2005 CAEP / ACMU Scientific Abstracts - Poster Presentations: 85-99

A survey of one CCFP(EM) program's graduates: their background, their intended type of practice and their actual practice.

Shepherd LG, Burden JK. Division of Emergency Medicine, University of Western Ontario, London, ON

INTRODUCTION: The purpose of this study was to examine one College of Family Physicians of Canada Certification of Special Competence in Emergency Medicine [CCFP(EM)] program's graduates to determine their background, their intended type of practice and their actual practice. METHODS: All 83 physicians who had completed a CCFP(EM) residency year of training at the University of Western Ontario (UWO) from 1982-2004 were surveyed. Cross tabulations tables for all combinations of two characteristics/factors from the data set were calculated. Chi-square tests of interdependence were applied. RESULTS: We received 72 survey replies for a response rate of 87.0%. 71% of the respondents were male. Only 8% grew up in a rural community versus 43% and 49% from regional and urban centres respectively. Overall, 50% of respondents intended to practice emergency medicine exclusively at the start of their CCFP(EM) residency training while 47% intended to undertake a blended practice of family medicine and emergency medicine with 3% undecided. Neither gender nor medical school attended influenced intended type of practice. The majority of graduates (range 72-53% over the first four positions of employment) practiced emergency medicine exclusively. The number of physicians practicing a blended emergency and family medicine practice was never greater than 20% throughout all positions. Examining all positions of employment, 11.3% were in a rural setting vs. 48.4% and 40.3% in regional and urban centres respectively. There were no relationships demonstrated between gender, size of city in youth and eventual location of practice. For all positions "type of practice" was the highest ranked factor of influence in choosing position of employment. CONCLUSIONS: The majority of graduates of the UWO CCFP(EM) program have worked in emergency medicine positions and had this intention from the start of residency. No demographic factors surveyed had significant correlation with intended or actual practice. Key words: workforce; emergency medicine; medical training

ED teaching shifts: Are they effective for teaching medical students?

Clow J, Frank JR, Lee C, Nuth J, Weitzman B. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: The ED has been recognized as a rich environment for teaching medical students. However, in an era of overcrowding and under funding, medical students can sometimes not receive optimal teaching and supervision. Teaching shifts have been promoted as an answer to these challenges. We investigated the perceptions of students and faculty with respect to the effectiveness of a dedicated teaching shift as part of a new third-year EM clerkship. METHODS: We conducted a cross-sectional survey of all medical students in the initial cohort to complete a new EM clerkship, as well as all EM residents and EM faculty eligible to teach medical students. Via email and paper, respondents were asked to rate the effectiveness of the teaching shifts, perception of the number of observed histories and physicals on teaching shifts, and to indicate the strengths and weaknesses of the teaching shift format. Narrative answers were coded for analysis. RESULTS: Respondents included 58 of 75 (77.3%) of students and 39 of 46 (84.8%) of teachers. Students and faculty rated their overall satisfaction as 4.51 and 4.25, respectively (p = 0.17). Students and teachers rated more histories and physicals were observed during the teaching shifts (4.23 and 4.08 out of 5, respectively, p = 0.56). Identified strengths included: practical teaching, good feedback, dedicated supervision, and observed histories and physicals. Challenges identified included: dependence on patients present in the ED, variable quality in teachers, large groups and scheduling issues. CONCLUSIONS: Students and teachers perceive the ED teaching shift to be effective. Key words: medical education; emergency medicine

Use of an online needs assessment to identify learning needs of rural and urban emergency practitioners for a web-based learning environment.

Curran J, Murphy A, Sinclair D, Best S. Department of Emergency Medicine, IWK Health Centre/Dalhousie University, Halifax, NS

INTRODUCTION: Access to timely and relevant pediatric emergency medicine continuing education opportunities has been identified as a key priority by CAEP. A Multidisciplinary Pediatric Emergency Care [MPECW] Learning Centre was developed to address gaps in the current delivery of education within rural and urban emergency departments[EDs] in Nova Scotia. An online needs assessment was conducted to determine content areas for inclusion in the Learning Centre. METHODS: The needs assessment was developed during roundtable discussions of the investigative team based on literature review, current trends, experience and incidence of conditions presenting to emergency departments. The needs assessment was pilot tested with a group [n = 12] of multidisciplinary practitioners and modified. Study participants [n = 157] from eleven provincial EDs were asked to complete an online needs assessment and rank pediatric emergency content areas for relevance, volume, and importance. Needs assessment data was analyzed using SPSS. RESULTS: Forty-seven percent [97/204] of participants who signed consent forms completed needs assessments. Eleven percent of respondents were male and 77% were between 30-49 years of age. Of participants completing needs assessment, 87% were nurses and 11% were physicians. Greater than 10 years of experience in emergency care was reported by 38% of clinicians. The content areas that were ranked most frequently as having a high degree of relevance to their practice were lacerations [74%], managing airways [71%] and asthma [53%] Managing airways [48%], advanced pediatric assessment [34%] and reading cardiac rhythm strips [33%] were ranked as number one in level of importance by respondents. CONCLUSIONS: Web-based technology is a useful means for sharing knowledge and improving access to continuing education. This study demonstrates that the utilization of an online needs assessment survey is an effective means for gathering information related to learning needs of emergency practitioners in urban and rural health centres. Key words: e-medicine; medical education; lifelong learning

Perceived barriers to emergency ultrasound use by emergency medicine residents: pilot study.

Woo MY, Reardon M, Lee AC, Frank JF. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: Emergency Ultrasound training has begun at many residency programs across Canada. However, little is known about their effectiveness. We set out to identify potential barriers to Emergency Ultrasound use by Emergency Medicine Residents. METHODS: A questionnaire was developed based on current literature and using standard methods. Two Academic Emergency physicians reviewed the validity and reliability of the questionnaire. The questionnaire was then pilot tested by an Emergency Medicine Resident. Research ethics approval was obtained. The questionnaire was given to all Emergency Medicine Residents at the University of Ottawa. The survey consisted of 24 questions regarding demographics, current use, and potential barriers to Emergency Ultrasound use. RESULTS: The response rate was 75% (12/16). 58% of respondents agreed or strongly agreed that clinical shifts in the Emergency Department are too busy to perform Emergency Ultrasound. Equally 67% felt that there was not enough supervision. 67% agreed that it is too difficult to review scans with attending staff while 100% agreed or strongly agreed that not enough attending staff use Emergency Ultrasound. While on off-service rotations, residents were unable to do any Emergency Ultrasound scanning and 75% agreed that this was a barrier to scanning. CONCLUSION: Identification and addressing potential barriers to Emergency Ultrasound is important in providing a successful training program for Emergency Medicine Residents. Increasing the number of attending staff who perform Emergency Ultrasound may improve Emergency Ultrasound use by Emergency Medicine Residents. Key words: emergency medicine; ultrasound; medical education

Residents' attitudes and practices regarding the use of analgesia and sedation for lumbar puncture in children.

Breakey VR, Pirie J, Goldman R. The Hospital for Sick Children, Toronto, ON

INTRODUCTION: Although analgesia and sedation for painful procedures in children are safe and effective, pain management during lumbar puncture (LP) in children is often sub-optimal. The purpose of this study was to document factors influencing residents' decisions to use analgesia and sedation during LP and compare practices of Pediatric Residents (PR) and Emergency Medicine Residents (ER). METHODS: PR and ER Residents from across Canada responded to a mailed survey regarding the use of analgesia and sedation for LP in children. Student t-test and χ-squared test were used to compare the groups using SPSS statistical software. RESULTS: 245/374 (67%) residents completed the survey. 57% and 1% of PR and ER respectively reported frequently doing LPs with no local anesthetic (p < 0.005). PR reported more frequent use of EMLA (64% vs. 27%, p < 0.005) whereas PR reported less frequent use of lidocaine (29% vs. 94%, p < 0.005). Both groups recorded witnessing adverse effects of local anesthesia at a low rate (3 vs. 5%) and the rates were not significantly different. 78% of PR reported using sedation at least once for LP versus 60% of ER (p < 0.005). 35% of PR reported frequent use of benzodiazepines, compared to 20% of ER (p < 0.05), but there was no significant difference in the reported use of Ketamine (11% vs. 9%). 19% of PR witnessed adverse effects of sedation versus only 5% of ER (p < 0.05). 39% of PR and 57% of ER reported formal education in the use of sedation (p < 0.05). More PR were responsible for teaching trainees (75% vs. 44%, p < 0.005). PR were less likely to recommend the use of local anesthetic during LP when teaching the procedure (p < 0.005). CONCLUSIONS: Most PRs report infrequent use of local anesthesia for LP in children but use more sedation than ER. PRs indicate less education in sedation than ER and higher incidence of adverse effects of sedation. These findings should initiate development of an educational curriculum to improve procedural competency and ensure PRs are capable teachers, as they educate more trainees. Key words: procedural sedation; lumbar puncture

Effective EM medical education: preliminary evaluation of a new core emergency medicine clerkship.

Frank JR, Nuth J, Weitzman B, Lee C. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: There is renewed interest in Canada in enhancing medical student education in emergency medicine (EM), but very few outcome studies have been done to identify effective methods. We conducted a systematic program evaluation of the initial cohort in a new EM clerkship at the University of Ottawa in order to identify the effectiveness of both the activities and the clerkship overall. METHODS: We used multiple methods to obtain data on program activities and overall program effectiveness. Student satisfaction data were obtained from surveys of the initial cohort who completed the clerkship. Change in student competence was assessed in each procedural skill workshop. Data forms were collected after each activity, before and after each skills workshop, and at the end of the clerkship rotation. Faculty and the Undergraduate Dean were surveyed at the end of the first year. Primary outcome was the overall satisfaction ratings of students and faculty. Secondary outcomes included: change in pre-post competence scores in clinical skills, student achievement of procedure performance, and student satisfaction with individual learning activities. RESULTS: Data were analyzed on the first 8 clerkship rotations. Overall student evaluation of the value of the clerkship was 4.7 on a 5-point Likert scale. Teachers and the Dean rated the clerkship highly. All skills workshops demonstrated significant change in objective skills competence: Cohen's D = 1.65 for suturing, 1.38 for IV, 1.58 for NG, and 1.38 for Foley. 99% of students met expectations in bedside procedure performance. ACLS, procedure labs, and web materials were the highest rated activities. Triage and EMS rideout shifts were rated lowest. CONCLUSIONS: Preliminary data indicate that this design for the new EM clerkship is effective. Key words: medical education; undergraduate training; emergency medicine

Etiology of pediatric out-of-hospital cardiac arrest by coroner's diagnosis.

Ong MEH, Stiell IG, Osmond MH, Nesbitt L, Gerein R, Campbell S, McLellan B, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: Determining etiology of pediatric Out-of-Hospital Cardiac Arrest (OHCA) based on clinical impression has limitations and autopsy remains the 'gold standard'. We sought to determine etiology of pediatric OHCA in a population-based sample from autopsy and coroner's diagnosis. METHODS: As part of the Ontario Pre-hospital Advanced Life Support (OPALS) study, we conducted a prospective cohort study including children below age 19 with OHCA in 20 cities. Deaths were matched with provincial coroner's office records, autopsies and investigation notes were reviewed, and descriptive statistics compiled. RESULTS: From 1992 to 2002, there were 474 cardiac arrests in children giving an annual incidence of 59.7 per million children. Characteristics were mean age 5.8, <1 year of age 43.0%, male 59.1%, bystander witnessed 25.1%, bystander CPR 20.3%, survival to discharge 2.3%. 439 matched to coroner's office records. Estimated annual incidence rates per million by age groups were: 175.0 (age 1-4 years), 33.0 (age 5-14 years) and 61.6 (age 15-18). Annual incidence rates per million according to coroner's cause of death were: natural (26.2), accidental (17.4), suicide (3.7) and homicide (1.9). The post mortem rate was 84.3% and mean Injury Severity Score was 31.4 (SD 16.5). The commonest causes of natural death were SIDS (30.3%), cardiovascular (19.2%), respiratory (18.3%), neurological (8.7%) and perinatal (7.2%). The commonest causes of accidental death were drowning (27.5%), residential accidents (18.8%), fire (13.0%), motor vehicle collision (12.3%), pedestrian (7.2%) and bicycle (4.3%). CONCLUSION: This is the largest study looking at the causes of pediatric OHCA from coroner's diagnosis. Besides 'medical' causes of mortality, up to 52.6% of these deaths were from 'unnatural' causes (accidental, suicide, homicide, undetermined) and may be amenable to prevention or intervention. Our findings will be useful for planning prevention, treatment and future research of pediatric OHCA. Key words: prehospital; pediatrics; cardiac arrest

Patient response to written notification during prehospital care trials using waiver of informed consent.

Spence JM, Notarangelo V, Frank J, Long J, Morrison LM. Division of Emergency Medicine, University of Toronto, Toronto, ON

INTRODUCTION: Resuscitation research has been allowed to proceed using Waiver of Informed Consent when compliance with guidelines is assured. In these circumstances, there is a commitment to notify enrolled patients. This study describes the notification experience for 2 prehospital care (PHC) trials in a city serving 2.5 million people with a single EMS system. METHODS: Results of written notification were reviewed for 2 studies (N = 620): 1) ORBIT, an RCT comparing rectilinear biphasic and monophasic damped sine waveform for out-of-hospital cardiac arrest 2) PrePACE, an RCT comparing dopamine and transcutaneous pacing for unstable bradycardia. RESULTS: The ORBIT study enrolled 538 patients, 72% male, with a mean age of 67 years. Survival to discharge was 8%. In 44 (8%) patients, contact information could not be obtained from ambulance or hospital records. Notification was attempted for 494 (92%) patients for whom information was available. No response was obtained for 408 (83%) letters; 48 (10%) letters were returned. Researchers were contacted by telephone regarding 38 (8%) subjects: 17( 3%) requested information, 14 (3%) responded positively, 1 (0.2%) did not return follow-up calls, and 2 (0.4%) were withdrawn from the study. PrePACE enrolled 82 subjects, 54% male, with a mean age 74 years. Survival to discharge was 17%. Contact information was unavailable for 1 (1%). For the remaining 81 patients, no response was obtained from 67 (82%); 4 (5%) letters were returned. Researchers were contacted 10 (12%) times: 7 (9%) requested information, 2 (2%) responded positively, 1 (1%) did not return follow-up calls. No patients were withdrawn from the study. CONCLUSIONS: Contact information may be difficult to obtain for critical patients treated in the PHC setting. A significant number of persons contact researchers; however, most requests are for information. Most responses are positive. Small numbers may be withdrawn from studies after written notification of participation. Key words: EMS; informed consent; clinical trials

ED offload study: the subjective impressions of patients awaiting EMs offload in the ED.

Jamieson T, Fried B, Friedman SM. Department of Family and Community Medicine, University of Toronto, Toronto, ON

INTRODUCTION: To characterize patient impressions during EMS offload delay. METHODS: Convenience sample in downtown teaching hospital. A standardized survey was administered to patients upon arrival by EMS and hourly until offload. Fisher's and McNemar's tests performed using Excel and SAS. RESULTS: Data was collected for 76 hours (12 intervals, 16 weeks). 60 patients arrived by EMS, 30 met inclusion criteria and 22 (73.3%) consented. Mean offload delay was 71 minutes (range 16-283). At initial survey 32% (95% CI 0.12, 0.51) rated privacy as good or very good, 27% (95% CI .09, 0.46) were concerned others could see them, and 18% (95% CI 0.02, 0.34) were concerned that personal information could be overheard. Good or very good ratings were scored for comfort by 50% of patients (95% CI 0.29, 0.71), dignity by 64% (95% CI 0.44, 0.84), and safety by 86% (95% CI 72, 100). Hourly patient interviews demonstrated worsening perceptions regarding personal information being overhead (P = 0.0053), exposure (p = 0.0128), privacy (p = 0.0124), and comfort (p = 0.0097). Median ten point pain score increased from 4 to 7 for patients over two or more hourly surveys (N = 9). Interviews of 21 patient-medic pairs demonstrated a significant relationship between patient and medic ratings of patient privacy (p = 0.0088). Patients tended to report higher privacy ratings (p = 0.0030) than their medics. CONCLUSIONS: Patient impressions of privacy were inferior to perceived safety and comfort. Impressions of overall privacy and comfort diminished over time. There is a significant relationship between medic and patient estimates of patient privacy. Key words: EMS; overcrowding; patient satisfaction

Pre-hospital index, high velocity impact and emergency medical technician judgement as trauma center triage criteria.

Emond M, Lavoie A, Moore L, Sampalis JS. Division of Emergency Medicine, Laval University, Quebec City, QC

INTRODUCTION: Our objective was to compare prehospital trauma triage tools to emergency medical technician (EMT) judgment for the triage of injured patients. METHODS: A retrospective cohort consisting of 17,377 trauma patients transported to two level I trauma centers was identified. Two triage tools: the Pre-Hospital Index (PHI) and High Velocity Impact (HVI) were evaluated and compared to EMT judgment for their efficiency at triage. Outcome measures were obtained by univariate and logistic regression analyses. RESULTS: 69,8% of trauma patients being transported directly to level I trauma centers did not meet the minimum requirements for transport by either the PHI, HVI or EMT judgment. 994 patients had a PHI e 4 (5.5%), 3,610 patients had HVI (20.8%), and 2,875 patients were judged to be "major" trauma by EMTs (16.6%). There were 4,288 (24.5%) patients with either a PHI e 4, or HVI. There were 991 (5.7%) patients receiving the classification of "major" trauma by EMT judgement with PHI < 4 and no HVI. Logistic regression was performed to identify outcomes, which were well correlated with each triage method. Overall, PHI was found to be the best predictor of death and death in the first 72 hours after arrival at hospital. EMT judgment was found to be the best predictor for the need for Intensive Care Unit (ICU) admission, high injury severity scores (ISS). HVI was not found to be the best predictor of any severity indicator. Subsequent analyses in the geriatric trauma population (age > 65 y) showed significant lowest predicting capacities of all criteria. The best sensitivity at detecting death at 72 h was achieved by the combination of all three criteria. CONCLUSIONS: PHI in combination with EMT judgment identify seriously injured trauma patients who have high mortality rates, high ISS, high rates of ICU admission. The HVI may add only little to the armamentarium of pre-hospital personnel in identifying seriously injured patients. All of those predictors perform differently in the geriatric trauma population. Key words: EMS; trauma; prediction tools; geriatrics

Occupational injuries and stressors among Canadian air medical health care professionals in rotor-wing programs.

Sibley AK, Tallon JM, Day A, Ackroyd-Stolarz S. Department of Emergency Medicine, University of Alberta, Edmonton, AB

INTRODUCTION: Air medical crews are faced with unique occupational risks including: noise, vibration, and the physiological and psychological stresses of flight. Despite this knowledge, little evidence exists about the effects that these factors have on the physical health of the air medical crew. Following a comprehensive search of the literature, we were unable to identify any studies that evaluated the occupational injuries specifically incurred by air medical healthcare professionals. We sought to characterize the epidemiology of occupational injuries experienced by Canadian rotor-wing healthcare providers. METHODS: A survey was sent to the four rotor-wing programs in Canada and distributed among the crews by the respective Air Medical Directors (AMDs). All crew members participating directly in patient care were asked to complete the survey detailing any acute occupational injuries sustained within the previous year. A series of both open and closed-ended questions was used to collect participant demographics as well as information regarding any injuries sustained. Return of the survey implied consent and AMDs were unaware of crew participation. RESULTS: One hundred and six (40.6%) participants completed the survey. Three hundred and thirty acute injuries were reported. Hand lacerations and leg contusions were most prevalent (31 and 24 individuals incurred these injuries, respectively). Acute back injuries were also prevalent with 25 (23.6%) participants reporting at least one back injury. Overall, an injury rate of 3.2 injuries per person per year was reported. Lifting was cited as a common factor in injury (30 cases). Most injuries required little treatment with only 17 needing physician intervention, and only 6 injuries required more than one week off work. CONCLUSIONS: Injuries among Canadian air medical crews are common but fortunately the majority are minor in nature. Specific injury prevention strategies may focus on stretcher design, cabin ergonomics, as well as extremity protective equipment. Key words: occupational health; EMS; aeromedical

Pre-hospital ALS procedures in major trauma.

Banihashemi B, Nesbitt L, Maloney J, Trickett J, Stiell IG. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

INTRODUCTION: Pre-hospital advanced life support (ALS) care is routinely provided by paramedics to major trauma patients. However the literature does not clearly indicate which, if any, interventions are effective. As a feasibility study, we evaluated pre-hospital ALS procedures and their association with mortality and morbidity in major trauma. METHODS: We conducted a health records review that included Ontario Advanced Life Support (OPALS) Study cases for 2003 that had an Injury Severity Score of greater than 12 and were transported to the regional trauma hospital via land in a mixed BLS-ALS EMS service. Excluded were patients who were younger than 16 years of age. Data were collected from ambulance reports, dispatch data, and hospital records. We reviewed IV line insertion, intubation, and fluid therapy as the main ALS procedures performed by paramedics. RESULTS: Among the 116 patients, mean age was 46 years, 26% had a GCS score < 9, and the mortality rate was 21.6%. ALS procedures (see Table 1, Abstract 96):

15 cases were intubated within the first 30 minutes of ED arrival but had no attempt for pre-hospital intubation. In 15 cases, there was a delay of more than 5 minutes at the scene to establish an IV line. 54% of this subgroup received more than 500 ml of IV fluid in ED. 27% received more than 500 ml in the pre-hospital setting. 27% of the cases who were not attempted for pre-hospital IV line received more than 500 ml of IV fluid within the first 30 minutes in ED. CONCLUSIONS: In addition to characterizing the use of ALS procedures for major trauma, this study showed that there may be a need to review the pre-hospital indications for intubation and fluid bolus. Key words: EMS; trauma; procedures

Impact of an emergency department-based geriatric nurse practitioner on hospital readmission rates.

Theakston KD, Campbell KE. Division of Emergency Medicine, University of Western Ontario, London, ON

INTRODUCTION: The frail elderly are a complex patient group at high-risk for ED and hospital readmissions. The purpose of this prospective study was to describe the characteristics of the frail elderly population presenting to an acute care teaching hospital ED and assess the impact of an ED-based Geriatric Nurse Practitioner (GNP) on hospital readmission. METHODS: A GNP was seconded from the Geriatric Program. All community dwelling patients >74 years old presenting to the ED were screened by their emergency nurse for referral to the GNP using a simple 6-item triage tool (TRST) previously validated to identify elderly patients at high risk for ED and hospital readmission after ED discharge. The GNP conducted a geriatric assessment in the ED or by telephone. Geriatric issues were identified and a plan was developed collaboratively with the patient, family, and family physician to ensure that these frail elderly were linked with appropriate community resources. Prospectively collected data from the TRST and the standardized GNP assessment form were abstracted to a database and analyzed using SPSS. The primary study outcome was the 30-day hospital readmission rate after their index visit to the ED. RESULTS: During the 6-month study period, 176 patients were referred to the GNP. These patients had a high percentage of geriatric risk factors: falls (48%), depression (30%), cognitive impairment (42%), recent functional decline (71%), malnutrition (15%). On their index ED visit 26% required admission to hospital. In the 6 months prior to the study there were 6 geriatric service referrals. During the study, GNP assessment resulted in 64 new Homecare enrollments and 40 referrals to specialized geriatric outpatient services. The 30-day hospital readmission rate after the ED GNP assessment and intervention was only 6/176 (3.4%). CONCLUSIONS: This prospective cohort study describes a process to identify a frail elderly ED population and the positive impact of introducing an ED-based GNP on hospital readmissions. Key words: geriatrics; emergency medicine; nurse practitioner

Anxiety in older persons and unscheduled return visits to the emergency department.

Schwindt GC, Lee JS. Emergency Medicine Research Program, Sunnybrook & Women's Health Sciences Centre, Toronto, ON

INTRODUCTION: Previous research shows that older persons are twice as likely as younger persons to return to the emergency department (RTED). Several factors are associated with increased risk of RTED in older persons, including cognitive impairment, difficulty walking, polypharmacy, recent hospitalization or ED visit, and poorer mental health, particularly depression. Anxiety is associated with increased likelihood of RTED in the general population, however the role of anxiety in predicting RTED in the elderly has not been specifically examined. The objective of the present study was to assess whether anxiety, as measured by the Hospital Anxiety and Depression Scale Anxiety sub-scale (HADS-A), predicts unscheduled RTED among older persons. METHODS: We conducted a prospective cohort study of patients ≥70 years of age discharged from the ED after a fall. After providing consent, subjects completed a baseline HADS-A and were contacted at 30 and 60 days post-discharge and assessed for subsequent RTED. Logistic regression (LR) analysis was performed, and the multivariate odds ratios (OR) and respective 95% confidence intervals (CI) are reported. RESULTS: 81 subjects participated (mean age 79.7 years, 70% female, mean mini-mental status exam [MMSE] 27.9). OR for any RTED by 60 days for the following risk factors were not significant: Age per year (OR = 1.0; 95% CI 0.9-1.1), MMSE per 1 point (OR = 1.0; 95% CI 0.8-1.3), and fracture at first visit (OR = 1.2; 95% CI 0.3-4.3). However, controlling for age, injury, and MMSE, a clinically significant increase in HADS-A of 4 points was associated with a 2.7 times greater OR of RTED (95% CI 1.3 to 5.8). CONCLUSIONS: Higher anxiety was associated with a higher likelihood of RTED. These results are relevant to studies attempting to modify RTED. Future studies should assess the relationship of anxiety to appropriateness of return visits in older persons. Key words: elderly; anxiety; emergency medicine

Application of the Canadian CT-Head Rule in patients 65 years of age and over.

Lee JS, Stiell IG, Brison R, Clement C, Rowe BH, Schull MJ, Wells GA, for the CCC Study Group. University of Toronto, Toronto, ON

INTRODUCTION: The Canadian CT Head Rule (CCHR) consists of 5 high and 2 medium-risk criteria, and is highly sensitive for clinically important brain injury (CIBI) and need for neurologic intervention (NI) after minor head injury (MHI). However, all patients ≥65 years require head CT to achieve this high sensitivity. We sought to assess the importance of the age ≥65 criteria to the CCHR. METHODS: The CCHR was derived and validated in two prospective cohorts of adults presenting after MHI to 10 tertiary care EDs. We performed logistic regression on data from both cohorts and calculated odds ratios(OR) and 95% confidence intervals(95% CI) for the CCHR variables stratified by age ≥65. We defined MHI as GCS 13-15 with witnessed LOC, amnesia, or confusion. RESULTS: Of 5858 patients, 655 were ≥65 years (mean age 75.5), 56% were male, 21.5% had CIBI and 3.4% required NI. Omitting the age ≥65 criteria would have missed 24/141 subjects with CIBI and 3/21 patients requiring NI. OR with 95% CI of the CCHR criteria are presented in Table 1 (of Abstract 99):

The criteria performed similarly in those ≥65 for CIBI. Vomiting ≥2 times and depressed skull fracture were poorer predictors of NI in those ≥65. CONCLUSIONS: Age 65 or over is an important component of the CCHR. Further research should seek to improve the specificity of the CCHR without sacrificing sensitivity in this rapidly growing segment of the population. Key words: clinical guidelines; head trauma; elderly