words: error, adverse drug reaction

128 Falls and anxiety: the life-line emergency response system trial (fallers trial).

Lee JS, Hurley M-J, Carew D, Fisher R, Drummond N. Sunnybrook & Women's Health Sciences Centre, University of Toronto, Toronto, ON

INTRODUCTION: Up to 45% of persons over 65 fall each year, and 43% restrict their activities due to fear of falling. We hypothesized that an emergency response system (ERS), (a portable button used to summon help), could reduce elders' anxiety and thus reduce health care use. Our objectives were to measure the impact of an ERS on: 1)patient anxiety and 2)health care usage. We measured anxiety with previously validated scales (the Hospital Anxiety and Depression (HAD) and the Falls Efficacy Scores). METHODS: We randomized consenting patients >70 years of age discharged from the ED after a fall to receive ERS+ (n = 23), or conventional care (ERS-, n = 19). RESULTS: A total of 55 subjects completed 2 months follow-up; 71% were female. Their mean age was 80.3 years, mean Folstein score was 28/30 and 19/55 subjects had a fracture at presentation. There was no statistically significant difference between groups at baseline. By 2 month follow-up, 5/25 (20%) ERS+ patients had a recurrent fall vs. 7/30 (23%) ERS- (p = 0.76). The mean change in anxiety on the HAD scale was -0.07 in the ERS+ and -0.56 in the ERS- group (p = 0.35). Fear of falling decreased 56% in the ERS+ and 50% in the ERS- groups (p = 0.42). Six of 25 ERS+ patients returned to the ED (24%) vs. 6/30 (20%) in the ERS- group (p = 0.75), and 5/25 (20%) ERS+ were hospitalized vs. 3/30 (10%) in the ERS- group (p = 0.13). The mean length of hospital stay was 0.23 days in the ERS+ vs. 2.6 days in the ERS- group (p = 0.10). There were no statistically significant differences between groups in outcomes. CONCLUSIONS: The ERS did not reduce post-fall anxiety, although the HADS may not be sensitive to changes over follow-up periods as short as two months. There was a non-significant trend towards decreased health-care use in the ERS+ Group. This study was under powered to exclude clinically relevant differences in health care use between groups. Future, larger studies using clinical outcomes, such as return to the ED, as the primary outcome are warranted.

Key words: injury prevention, falls

129 Advance directives in the QEII Health Sciences Centre emergency department setting.

Joanis V, Pauls M. Department of Emergency Medicine, Dalhousie Medical School, Halifax, NS

INTRODUCTION: Advance directives (AD) allow individuals to specify their treatment wishes in the event they become incapable of communicating. ADs are particularly relevant in the emergency setting where important treatment decisions must be made quickly. We sought to determine the incidence and availability of advance directives in a Canadian tertiary-care emergency department. METHODS: Between June and August of 2003 a convenience sample of patients presenting to the QEII Health Sciences Centre Emergency Department was interviewed. The incidence of completed ADs, AD availability, and factors influencing the choice to complete or not complete an AD were determined. Variables predictive of AD completion were identified using bivariate analysis. RESULTS: 24% of patients interviewed had completed an AD (n = 165). Age (p < 0.00001) and the perception of suffering from a chronic medical problem (p = 0.015) were independent predictors of advance directive completion. Relieving family members of decision-making was the most frequent motivation (67.5%). The decision to complete an AD was most often initiated by the patient themselves (67.5%) or a family member (62.5%). Lawyers were involved in 55% of cases, while family physicians were involved in only 5% of cases. Only 27.5% of patients with ADs had informed their family physician, but 60% said they intended to inform the emergency department staff. Only 5% of patients with ADs had them readily available. Many patients kept them in inaccessible locations such as safety deposit boxes. CONCLUSIONS: A minority of our emergency department population has completed an AD, and most did so with their lawyer rather than their doctor. Many of those who have completed an AD intend to inform their emergency health-care providers, but very few keep it readily available. There is a need for more education about ADs; in order to increase their utilization, involve health-care providers to a greater degree in their creation, and to make them more accessible.

Key words: advanced directive

130 Public expectations of emergency department care: a focus group study.

Watt D, Wertzler W, Brannan G. Division of Emergency Medicine, University of Calgary, Calgary, AB

INTRODUCTION: To explore the public's expectations of Emergency Department (ED) care and compare these with ED staff perceptions. METHODS: Twelve focus groups were conducted with residents of Calgary, Alberta and with ED staff in the Calgary Health Region (CHR). Included in the study were recent users of the ED, those who had not used the ED within 3 years ('non-users') and staff from the four hospitals in the CHR. A purposeful sample was selected to equally represent gender, the four geographic quadrants of the CHR, and Canadian Triage and Acuity Scores. An experienced moderator conducted the focus groups which were taped then transcribed. The transcripts were analyzed using standard qualitative analysis methods to identify common themes. RESULTS: A total of 34 recent ED users, 22 non-users and 31 ED staff participated in the study. Common expectations were categorized into six thematic areas: staff communication with patients, appropriate waiting times, the triage process, information management, quality of care, and improvements to existing services. Communication was the most prominent expectation across all groups. Participants expected staff to have good listening skills, provide reassurance, explanations and frequent updates. Most participants expected wait times of 3-6 hours, but considered this inappropriate. In contrast to the perceptions of the staff participants, the public believes they understand the principles of triage. Users and providers felt the quality of care was high. Participants suggested several improvements to ED care, including the need for a centralized patient health record. CONCLUSIONS: In general, those who have used the ED recently had similar expectations to those who have not. ED care providers understand some, but not all, of the public's expectations. This study highlights the importance of staff communication in meeting patients' expectations. The findings of this study were used to develop a quantitative questionnaire.

Key words: quality improvement, outcomes, emergency health services

131 Famous last words: emergency department discharge instructions.

Langhan TS, Haager MB, Oster A, Storck A, Burton-MacLeod R, Mackie A, Scott M. Jones J, McPherson S. Department of Emergency Medicine, University of Calgary, Calgary, AB

INTRODUCTION: Based on the limited published studies, patient recall of emergency department discharge instructions is suboptimal. We conducted a Quality Improvement initiative to determine the extent of patients' recall of discharge instructions within our own institution. METHODS: A telephone survey and retrospective chart review of a convenience sample of discharged emergency department patients from a tertiary care hospital was undertaken. A standardized questionnaire was administered by trained interviewers within four days of ED discharge. The results of the questionnaire were compared with chart documentation for the following data elements: discharge diagnosis, prescribed medications, and required follow-up. RESULTS: A total of 233 calls were initiated to patients discharged from the ED over a ten day period in November and December 2003. Seventy-nine patients consented and completed interviews. Of these, 73 charts were available for comparison and analysis. 78% (57/73) of patients recalled the same or similar diagnosis as documented on the chart. 40% (29/73) of patients recalled the same or similar follow-up instructions as documented on the chart. 27% (20/73) of patients had the same or similar recall of discharge medications as documented in their chart. 44% (32/73) of patients stated that no medications were prescribed at discharge and no prescribed medications were documented in the chart. CONCLUSION: Patient recall of discharge diagnosis and instructions was better than anticipated. Interpretation of these results is limited by our small sample size, potential selection bias, retrospective study design, and incomplete chart documentation.

Key words: quality improvement

132 Problem patients and primary care in the ED: the medication requesting patient - a closer look.

Arntfield RT, Sedran RJ. Medical Student, University of Western Ontario Medical School, London, ON

INTRODUCTION: Patients commonly present to the emergency department (ED) requesting medications and prescription refills. Examining how physician access contributes to such requests may offer an understanding of the burden that primary health care shortages have on the ED. These patients often pose logistical and ethical challenges, and examination of patient requests and physician prescribing patterns is warranted. METHODS: With ethical approval, a retrospective chart review was performed. Charts coded with the presenting complaint of "medication request" were collected for the period of January 1st/2002 to June 1st/2003 at the London Health Sciences Centre, South Street Campus. RESULTS: 180 patients requested medication (58.3% males, 41.7% females). The most common reason for using the ED for medication requests was the lack of access to a primary care practitioner (26.7%). The majority of patients (84.4%) were successful in receiving medication to go (50.0%), or a prescription (45.0%) during their visit. Patients with previous medication requests (33.3%) showed similar success rates (83.3%) as those with first time visits (85%). Patients with access to family doctors (56.1%) showed marginally higher success rates (87.1%) than those without access (81.0%). Opioid analgesics were requested in 23.9% of visits, and benzodiazepines in 16.1% of visits. Opioid analgesic requests were met significantly less often (58.1%) than all remaining (84.4%, p = 0.0001). Drug seeking behaviour was flagged on patients' charts in nine (5%) of cases. CONCLUSION: Patients without a primary care practitioner, or those unable to gain a timely appointment account for nearly half of the medication requests in the ED. Thirty seven percent of these patients attend requesting opioid analgesics and/or sedative/hypnotics and the majority are successful in obtaining them. The lack of access to primary health care significantly contributes to the need for patients to attend the emergency department for their medication needs.