2005 CAEP / ACMU Scientific Abstracts - Oral Presentations: 45-58

The effect of triage-applied Ottawa Ankle Rules on length of stay in a Canadian urgent care department: a randomized control trial.

Fan J, Woolfrey K. Division of Emergency Medicine, McMaster University, Hamilton, ON

INTRODUCTION: Do triage nurses ordering X-rays according to the Ottawa Ankle Rules (OAR) before physician evaluation will decrease the length of stay for patients visiting an urgent care department? METHODS: From July to September 2004, a randomized control trial of consecutive patients with ankle/foot twisting injuries arriving at an urgent care department took place. Patients aged ≥18 years with a ≤7 day old injury were included. They were excluded if there were neurovascular deficits, limb deformities, open fractures, or non-isolated ankle/foot injuries. Patients were randomly allocated to an X-ray-ordering clinical pathway (intervention) or standard departmental care (control). Those assigned to the intervention group had triage nurses apply the OAR and send those with positive OAR for X-rays before physician evaluation. Physicians were blinded to negative OAR nurse assessments. Investigators were blinded to group allocation. The primary outcome was the total median length of stay (TLOS). The secondary outcomes were patient satisfaction (5-point ordinal scale) and the proportion willing to return (WOR) for future care. Mann-Whitney Test was used to analyze the TLOS and satisfaction rating differences between groups. Two-proportion t-test was used to analyze the WOR outcome. This study had 80% power to detect an effect size of 25 minutes. RESULTS: 167 patients were eligible, 130 patients consented and were enrolled. 3 patients were then excluded, 3 were lost to follow-up, and 1 left without being seen. The intervention and control groups had median TLOS of 73.0 mins and 79.7 mins respectively. There was a non-significant time difference of -6.7 mins (95% CI: -20.9, 7.4 mins) between groups. There were no differences in patient satisfaction ratings (0; 95% CI: -1,0) or WOR (3.8%; 95% CI: -3.3%, 11.0%). CONCLUSION: Triage nurses using OAR and ordering X-rays before physician evaluation for twisting ankle/foot injuries does not decrease the length of stay in an urgent care department. Key words: clinical prediction rule; Ottawa Ankle Rules

The use of Hounsfield units on initial CT-scan of the head to rule out a subarachnoid hemorrhage.

Al-Salamah M, Perry JJ, Forbes M, Al-Kenawi A, Stiell IG, Wells GA. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: We conducted this study to assess the diagnostic value of obtaining Hounsfield units (HU) of the cerebrospinal fluid (CSF), on the initial computed tomography (CT) scan of the head, in ruling out subarachnoid hemorrhage (SAH) in patients presenting with acute headache. METHODS: Data was collected prospectively and consecutively on all alert, neurologically intact patients presenting to two tertiary care EDs with a sudden (<1hour to peak), severe headache suggestive of a SAH. A research assistant, blinded to the outcome, retrieved CT scans from the Picture Archiving & Communication System (PACS). The average HU was obtained from the CSF spaces by taking an elliptical sample of 12-25 pixels while avoiding the vessels inside the cisterns. SAH was diagnosed by visible blood on CT scan or confirmed by angiogram following a positive lumbar puncture. The average HU of each cistern was compared using the student's t test and cutoffs of 100% sensitivity were selected. RESULTS: The sample size was 569, with 31 cases of SAH; seven had a negative CT scan. The mean age was 44 ± 17 years and 63% were female. The Supracellar cistern, Sylvian fissure and Basal cistern predicted SAH (p < 0.001). We found the optimal combination to be an average HU <6 in the right or left Sylvian fissure or <3 in the right or left anterior horns of the Supracellar cistern. This cutoff displayed 100% (95% CI 86%-100%) sensitivity, 26% (23%-30%) specificity, 7% (5%-10%) positive predictive value and 100% (99%-100%) negative predictive value for SAH. Compared to current practice, it could reduce the need for lumbar punctures from 95% to 70% of all patients without missing any cases of SAH. Other more complex combinations could reduce the need for lumbar puncture to 46%. CONCLUSION: Measuring HU provides significant potential for reducing the need for confirmatory lumbar punctures to rule out SAH after a CT scan. Key words: computed tomography; lumbar puncture; subarachnoid hemorrhage

Implementation of a prehospital advance directive protocol in southeastern Ontario.

Mengual RP, Feldman MJ, Jones GR. Department of Emergency Medicine, Queen's University, Kingston, ON

INTRODUCTION: Do not resuscitate (DNR) orders are universally accepted in the health care setting, but are less widely recognized in the prehospital setting. This study documents the satisfaction of paramedics and surviving family members with a prehospital DNR protocol that allows paramedics to honour verbal and non-standard written DNR requests for patients encountered in cardiac arrest. METHODS: This ongoing prospective observational study reviewed all cardiac arrests in Southeastern Ontario between March 1, 2003 and December 1, 2004. Following a DNR request, paramedics were required to complete a survey, and a follow-up structured telephone interview was conducted with surviving family members. RESULTS: There were 841 cardiac arrests during the study period, of which 73 met inclusion criteria. Paramedic surveys were available for 66 (90%) of these, and surviving family members were successfully contacted in 44 (60%) cases. Two families declined follow-up interview. The mean patient age was 73, of which 61% were male. Forty-nine (67%) of the DNR requests were verbal, 21 (29%) written, and three not specified. Paramedic comfort was rated as 4.92 on a five-point Likert scale (95% confidence interval 4.86-4.98). Survivor comfort was rated by paramedics as 4.84 (95% C.I. 4.75-4.95). Survivors reported comfort with the decision to withhold CPR in 41 of 42 cases (98%) and with paramedic care in all cases. One survivor reported discomfort, stating the DNR request was consistent with the patient's wishes, but she was uncomfortable having to make the request. CONCLUSIONS: This novel prehospital DNR protocol allows paramedics to honour verbal and non-standard written DNR requests made by substitute decision-makers. Interim findings demonstrate that satisfaction with the protocol among paramedics and surviving family members is uniformly high. Conclusions are limited by a small sample size, lack of comparison group, and limited follow-up, however it appears that such a protocol is appropriate for the prehospital setting. Key words: advance directive; cardiac arrest; emergency health services; resuscitation

Assessment of the performance of medical priority dispatch system with respect to prehospital Canadian triage and acuity scale.

Feldman MJ, Lyons DG, Verbeek PR, Chad SJ, Craig AM, Schwartz B. Department of Emergency Medicine, Queen's University, Kingston, ON

INTRODUCTION: The Medical Priority Dispatch System (MPDS) consists of 33 protocols used by emergency medical services (EMS) dispatchers to interrogate callers and determine dispatch priority. Although use of MPDS is common, there is little evidence that dispatch priority correlates with patient acuity. The Canadian Triage and Acuity Scale (CTAS) is a validated tool used to prioritize patient care requirements, and correlates with both admission rates and need for investigations. OBJECTIVE: To determine the performance of MPDS with respect to prehospital CTAS. METHODS: The Toronto EMS communications database was queried to obtain all calls from March 1, 2003 until February 29, 2004. All duplicate calls, non-emergency transfers, and cancelled calls were excluded. Only protocols accounting for > 1% of calls were analyzed. A focus group consisting of paramedics, dispatchers, EMS physicians, and EMS managers assigned a range of MPDS dispatch priorities considered appropriate to each CTAS level. Sensitivity, specificity, overtriage, and undertriage rate was calculated for all protocols collectively and individually. RESULTS: Of 197,882 calls, 54,598 were excluded due to cancellations by caller or patient, and 26,879 were excluded due to missing data fields. Nineteen protocols accounted for 96.2% of calls. The focus group defined 5% undertriage as an appropriate target for dispatch protocols. The overall sensitivity and specificity of MPDS was 56.8% and 56.8%, respectively. Overall overtriage and undertriage rates were 65.7% and 23.2%, respectively. Only protocols for patients with diabetic problems or shortness of breath undertriaged less than 5% of calls. CONCLUSIONS: Comparison of MPDS to CTAS represents a novel method of evaluating dispatch protocols. MPDS exhibits low sensitivity and specificity for detecting high patient acuity, and seventeen of nineteen protocols undertriaged high acuity cases in >5% of calls. These protocols may represent targets for revisions of the MPDS. Key words: CTAS; emergency health services; triage

OPALS major trauma study: Does the addition of ALS to a multicentre BLS system affect traumatic brain injury outcomes?

Stiell IG, Nesbitt LP, Pickett W, Brisson D, Banek J, Field B, Spaite D, Munkley D, Luinstra-Toohey L, Lyver M, Campeau T, Wells GA, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: The Ontario Prehospital Advanced Life Support (OPALS) Study is a multicenter before-after controlled clinical trial. Within this, we sought to determine whether the addition of a full ALS program to an optimized BLS EMS program improved outcomes for patients with acute traumatic brain injuries (TBI). METHODS: Adult major trauma (ISS >12) patients were enrolled in 17 communities. During the before phase, care was provided at the BLS level. During the after phase, ALS providers performed endotracheal intubation and provided IV fluid therapy, as required. Patient data were abstracted from the Ontario Trauma Registry and prehospital records. TBI patients were defined as those with a total GCS < 8 on arrival to the lead trauma hospital. Study outcomes were survival to hospital discharge and functional independence measure (FIM). Results were evaluated using descriptive, contingency table and logistic regression analyses. RESULTS: 401 patients (216 BLS, 185 ALS) were enrolled: mean age 44.5 (range 16-97), male 75.3%, injury type (blunt 93.3%, penetrating 6.5%); median ISS 26 (IQR: 25-38); survival to discharge 54.9%. Patients in the ALS phase received these interventions: oral intubation 17.5%, nasal intubation 9.7%; IV fluid bolus 8.4%. TBI patients in the two study phases had similar rates of survival, both overall (54.8% ALS vs. 54.4% BLS; P = 0.93), and within a priori subgroups: e.g. motor vehicle collision (60.6% vs. 54.8%; P = 0.53), falls (45.7% vs. 43.1%; P = 0.86), age > 60 years (28.6% vs. 27.5%; P = 1.00). The adjusted odds of mortality for ALS vs. BLS TBI patients were non-significant (1.31; 95% CI: 0.83-2.07). There were no differences in FIM among TBI patients at discharge (76.4 ALS vs. 84.6 BLS; P = 0.13) or 6 months post-discharge (108.3 vs. 107.7; P = 0.94). CONCLUSIONS: The OPALS Study is the largest controlled trial of prehospital care for critically injured patients. The addition of a full ALS EMS program did not improve patient outcomes for traumatic brain injuries. Key words: emergency health services; emergency medical services; trauma; traumatic brain injury

Inter-rater reliability and comfort of application of a termination of resuscitation decision rule for primary care paramedics.

Morrison LJ, Visentin LM, Verbeek PR, on behalf of the TOR investigators from 12 Land Base Hospitals and associated EMS Services; Cambridge, Cornwall, Durham, Grey Bruce, Hamilton, Peel, Peterborough, Sault Area, Simcoe/Muskoka, Timmins, Toronto, York. Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON

INTRODUCTION: This study aims to evaluate the reliability of Primary Care Paramedics (PCPs) in the application of a Termination of Resuscitation (TOR) clinical decision rule and to measure their comfort level using this rule to terminate resuscitation. METHODS: This survey was completed during the prospective validation study of the TOR rule in out-of-hospital cardiac arrest with PCP care only, conducted in 12 rural and urban communities. PCPs were asked to theoretically apply the TOR rule and rate their comfort level using the rule, on a 5 point Likert-type scale, where 1 = Very comfortable and 5 = Very uncomfortable. A Kappa score for agreement with truth was calculated for each TOR event as interpreted by the PCP crewmembers responsible for delivering patient care. A t-test statistic comparing mean comfort level between PCPs interpreting the rule correctly versus incorrectly was computed. RESULTS: A total of 1184 attendant PCPs and 1211 driver PCPs completed the rule portion of the data collection form, with 1160 cases with both driver and attendant data available. Kappa for agreement of interpretation of the rule between driver and attendant PCP was 0.89 (95% CI, 0.87, 0.92); between attendant and truth, Kappa = 0.88 (95% CI, 0.85, 0.91); between driver and truth, Kappa = 0.88 (95% CI, 0.85, 0.91). PCPs who applied the rule correctly were significantly more comfortable (N = 2253, mean comfort score = 2.0 or comfortable, 95% CI, 2.0, 2.1) than those who did not (N = 134, mean comfort score = 3.0 or neutral, 95% CI, 2.8, 3.3), p < 0.0001. CONCLUSIONS: PCPs were able to correctly apply the TOR clinical decision rule and were comfortable doing so. Comfort was associated with correct interpretation of the rule. Applying the rule correctly and comfort with the rule are important considerations in prospectively implementing a TOR rule for PCPs. Key words: cardiac arrest; clinical prediction rule; emergency health services; resuscitation

Evaluation of a training program in endotracheal intubation for rural primary care paramedics.

Jones G, Reed A, Halladay M. Department of Emergency Medicine, Queen"s University, Kingston, ON

INTRODUCTION: Endotracheal intubation (ETI) is considered the gold standard for airway management in cardiac arrest and is part of the skill set for Advanced Care Paramedics (ACP) but not for Primary Care Paramedics (PCP). Delivery and retention of advanced skills such as ETI can be problematic in the rural setting. We designed and evaluated a novel focused ETI training program for PCPs in rural and small town ambulance services. METHODS: A two week training program included didactic teaching, mannequin practice and intubation on live patients in the operating room followed by a defined schedule of continuing education and yearly recertification by the EMS Medical Director. Paramedics were allowed to intubate patients in cardiac arrest according to a protocol which was integrated with automatic defibrillation and the administration of endotracheal epinephrine. All patients were transported to hospital where tube placement and complications were recorded by an emergency physician. RESULTS: Between April 2000 and December 2003, 41 PCPs attended 240 patients in cardiac arrest and attempted ETI on 237. ETI was successful in 207/237 patients (87%), with 173/207 (84%) intubated on the first attempt and additional 34/207 (16%) on a subsequent attempt. Complications were recorded for 6 patients and included one unrecognized esophageal intubation. Six of 240 (2.5%) patients survived to hospital discharge, 3 of whom regained a pulse with defibrillation alone. CONCLUSION: PCP's in rural and small communities can successfully intubate cardiac arrest patients following a training program that includes didactic teaching, mannequin practice, operating room experience and a schedule of continuing education. This study has implications for the management of cardiac arrest and the development of cease resuscitation protocols in the rural setting. Key words: airway management; emergency health services; resuscitation

OPALS major trauma study: impact of advanced life support on survival and morbidity.

Stiell IG, Nesbitt L, Pickett W, Brisson D, Banek J, Field B, Spaite D, Munkley D, Luinstra-Toohey L, Lyver M, Campeau T, Wells G, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: The Major Trauma component of the Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental impact on survival of adding ALS to a multicenter BLS system. METHODS: This before-after controlled clinical trial was conducted in 17 communities (population 20,000 to 750,000) and enrolled adult major trauma (ISS >12) patients during BLS and a subsequent ALS phases. ALS providers performed endotracheal intubation and administered IV fluids and drugs, as required. Patient data were abstracted from the Ontario Trauma Registry, then ambulance, centralized dispatch and ED records. Trauma cases were compared with norms from the Major Trauma Outcome Study (MTOS). The primary outcome was survival to hospital discharge. Secondary outcomes were prehospital times and functional independence (FIM). Study phases were compared via chi-square, Students' t, and Mann-Whitney U tests, and multiple logistic regression. RESULTS: On average, OPALS trauma cases were more severe than MTOS norms (M = 0.691). The 2,750 patients enrolled during BLS (N = 1,276) and ALS (N = 1,474) phases were characterized: mean age 46.1 (range 16-98), male 71.8%, injury type (blunt 91.4%, penetrating 5.9%, burn 2.6%); median ISS 22 (IQR: 17-29); GCS < 8: 25.1%. Intubation and IV fluids were administered in 13.3% and 14.2% of ALS patients, respectively. Time on scene increased with ALS: median 17 vs. 15 minutes, P < 0.001). Patient survival did not change overall (81.1% ALS vs. 82.1% BLS; P = 0.52), nor among patient subgroups defined by injury mechanism (P = 0.32 to 0.59), ISS (P = 0.22 to 0.29) and GCS (P = 0.42 to 0.50). The adjusted odds of mortality for ALS vs. BLS patients were non-significant (1.08; 95% CI: 0.76-1.54). There were no differences in FIM among discharged patients (94.3 ALS vs. 94.7 BLS; P = 0.82). CONCLUSIONS: The OPALS Major Trauma Study is the largest controlled trial to examine potential benefits of ALS programs. The addition of prehospital ALS interventions did not improve trauma patient outcomes. Key words: emergency health services; trauma

Prospective evaluation of the management of moderate to severe cellulitis with parenteral antibiotics at a pediatric day treatment centre.

Gouin S, Gauthier M, Chevalier I, Dehault C, Lamarre V. Division of Emergency Medicine, University of Montreal, Montreal, QC

INTRODUCTION: The objective is to assess the clinical outcome of pediatric patients with moderate to severe cellulitis managed at a Day Treatment Centre (DTC). METHODS: Prospective cohort of all patients (3 months-18 years) with a presumed diagnosis of moderate to severe cellulitis made in a pediatric Emergency Department (ED) from Sept. 2003 to Nov. 2004. Patients were treated in the DTC, except in the presence of orbital or peri-orbital cellulitis, septic arthritis, osteomyelitis, chondritis, immunosuppression or surgical intervention required, in which cases they were hospitalized. Patients treated in the DTC were given ceftriaxone (IV or IM) (50 mg/kg) daily or clindamycine (IV and PO) if allergic. RESULTS: During the study period, a presumed diagnosis of moderate to severe cellulitis was made in 124 patients in the ED. Fifty-two patients were treated at the DTC (42%) and 88% received ceftriaxone. Their mean age was 7.6 (range: 1-16) years and 65% were male. The sites of infection were: lower limbs (54%), upper limbs (33%) and face (13%). The cellulitis had a median width of 7 (range: 1-38) cm and median length of 6 (range: 1-26) cm. Blood cultures were performed in 98%; one was positive for S. aureus. After 3 days of therapy, 39 patients (75.0%) were successfully discharged and switched to an oral agent. For these patients no relapse occurred. Thirteen patients required inpatient admission for further therapy for a mean additional duration of 3.9 (SD 2.5) days. Reasons for admission included osteomyelitis (2), abscess requiring drainage (2), underlying skin condition complicating therapy (1) and evolution of cellulitis deemed unsatisfactory by the treating physician (8). No patient was diagnosed with necrotizing fasciitis in the course of therapy. Forty-two anonymous satisfaction questionnaires were handed in and revealed very good to excellent parental satisfaction with treatment at the DTC in 95%. CONCLUSIONS: The DTC is a safe alternative to hospitalization for pediatric patients with moderate to severe cellulitis. Key words: cellulitis; pediatric

Prospective validation of a pediatric appendicitis score.

Goldman RD, Crump S, Stephens D, Langer JC. The Division of Pediatric Emergency Medicine, Department of Pediatrics, Population Health Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON

INTRODUCTION: Several clinical scores have been developed for appendicitis in adults. Samuel's pediatric appendicitis score (PAS) was developed on a cohort of patients in the UK. The aim of our study was to prospectively validate this score. METHODS: We prospectively recruited children 1-17 years old that came to our tertiary pediatric Emergency Department (PED), with a chief complaint of abdominal pain less than 7 days over a 12-month period. PAS components included fever > 38oC, anorexia, nausea/vomiting, cough/percussion/hopping tenderness (2-points), right-lower-quadrant tenderness (2-points), migration of pain, leukocytosis >10,000 (10⁹/L) and polymorphonuclear-neutrophilia > 7,500 (10⁹/L). A follow-up call was made to verify final outcome. Sensitivity, specificity and the receiver operating characteristic (ROC) curve of the PAS with respect to diagnosis of appendicitis was calculated. RESULTS: We collected data on 533 children. 97 (18%) had pathology proven appendicitis. Mean (median, range) score for children with appendicitis and without appendicitis was 6.7 (7, 2-10) and 1.8 (1, 0-9) respectively. If a PAS of 2 were used to discharge patients without further investigation, only 4 (4%) of children with appendicitis would have been sent home. The sensitivity at this level was 96% and specificity 74% . If a PAS of 6 or over were used to take children to the operating room without further investigation, only 14 (3%) would have undergone a negative appendectomy. The sensitivity at this level was 57% and specificity 97%. For the Samuel PAS the area under the ROC curve was 0.94. CONCLUSIONS: The Samuel PAS is useful, as a value of 2 is valid for ruling out appendicitis, and a score of 6 is valid for predicting the presence of appendicitis. Children with PAS of 3-5 should undergo further investigation such as ultrasound or computerized tomography. Key words: appendicitis; clinical prediction rule; pediatric

Epidemiology of pediatric cardiac and respiratory arrest in the cities of the CanAm Pediatric Study Group.

Stiell IG, Nesbitt LP, Berg RA, Berger S, Campbell S, De Maio V, Gallagher J, Hutchison J, Mears G, Mechem C, Nadkarni V, Osmond MH, Richmond N, Schwartz B, Tunik M, Valenzuela T, Wells GA, for the CanAm Pediatric Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: The CanAm Pediatric Study Group is a consortium of U.S. and Canadian cities and was created to conduct clinical trials for out-of-hospital pediatric cardiac (CA) and respiratory arrest (RA). In order to properly plan these trials, the group sought to determine the current incidence, etiology, and outcomes of children who suffer either cardiac or respiratory arrest. METHODS: The CanAm Pediatric Study Group communities represent 7 discrete geographic regions with a combined population of 27 million and are served by 30 different EMS ALS services. We conducted a cohort study that included all children <19 years with out-of-hospital CA or RA in a 12-month period. Data were collected from ambulance reports, dispatch data, and hospital records. Obtaining IRB and HIPAA approvals proved to be time consuming. We performed descriptive statistics with 95% CIs. RESULTS: Among the 525 children, we compared the 447 who suffered cardiac arrest to the 78 who suffered respiratory arrest for these characteristics: median age 2 (IQR 0-12) vs 6 (IQR 1-11); male 60.7% vs 62.3%; bystander witnessed 36.9% vs 56.4%; trauma related 25.1 vs 28.2%; SIDS 7.2% vs 0%; bystander CPR 18.6% vs 21.8%; asystole 69.3% vs 0%; PEA 25.2% vs 0%; VF/VT 5.5% vs 0%. Table 1 (of Abstract 55) compares interventions and outcomes for the two groups:

The annual incidences per 100,000 pediatric population were CA 8.3 and RA 1.4. CONCLUSIONS: This is the largest multicenter population-based cohort of pediatric CA and RA reported to date and reveals large differences from the adult arrest population. Future research and EMS management strategies need to prioritize the unique features of these lethal pediatric conditions. Key words: cardiac arrest; emergency health services; pediatric; resuscitation

Administration of analgesic medication by parents to children suffering from limb or clavicle area injury.

Maimon M, Marques L, Goldman RD. Division of Emergency Medicine, Hospital for Sick Children, Toronto, ON

INTRODUCTION: Our objectives were to document if parents administer analgesia to their children after suffering trauma to a limb or clavicle, and if they do so, what pharmacologic regimens are used. METHODS: We interviewed parents of children (0-18 years old) presenting to a large urban pediatric Emergency Department with an acute limb or clavicle injury. Demographic information, injury related circumstances and outcome were recorded. Student t-test and Chi-squared test were used to compare between parents who administered analgesic medications and those that did not. Statistical analysis was done using SPSS. RESULTS: A total of 214 families completed the interviews in the emergency department. 146 (68%) were found to have fractures, 59 (28%) discharged with a diagnosis of soft tissue injury and 9 (4%) had dislocation. 72% (153/214) of injuries were in the upper limb and 27% (58/214) in the lower limb. 3 (1%) patients had an injury that involved the shoulder. Most parents (44%, 94/214) chose to use non-pharmacological measures to treat their child's pain. 27% (59/214) used pharmacologic analgesia. 29% (61/214) of parents administered no analgesia before coming to the ED. The 3 most common reasons for not treating the child's pain were "Did not want to mask my child signs and symptoms" (37/181, 20%), "My child's pain was not bad enough" (33/181, 18%) and "Did not want to delay treatment by a doctor" (27/181, 15%). Of the 59 children that were treated for pain, 43/56 (77%) got the appropriate dose. When asked regarding treating the pain with anti-pain medication in the future in a similar scenario, 53% (112/212) reported they will treat their child for pain. 27% (58/212) of the families were still concerned that treating their child for pain will "interfere with the child assessment and treatment". CONCLUSION: Most children did not receive pharmacologic analgesia after an acute painful injury, before arriving to the ED. An educational endeavor is needed to improve parents' awareness of pain management in acute injury conditions. Key words: pain management; pediatric

What factors influence a parent's decision to enrol their child in a pediatric emergency research study?

Arasu M, Soo J, Millar KR. Division of Emergency Medicine, Alberta Children's Hospital, Calgary, AB

INTRODUCTION: This study aimed to determine the most significant factors that deter or encourage parents to enroll their children in pediatric emergency dept (PED) research studies. METHODS: We conducted a prospective survey of parents visiting the PED of the Alberta Children's Hospital from July to August, 2004. All parents presenting with children <17 years who were CTAS 3, 4, or 5 were eligible. The survey explored the importance of various factors in either positively or negatively influencing a parent to enroll their child into a research study. Parents were asked to rate their degree of agreement with how each factor might influence their decision to provide consent. RESULTS: Of 131 eligible respondents, 117 completed the survey, 11 declined, and 3 surveys were not returned. 94% of respondents agreed that more research was needed for childhood medical conditions. Parents would be positively influenced to enroll their child in a study if they perceived that: a) the study results would directly benefit their child [91% agree (A) or strongly agree (SA)], b) the treatment for their child's condition was unknown [85% A/SA], c) they could get a medication for their child which they otherwise could not afford [79% A/SA], d) the study was easy to understand [78% A/SA], e) their child would have access to otherwise unavailable medications (66% A/SA). Factors identified as being deterrents to enrolling their children in studies included: a) if the study involved "experimental therapy" [54% A/SA], b) if they were unable to consult with their spouse prior to providing consent [43% A/SA], c) if they were approached in the middle of the night [38% A/SA], and d) if the study required them to bring their child back for follow-up [37% A/SA]. The child's age, illness severity and wait time were not significant deterrents. CONCLUSIONS: This study may assist PED researchers to better address parents' concerns relating to enrolling children in research studies. Understanding parental perceptions may assist in improving recruitment for PED studies. Key words: pediatric; research

Culture results via the internet -- A novel way for communication after an emergency department visit.

Goldman RD, Antoon R, Tait G, Zimmer D, Viegas A, Mounstephen B. Division of Pediatric Emergency Medicine, Population Health Sciences, The Research Institute, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON

INTRODUCTION: The Internet is a health-information source for parents, children and pediatricians. Follow-up after patient discharge from the Pediatric Emergency Department (PED) is difficult although necessary to report tests received after discharge. The aim of this study was to determine whether the Internet could be used to facilitate the delivery of culture results to care-givers. METHODS: During a 10-month period, we approached parents of children that had cultures taken and were discharged from our tertiary PED. Internet access, e-mail use and demographic information were collected. Parents were given a unique ID and password to retrieve information on culture results from the study web-site. Results were posted on the web-site soon after they were received from the Hospital laboratory and an e-mail was sent to the family. Access pattern to the web-site was recorded, and a follow-up call with the family (after 5 or 10 days) was made. RESULTS: A total of 527 families were approached, 224 were excluded. Of 303 cultures available, 24 (8%) were positive and 5 (2%) were positive with contamination. 186 (61%) parents accessed the Internet-system after a mean of 94 hours (range 1m-611hr) after the e-mail was sent. Of the 243 (80%) families reached for follow-up, 66 (27%) "had no time" to enter the website. Almost 95% wanted future cultures and other tests to be posted in a similar way. CONCLUSIONS: The majority of recruited families used the new web-based follow-up system and were extremely satisfied. Future efforts should be made to increase awareness of parents and patients about the importance of obtaining culture results which would help implement a web-system such as ours. Key words: emergency health services, quality