2007 CAEP/ACMU Scientific Abstracts - Oral Presentations: 31-44

2007 Scientific Abstracts

CJEM 2007;9(3):183-226

Abstracts: 1-30, 31-44, 46-48, 100-130, 131-159, 161-189, 191-216

Oral Presentations

31 PATIENT-REPORTED adverse drug related events from emergency department discharge prescriptions

Hohl CM, Abu-Laban RB, Zed PJ, Brubacher JR, Tsai G, Kretz P, Nemethy K, Bjilsma JJ, Purssell RA. Department of Emergency Medicine, Vancouver General Hospital; Faculty of Medicine, University of British Columbia, Vancouver, BC

Introduction: Preventable adverse events (AE) claim the lives of up to 23,750 Canadians annually. Adverse drug related events (ADREs) are the second most common type of preventable AE. Our objective was to quantify and describe patient-reported ADREs from Emergency Department (ED) discharge prescriptions. Methods: This prospective study was carried out in a tertiary care center with an annual census of 65,000. Research assistants (RAs) enrolled a convenience sample of patients during shifts which mirrored our ED's discharge pattern. RAs identified discharge prescriptions and made up to 5 attempts to contact patients by phone 2 - 4 weeks after the index visit. Patients were asked to describe any AEs they had experienced and believed were associated with discharge medications. We deemed an ADRE to be present if reported symptoms were consistent with a recognized ADRE, and symptom onset and resolution occurred within a plausible timeframe after commencing and discontinuing the medication. Adherence was determined from a provincial prescription dispensing database and by pill count. Results: Of 1965 patients screened, 301 were discharged with a prescription and agreed to participate. Follow-up was successful in 257 patients (85.4%). The most common prescriptions were for acetaminophen with codeine (27.2%), ciprofloxacin (8.2%) and cephalexin (6.2%). Fifty-four patients (20.9%, 95% CI 16.4% to 26.3%) reported ADREs including: constipation (5.8%), nausea (5.8%), drowsiness (4.3%), allergic reactions (1.2%) and diarrhea (1.2%). There was a trend between the occurrence of ADREs and non-adherence to medication (crude OR 1.8; 95% CI 1.0 to 3.3) which persisted with logistic regression modeling (adjusted OR 1.6; 95% CI 0.9 to 3.0), but not between ADREs and ED revisits. Conclusions:Patient-reported ADREs to ED discharge medications are common. The presence of an ADRE is associated with a trend towards a higher incidence of non-adherence to discharge medication. Key Words: Adverse drug events, Prescriptions

32 The Narcotic Overdose Respondent Intervention Survey (NORIS)

Dong KA, Blitz S, Rowe BH, Wild C. Department of Emergency Medicine, University of Alberta, Edmonton, AB

Introduction: Drug use and overdose is an important problem in many Canadian centers. Most overdoses in the community are witnessed and death occurs over several hours, giving ample opportunity for those present to intervene; however, morbidity and mortality remains high. The objective of this study was to document the circumstances surrounding drug overdose in a cohort of opiate and non-opiate users in a major Canadian centre. Methods: Clients accessing a needle exchange program were approached for participation in the study. After informed consent was obtained, participants answered a series of questions regarding demographics, personal experience with overdose, emergency medical services (EMS) use, and response to witnessing an overdose. Support for a community based naloxone intervention was also assessed. Results: A total of 153 clients participated in the survey. Most respondents were male (74%) and the median age was 40 years (IQR 33.0, 46.0). The most commonly used drugs in the last six months were marijuana (61%), crack cocaine (58%), alcohol (50%) and morphine (49%). The median number of overdoses ever experienced was 1 (IQR 0, 4) and the median number of overdoses ever witnessed was 2 (IQR 1, 10). Over 30% of respondents avoided calling EMS at least some of the time; fear of police involvement and/or thinking they would be blamed for the overdose were cited as main concerns. Support for a community based naloxone program was widespread (> 80%). Regular opiate users were more likely to have experienced an overdose (p < 0.001) and to have attempted artificial respiration and chest compressions in an overdose setting than non-opiate users (p = 0.001). Conclusions: Overdoses are commonly experienced and witnessed by regular drug users; however, significant barriers to EMS activation exist. Community programs should focus on overdose prevention and basic life support training. Community based naloxone programs warrant further consideration and study. Key Words: Narcotic overdose, Naloxone, Community

33 DEVELOPMENT of a novel adverse events scale for clinical trials of ED procedural sedation

Murray HE, Messenger DW, Dungey PE, VanVlymen J, Sivilotti MLA. Department of Emergency Medicine, Queen's University, Kingston, ON

Introduction: Previously published trials of procedural sedation used adequacy of sedation as the primary outcome, while individual adverse events were represented as secondary outcomes. As procedural sedation becomes routine in the ED, and as clinical trials require more comprehensive primary outcomes, a novel framework is needed to identify both the number and severity of individual adverse events encountered. Objective: To evaluate the feasibility and criterion validity of a newly developed adverse events scale. Methods: Prior to a clinical trial, a focus group of emergency physicians and anesthesiologists ranked cardiac and respiratory adverse events according to relative severity. By consensus, a four-level, mutually exclusive ordinal scale (none, mild, moderate and severe) was created. Physicians blinded to the scale recorded individual adverse events, and ranked overall severity on a 10-point score. Criterion validity was tested through correlation between the scale and both the 10-point severity score and the total number of observed adverse events using Kendall's tau-b. Results: Of 63 patients enrolled, at least one adverse event was experienced by 41(65%): 18 (28.6%) mild, 18 (28.6%) moderate, 5 (7.9%) severe. In all, 123 individual adverse events were observed. All events were rapidly corrected with no morbidity. Correlations between the scale and the severity score (0.74±0.05), and the total number of adverse events (0.78±0.05) were very high (p<0.001). Inter-rater reliability of the scale was not tested. Conclusions: Our new scale is simple and comprehensive, with high face validity. It performed well in this clinical trial and was very sensitive to a range of cardio-respiratory events. Even minor and transient adverse events can be important markers both for future research and ongoing quality assurance focused on safety. This scale can provide an instrument for clinicians and researchers in this emerging area. Key Words: Procedural sedation, Adverse events, Outcomes

34 DRUG-RELATED visits to the emergency department of a large Canadian hospital: a prospective study

Zed PJ, Abu-Laban RB, Balen RM, Loewen PS, Hohl CM, Brubacher JR, Wilbur K, Wiens MO, Samoy LJ, Lacaria K, Purssell RA. Departments of Pharmacy and Emergency Medicine, Queen Elizabeth II Health Sciences Centre; Capital District Health; College of Pharmacy and Department of Emergency Medicine, Dalhousie University, Halifax, NS

Introduction: Few data are available for the rate and characterization of drug-related visits (DRVs) to Canadian emergency departments (EDs). Our objective was to determine incidence, severity, preventability and classification of DRVs in the ED of a large tertiary care Canadian teaching hospital.Methods: A prospective, observational study of adults presenting to the ED over 12-weeks in 2006 was conducted. Patients were randomly selected for inclusion using a systematic sampling methodology stratified a priori by time of day, day of week and ED treatment location, to ensure a generalizable sample. Pharmacist research assistants assessed subjects to determine if their visit was drug-related according to one of eight categories. Severity and preventability were classified using predefined definitions. Primary outcomes were reported as proportions presented as percentages with 95% confidence intervals (CIs). Results: 1017 patients were enrolled (mean age 49.6 ± 20.8 years, 52.1% female). A DRV was identified in 12.0% (95%CI 10.1-14.1%) of which 68.0% (95%CI 59.3-75.6%) were deemed preventable. Severity was classified as mild, moderate and severe in 15.6% (95%CI 10.2-23.1%), 74.6% (95%CI 66.2-81.5%), and 9.8% (95%CI 5.7-16.4%) of cases, respectively. The most common reasons for DRVs were adverse drug reactions 39.3% (95%CI 31.1-48.2%), non-compliance 27.9% (95%CI 20.7-36.4%) and wrong/suboptimal drug 11.5% (95%CI 7.0-18.4%). 96 individual drugs were implicated in 122 DRV cases; 80 patients had 1 drug implicated, 27 had 2 drugs implicated, and 15 had 3 drugs implicated. The most common drug classes associated with DRVs were central nervous system agents (40.8%), cardiovascular agents (18.4%), non-opioid analgesic/anti-inflammatory agents (14.0%), and antibiotics (11.2%). Conclusions: A drug-related cause was found in approximately one of every nine ED visits, and over two-thirds were deemed preventable. Drug-related visits to the ED are a significant problem that merit further research and intervention. Key Words: Drug related, Adverse events

35 ED overcrowding: the perspectives of medical directors in Alberta

Rowe BH, Tam SL, Holroyd BR, Bullard M, Latoszek K, Yoon P. Department of Emergency Medicine, University of Alberta, Edmonton, AB

Introduction: Overcrowding of emergency departments (EDs) in Canadian urban hospitals is a well recognized problem; however less is known about ED overcrowding across an entire province. The present study aims to describe the frequency, impact, and factors associated with ED overcrowding in the province of Alberta. Methods: A 29-item, paper-based questionnaire was distributed to ED Medical Directors at either hospitals with EDs or Health Care Centres with acute care services (N=102 sites) in the Fall of 2006. ED administrative data were provided by the Alberta Health and Wellness registries. Statistical tests including chi-square and T-tests were applied for data comparison. Results: The survey was completed by 85 ED Directors (83% response rate). While 33% reported overcrowding as an overall serious problem during the past year, 94% reported this major problem in regional and urban sites. Many directors reported that ED overcrowding had a major impact on increasing stress among physicians (58%) and nurses (71%) and led to increased patients in the ED waiting for beds (41%). Directors further reported the quality of patient care was severely impacted including increased waiting times (69%), risk of poor patient care outcomes (37%), and medical error (18%). Directors attributed ED overcrowding to a variety of issues including a lack of admitting beds (40%), as well as shortages of medical (42%) and nursing (77%) staff. In rural areas, in particular, ED medical directors perceived a lack of alternatives to the ED to be a significant contributing factor to ED overcrowding. Most ED medical directors perceived access block or an insufficient number of inpatient beds to be the primary cause of overcrowding. Conclusions: Most ED Medical Directors admitted ED overcrowding was a serious problem across Alberta, with a variety of perceived consequences. The finding of the present study illustrates the urgent need to develop innovative, system-wide solutions to this medical crisis. Key Words: Overcrowding, Canadian urban hospitals

36 THE effect of medical students on patient flow in a low acuity area of an academic emergency department

Frank JR, Shi K, Dunlop N, Cwinn A, Lee AC. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

Introduction: One of the barriers to effective teaching in the ED is the necessity to ensure patient flow in a chaotic and often overcrowded setting. It is not known if students impact on ED physician productivity in a low acuity area. We evaluated the effect of the presence of medical students on the patient flow in an academic ED. Methods: This cohort study was approved by the Research Ethics Board and conducted at a tertiary care teaching ED with 60,000 annual patient visits. We used administrative databases to identify the number of patients seen by each attending ED physician per 6-hour shift in the low acuity area over 24 months. Patients seen in this area usually presented with lacerations, minor trauma, minor infections, etc. We then matched these shifts with the master housestaff schedule to compare shift productivity with and without students using paired t-tests. The primary outcome was the number of patients seen per shift per physician with or without trainees. Results: There were 21,196 patient registrations in the low acuity area during the study period. We excluded encounters that left without being seen, were incomplete, or involved EPs that never supervised housestaff leaving 16,566 encounters. Only 1,339 cases were seen by learners: 1,190 by 4th year medical students, 74 by 3rd year medical students, and 75 by foreign trainee program housestaff. The mean number of cases seen in the low acuity area per shift was significantly different with students (p = 0.01) with means of 11.3 with learners and 14.3 without. This represents a 21.0% relative reduction in patients seen when students were present. Conclusions: ED physicians supervising medical students saw 21% fewer patients per shift in the low acuity area. In an era of overcrowding, educators and ED administrators need to carefully consider balancing the education and service missions of the department to ensure flow. Key Words: Patient flow, Overcrowding

37 VARIABILITY of emergency physician time by triage category

Dreyer JF, Zaric GS, McLeod SL, Anderson C, Carter, ME. Division of Emergency Medicine, The University of Western Ontario, London, ON

Introduction: The Canadian Triage and Acuity Scale (CTAS) is a 5 level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). Many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level to determine emergency physician (EP) workload and staffing needs. We sought to accurately determine the time it takes EPs to assess and treat ED patients in each triage category. Methods: Twenty hospital-based EDs agreed to participate in this study. Data was collected by research assistants who directly observed EPs for entire shifts and recorded the activities of the EP on a moment-by-moment basis. The individual times of all physician activities associated with a given patient were summed to derive a directly observed estimate of EP time required to treat a patient. Results: 17,197 patients were observed in this study over 767 shifts. On average, 1.4% of all patients were categorized as CTAS 1 (range 0.5-3.9%), 13.4% CTAS 2 (range 6.9-26.2%), 47.3% CTAS 3 (range 32.5-61.8%), 34.2% CTAS 4 (range 18.3-52.8%) and 3.7% CTAS 5 (range 0.5-11.2%). Average EP time by triage category was 115.4 minutes for CTAS 1 (range 17.2-274.7 min), 34.4 minutes for CTAS 2 (range 19.6-55.9 min), 21.9 minutes for CTAS 3 (range 12.9-35.1 min), 15.0 minutes for CTAS 4 (range 9.8-25.2 min) and 11.0 minutes for CTAS 5 (range 6.2-24.6 min). Conclusions: There was significant variability in the distribution of CTAS scores between sites. There was also marked variation in EP time in each triage category. This brings into question the appropriateness of using CTAS alone to determine physician ED staffing levels. CTAS may be an adequate tool to determine patient acuity, but may only be a rough indicator of patient complexity and physician workload. Key Words: Triage, Emergency, Physician workload

38 PREDICTORS of emergency physician workload

Dreyer JF, Zaric GS, McLeod SL, Anderson C, Carter, ME. Division of Emergency Medicine, The University of Western Ontario, London, ON

Introduction: Many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level, (as determined by the Canadian Triage and Acuity Scale [CTAS]), to establish emergency physician (EP) workload and staffing needs. If CTAS levels are not accurate predictors of EP workload, then the use of CTAS for setting staffing levels may be inappropriate. We sought to determine if CTAS and other factors related to patient demographics, treatments, mode of arrival and disposition status, could predict EP workload. Methods: Ten hospital-based EDs agreed to participate in this study. Physician activities were recorded on a moment-by-moment basis by research assistants who directly observed EPs for entire shifts. Times per patient were fit to lognormal survival models to identify predictors of workload. Results: Data was collected on 17,197 patient encounters over 797 shifts. CTAS was shown to be a significant predictor of workload, both in univariate and multivariate analysis. Other patient variables that were significant predictors of EP workload included: patient age, mode of arrival, previous visit to the ED within 30 days, laboratory and imaging investigations, mental health, social work and medical/surgical consultations, payor information, presentation to the ED on a weekend, discharge disposition, and the presence of an insurmountable language barrier. Conclusions: While CTAS by itself is a significant predictor of EP workload, models that use CTAS as well as other factors achieve a much better fit than those that use CTAS only. We were able to develop a formula to predict EP workload that included CTAS as well as additional variables that are commonly abstracted from patient charts. We believe that such a formula is more accurate in predicting patient complexity and EP workload than CTAS alone. Key Words: Triage, Physician workload

39 IMPACT of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial

Holroyd BR, Bullard M, Latoszek K, Gordon D, Allen S, Tam SL, Blitz S, Yoon P, Rowe BH. Department of Emergency Medicine, University of Alberta, Edmonton, AB

Introduction: Weak methods and poor reporting of outcomes limit the current evidence base in interventions to address emergency department (ED) overcrowding. Triage liaison physicians (TLP) have previously been employed; however, their effectiveness remains unclear. This study aims to evaluate the implementation of TLP shifts in the ED using valid methods and comprehensive outcomes. Methods: A 6-week TLP clinical trial was conducted in a tertiary care Canadian ED in 2005-06. A TLP was deployed from 11:00-20:00 daily to initiate early patient management, assist triage nurses, answer medical calls, and manage ED administration. Within each of three 2-week blocks, seven days were randomized to TLP and the other seven to control (without TLP) shifts. Outcomes included patient length of stay (LOS), proportion of patients who left without complete assessment (LWBS), staff satisfaction and episodes of ambulance diversion. Results: TLPs assessed a median of 14 patients/shift (IQR: 13, 17), received 15 telephone calls/shift (IQR: 14, 20), and spent 17-81 minutes/shift consulting on the telephone. The number of patients, their age, gender, and triage score during the TLP and control shifts were similar. Overall LOS in the 24 hours during which included a TLP shift declined by 36 minutes compared with control days (4:21 vs. 4:57; p = 0.001). LOS reduction varied based on triage level; CTAS triage level 3 improved by 39 min. In addition to TLP coverage status, LOS was influenced by sex, triage level, and age. LWBS cases were 20% less common on the days with TLP coverage. The overall ambulance wait time and number of episodes of ambulance diversion were reduced on TLP days; however, this difference did not reach statistical significance. Conclusions: The results of this study indicate that a TLP physician provides benefits to an overcrowded ED. The results strongly suggest that the implementation of this intervention could provide significant improvement to the delivery of emergency medical care in a tertiary care ED. Key Words: Triage, Liaison physician, Overcrowding

40 IMPACT of an overcapacity care protocol on emergency department overcrowding

Innes GD, Grafstein E, Stenstrom R, Harris D, Hunte G, Schwartzman A. Department of Emergency Medicine, Providence Health Care and St. Paul's Hospital, Vancouver, BC

Introduction: In 2005, at this tertiary inner city hospital, because of prolonged boarding of admitted patients, 9249 triage level 2 and 3 (emergent and urgent) patients were blocked in ED waiting areas for 3 hours (estimated access gap= 27,750 hrs). Serious adverse events and waiting room deaths led to implementation of the overcapacity protocol (OCP) in February, 2006. The OCP dictates that arriving level 1-3 patients are placed in overcapacity ED care spaces rather than waiting areas. When the ED goes overcapacity by 2 patients, admitted patients boarded in the ED move to overcapacity care spaces on inpatient units. Our objective is to describe OCP impact on EDLOS and patient flow. Methods: This before-after analysis uses administrative data to compare the post-OCP period (March through August, 2006) to the corresponding control period in 2005. Outcomes include mean ED LOS for admitted patients as well as EDLOS and hospital LOS for admitted medical, surgical and mental health (MH) patients. Results: During the post-OCP period, ED volume rose from 30483 to 30846 (1.2%), CTAS 1-3 volume rose from 13078 to 13828 (5.7%), and daily ambulance arrivals rose from 46.1 to 46.6 per day (1%). Despite this, mean ED LOS for all admitted patients fell from 18.9 to 13.9 hrs (p<0.001). EDLOS fell by 9.0 hours, 1.6 hours and 9.2 hours for admitted medical, surgical and MH patients respectively. Similarly, hospital LOS fell by 1.0, 0.8 and 0.8 days for medical, surgical and MH patients (p<0.001 for all). After OCP, arriving emergent-urgent patients were rarely left in ED waiting areas. During the post-OCP period, no critical events were reported in ED waiting areas or inpatient OCP care spaces. Conclusions: A 5.0 hour mean reduction in EDLOS for 8200 annual admissions provides access to an additional 41,000 hours of ED stretcher and nursing time, more than the access gap estimated prior to OCP implementation. The OCP reduces ED LOS for admitted patients, reduces ED access block and appears to reduce adverse outcomes for ED patients. Key Words: Triage, Overcrowding, Overcapacity

41 ED overcrowding inflation in a tertiary care teaching hospital

Bullard MJ, Holroyd BR, Sochaki K, Rowe BH. Department of Emergency Medicine, University of Alberta, Edmonton, AB

Introduction: The Emergency Medicine Research Group (EMeRG) at the University of Alberta (U of A) recently completed a "Report on Overcrowding in Emergency Departments in Canada" supported by a grant from the Canadian Agency for Drugs and Technologies in Health (CADTH; formerly the Coordinating Office for Health Technology Assessment {CCOHTA}). A number of overcrowding markers were defined through a number of national benchmarking techniques. This study follows the trends of several of these markers in an academic tertiary care ED over the past 6 years. Methods: An Emergency Department Information System was introduced in 2000 which automatically time stamps a number of key work activities and tracks CTAS triage scores and dispositions. Using a data programmer, queries of overall and triage level 3 wait times, fractile response times, emergency inpatient (EIP) times, rate of left without being seen (LWBS) patients, and patient acuity were developed. Results: From 2000 to 2006 EIP times increased by 169% from 43,395 to 116,891 hours. The overall number of adult LWBS patients increased by 53% while the triage level 2 and 3 LWBS patients increased by 223% (from 531 to 1766). In addition as patient acuity continued to rise (triage level 1, 2, and 3 increased from 48.3% to 63.2%), the number of triage level 3 patients spending more than 2 hours to ED bed placement went up from 6.8 to 22.4%. Despite these changes time from bed placement to be seen by a physician actually dropped over the same period. Conclusions: Despite internal efforts at improving ED efficiency, real time data capture shows an alarming increase in ED overcrowding measures, even with a relatively static patient census. This is consistent with reports from EDs across the country. Patient acuity is increasing, minor cases decreasing, and the overriding problem is "boarded' inpatients in the ED preventing many patients timely access to an emergency stretcher to receive care. Key Words: Triage, Overcrowding

42 A description of the impact of the long stay patients on hospital beds availability

Afilalo M, Rosenthal S, Unger B, Guttman A, Soucy N, Léger R, Colacone A. Sir Mortimer B. Davis-Jewish General Hospital, Emergency Department, McGill University, Montréal, QC

Introduction: Lack of hospital beds to admit emergency department (ED) patients is cited as the #1 cause of ED overcrowding. The hospital beds access block is in part accentuated when non-acute patients occupy acute care beds for extended periods. Certain groups of patients occupying acute care beds are known (e.g. long term care, palliative) and there are specific out of hospital resources for them. Nevertheless, there is another group of long stay patients (LSP) whose magnitude on both hospital resources and out of hospital needs are unknown. The goal of this study is to describe the impact of the LSP on hospital beds availability. Methods: Administrative data on hospitalized patients' length of stay (LOS) in days from a 637 beds tertiary care hospital (SMBD-Jewish General Hospital) for the years 2004-05 and 2005-06 are described. Mothers and new born babies, long term care patients and palliative patients were excluded. Results: 2004-05: 13,014 patients were hospitalized which represents 123,633 patients-days; 65% of patients were hospitalized from the ED; 94% of patients had an in-hospital stay of < 30 days (77,252 patients-days); 4% stayed 30 to 59 days and (23,285 patients-days); 1% stayed 60 to 89 days (8,683 patients-days) and 1% stayed ≥ 90 days (13,860 patients-days). 2005-06: 13,716 patients were hospitalized which represents 126,706 patients-days; 67% of patients were hospitalized from the ED; 94% of patients had an in-hospital stay of < 30 days (82,389 patients-days); 4% stayed 30 to 59 days (23,864 patients-days); 1% stayed 60 to 89 days (10,754 patients-days) and 1% stayed ≥ 90 days (9,699 patients-days).Conclusions: Although patients with a LOS ≥ 30 days represent only 6% of hospitalized patients, they occupy 123 beds daily, representing at this hospital 1 out of 5 beds. Thus increasing the turnover of these beds by appropriate out of hospital resources would improve bed accessibility for ED patients. Key Words: Overcrowding, Hospital beds

43 IMPACT of a prehospital bypass protocol on time to primary percutaneous coronary intervention in acute myocardial infarction

Caudle J, Piggott Z, McClellan C, Graham K, Brison RJ. Department of Emergency Medicine, Department of Medicine, Queen's University, Kingston, ON

Introduction: Cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI) time to reperfusion is a key determinant in reducing mortality and morbidity with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. For the 50% of patients who access health care through emergency medical services (EMS), delays relate to time to EKG diagnosis and to accessing definitive care in a cardiovascular lab. In 2004 the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) bypass protocol to reduce time to reperfusion by transporting patients with STEMI directly to the nearest catheterization lab. The model was implemented in Frontenac County in April 2005. This study assesses its effectiveness in reducing door-to-balloon times. Methods: A before/after design was used assessing two one-year periods ending March 2005 and June 2006 respectively. Data were abstracted from charts of patients with STEMI who were transported by regional EMS and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation. Information on demographic and descriptive variables was also abstracted. Times are presented as medians and interquartile ranges (IQ). Statistical comparisons were made with the Mann Whitney U test and presented graphically with Kaplan-Meier curves. Results: Patients transported under the ED bypass protocol (N=40) were compared to historical controls (N=49). Median door to balloon time was reduced from 90 minutes pre-protocol (IQ range 76-107) to 62 minutes (IQ range 40-62) post-protocol (p<0.0005). Conclusions: Implementation of a prehospital bypass protocol has significantly reduced time to reperfusion for patients with STEMI transported by EMS in our region. Key Words: Prehospital Bypass protocol, PCTI, STEMI

44 THE adequacy of bag mask and endotracheal tube ventilation by paramedics

Denike D, Cain EJ. Emergency Health Services Nova Scotia and the Division of EMS, Dalhousie University, Halifax, NS

Introduction: The 2005 AHA recommendations call for 6-7 mL/kg tidal volumes in cardiac arrest patients with peak pressures in the unprotected airway of less than 4-5 cm H20. For the perfusing patient, recommended tidal volumes are 7-10 mL/kg with peak pressures of less than 20 cm H20. We measured the ventilation performance of paramedics with bag-valve-mask (BVM) and bag-valve-tube (BVT) in both adult and child manikins and compared these to the AHA recommendations. Methods: After giving verbal consent, paramedics (n=794) ventilated a manikin depicting a 60 kg adult for one minute with both a mask and via an endotracheal tube. 532 paramedics similarly ventilated a manikin depicting a 19 kg child. The inflation criterion was observable start of chest-rise. Exhalation volume was blinded to the paramedic, and tidal volume calculated from an instructed rate of 12 for the adult and 20 for the child. Scatter graphing depicted tidal volumes (mL) versus peak airway pressure. Tidal volume was expressed as mL/kg and performance as the percentages that were compliant with the AHA recommendations. Results: Tidal volumes delivered by BVM were compliant with the 6-7 mL/kg recommendation in 15% (adult) and 5% (child); 7-10 mL/kg was observed for 30% (adult) and 23% (child). Tidal volume for the intubated manikins (BVT) were in the 6-7 mL/kg range for 17% (adult), 9% (child) and for the 7-10 mL/kg range in 32% (adult) and 31% (child). For the unprotected airway, paramedics exceeded 20 cm H20 in 4% (adult) and 19% (child). Conclusions: Recommended ventilation ranges for tidal volume were not achieved by the majority of paramedics. As well, there were wide variances in individual performance for tidal volume. Most paramedics controlled peak airway pressures. Key Words: Ventilation, Bag-valve, Paramedic

Abstracts: 1-30, 31-44, 46-48, 100-130, 131-159, 161-189, 191-216