Oral Abstracts - Wednesday

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pulmonary disorders

W093

PULMONARY EMBOLISM POSITIVE POINT PREVALENCE IN 32 CLINICAL STUDIES THAT UTILIZE CHEST CTA IN THE DETECTION OF PULMONARY EMBOLISM IN AT RISK PATIENTS

E. Sloan 1, C. Sloan 2, T. Dunne 3

1

University Of Illinois College Of Medicine, Chicago, Usa, 2 Tufts University College Of Medicine, Boston, Usa, Rush University College Of Medicine, Chicago, Usa

3

Background: The pulmonary embolism (PE) point prevalence in patients considered to be at risk for PE may be sufficiently low to allow for a safe reduction in chest CT Angiography (CTA) use. A benchmark remains unidentified for the rate at which chest CTA should be positive for PE in clinical practice, especially in the Emergency Department (ED). The objective of this study was to determine the PE point prevalence rates in studies that utilize CTA in the diagnostic process, including both studies that established CTA test characteristics and clinical studies that used CTA to diagnose PE. Methods: Included in the analysis were studies that identified the use of CTA in the diagnosis of PE in at risk patients and overall populations, and patients with clinical criteria that suggested high risk for PE. Results: Of 164 possible PE studies examined, 32 (20%) specifically reported the outcomes of CTA use for the diagnosis of PE among 26,989 at risk patients. The overall PE point prevalence positive rate in these 32 CTA use studies was 17.6 + 14.9%. ED studies with CTA use reported a lower CTA positive rate (10.1%) than studies from other clinical settings (27.1%) (p<.05). Studies that examined PE point prevalence in at risk patients had a lower CTA positive rate than those studies that primarily established CTA test characteristics (15.0 vs. 21.7%).

Conclusions: The overall 17.6% point prevalence rates for PE in studies that examined CTA utilization were similar to the 18% PE positive point prevalence rate observed in all 164 PE patient diagnostic studies reviewed.

In the ED, CTA testing was positive in 10% of patients. This low CTA positive rate suggests that CTA may be over-utilized, especially if this test is not preceded by D-dimer testing in patients without clinical criteria that strongly suggest high PE risk. This 10% ED patient positive CTA rate for PE can serve as a benchmark for comparison as emergency physicians strive to improve quality and patient safety through optimizing the use of CTA in at risk ED patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pulmonary disorders

W094

PULMONARY EMBOLISM (PE) POINT PREVALENCE RATES IN SUSPECTED PE PATIENTS FROM 164 CLINICAL STUDIES ARE LOW ENOUGH TO ALLOW FOR MORE FREQUENT PRELIMINARY D-DIMER USE

E. Sloan 1, T. Dunne 2, C. Sloan 3

1 3

University Of Illinois College Of Medicine, Chicago, Usa, 2 Rush University College Of Medicine, Chicago, Usa, Tufts University College Of Medicine, Boston, Usa

Background: The diagnosis of pulmonary embolism(PE) in Emergency Department (ED) patients is a clinical priority, often necessitating the use of advanced diagnostics such as CT Angiography (CTA). Attempts to safely reduce chest CTA use depends, in part, on the presumed prevalence of PE in the at-risk patient population being evaluated. Although D-dimer use might be able to reduce CTA use, this preliminary test can be more broadly used if the PE point prevalence is sufficiently low in the clinical setting. The objective of this study was to determine the point prevalence of PE in the overall and high-risk patient populations (based on history, symptoms, signs, and laboratory testing) from ED-based studies and those from other clinical settings.

Methods: A Medline search used relevant search terms to identify clinical trials of patients suspected of having PE. High-risk populations were identified by clinical judgment, symptoms, signs, PERC rule, Wells criteria, D-dimer, and VQ testing.

Results: Using data from all 164 published clinical studies, the average patient PE point prevalence was 18%.

In the 80 ED based studies, the prevalence was 13%. The PE prevalence rate in patients defined to be high-risk patients based on clinical scales was 16%. In patients groups defined to be high risk based on clinical judgment, symptoms, or physicals signs, the PE point prevalence rate was 22%. The PE point prevalence rates in high-risk patients as defined by a positive D-dimer or VQ scan were 15% and 30%, respectively. In high-risk patients identified in ED studies, the PE point prevalence was 38%.

Conclusions: All of the patient PE point prevalence rates in populations from published clinical studies are lower than the 40% high risk patient cutoff at which D-dimer use is not recommended prior to CTA use. Without the presence of specific clinical judgment criteria, signs, symptoms, or tests that indicated suspected PE patients are at high-risk, there can be more D-dimer testing to exclude PE. This could reduce the number of negative CTAs performed, leading to enhanced patient safety, improved patient outcomes, and optimized resource utilization.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pulmonary disorders

W095

COMMUNITY-ACQUIRED PNEUMONIA DISCHARGED FOR OUT-OF HOSPITAL TREATMENT FROM THE EMERGENCY DEPARTMENT: THE REBOUNDS

R. Ferrari 1, G. Monti 1, M. Cavazza 1, S. Tedeschi 2, F. Tumietto 2, P. Viale 2

1

Emergency Department, Policlinico Sant'orsola - Malpighi, Bologna, Italy, Bologna, Bologna, Italy

2

Infectious Diseases, University Of

Background: Community-acquired pneumonia is common cause of hospital admission and leading cause of increased morbidity and mortality.

Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about treatment and management strategies; the most notable scale in common clinical use is CURB-65 which showed some limitations but also high specificity and high positive predictive value.

Methods: To critically analyze pneumonia “rebounds” cases, once discharged from the Emergency Department and afterwards admitted, we conducted an observational prospective clinical study in the acute setting of a university teaching hospital.

We prospectively analyzed, in 1 year period, demographic, medical, clinical and laboratory data, and the outcome (“rebounds” in 30 days).

Results: 249 Patients (media 0.72 / day) were discharged home with diagnosis of community-acquired pneumonia; 45 cases (18.1%) resulted in the high-intermediate risk class according to CURB-65.

12 patients (4.8%) presented to the Emergency Department twice and were then admitted (in media 4 days later). At their first visit 3 were in the high-intermediate risk group, but all 12 were in the low risk group at their admission.

The “rebound” cohort showed some slight abnormalities in laboratory parameters (coagulation, renal function) and peculiar severe chest X-rays characteristics (bilateral or lobar infiltrates, pleural effusion). None died in-hospital; they all were discharged home in media after 9 days.

Conclusions: The ability and power of CURB-65 to correctly predict mortality for community-acquired pneumonia patients discharged home from the Emergency Department is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the decision and management process, beyond the routinely helpful support given by prediction rules.

Many patients with a high-intermediate risk according to CURB-65 can safely be treated as outpatients, according to adequate welfare conditions; in this scenario we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the Emergency Department to assess the effectiveness of therapy, to ascertain the maintenance of clinical stability, and to have a contact with the General Practitioner, before the final decision to safely discharge or admit.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pulmonary disorders

W096

ACUTE CARE DIAGNOSTICS COLLABORATION: ASSESSMENT OF WELLS SCORE AND REVISED GENEVA SCORE INTEGRATED WITH HELICAL COMPUTED TOMOGRAPHY IN A BAYESIAN CLINICAL DECISION MODEL

L. Cochon 1, M. Supino 2, A.A. Baez 2

1

Universitat De Barcelona, Barcelona, Spain, 2 Jackson Memorial Hospital, Miami, Usa

Background: The objective of this study was to assess the diagnostic accuracy of Wells criteria in comparison to the rGeneva score for the diagnosis of PE validated by helical computed tomography (hCT) using Bayesian statistical methodology.

Methods: Wells criteria and rGeneva were used as pre-test probability (PRE) tools to risk stratify patients into low, moderate and high risk subgroups. For Wells criteria, <2 points was low risk, 2-6 moderate, and >6 high risk. Using rGeneva 0-3 was low, 4-10 moderate and >11 high risk. Percent risk was inserted as PRE in a Bayesian nomogram with likelihood ratios (LR) for hCT obtained from pooled meta-analysis studies. Absolute (ADG) and relative diagnostic gains (RDG) were then calculated. Absolute diagnostic gain was defined as the net difference between pre-test and post-test probabilities. Relative gain was obtained as the percentage of absolute gain in pre-test probability. ANOVA was used to evaluate the strength of association with a p-value set at 0.05 Results: Meta-analysis data for hCT in PE demonstrated a sensitivity of 86.0%, specificity 93.7%, LR+ 14 and LR- 0.15. Bayesian statistical modeling integrating risk score percentage as PRE and LR for hCT yielded post-test probabilities. For Wells criteria low and LR+ post-test was 14.0%, ADG 10.6% and RDG 311.8%.

Moderate risk population showed post-test of 84.0%, ADG 56.2% and RDG 202.2%. High risk revealed 14.0%, 10.6%, 25% for post, ADG, and RDG respectively. Using rGeneva as pre-test probability and LR+, for low risk post-test was 55.0%, ADG 47.0% and RDG 587.5%. Moderate risk yielded a post-test probability of 84.0%, ADG 56.0% and RDG 200.0%. High risk population and rGeneva resulted in a post-test probability of 98.0%, ADG 24.0% and RDG 32.4%.

Conclusions: Bayesian statistical modeling demonstrated that utilizing Wells criteria in patients with moderate risk of pulmonary embolism in combination with helical CT scan yielded a greater absolute diagnostic gain in comparison to the revised Geneva score. On the other hand, revised Geneva score demonstrated a greater diagnostic accuracy in patients in low and high risk populations.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies

W097

ECHOCARDIOGRAPHIC PROFILE PERFORMED BY THE EMERGENCY PHYSICIAN IN PATIENTS WITH ACUTE DECOMPENSATED CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN THE EMERGENCY DEPARTMENT

M. Ben Lassoued 1, R. Jebri 1, R. Hammami 1, O. Andolsi 1, O. Khila 1, M. Arafa 1, K. Lamine 1

1

Military Hospital Of Tunis, Tunis, Tunisia

Background: Acute decompensated chronic obstructive pulmonary disease (COPD) is a common pattern in the emergency department (ED). It is usually associated with cardiovascular comorbidities. Knowing the echocardiographic abnormalities by the emergency physician (EP) can help the management of these patients.

The objective of this work is to study the echocardiographic profile of patients with acute decompensated COPD treated in the ED Methods: A prospective observational study was conducted in ED over a six-month period including patients with acute decompensated COPD. COPD diagnosis was made based on clinical and spirometric criteria.

Cardiovascular comorbidities and different electrical data were collected. The patients underwent transthoracic echocardiographic examination conducted by an EP who had a master's degree in echocardiography and Doppler prior to the study.

Results: Forty-eight patients were included in the study, mean age 65 Âą 11 years, sex ratio 2.33. Sixteen patients (33.3%) had combined cardiovascular diseases: 8 ischemic heart disease, 7 arrhythmias, 3 valvular heart disease, 8 hypertension, and 1 occlusive arthritis. Electric signs of ventricular or auricular hypertrophy were recorded in 28 patients. The echocardiography was performed in 46 patients. The Table 1 summarizes the different echocardiographic abnormalities found. <FILE IMAGE='214_20150531011353.jpg'> Conclusions: Conclusion: COPD is often associated with cardiovascular co-morbidities coexisting in the same patient. The echocardiography performed at the bedside by the EP allows identifying the echocardiographic profile of these patients. This invaluable diagnostic adjunct will help to improve the management of COPD patients in the ED.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Respiratory and ENT Emergencies

W098

THE IMPACT AND THE OUTCOME OF UNCONVENTIONAL INDICATIONS TO NON-INVASIVE MECHANICAL VENTILATION FOR ACUTE RESPIRATORY FAILURE IN THE EMERGENCY DEPARTMENT

R. Ferrari 1, R. Voza 1, D. Agostinelli 2, D. Pomata 1, G. Monti 1, M. Cavazza 1

1

Emergency Department, Policlinico Sant'orsola - Malpighi, Bologna, Italy, Studi, Bologna, Italy

2

Internal Medicine, Università Degli

Background: In the last decades Non-Invasive Mechanical Ventilation spread out from the Intensive Care Units to the Emergency Departments, with main evidence in efficacy when treating Acute Respiratory Failure due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Acute Cardiogenic Pulmonary Edema.

In the meantime, many different causes, considered as “unusual” indications for NIMV, showed lower levels of efficacy and strength of recommendation, but are increasing in use Methods: We performed an observational prospective study, in the Emergency Department of a University Teaching Hospital, including every non-selected patient treated by NIMV in a 4 months time, to assess the impact and the outcome of conditions considered as unconventional for NIMV. Failure was defined as in-hospital death or tracheal intubation Results: Total: 297 Patients (media 2.43 / day); pH: (media, median) 7.32, 7.33; P/F: 214, 209; NIMV as a ceiling treatment: 27.4%; failure rate: 22.7%.

Unconventional indications: rate: 51.1%; ceiling: 32.6%; failure rate: 26.7%; ceiling in failures: 52.8%; failure without tracheal intubation: 80.0% Conclusions: The use of NIMV for unconventional indications is spreading in the Emergency Department: its failure rate is higher than in usual cases, as already known in the literature (data usually coming from Intensive Care Units), but in this subgroup the rate of patients with no indication to invasive ventilation in case of failure (“NIMV as a ceiling treatment”) is dramatically high.

We could not find any early predictors of outcome from the lab to help risk stratification in the Emergency Department; in failure cases arterial blood gas data showed some slight abnormalities on the metabolic side (more than the respiratory one); pneumonia and inhalation showed a particularly high failure rate

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Geriatrics

W099

PREDICTORS OF REPEAT EMERGENCY DEPARTMENT VISITS AMONG PATIENTS AGED OVER 65

R. Jabri 1, H. Ghazali, G. Chaabeni, A. Yahmadi, N. Elheni, M. Mougaida, M. Chkir, S. Souissi

1

Regional Hospital, Emergency Department, Ben Arous, Tunisia

Background: Objective: Identify predictors factors of repeat emergency department visits among patients aged more than 65 years old.

Methods: Prospective and observational study. Inclusion of patients aged more than 65 years old who were discharged from the emergency department at the index visit during one month period (October 2014). We collected data from the medical observation: demographics, co-morbidities and clinical findings. The Identification of Seniors At Risk (ISAR) score was used to assess functional decline. Follow-up of 1 month.

Repeat returns (more than 2 emergency department visits within 30 days following the index visit) were recorded by a phone contact. Multiple logistic regression method was used to identify predictors of repeat returns in emergency department over 1 month period.

Results: Inclusion of 125 patients. Mean age: 76 Âą 7 years. Sex-ratio: 0,85. Among these patients, 31 (25%) made repeat visits during the next 30 days. Univariate analysis identified the following factors as significantly related to repeated visits in the emergency department: age> = 75 years, mean ISAR score> = 2, history of renal failure, emergency department visit a month prior to the index visit, hospitalization in the last 6 months, patients who depend on someone else help at home and those taking more than 3 medications daily. In multivariate analysis: emergency department visit a month prior to the index visit (Odds Ratio adjusted = 2, p = 0.003, 95% Confidence interval 1.5 to 9.15), hospitalization in the last 6 months (Odds Ratio adjusted = 1 73, p = 0.03, 95% Confidence interval 1.68 to11) and patients who depend on someone else help at home (Odds Ratio adjusted= 2.48; p = 0.003, 95% Confidence interval 1.92 to 18.3) were independently associated with repeat visits in the emergency department.

Conclusions: Identifying the predictors factors of repeat emergency department visit of elderly can improve their quality of life and reduce the demand for further hospital care in this age group.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Geriatrics

W100

NEGLECTED CAUSES OF ACUTE RESPIRATORY FAILURE FOR THE ELDERLY IN THE EMERGENCY DEPARTMENT

R. Ferrari 1, D. Agostinelli 2, D.P. Pomata 1, M. Cavazza 1

1

Emergency Department, Policlinico Sant'orsola - Malpighi, Bologna, Italy, Bologna, Bologna, Italy

2

Internal Medicine, University Of

Background: Diagnostic assessment of Acute Respiratory Failure in the elderly is complex and challenging, since the Emergency Department: frailty, disability and comorbidities involve main consequences on proper treatment, management and outcome.

Methods: We retrospectively analyzed prospective the observational data we collected in last years about Patients evaluated and treated in our Emergency Department, to identify conditions at maximum risk for inappropriateness in Acute Respiratory Failure Patients aged > 65 or > 80 years.

Results: We studied 208 adult Patients in 6 months for Acute Asthma (media 1.15/day) aged (expressed as media, median, minimum and maximum) 41, 39, 14 and 100 years, respectively; 27 cases were > 65 years old (13%), 8 > 80 (3.8%).

We evaluated 124 Patients non-invasively ventilated in 3 months (media 1.38/day) in the Emergency Department for Acute Respiratory Failure with final diagnosis (at the end of hospital staying) of Acute Exacerbation of Chronic Obstructive Pulmonary Disease, aged 81, 83, 56, 97 years (success group), and 81, 82, 63, 94 years (death or tracheal intubation), respectively.

Conclusions: In the everyday differential diagnostic assessment of Acute Respiratory Failure in the elderly, Asthma seems to be underestimated and Chronic Obstructive Pulmonary Disease overrepresented.

Acute Asthma is still at risk to be considered as a hyperacute anaphylactic episode, exclusive for young people.

Neither every wheezing in older people, nor any hypercapnic Acute Respiratory Failure, should automatically be labelled as Chronic Obstructive Pulmonary Disease.

Both Chronic Obstructive Pulmonary Disease and Asthma have various phenotypes, different in treatment and management: older age seems to represent a peculiar and specific phenotype per se.

In chronic broncho-pulmonary disease the elderly subgroup is at main risk for developing Acute Respiratory Failure and its complications because of under-diagnosis, inadequate therapy, and the consequent progressive deterioration up to Acute Respiratory Failure.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation

W101

BEING MORTAL: THE OREGON DEATH WITH DIGNITY EXPERIENCE (PHYSICIAN ASSISTED SUICIDE IN OREGON AND AROUND THE WORLD)

D. Woods 1

1

Rogue Regional Medical Center, Medford, Usa

Background: Physician Assisted Suicide remains a hotly debated topic in regions of the world which do and do not have legalized forms of Physician Assisted Suicide. Many misconceptions exist when this topic is discussed. Many differences exist in the laws and regulations, even within a county such as the US. The problem remains: what to do for a patient who is at the end of their life when their pain and suffering cannot be adequately controlled and they desire an end to their pain and suffering?

Methods: Current laws, regulations, and statistics will be reviewed from the 4 states in the US and other countries with legal Physician Assisted Suicide. Legal and moral issues will be reviewed.

Results: Can provide at a later date if there is sufficient interest in the topic. I need feedback before proceeding and can resubmit with results section filled in if the topic is of interest.

Conclusions: Physician Assisted Suicide will, and should, remain a hotly debated topic. The best interests of our patients will be served by dialogue based on facts and understanding.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Education

W102

THE IMPACT OF DYING IN THE EMERGENCY DEPARTMENT

R. Ferrari 1, C. Lanzarini 1, A. Longanesi 1, R. Rapagnani 1, D. Rotondo 1, M. Cavazza 1

1

Emergency Department, Policlinico Sant'orsola - Malpighi, Bologna, Italy

Background: Within a project named “Soft Emergency – not only to cure but also to care”, one of the main phases concerned “Bad news communication”.

To create a specific educational program about communicating bad news in the emergency setting we thought to be necessary to evaluate, both form a quantitative and a qualitative point of view, the impact of dying on our Emergency Department.

Methods: We retrospectively reviewed every case of death occurred during the year 2014 within the Emergency Department of a University teaching Hospital.

We then analyzed each single case about its peculiar characteristics.

Results: 66312 cases were evaluated (media 182 / day); we recorded 140 deaths in the Emergency Room (11 already dead); in the different areas of the Ward (brief observation and regular ward; high-dependency medical unit) we documented , 61/10291 (31 in the first 12 hours) and 65/1257 cases (34 in the earlier 12 hours), respectively.

Every single case was unique: from the already dead, to sudden death; from cases with useless long lasting cardio-pulmonary resuscitation efforts, to those with careful palliative measures; from cases with an unexplained cause, to those clearly predictable; from cases in which time made possible to debate and share decisions with both the patient and the family, to those in which family members were neither attending nor aware of the occurring events.

Conclusions: In the year 2014 266 people died inside our Emergency Department.

Each case represented a peculiar medical management, welfare and olistic committment, and emotional involvement; it is not possible to share any standard recommendation, mainly about times and ways of resuscitation for the patient, and of communications for the family.

Death, and its communication in the emergency setting, are primarily important, both in frequency and significance, on the every-day life of the Emergency Department: the burden of these dramatic issues weigh on Emergency Physicians and Emergency Nurses in the worst moments and conditions, just after useless long-lasting resuscitation efforts, and often with neither a specific education, nor logistics support, nor the chance of an immediate debriefing.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Social role of emergency medicine

W103

PALLIATIVE CARE SCREENING IN THE EMERGENCY DEPARTMENT: A QUALITY IMPROVEMENT INITIATIVE

S. Christos 1, S. C., S. F., N. P., M. S.

1

Presence Resurrection Medical Center, Department Of Emergency Medicine, Chicago, Usa

Background: In 2009–2010, a total of 19.6 million emergency department (ED) visits in the United States were made by person’s aged 65 and over, and with the aging population this number will increase. Many of these patients will present with advanced and end-stage diseases in need of symptom management, pain relief and referral for long term care. Emergency Physicians (EPs) have the opportunity to support early front-loaded palliative care (PC) interventions that will promote quality of life with improved outcomes, provide support for families and caregivers and reduce costs by reducing length of stay and utilization of intensive care and other resources.

Methods: A brief validated PC screening tool was implemented in the ED over two-months. Patients 65 years old and over were screened. Patients were scored on their present health status, functional status and other criteria including need for complex care, unacceptable level of pain or other symptoms of distress > 24 hours. A score of > 5 would prompt the ED physician to ask the patient’s primary medical doctor (PMD) for a palliative care consult. Data regarding age, gender, length of stay (LOS), disposition and hospital costs were collected by retrospective chart review. The data was analyzed for comparison of patients receiving palliative care consultation versus patients without consultation.

Results: Patient’s LOS was shorter in the PC consult vs no consult group (LOS > 2day 59% vs 82%, LOS > 3 days 41% vs 65% and LOS > 4 days (37% vs 53%). Fewer patients were transferred to a SNF in the PC consult vs no consult group (33% vs 65%); more patients were discharge home (15% vs 6%) or to hospice (30% vs 6%) in the PC group. Finally, total costs (median) were less in the PC consult vs no consult group ($5280 vs $8465).

Conclusions: These results suggest that patients receiving early palliative care consultation from the emergency department will have decreased length of stay, more likely to be discharged home or to hospice and there will be a total median hospital cost reduction.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W104

DOES EMERGENCY DEPARTMENT TRIAGE PAIN SCORE PREDICT DISPOSITION?

J. Riordan 1, M. Wakim 1, J. Patrie 1, W. Dell 1

1

University Of Virginia, Charlottesville, Usa

Background: Emergency Severity Index considers severe pain as one component in assigning a five-level triage scale. We know that higher acuity patients tend to be admitted. According to the index, severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. Is Pain Score a marker of critical illness, or is pain, more appropriately used as an early identifier of patients requiring early analgesia? This study seeks to determine if pain score is associated with emergency department disposition.

Methods: This was a retrospective, observational, cohort study of all visits to an academic emergency department from 4/1/13-3/31/14. Data was collected from the electronic medical record (EPIC) into EXCEL. Pain scores were extracted along with: disposition, age, ESI acuity and gender. Statistical analysis created two regression models.

Results: 50,939 patient encounters had complete variables for analysis. The first analysis compared a priori variables ability to predict discharge. The multivariate model yielded a C-statistic =0.79. Acuity level, age, pain score and sex all predicted discharge. The second analysis compared a priori variables ability to predict severe pain. This model yielded a C-statistic =0.68. Age, sex, acuity level and disposition all predicted severe pain.

Patients without severe pain were 1.6 times (1.51, 1.70) more likely to be assigned an ESI 2 than those with severe pain.

Conclusions: Acuity was the strongest predictor for discharge followed by age. Pain also predicted discharge with moderate pain (4-6) being the most likely to be discharged followed by severe pain (7-10). Patients without pain were least likely to be discharged followed by mild pain (1-3). Age was the strongest predictor for ESI pain score. Middle age patients were the most likely to report severe pain. Women were more likely to report severe pain than men. Discharged patients were more likely to report severe pain. Acuity did predict severe pain. However, it was acuity level 4 which demonstrated the highest probability of severe pain. Acuity level 2 had the lowest probability of severe pain.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W105

BEDSIDE ULTRASONOGRAPHY OF OPTIC NERVE VERSUS OPHTHALMOSCOPY FOR PREDICTING ELEVATED INTRA CRANIAL PRESSURE

K. Golshani 1, M. Ebrahim Zadeh 1, B. Masoumi 1, R. Azizkhani 1

1

Isfahan University Of Medical Sciences, Isfahan, Iran

Background: Increased intracranial pressure is a challenging diagnosis. Measuring CSF pressure is an important tool for making the correct diagnosis but it is not practical to use it for all patients with possible increased intracranial pressure. In this study the authors compared two commonly used noninvasive methods (ophthalmoscopy and bedside ultrasonography) in the diagnosis of elevated intra cranial pressure (ICP) with non-contrast brain CT scanning as a frequent and available method in a lot of emergency departments.

Methods: 131 patients with possible clinical diagnosis of elevated ICP enrolled to the study. Age less than 18 years old, direct blunt or penetrating trauma to the eyes or other ophthalmic diseases that limit effective ophthalmoscopy were excluded. A minimum sample size of 117 was calculated with a sensitivity of 0.9, a prevalence of 30%, alpha= 0.05 and d=0.1. In a period of 30 minutes from admission ophthalmoscopy, ophthalmic bedside ultrasonography and brain CT scanning obtained and the results were recorded. Optic nerve disk widening, ocular venous engorgement, blurring or hemorrhage over optic nerve disk, elevation of optic disk, and retinal venous tortuosity considered as the signs of ICP rising in ophthalmoscopy. Optic nerve diameter 3 mm beneath the retina calculated three times ultrasonographically by a linear probe and mean measures more than 5 mm considered as increased ICP. CT scan findings in favor of elevated ICP consist of; cerebral edema, midline shift, cistern compression, ventricular collapse and its enlargement.

Results: The mean age of participants was 46.29 Âą 10 years (77% male). The number of diagnosed elevated ICPs with ophthalmoscopy and ultrasound were 98 (74.8%) and 102 (77.9%) cases, respectively. The calculated sensitivity and specificity of ophthalmoscopy and ultrasonography in detection of ICP rising were 100.0% (95% CI: 88.6, 100.0) and 35.4% (95% CI: 26.0, 46.2), 100.0% (95% CI: 84.0, 100.0) and 31.9% (95% CI: 23.0, 41.7), respectively.

Conclusions: The present study revealed that in contrast to their specificity, optic nerve bedside ultrasonography and ophthalmoscopy are useful screening tools for discovering elevated ICP.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W106

SPECIFICITY OF BEDSIDE ULTRASOUND TO DIAGNOSE RENAL STONES/HYDRONEPHROSIS IN THE EMERGENCY DEPARTMENT

M.A. Majeed 1, N. Alsukaity 1, A. Alhubashi 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: Flank pain is considered one of the very common presentations of patients in Emergency Departments on a daily basis. Due to the high sensitivity and specificity of CT scan, it has become the standard imaging modality for evaluating acute flank pain with the potential of renal claculi. The introduction of emergency department US however has made it one of the most preferred initial modalities for detecting renal stones considering the fact that it is commonly available, inexpensive and risk free when it comes to radiation exposure.

Objectives : To compare bedside US with CT in detecting renal calculi and hydronephrosis in adult patients presenting to ED with acute flank pain.

Methods: Prospective diagnostic cohort study of adult patients presenting to ED with acute flank pain over 3 months period. Patients had a bedside US by an emergency physician in ED prior to CT (gold standard) to assess for signs suggestive of renal calculi/ hydronephrosis.

Inclusion criteria : All adult patients (18 years and older) who present with acute flank pain and not previously diagnosed to have renal calculi.

Exclusion criteria: Patients who have been already diagnosed with renal stones.

Results: The results were very reassuring. We had total 24 patients in our pilot study. 8 were females and 16 were male. The mean age was 54years (28-90). All the patients had departmental US followed by the CT KUB. The bedside ultrasound showed sensitivity of 83.3% (95% CI= 36-97%), specificity 100% (95% CI= 82-100%), negative predictive value 95% (95% CI= 75-99%) and positive predictive value 100% (95% CI= 48-100%).

Conclusions: Our results clearly show the effectiveness of bedside ultrasound in the hands of ED physicians.

Patients without evidence of stones and hydronephrosis on ED bedside US could be safely assumed to have no stones or less than 6 mm if detected on CT. The smaller stones typically do not require surgical intervention.

Hence based of the clinical judgement patients with negative US can be discharged home or further imaging can be requested.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W107

ARE ED PHYSICIANS ANY GOOD TO PERFORM DVT SCANNING IN THE EMERGENCY DEPARTMENT?

M.A. Majeed, A. Alhubshi 1, N. Alsukaity 1, A. Naveed 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: Deep vein thrombosis is a common condition presenting in the Emergency Department (ED). Itâ&#x20AC;&#x2122;s often difficult to diagnose and if missed could be lethal. However, early diagnosis and implementation of treatment considerably improves the prognosis. Therefore, itâ&#x20AC;&#x2122;s crucial to accurately diagnose the symptomatic and those without symptoms. Many diagnostic tools exist; compression ultrasonography (CUS) is currently the most effective diagnostic tool in the emergency department, shown to be highly accurate.

Objective: To evaluate to sensitivity and specificity of bedside ultrasound in diagnosing DVT in the Emergency Department.

Methods: We did a pilot study in the Emergency Department of University Hospital Birmingham over a period of 6 months (Aug 2014- Jan 2015). We had total of 18 patients, 8 female and 10 male with a mean age 17 years (23-72). All of these 18 patients had point of care leg US done first in the ED and then by radiologist in the Vascular lab. The radiologists were blinded to our results. A verbal consent was taken and documented in the patient notes.

Inclusion: All adult patients with unilateral calf pain with suspected DVT were included.

Exclusion: Patients under 16 years and those with traumatic calf pain were excluded.

Results: Out of 18 patients 3 had positive scan in the ED but 2 in the vascular lab. Rest of the 15 patients had negative scan in the ED and vascular lab. We achieved 100% sensitivity (95% CI= 20-100%), 94% specificity (95% CI= 70-99%), positive predictive value 67% and negative predictive value of 100%.

Conclusions: Bedside US has many advantages for evaluating potential cases of DVT including high sensitivity and specificity with minimal time and expense. This technique provides means for the emergency physician to rapidly screen patients at bedside for DVT. Our results clearly show that Emergency physicians are capable of accurately diagnosing DVT using bedside US. We need to train more ED physicians to perform DVT scanning which will improve patient care and save time and money.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W108

EVALUATION OF THE INFERIOR VENA CAVA DIAMETERS AND ITS COMPLIANCE DURING THE RESPIRATORY CYCLE BY THE FOCUSED CARDIAC ULTRASOUND: EMERGENCY PHYSICIAN VERSUS CARDIOLOGIST

M. Ben Lassoued 1, R. Jebri 1, M. Arafa 1, R. Hammami 1, O. Khila 1, O. Andolsi 1, K. Taamallah 2, W. Fehri 2, K. Lamine 1

1

Military Hospital Of Tunis Emergency Department, Tunis, Tunisia, Department, Tunis, Tunisia

2

Military Hospital Of Tunis Cardiology

Background: The objective of this study is to evaluate the concordance between the emergency physician and the cardiologist on the assessment of the inferior vena cava diameters and its compliance during the respiratory cycle by Focused Ultrasound Cardiac, more commonly named FOCUS, for patients treated in the emergency department.

Methods: A prospective observational study was conducted in the emergency department over a four-month period including patients older than 16 years, in whom an urgent indication of FOCUS was made.

Patients enrolled in the study underwent a double echocardiographic exploration: the first one by an emergency physician who had undergone three month training in echocardiography unit, and a second examination by an experienced cardiologist. The evaluation of the echocariographic findings was made in a Time-motion mode and two-dimensional mode. An inferior vena cava which expiratory diameter is greater than 20 mm was considered dilated. An inspiratory collapse of the inferior vena cava below 50% was considered pathological. A diameter less than 12 mm with a spontaneous collapse was suggestive of volume depletion. The correlation analysis was performed using the intra-class correlation coefficient Cronbach's alpha.

Results: Seventy-eight patients were included, Mean age: 51 +/- 13 years, sex ratio: 2.25. The concordance between the two operators to evaluate expiratory inferior vena cava diameter in tow-dimensional mode was alpha = 0, 92 (95% CI = [0.78 to 0.98]; p <10-3); in time motion mode it was alpha = 0.88 (95% CI [0.80 to 0.95]; p <10- 3). The concordance between the two operators for the assessment of inspiratory collapse of the inferior vena cava in two-dimensional mode was: alpha = 0.95 (95% CI [0.88 to 0.98]; p <10- 3) and in time motion mode it was: alpha = 0.93 (95% CI [0.80 to 0.97]; p <10- 3).

Conclusions: The concordance between the two operators for the evaluation of the inferior vena cava diameter and its compliance during the respiratory cycle was excellent. This encourages the implementation of the FOCUS bedside in the emergency department.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Imaging / Imaging by Ultrasound

W109

FOCUSED ULTRASOUND CARDIAC CONTRIBUTION PRACTICE BY THE EMERGENCY PHYSICIAN IN THE DIAGNOSTIC MANAGEMENT, TREATMENT AND ORIENTATION OF PATIENTS IN THE EMERGENCY DEPARTMENT

M. Ben Lassoued 1, R. Jebri 1, R. Hammami 1, M. Arafa 1, O. Andolsi 1, O. Khila 1, K. Lamine 1

1

Military Hospital Of Tunis, Tunis, Tunisia

Background: The objectives of the Focused Ultrasound Cardiac, more commonly named FOCUS, specific to emergency medicine were approved by the 2010 consensus of the American Society of Echocardiography and the American College of Emergency Physicians.

The objective of our study is to evaluate the contribution of Cardiac Ultrasound FOCUS directed by the emergency physician as part of the diagnostic management, therapeutic and targeted referral of patients admitted in the emergency department.

Methods: A prospective observational study was conducted in the emergency over a six-month period including patients with acute chest pain, dyspnea or acute traumatic shock or not. The patients underwent FOCUS examination conducted by an emergency physician who had a master's degree in echocardiography and Doppler. The examination FOCUS was performed before any therapeutic management. The main evaluation criteria were: diagnostic, therapeutic and orientation changes after realization of FOCUS and the secondary endpoint was the concordance between the diagnosis of EP and final diagnosis of a specialist.

Results: Eighty-two patients were included in the study, mean age was 62 +/- 13 years, the sex ratio: 2.

Fifty-five patients (59.7%) had cardiovascular co-morbidities: 25 ischemic heart disease, 18 arrhythmias, 12 valvular heart disease, 28 high blood pressure and 9 arthritis occlusive. Ninety FOCUS exams were performed, it was found: - A change of diagnosis in 38% of cases - A change in the therapeutic management in 43% of cases -And a change in the patient's orientation in 26% of cases.

A concordance between the diagnosis of the emergency physician and final diagnosis of a specialist was observed in 94% of patients. It was obtained: sensitivity 89%, specificity 94%, positive predictive value of 95% and a negative predictive value of 85% of the examination FOCUS to the selected initial diagnosis.

Conclusions: FOCUS directed by the emergency physician is a rapid examination, reliable and useful to emergencies. This imaging tool will allow getting in a few minutes and noninvasively, very valuable information that can improve the diagnostic management, treatment and orientation of patients in the emergency department.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Critical Care

W110

FEASIBILITY OF THE SONOGRAPHIC ASSESSMENT OF THE VENOUS EXCAVATION (SAVE) PROTOCOL

J. Seo 2, H. Doh 1, S. Lee 4, J. Lee 5, H. Kim

3

1

Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 2 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 3 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 4 Dongguk University Ilsan Hospital, Goyang-Si, South Korea, 5 Dongguk University Ilsan Hospital, Goyang-Si, South Korea Background: Central venous cannulation (CVC) plays several important roles in treating critically ill patients.

Adverse events frequently occur during cannulation, despite using ultrasound guidance. For that reason we usually check the chest x-ray for confirmation. The purpose of this study was to evaluate the usefulness and effectiveness of peri-CVC ultrasound exam of internal jugular vein (IJV) compared with chest x-ray.

Methods: The authors assembled a prospective observational cohort of emergency department (ED) patients undergoing CVC via IJV. Among the enrolled patients, 30 patients underwent SAVE. The SAVE consisted of 1) pre-CVC lung ultrasound, 2) ultrasound guided puncture of central vein and checking complications, 3) sonographic detection of guide-wire before dilation, 4) post-CVC LUS, 5) detection of catheter tip using agitated saline. The primary outcome was the completeness and the success rate of each stage. The secondary outcome was an estimated time each stage of the SAVE exam. After the procedure the whole time used using CVC via ultrasonography was compared with the time it took for the protable x-ray to be posted on the PACS program.

And physicians described anatomical site, reason for cannulation, and acute mechanical complications.

Results: In all subjects, guide-wire was visible within the lumen of the IJV. Median access time, from insertion to the detection of guide-wire in IJV via ultrasound, was 9 seconds. After the CVC was inserted, post-CVC LUS was completed within 8 seconds on median time. It took more than 11 minutes to identify chest x-ray image.

After shooting the agitated saline, it took a median time of 0.7 seconds to show in the right ventricle. No acute mechanical complications arose.

Conclusions: This study shows that the SAVE can effectively replace portable x-ray by detecting catheter malposition and by detecting CVC related complication without delay.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation

W111

VULNERABILITY STUDY OF HEALTH HUMAN RESOURCES IN THE IRANIAN MINISTRY OF HEALTH AND MEDICAL EDUCATIO

S. Hosseini Kasnavieh 1, H. Basirghafouri, G. Masumi, M. Chardoli, M. Yasinzadeh, N. Tavakoli, H. Amiri

1

Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 2 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 3 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 4 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 5 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 6 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran, 7 Iran University Of Medical Sciences, Tehran, Iran, Tehran, Iran Background: Health human resources is the major asset of the health system. The status of human resources in upstream and regulatory health organizations can exert high impact on the effectiveness of health policies and the performance of health system. This study, hence, was designed to explore the possible area of human resource damage to the employees of the Iranian Ministry of Health and Medical Education (MOHME).

Methods: Methods: A total of 316 MOHME staff was surveyed. A questionnaire containing 36 items related to three dimensions of human resources damage, including behavioral, structural, and contextual dimensions was designed and used as the study tool. The content validity of the questionnaire was ensured by applying the experts’ opinions. The reliability of the instrument was ensured by obtaining a Cronbach’s alpha of 0.93. T-test and Friedman test were sued for inferential analysis of the data Results: The behavioral dimension was perceived to represent the most vulnerable area of human resources damage, followed by structural and contextual dimensions. In regard to the behavioral dimension, ‘motivational factors’ was perceived to be the most important area of damage, followed by ‘job satisfaction’ and ‘job security’.

Regarding structural dimension, ‘appointment and job promotion’ received the highest perceived significance, followed by ‘payment system’ and ‘recruitment Conclusions: This study ranks the area of damage to health human resources in MOHME. Our results support the previous studies highlighting the role of behavioral factors in bringing damage to human resources. Our findings, therefore, could be applied to development of human resources supporting plans aimed at improving the performance of upstream governmental health organizations. Specifically, providing motivating incentives and implementing strategies supporting job satisfaction and job security can bring significant protection to health human resources

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation W112 STREAMING EXPEDITES PATIENT CARE AND SAVES TIME IN A BUSY EMERGENCY DEPARTMENT M. Majeed 1, A. Naveed 1, E. Miller 1

1

University Hospital Birmingham, Birmingham, United Kingdom

Background: The word stream means “steady flow”. THE CONCEPT OF STREAMING patients with relatively low acuity conditions through a dedicated area, in order to reduce their waiting times and lengths of stay was first trialled on North America.

This led to the idea of streaming. Now having a senior nurse/doctor at the initial point of contact can change this process as to weather this patient needs to go to minors, majors or resus.

Objectives: To evaluate the impact of streaming process Early contact with the medical personnel Earlier initial assessment/ risk stratification Flow of the patient in ED Patients assessed in the most appropriate area.

Methods: Setting: This prospective study was done in the Emergency Department of University Hospital Birmingham from 23rd December 2014 to 23rd January 2015.

Method: A band 6 or above nurse was the initial point of contact at the reception, who would ask few questions 2-3 mins top, and then decide where this patient needs to go to minors, majors or resus. She then gave the patient a color-coded card (red- resus, orange- majors, green-minor) to take it to the receptionist in the next window. Then the patient’s notes will be printed in the dedicated area (minors, majors and resus), where a dedicated team of nurses will assess the patient.

Results: Results: The results were very impressive. With this streaming patients were seen by the band 6 or above nurse at the first point of contact. Hence all the patients were met by a health professional.

We managed to drop the assessment time form over an hour to few 5-6 minutes. This in turn had the impact on the patient satisfaction and time to be seen by medical personnel. This lead to early decision and quick processing through the ED. Conclusions: This trial has demonstrated that streaming patients in the emergency department of a tertiary adult teaching hospital reduces waiting times for the triage and assessment. Our trial proves what previous studies have shownIn conclusion streaming leads to early contact with medical personnel, assessment, saves time and expedites patient care.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation

W113

COMPLIMENTS, COMPLAINTS PATIENT-SATISFACTION

AND

CLAIMS:

AN

ALTERNATIVE

MODEL

FOR

SCORING

K. Janssens 1, B. Farrelly, R.L. Drew, N. Salter

1

St. Michaels Hospital, St. Vincent's University Healthcare Group, Dublin, Ireland

Background: In the environment of patient-centered care, America has attempted to consider patient experience in allocation of funding using a system predominantly derived from a patient-satisfaction (PS) survey. In Ireland, a national survey system does not exist, though individual hospitals may use them locally.

There does however exist national repositories of data pertaining to unsolicited feedback on patient experience: compliments, complaints and compensation claims. The aim of this study is to explore how these datasets can reflect patient experience in the emergency department (ED), and whether these factors can be combined to form a more accurate national measure of PS. Methods: We analysed data from two national agencies: one registering compliments and complaints, another registering claims; as well as a Dublin hospital which submits data to both. We used weighted averaging to calculate scores based on these 3 factors (compliments, complaints and claims). We compared this to scores on PS surveys from the same time period (2012). We compared the 3C-score to PS-score. We also examined clinical circumstances behind data to explore trends.

Results: There were 52% as many compliments as complaints. These were predominantly in relation to treatment and service delivery (64%), staff manner (30%). Nationally, 21% of all claims settled arose from the ED. Of these, 88% related to treatment or service delivery. ED related claims were predominantly related to injuries, while compliments were predominated by illnesses. The average 3C score was 34% and the average PS score was 53%. Correlation coefficients between 3C scores and PS scores were consistently <0.5. We combined both scores to create a 4-factor score incorporating 2 compliment and 2 complaint type factors in which an evaluation of “good” across all priority areas would achieve 50%. Our hospital scored 34%.

Conclusions: Patient experience is unlikely to be accurately reflected using PS surveys. Unsolicited feedback in the form of compliments, complaints and claims can be extremely valuable but also likely inaccurate. We propose a combined 4-component score, which could be used by clinicians and managers to assess patient’s experience, for risk-stratification and to assess performance.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W114

COGNITIVE FUNCTION DECLINE IN EMERGENCY MEDICINE SHIFTS

A. Tse 1, L. Sanchez 1

1

Harvard Affiliated Emergency Medicine Residency Beth Israel Deaconess Medical Center, Boston, Usa

Background: Emergency Medicine (EM) is a high-stakes field, where cognitive function and vigilance are critical for patient safety. EM shift duration varies and is not necessarily optimized for physician performance and patient safety. EM practice requires several cognitive functions, including working memory, a cognitive system for temporary storage and manipulation of remembered information. An EM physician must evaluate, diagnosis, and treat several patients in quick succession during a shift, and circle back multiple times to each patient in order to progress towards their ultimate disposition. The n-back test involves numerous executive processes, including active maintenance of the last n items and updating of new items so that they can be actively maintained (Chatham et al, 2011). In brief, subjects are asked to monitor a series of stimuli and to indicate if the currently presented stimulus is the same as the one presented n trials previously. When n=1 or higher, performing the test requires working memory to be updated continuously. <FILE IMAGE='248_20150601050851.jpg'> Methods: EM residents and attendings were asked to voluntarily participate at an urban Level I trauma center from February to May 2015. Participants (n=51) were first introduced to a 30-second, computer-based, n-back test. They set alarms to perform the test during their scheduled shifts at pre-set times (the beginning, one third through, two thirds through, shift end). They were blinded to their scores. The primary outcome was the pattern of scores within a shift.

Results: A decline in test scores was found from shift beginning to end. The mean scores at the beginning, one third through, two thirds through, and shift end were 88.63% (95% CI, 85.32%-91.94%), 83.31% (95% CI, 79.36%-87.26%), 77.59% (95% CI, 74.66%-80.43%), and 65.08% (95% CI, 60.90%-69.19%), respectively. The mean delta score from shift beginning to end was 23.55% (95% CI, 11.55%-35.55%).

Conclusions: Using a modified n-back test to test cognitive function, EM physician performance declined from the beginning to the end of their shifts. Within-physician performance revealed a delta change of 23.55%. This preliminary research suggests that cognitive function may decline over the duration of an EM shift.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W115

THE EFFECTS OF SCREENING FOR EBOLA ON EMERGENCY DEPARTMENT THROUGHPUT

W. Mwangi 1, R. Nagurka 1, M. Steenberg 1, G. Sugalski 1, T. Murano 1, S. Lamba 1, S. Keller 1

1

Rutgers New Jersey Medical School, Newark, Usa

Background: Emergency Department crowding and boarding are ongoing issues in healthcare that are compounded by unexpected events. With the connected global community, hospitals are susceptible to international epidemics like the recent Ebola Virus Disease outbreak in West Africa. University Hospital in Newark, New Jersey is a designated United States Center for Disease Control and Prevention Ebola Assessment Hospital and is a receiving hospital of Newark Liberty International Airport. Initially, patients suspicious for being infected with Ebola were evaluated in isolation rooms within the Emergency Department.

Due Ebolaâ&#x20AC;&#x2122;s highly infectious nature and recognizing that these patients require isolation and high level of individualized care, an extended treatment area physically outside of the Emergency Department was established. Resources such as physicians, nursing staff and some medications were provided by the Emergency Department.

It was hypothesized that the complex work-up for suspected Ebola patients may impact Emergency Department functioning and throughput processes. The purpose of this study was to determine the effect screening suspected Ebola patients in the extended treatment area had on the length of stay for patients in the Emergency Department.

Methods: Patient data were retrospectively obtained for the months when patients with suspected Ebola presented to the Emergency Department. Arrival, disposition and discharge times, and hourly volume were analyzed using two-tailed T-tests. Monthly average time to disposition was compared to the average time to disposition of each day when there were patients evaluated for Ebola.

Results: Eleven patients were evaluated for Ebola over a three-month period. There was a significant increase (p<0.001) in the Emergency Department length of stay regardless of where the suspected Ebola patient was evaluated. Probability 5/5 times for getting a longer length of stay with suspected Ebola patients is p<0.03. <FILE IMAGE='156_20150529200232.jpg'> Conclusions: There was an increased average length of stay of other Emergency Department patients on days when there was a patient being evaluated for Ebola regardless of where the potential Ebola patient was evaluated. This may be because as these patients utilize manpower and resources for the Emergency Department.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Risk management / ED and Legal Affairs

W116

UTILIZING PHYSICIAN AND PATIENT COMPLAINTS AS A QUALITY ASSURANCE EMERGENCY MEDICINE

MARKER IN

K. Gurley 1, R. Wolfe 1, S. Grossman 1, J. Edlow 1, J. Burstein 1

1

Beth Israel Deaconess Medical Center Department Of Emergency Medicine At Harvard University, Boston, Usa Background: The value of systematic evaluation of both patient and physician complaints in emergency medicine remains poorly characterized as a marker for ED quality assurance.

Methods: We conducted a prospective, observational cohort study of consecutive patients presenting to an academic ED with 57,000 annual visits from Jan 2008 to December 2014. Randomly assigned, trained reviewers not involved in the patients care used a structured tool to determine the presence of error and adverse events using an 8-point Likert scale. If a reviewer felt that the case had a possible error or adverse event that resulted in the need for intervention, additional treatment, or caused patient harm, it was referred to a 20-member quality assurance (QA) committee of ED physicians and nurses who made a final determination as to whether or not an error and/or adverse event occurred.

Results: We identified 570 complaints within a data-base of 383,419 cases of which 33 were patient-generated and 537 were physician-generated. Physician errors that led to a preventable adverse event were detected in 2.9% (95%CI 1.38 range 1.52% to 4.28%). 9.1% of patient complaints correlated to preventable errors leading to an adverse event (95%CI 9.81 range -0.71% to 18.91%). 2.6% of complaints made by a physician alone were preventable physician errors leading to an adverse event (95%CI 1.35 range 1.25% to 3.95%). Near miss events were more accurately reported by physicians, with physician error found in 12.1% of reported cases (95%CI 2.76 range 9.34% to 14.86%) and in 9.1% of those reported by patients (95%CI 9.81 range -0.71% to 18.91%). Adverse events in general were found in 12.1% of patient complaints (95%CI 11.13 range 0.97% to 23.23%) and in 5.8% of physician complaints (95%CI 1.98 range 3.82% to 7.78%).

Conclusions: Screening and systemized evaluation of emergency department patient and physician complaints may be an underutilized and efficient quality assurance tool. Patient complaints may more accurately identify physician errors that result in preventable adverse events, while physician complaints may be more likely to uncover a near miss that did not lead to an adverse event.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Cardiovascular / CPR / Resuscitation

W117

LONG TERM OUTCOME OF EMERGENCY RESPONSE TEAM SYSTEM TO DECREASE CARDIAC ARREST OUTSIDE OF THE INTENSIVE CARE UNIT

J. Suriyachaisawat 1, A. Surakarn 1

1

Bangkok Hospital Group, Bangkok, Thailand

Background: Emergency Response Team ( ERT ) system was planned and implemented since June 2009 to detect pre-arrest conditions and for any concerns especially for normal ward. The ERT consisted of on duty physicians and nurses from emergency department. From the data on ERT system implementation in our hospital in early phase ( during June 2009-2011) , there was no statistic significance in difference in In-Hospital cardiac arrest incidence and overall hospital mortality rate. Since the introduction of the ERT service in our hospital, we have conducted continuous educational campaign to improve awareness in an attempt to increase use of the service.

Methods: To investigate long term outcome of ERT system in cardiac arrest outside of the intensive care unit and overall hospital mortality rate.We conducted a prospective, controlled before-and after examination of the effect of a ERT system during 2009-2012 on the incidence of cardiac arrest outside of the ICU. We performed Chi -square analysis to find statistic significance.

Results: Of a total 623 ERT cases from June 2009 until December 2012, there were 72 calls in 2009, 196 calls in 2010 ,139 calls in 2011 and 245 calls in 2012.The number of ERT calls per 1000 admissions in year 2009-10 was 7.69 , 5.61 in 2011 and 9.38 in 2013.The number of Code blue calls per 1000 admissions decreased significantly from 2.28 to 0.99 per 1000 admissions ( P value < 0.001 ) . The incidence of cardiac arrest decreased progressively from 1.19 to 0.34 per 1000 admissions and significant in difference in year 2012 ( P value < 0.001 ). The overall hospital mortality rate decreased by 8 % from 15.43 to 14.43 per 1000 admissions ( P value 0.095).

Conclusions: ERT system implementation was associated with progressive reduction in cardiac arrests over three year period , especially statistic significant in difference in 4th year after implementation. We also found an inverse association between number of ERT use and the risk of occurrence of cardiac arrests, But we have not found difference in overall hospital mortality rate.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Cardiovascular / CPR / Resuscitation

W118

IMPACT OF INTRA-ARREST FLUID LOADING WITH DIFFERENT DOSES OF CRYSTALLOID INFUSION ON HAEMODYNAMICS IN EXPERIMENTAL CARDIAC ARREST

R. Skulec 1, A. Truhlar 2, R. Cerna Parizkova 3, Z. Turek 3, D. Astapenko 3,4, V. Cerny 3,4,5,6

1

Emergency Medical Service Of The Central Bohemian Region, Kladno, Czech Republic, 2 Emergency Medical Service Of The Hradec Kralove Region, Hradec Kralove, Czech Republic, 3 Department Of Anesthesiology And Intensive Care, Charles University In Prague, Faculty Of Medicine In Hradec Kralove, Hradec Kralove, Czech Republic, 4 Department Of Research And Development, Charles University In Prague, Faculty Of Medicine In Hradec Kralove, Hradec Kralove, Czech Republic, 5 Department Of Anesthesiology, Perioperative Medicine And Intensive Care J.E. Purkinje University, Masaryk Hospital, Usti Nad Labem, Czech Republic, 6 Dept. Of Anesthesia, Pain Management And Perioperative Medicine Dalhousie University, Halifax, Canada Background: Fluid loading during cardiopulmonary resuscitation (CPR) for non-hypovolemic cardiac arrest remains controversial. Thus, we conducted experimental study to evaluate impact of two different doses of balanced crystalloid infusion on haemodynamics in a porcine model of ventricular fibrillation.

Methods: Ventricular fibrillation was induced for 15 minutes in 19 anesthetized domestic pigs. Before induction, the animals were randomized to receive either 1000 ml (34±3 ml/kg, group A, n=7) or 500 ml (16±2 ml/kg, group B, n=7) of balanced crystalloid solution or to undergo no fluid loading during CPR (group C, n=5). After spontaneous circulation (ROSC) was restored, the animals were observed for 90 minutes.

Results: In all groups, significant increase of intracranial pressure followed by its decrease after ROSC was observed. While in groups B (from 12±2 to 18±2 mm Hg, p<0.05) and C (from 13±1 to 18±3 mm Hg, p<0.05) it was comparable (p>0.05), the rise of intracranial pressure in group A was significantly higher (from 12±3 to 23±3 mm Hg, p<0.05). Whereas coronary perfusion pressure was lower in group A than in control group C during volume loading, fluid infusion induced its mild increase in group B (group A: 12.1±2.4, group B: 16.0±2.6, group C: 13.6±2.8 mm Hg, p=0.043). Cerebral perfusion pressure was lower in group A and C during volume loading than in group B (group A: 10.1±3.4, group B: 14.8±3.4, group C: 8.5±1.0 mm Hg, p=0.041). Cardiac index ten minutes after ROSC significantly differed among all groups (group: 8.9±2.2, group B: 7.1±1.3, group C: 4.9±1.9 l/min/m2, p=0.007) and the dose of crystalloid infusion positively correlated with cardiac index increase (r=0.815, p<0.001).

Conclusions: Fluid loading during CPR had significant impact on haemodynamics in our experimental model.

While high dose led to unintentional increase of intracranial pressure and decrease of coronary perfusion pressure, low dose did not affect intracranial pressure and was associated with mild increase of coronary and cerebral perfusion pressure.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Administration, Health Policy, and Legislation

W119

COLLABORATIVE EFFORT BETWEEN A RURAL PUBLIC SCHOOL SYSTEM AND A UNIVERSITY BASED FLIGHT PROGRAM - DEVELOPING AND IMPLEMENTING A SCHOOL BASED FIRST AID, CPR AND AED TRAINING PROGRAM

H. Dhindsa 1, B. Nicholson 2, J. Lovelady 3, V. Sikka 1, B. Bogue 3, K. Baker 3

1

Virginia Commonwealth University - Department Of Emergency Medicine, Richmond, Usa, 2 Boston Medical Center - Department Of Emergency Medicine, Boston, Usa, 3 Virginia Commonwealth University - Emergency Aviation, Department Of Emergency Medicine, Richmond, Usa Background: Every year approximately 7000 children suffer cardiac arrest, most often at school, or while involved in sports. The chance of survival increases from 5-10 percent to as high as 70 percent with immediate interventions such as CPR and AED use. New regulations in Virginia require public school system employees be trained in first aid/CPR/AED. Many schools in rural areas with limited resources have struggled to determine how to meet this unfunded regulatory mandate.

Methods: A rural county public school system in Virginia partnered with the helicopter flight program of Virginia Commonwealth University(VCU). VCU agreed to provide free training to the school system. Flight team members underwent instructor training from the American Heart Association (AHA) in order to become certified to teach the 16 hour AHA Heartsaver First Aid/CPR/AED course.

Results: The program was launched in August, 2013. To date 40 employees have been trained, and by the end of the school year 80 employees will have been trained. This will ensure that all six schools have staff with the required training. The next phase of this program will train employees of the school system to become instructors in order to build a component of self-sustainability into the program.

Conclusions: This project demonstrates how collaboration between a rural public school system and a university flight program can result in successful implementation of a high quality First Aid/CPR/AED program.

Such partnerships can help rural school systems meet regulatory training requirements to improve outcomes for students that suffer potentially devastating cardiac events.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Pre-Hospital / EMS / Out of Hospital

W121

SENSITIVITY, SPECIFICITY AND PREDICTIVE VALUES OF EMERGENCY MEDICAL SERVICE PROVIDER ASSESSED CARDIAC SYMPTOMS ON ACUTE MYOCARDIAL INFARCTION

J. Park 1, T. Kim 2, Y. Ro 3, W. Cha 4, S. Moon 5, S. Shin 1, Y. Kim 2, J. Joo 2

1

Seoul National University Hospital, Seoul, South Korea, 2 Seoul National University Bundang Hospital, Bundang, South Korea, 3 Laboratory Of Emergency Medical Service, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea, 4 Samsung Medical Center, Seoul, South Korea, 5 Korea University Ansan Hospital, Ansan, South Korea Background: For acute myocardial infarction (AMI) patients, emergency medical service (EMS) provider assessed symptoms have critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic performance of EMS assessed symptoms of cardiovascular disease for actual AMI. Methods: Patients from 2008 to 2012 transported to 4 study hospitals by EMS were included. Using EMS records and ED database, all patients were stratified according to the presence of EMS assessed cardiac symptoms and ED diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitation, and syncope. Disproportionate stratified sampling was used and hospital record of sampled patients were reviewed to identify the actual diagnosis of AMI. Using the inverse probability weighting, verification bias-corrected diagnostic performance were estimated.

Results: Overall, 92,353 patients were enrolled for the study. Of these, 13,971 (15.1%) complained cardiac symptoms to EMS provider. Of all included, 1,001 (1.08%) had ED diagnosis of AMI. 775 patients were sampled for hospital record review. The sensitivity of EMS provider assessed cardiac symptom on the final diagnosis of AMI was 73.3% (95% CI: 70.8 to 75.7), specificity was 85.3% (95% CI: 85.3 to 85.4), positive predictive value was 3.9% (95% CI: 3.6 to 4.2), and negative predictive value was 99.7% (95% CI: 99.7 to 99.8). Diagnostic performance of each cardiac symptoms were also estimated.

Conclusions: We found that EMS provider assessed cardiovascular symptoms had moderate sensitivity and specificity for diagnosis of AMI. EMS policy makers can use these data to evaluate the pertinence of specific prehospital treatment of AMI.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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EVALUATION OF CONSULTANTSâ&#x20AC;&#x2122; SATISFACTION IN A TUNISIAN EMERGENCY DEPARTMENT (ABOUT 300 PATIENTS)

M.A. Hadj Ali 1, A. Zorgati 2, L. Boukadida 3, R. Youssef 4, S. Ounais 5, A. Jerbi 6, R. Boukef 7

1

Sahloul Hospital, Emergency Department, Sousse, Tunisia

Background: Over the last years, there is an increased rate of emergency consultation. The problem of overcrowding has become chronic. Emergency departments (ED) are facing the challenge of ensuring access to care. Organization is certainly important. Satisfaction of patients is one of quality indicators. Its evaluation must be regularly made to identify problems and improve the global health care.

Methods: We conducted a punctual study which included 300 patients consulting our emergency department for various complaints in both periods of shifts: day and night. The survey tool consisted of satisfaction questionnaire. General informations about patients were noted too. The questions were conducted in Arabic language. The questionnaire assessed satisfaction of the consultants regarding some items: initial reception, utility of the triage unit, organization of this department and the global medical care. A satisfaction scale was used.

Results: The sex ratio was 0.84. The average age was 46.years. The majority of consultants came from home (91%) and only 5% of patients are referred. The consultants arrived to ED on their own (91.3%). Benign injuries are the most frequent reason for consultation (64.4%) followed by other medical complaints. Serious injuries are fewer than 2.5%.

The majority of patients were not satisfied by the initial reception: (48.3%), but 41.81% of patients thought that the passage through the triage was required and were satisfied. The largest share of patients was satisfied too by the global medical care (48.3%). We found that 19.3%of patients were not satisfied with the organization of the emergency and the lack of orientation. The Communication between patient and doctor still not sufficient Conclusions: It is now admitted that triage unit has a very important role in the improvement of the emergency care. But we must confess that it is not a final solution. Human factors are important too and both medical and paramedical staff must collaborate to promote a good quality service in the ED. The psychological care of emergency consultant is important and special attention should be paid to ameliorate the waiting room and the information of the patient and his family.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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BEYOND THE EMERGENCY SEVERITY INDEX, ARE PATIENT VARIABLES ASSOCIATED WITH DISPOSITION?

J. Riordan 1

1

University Of Virginia, Charlottesville, Usa

Background: The Emergency Severity Index tool was developed in the late 1990s. In June 2010, The American College of Emergency Physicians and The Emergency Nurses Association adopted joint policy statements endorsing support for this five-level triage scale. It is the most often used triage tool in United States emergency departments. Many departments have initiated novel treatment pathways. Patients are often assigned based upon their triage level. Often, 4s and 5s are placed into these pathways. How should level 3 patients be assigned? Are there variables within this group associated with disposition? <FILE IMAGE='124_20150524230902.jpg'> Methods: This was a retrospective, observational, cohort study of all emergency department visits to an academic medical center from 4/1/13-3/31/14. Data was extracted from the electronic medical record. Level 3 patients were included for analysis.

Results: 25,119 category 3 patients (98.7%) were analyzed. Both Univariate and Multivariate logistic regression analyses were performed for the dependent outcome variable discharge versus other. Predictor variables included: arrival method, age, gender, temperature, systolic blood pressure, diastolic blood pressure, respiratory rate, heart rate, oxygen saturation and pain score. These variables were selected a priori based on established value and widespread clinical importance. All variables were significant in both analyses.

Following adjustment, predictors were ranked based upon observed minus expected chi-square statistic under the null hypothesis. The Bias Correct C-statistic was 0.70.

Conclusions: Variables present on arrival for triage level 3 patients are associated with discharge. Attention to these could improve the efficiency and accuracy of novel care tracts.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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ER THROUGHPUT: STAFF PERCEPTIONS OF DELAYS

A. Gulati 1, T. Spiegel 1

1

University Of Chicago, Chicago, Usa

Background: There are many potential delays in throughput in a busy academic emergency department.

Identifying these delays can help the organization serve patients better and more efficiently. Perceptions vary regarding which factors contribute most to delays in throughput. This study aims to identify some of these factors and analyze the perceptions of delays among staff members.

Methods: All full-time clinical staff of the University of Chicago emergency department were asked to select the top 5 delays (among 19 options) that detract from overall throughput. Staff was also asked to choose the top 5 improvable delays in throughput. Responses were sorted by group: attending, resident, nurse and technician.

The percent of total participants within one group that selected a particular option was compared to the other groups.

Results: Response rate among physicians was 56% while response rates among other staff was 34%. 50% of all responses were physicians while 50% were other staff members. The top selections among physicians were: waiting for consultants, image acquisition, inpatient bed assignments, distractions and lab results. The top selections among ancillary staff were: physician decision time, inpatient bed assignments, waiting for consultants, radiologist read of images, image acquisition.

All groups indicated that the largest perceived delays are outside of the ERâ&#x20AC;&#x2122;s control. Staff within one group typically characterized the largest delays as ones that fall within the responsibility of another group, minimizing delays their own group is accountable for. The largest perceived delays tend to be operations that a group is least involved with or disrupts a groupâ&#x20AC;&#x2122;s own workflow.

Conclusions: Better communication between staff groups is needed to understand delays contributing to overall workflow. Since perceptions of delays are so varied among staff groups, data-driven methodologies to improve workflow are important to avoid fallacies related to perceptions in overall ER throughput delays.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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A QUALITATIVE STUDY OF THE CHALLENGES OF CLINICAL REFERRALS IN THE EMERGENCY DEPARTMENT

J. Cusack 1, S. Cusack 1, R. Cusack 2, R. O'sullivan 2

1

University College Cork, Cork, Ireland, 2 Cork University Hospital, Cork, Ireland

Background: Referrals and consultations are an important aspect of patient care in the emergency department (ED). Consultations range from stat therapy (e.g. emergency anaesthesia assistance) to arrangement of outpatient tests or follow-up (e.g. chest pain). Effective consultation has the potential to improve ED throughput and patient care. Delays associated with referrals and decisions are of growing concern for EDs as they further exacerbate ED overcrowding.

This study sought the opinions of Non-Consultant Hospital Doctors (NCHDs) on referral processes in Cork University Hospital (CUH) ED, with emphasis on any difficulties, complications and problems.

Methods: A qualitative approach was employed to capture data through a focus group interview of 12 NCHDs in CUH ED, moderated by a Consultant in Emergency Medicine. The interview was conducted from a set list of open and closed questions, and was concluded when data saturation was reached. The focus group was audio recorded, transcribed, and analysed using the Attride-Stirling framework for thematic network analysis to produce global, organising and basic themes.

Results: The global theme â&#x20AC;&#x2DC;Understanding Challenges in the Referral Processâ&#x20AC;&#x2122; emerged from three organising themes as follows: 1) Realities of Current Practice; 2) Communication and Interpersonal Relations in the Clinical Setting; and 3) Current Guidelines, Practices and Education of the Referral Process.

Conclusions: This study identifies a process adversely affected by interpersonal relations, staffing constraints and idiosyncratic behaviours. Pathways to improving the referral process are required including introduction of clear guidelines. Changing the current Irish model by which referrals take place (presently at a junior level) may be required.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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MINING BIG DATA TO ENHANCE EMERGENCY DEPARTMENT FLOW: A STUDY OF THE EFFECT OF VISITS AND ARRIVAL PATTERNS ON LENGTH OF STAY AND IMPLICATIONS IN MAXIMIZING ED CAPACITY.

M. Attia 1, J. Loiselle, B. King

1

Sidney Kimmel Medical College, Dept Of Pediatrics, Philadelphia, Usa

Background: ED is the gateway to hospitals generating 75% of admissions. ED overcrowding prolong wait times and length of stay (LOS) posing challenges with concerns for safety and satisfaction. Time tracking data from electronic records provide an unprecedented opportunity to understand ED flow and to create solutions.

Methods: ED visits (EDV) from 1/12-5/15 were analyzed to determine ED capacity (EDC), effect of EDV and ESI level on LOS when EDC was exceeded. EDC was carefully defined. Arrival patterns were examined hourly.

Stratified EDV and ESI levels were plotted against LOS to confirm EDC and to study the relationship between EDV, ESI level and LOS. Data were obtained from ED system for data acquisition and analysis.

Results: 177,849 visits were captured. Median daily EDV 142, mode 152, range 51-243. Median LOS 183 minutes, IQR 45. Median LOS exponentially rose for every 20 additional visits/day by 25 minutes and by 70 when maximum EDV was reached (>200 visits/day). When EDC was exceeded, practitionersâ&#x20AC;&#x2122; throughput remained stable. When EDC was increased utilizing additional resources the throughput improved. Overall, 50% of patients arrived between 12 midnight and 3 PM, with 50% arriving in the following 8 hours. There was a deviation from this pattern of arrival from April to September shifting to 45% and 55%. Admission rate was 14%.

50% of admissions occurred between 3pm and midnight, corresponding to the visits and 65% occurred between 3 pm and 7 am next day. ESI level were found evenly distributed throughout the 24 hours thus it did not influence the LOS or lead to clustered admissions.

Conclusions: Mining big data could yield invaluable information to resource EDs and inpatients units based on predicted EDV and the resulting admissions. Despite the power of big data, daily variations and variations within the same day occur and remain challenging. However, in anticipating EDV and admissions at various intervals throughout the day, (for example at 3 PM) could engender an appropriate and titrated response. There are significant advantages to patient safety and satisfaction as well as economical gains to this approach.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Abdominal / Gastrointestinal

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EMERGENCY PHYSICIAN ESTIMATIONS ABDOMINAL/PELVIC CT IMAGING

OF

THE

DIAGNOSTIC

UTILITY

OF

NON-TRAUMATIC

W. Paolo 1, L. Nguyen, W. Grant, S. Wojcik

1

Suny Upstate, Syracuse, Usa, 2 Suny Upstate, Syracuse, Usa, 3 Suny Upstate, Syracuse, Usa, 4 Suny Upstate, Syracuse, Usa Background: Acute abdominal pain is the leading cause for visits to the Emergency Department (ED). While computerized tomography (CT) has been shown to reduce the number of critical diagnoses missed when used early in the decision-making hierarchy, its utilization has been increasing without a concomitant match in patient acuity. The proper usage of diagnostic testing involves the understanding of the change in pre-test probability given a particular result.

Methods: We conducted a survey of emergency faculty members at a University Level-1 trauma center ordering a CT abdomen pelvis in non-traumatic patients over the age of 18. The physicians were asked to give a pre-test probability (ranging from 0% to 100%) for the specific disease entity in question and a final probability given the test results. An evidenced based review of positive and negative likelihood ratios were derived, which was used to calculate the actual post-test probability and compared to physician judgment.

Results: 219 patients encounters were included of which 126 were females (57.5%) and 93 were males (42.5%). The top three pathologies listed were bowel obstruction (23.7%), nephrolithiasis (19.6%), and appendicitis (12.3%). The median estimated physician pre-test probability for a negative CT was 40% (range 5%-100%) with a post-test probability of 0.00% (76.6% of all negative CT results) yielding a calculated difference ranging from 1-15%. The median estimated physician pre-test probability for a positive CT was 70% (range 3%-100%) with a post-test probability of 100% (79.5% of all positive CT results) yielding a difference ranging from -1- -10%.

Conclusions: The physicians surveyed varied greatly in their approach to the diagnostic utility of CT scanning of the abdomen and pelvis however > 75% of the time an overestimation of the power of CT scanning was evident.

Approaches to diagnostic thresholds were inconsistent with physicians ordering CT scans with probabilities at the extremes ranging from 3% likely to 100% likely.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Abdominal / Gastrointestinal

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NASOGASTRIC LAVAGE ASSESSMENT OF PATIENTS AT LOW RISK BY THE GBS AND AIMS65 SCORING SYSTEMS IN PATIENTS WITH UPPER GI BLEEDING

L. Cochon 1, E. Perlini 2, A. Deshpande 2, D. Sussman 2, A. Baez 3

1

Universitat De Barcelona, Barcelona, Spain, Jackson Memorial Hospital, Miami, Usa

2

University Of Miami Miller School Of Medicine, Miami, Usa,

3

Background: Upper GI bleeding (UGIB) is an important contributor to emergency department presentations and subsequent hospital admissions. Scoring systems like the Glasgow Blatchford Score (GBS) and the AIMS65 have been developed to predict the need for endoscopic intervention and mortality.

Methods: Sensitivity and specificity for NG lavage was obtained from several comparable studies on non-variceal UGIB. Sensitivity and specificity for NG lavage was divided into low and high range, likelihood ratio (LR) were calculated. Percentage risk used as pretest probability and LR for NG lavage were inserted into Bayesian nomogram to obtain posttest probabilities. Absolute (ADG) and relative diagnostic gains (RDG) were calculated. ANOVA was used to evaluate strength of association with a p value set at 0.05 Results: Sensitivity of 0.42 and specificity of .54 for low range with a LR+ of 0.91 and 0.84 and 0.91, LR + 9.33 for high range respectively. Using low range values for NG lavange and AIMS 65 low risk resulted in a post test probability of 3%, ADG and RDG of 0%. Low range NG lavage and GBS low risk population resulted in a post test probability o 5% with 0% ABDG and RDG. High range values for NG lavage and AIMS 65 low risk pretest probability yielded a post test probability of 22%, ADG of 19% and RDG of 633.3%. For high range NG lavage and low risk GBS post test probability was 33%, ADG of 28% and RDG 560%. ANOVA for low range NG lavage p= 1.0 ; for high range p= 0.95.

Conclusions: There was zero absolute or relative gain in post-test probability for low-risk as determined by the scoring systems. On ANOVA analysis, there was no incremental benefit of NG lavage to non-invasive scoring systems for low-risk patients even when using high end of LR (9.33).

For patients with low-risk of need for endoscopic intervention or mortality based on the GBS or AIMS65 scoring systems, nasogastric lavage provides no additional yield in predicting these poor outcomes. In patients with a low score on GBS or AIMS65, nasogastric lavage should not be performed.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Urology Genito-urinary

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EVALUATION OF EMPIRIC ANTIBIOTIC THERAPY OF URINARY TRACT INFECTIONS IN THE EMERGENCY DEPARTMENT. PROSPECTIVE STUDY ABOUT 236 CASES.

R. Jebri 1, O. Djebbi 1, E. Jbeli 1, M. Hagui 1, I. Bennouri 1, M. Benlassoued 1, K. Lamine 1

1

Military Hospital Of Tunis Emergency Department, Tunis, Tunisia

Background: Urinary symptoms is a common pattern for emergency department visit. According to the recommendations of the the French Agency for Safety of Health Products in 2008, this treatment is based on probabilistic fluoroquinolones. The purpose of this study is to verify the concordance between the results of the urine culture and the empirical treatment established in the emergency department and to detect the resistance to quinolones.

Methods: a prospective observational study conducted in the emergency department over four months. Were included patients age more than16 years in whom the diagnosis of urinary tract infection was made based on clinical and initial biology. All patients underwent a urine dipstick and a urine culture. An empirical treatment was started based on fluoroquinolones . The concordance between the results of the urine culture and the empirical treatment intiated in the emergency department was noted. Similarly, microorganisms responsible for urinary tract infections and resistance to fluoroquinolones have been identified.

Results: In the study period, 236 patients were diagnosed and treated as urinary tract infection and included in the study. The mean age was 52 +/- 16 years and the sex ratio was 0.56. Among the requested urianalysis, 170 had positive culture, 50 had a varied flora and 66 were negative. The positive predictive value of leukocytes in urine culture was 90.4% and the negative predictive value was 83.7%. An empirical treatment was given by excess in 28% cases. Similarly, 5.5% of patients were not treated for urinary infection while their culture was positive. Of the positive cultures, E. coli was identified in 86.5% of cases, followed by Klebsiella, Proteus and Enterobacter. The empirical treatment based on Fluoroquinolones, ignored the resistance in 22.7% of cases.

This resistance to quinolones has been identified for E coli. None of the multidrug-resistant strain was identified.

Conclusions: The resistance of the empirical treatment based on fluoroquinolones was identified in 22.7% of cases. The promotion of therapeutic alternatives as well as the surveillance of the use of fluorquinolones are essential to control the spread of resistance to fluoroquinolones in E. coli.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

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FIRST PASS SUCCESS OF THE GLIDESCOPE TITANIUM MAC VIDEO LARYNGOSCOPE IS HIGHER WHEN USED AS A VIDEO LARNGYOSCOPE THAN WHEN USED AS A DIRECT LARYNGOSCOPE FOR EMERGENCY INTUBATION

J. Sakles 1, B. Arcaris 1, A. Patanwala 1, J. Mosier 1, J. Dicken 1

1

University Of Arizona College Of Medicine, Tucson, Usa

Background: The GlideScope Titanium Mac Video Laryngoscope is a new video airway device with standard Macintosh blade geometry. It can be used as a primary video laryngoscope (VL) or as a traditional direct laryngoscope (DL).The objective of this study was to compare the first pass success (FPS) when it was used as a VL compared to when it was used as a DL. Methods: The GlideScope Titanium Mac VL was introduced into our Emergency Department (ED) on July 1, 2014. After each intubation in the ED the operator filled out a CQI data form that included multiple patient, operator, and intubation characteristics. First pass success was defined as successful intubation with a single laryngoscope insertion. Ultimate success was defined as successful intubation with the initial device used, regardless of the number of attempts. Adult patients were included in the analysis that underwent rapid sequence intubation (RSI) in the ED with a GlideScope Mac Titanium VL from July 1, 2014 to April 30, 2015. The primary outcome was the first pass success and the secondary outcome was ultimate success.

Results: Over the 10-month study period 352 adult patients underwent RSI in the ED. Of these the GlideScope Titanium Mac VL was used as the initial device in 148 (42%) patients. When used primarily as a VL the FPS was 74/79 (93.7%; 95% CI: 85.8%-97.9%). When used primarily as a DL the FPS was 29/69 (42.0%; 95% CI: 30.2%-54.5%). When the initial attempt as a DL device failed, operators switched to the video screen and were able to increase their FPS to 59/69 (85.5%; 95% CI: 75.0%-92.8%). The ultimate success was 78/79 (98.7%; 95% CI: 93.2%-100%) in the VL only group and 67/69 (97.1%; 95% CI: 89.9%-99.7%) in the DL to VL switch group.

Conclusions: The GlideScope Titanium Mac VL has a much higher first pass success when it is used as a VL device compared to when it was used as a DL device for emergency intubation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W131

THE USE OF APNEIC OXYGENATION IS ASSOCIATED WITH AN INCREASE IN THE FIRST PASS SUCCESS IN RAPID SEQUENCE INTUBATIONS IN THE EMERGENCY DEPARTMENT

J. Sakles 1, B. Arcaris 1, A. Patanwala 1, J. Mosier 1

1

University Of Arizona College Of Medicine, Tucson, Usa

Background: First pass success (FPS) has been demonstrated to be associated with a lower incidence of complications during emergency intubation. The objective of this study was to determine the impact of apneic oxygenation on the FPS of adult patients undergoing rapid sequence intubation (RSI) in the emergency department (ED).

Methods: Data were prospectively collected on patients intubated in an academic ED from July 1, 2013 to March 31, 2015. During this period the use of apneic oxygenation was encouraged, but not required, on patients undergoing RSI in the ED. Following each intubation, the operator completed a standardized data collection form. Adult patients 18 years of age or greater, who underwent RSI in the ED were included in the analysis. The primary outcome was FPS, which was defined as successful tracheal intubation on a single laryngoscope insertion. The secondary outcome was occurrence of oxygen desaturation, which was defined as oxygen saturation <90% during intubation. A logistic regression model was constructed to determine the effect of apneic oxygenation on FPS. Potential confounders that have been previously demonstrated to be associated with FPS were included in the model. These included operator post-graduate year (PGY), difficult airway characteristics (DAC) and device type.

Results: During the 21-month study period, 594 adult patients underwent RSI in the ED. Of these, 334 (56.2%) had apneic oxygenation utilized and 260 (43.8%) did not have apneic oxygenation utilized. In the apneic oxygenation group the FPS was 88.3% and in the no apneic oxygenation group the FPS was 81.9% (difference 6.4%; 95% CI: 0.6% to 12.2%). In the logistic regression analysis, the use of apneic oxygenation was associated with increased odds of FPS (aOR 1.9; 95% CI: 1.1 to 3.0, p=0.013). Oxygen desaturation occurred less frequently in patients who received apneic oxygenation compared to those who did not receive it (13.2% versus 20.8%, difference 7.6%; 95% CI: 1.5% to 13.7%).

Conclusions: The use of apneic oxygenation during the RSI of adult patients in the ED was associated with an increase in FPS and is recommended to be routinely used for emergency intubation.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Airway / Analgesia / Anesthesia /Sedation / Pain Management

W132

COMPARATIVE ASSESSMENT OF CAFFEINE VS. KETOROLAC INTRAVENOUS ADMINISTRATION EFFICACY IN ACUTE MIGRAINE HEADACHES WITHOUT AURA

A. Baratloo 1, A. Rouhipour 2, M. Forouzanfar 1, S. Arab Bafarani 1, S. Safari 1, F. Rahmati 1

1

Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University Of Medical Sciences, Tehran, Iran, 2 Pediatric Department, Valiasr Hospital, Ghazvin Medical University, Abyek, Iran Background: Despite high prevalence of headache in patients admitted to the ED, just few non-opioid analgesics are in access for pain control of such patients which are limited to Ketorolac and Apotel, even more limited for patients contraindicated to non-steroidal anti–inflammatory drugs. This study was aimed to compare the effect of intravenous injection of caffeine vs. Ketorolac in pain management of common migraine (migraine headache without aura) sufferers in the ED. Methods: Patients referred to the ED with acute migraine headache without aura, determined based on the last criteria of DSM IV, underwent double-blinded injection with 60 milligram Caffeine or Ketorolac, intravenously.

Then, they were assessed regarding pain control. Their headaches were recorded according to Visual Analog Scale (VAS) before and after 1 hour, and 2 hours from drug administration. 30 millimeters change in VAS was considered as a positive response to treatment. Finally, effects of both drugs were compared concerning pain control and possible side effects.

Results: In the present study 110 patients were equally categorized in to two receiving groups of Caffeine and Ketorolac (59.1% female). The mean of pain severity before therapeutic intervention were 8.4 ± 1.5 in both groups (p=0.96). After one hour from drug administration, their pain severity mean were 5.4 ± 2.4 and 4.9 ± 1.9 in Caffeine and Ketorolac group, respectively (p=0.23). After 2 hours, the mean of pain severity were 3.5 ± 2.6 and 3.5 ± 2.1 in Caffeine and Ketorolac group, respectively (p=0.49).

Conclusions: Both Caffeine (p<0.001) and Ketorolac (p<0.001) cause significant pain relief after the first and second hour from therapeutic intervention. There is no significant difference in therapy success between both drugs for reducing the pain in the first (p=0.42) and second hour (p=0.59). It seems that intravenous Caffeine citrate can be as effective as Ketorolac in pain management of patients suffering from migraine without aura.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Academics / Resident Education

W133

SIMULATION TRAINING FOR EMERGENCY TEAMS

J. Pek 1, E. Wong 1, F. Lateef

1

Singapore General Hospital, Singapore, Singapore

Background: Resuscitation of the critically ill in the emergency department can be chaotic. We believe that simulation training for emergency teams (STET) will help improve team performance during actual resuscitation.

This should translate to better patient outcomes as teams are better prepared for crisis management. We aim to evaluate the effectiveness of STET for resuscitation team training.

Methods: Eight sessions of STET using low fidelity simulation were conducted during March to April 2015. Each 1-hour session consisted of two scenarios including time allocated for feedback. Clinical updates, departmental workflows and patient safety issues were incorporated into the scenarios. Doctors and nurses participated in the sessions. The participants evaluated the effectiveness of the training after the session on a 5-point Likert Scale.

The following were assessed: benefits of simulation training; realism and appropriateness of scenarios; enhancement of medical knowledge and practical skills, thereby improving patient outcomes; and teamwork, with focus on leadership and communication.

Results: 22 doctors and 17 nurses participated in STET. The doctors were residents (Emergency Medicine, Internal Medicine, Family Medicine, Orthopaedics) in their first to third year of training. STET received a mean score of 4.3 across all domains. Participants scored the benefit of STET with a mean of 4.5. Though the scenarios were appropriate (mean score = 4.4), the low fidelity simulation lacked realism (mean score = 3.8).

With the right training objectives, STET could enhance both medical knowledge and practical skills (mean score 4.4 versus 4.3 respectively). Participants believe that learning points from STET could improve patient outcomes (mean score 4.4). Finally, STET provides an avenue for team training (mean score = 4.4) with development of team leadership and communication. Self-evaluation of the participants before and after STET yielded two trends â&#x20AC;&#x201C; participants either felt more confident and empowered, or they became aware of their limitations and need to improve.

Conclusions: STET was effective for purpose of resuscitation team training. However, the limitation of this educational intervention was that we do not know the directness and extent of its impact on actual clinical outcomes.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

W134

A FLOW PROCESSING MANAGER NURSE IN THE EMERGENCY DEPARTMENT TO IMPROVE SAFETY, OPTIMIZE THROUGHPUT AND INCREASE PERFORMANCES

C. Lanzarini 1, R. Ferrari 1, S. Canovi 1, G. Vitale 1, M. Cavazza 1

1

Emergency Department, Policlinico Sant'orsola - Malpighi, Bologna, Italy

Background: In an era of Emergency Department overcrowding, an efficient triage system is essential to allow the emergency team to treat patients according to the urgency of their condition.

The increase in waiting times is related to lower safety for both critical and subcritical cases, and decreased patient and health-care worker satisfaction.

The widespread 4-levels triage system showed to be inefficient “per se” in managing the growing complexity of the incoming phase.

Methods: A senior experienced nurse, with known both technical and non-technical skills, was added in the Emergency Department, acting after the usual nurse triage protocol, and before the Medical Doctor taking charge of the patient.

His tasks, as Flow Processing Manager, were: to upgrade triage evaluation process and improve throughput efficiency in a timely manner; to early identify time-dependent situations and outliers; to redirect and addressthe specific patient to a specific route, and to a specific Medical Doctor.

We performed a prospective “before and after” cohort study, from 08/4/2012 to 07/4/2013, and from 08/4/2013 to 7/4/2014, to assess the impact of Flow Processing Manager.

Results: The number of triaged patients augmented (67400 “before” versus 70922 “after”); waiting times (media; in minutes) slightly changed depending on “triage code” (red 7.04 versus 7.02; yellow 15.32 vs 21.25, green 84.10 vs 88.07, white 88.55 vs 78.04); total time spent in the Emergency Department (media) dramatically changed depending on “triage code” (red 221 versus 940; yellow 988 vs 1159, green 218 vs 699, white 161 vs 177); the number of patients admitted slightly increased (24687 versus 24759); Left Without being Seen rate decreased (1135 versus 741).

Conclusions: In the Emergency Department the introduction of an additional experienced nurse provider as Flow Processing Manager showed the ability to ameliorate patient throughput, waiting times and Left Without being Seen rates, improving both safety and quality of care, even coping with the dramatic increase in length of staying due to overcrowding and shortage of beds.

Emergency Department waiting rooms are high liability areas for hospitals: the addiction of a Flow Processing Manager can actually reduce risks in individual patients.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Clinical Policies / Practice Guidelines

W135

COMPARISON OF USING EMERGENCY SEVERITY INDEX (ESI) AND THE 4 â&#x20AC;&#x201C; LEVEL TRIAGE IN EMERGENCY DEPARTMENT

C. Yuksen 1

1

Ramathibodi Hospital, Bangkokj, Thailand

Background: Patients who visit emergency room must be prioritized into various levels of severities by emergency nurse. Emergency severity index (ESI) is the most acceptable and popular triage tool. Patients will be prioritized into 5 levels, from the highest to the lowest severities. Currently, Ramathibodi hospital uses 4 level triage systems. There are several limitations, such as prediction of resources utilization or admission.

Methods: Prospective cross sectional study was conducuted. Patients who visited at the emergency room, Ramathibodi hospital were triage using 4 levels triage tool by emergency nurse and subsequently re-triaged using ESI version 4 by independent emergency medicine residents. Medical treatments, resource needs, hospitalization, mortality, length of stay in ED and life saving intervention were recorded. Discrimination performances of 2 triage systems were compared Results: Five hundred and twenty patients were enrolled. Of which 216 (41.54 %) cases were male. Median age was 51 years old. ESI triage system yielded signigicantly better discrimination performances to predict length of stay in ED, resource needs, ICU administration, mortality and life saving intervention than 4 levels triage. Using ESI to predicted life saving intervention provided significant net reclassification improvement (NRI= 0.424 (95%CI: 0.226, 0.622), p <0.001), compared to 4 level triage. However, there was similar performance of predicting hospital discharge between both triage systems.

Conclusions: There was significantly better discrimination performaces of ESI verison 4, compared to 4-level triage.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Academics / Resident Education

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EFFICACY OF WEB-BASED LOGBOOK SYSTEM ON EMERGENCY MEDICINE RESIDENTS RECORDED ACTIVITIES AND SATISFACTION

J. Seyed Hosseini 1, A. Labaf 1, M. Ashrafi 1

1

Tehran University Of Medical Sciences, Tehran, Iran

Background: logbooks are useful materials in registering activities, defining goals and evaluation in any residency program. The purpose of this study was to evaluate efficacy of a newly initiated web-based electronic logbook system in compared with paper-based logbook based in registration of activities of emergency medicine residents activities and satisfaction of residents and faculty members.

Methods: A new web-based electronic logbook system developed inside our emergency medicine department.

This cross-sectional descriptive evaluation study was performed after 3 month initiation of the web-based electronic logbook system. Two major activities of PGY1 and PGY2 residents, procedures and shift activities were compared with previous year recorded activities in paper logbooks in same period of time. Also satisfaction of faculty members and residents was evaluated via separated survey.

Results: 40 residents paper logbooks and 47 residents web-based logbooks were evaluated. mean number of confirmed and registered cases of shifts and procedures per each resident in web based logbook were significantly more than paper based logbook (paper-based and web-based confirmed recorded shifts 10.4 and 20.1 respectively and paper-based and web-based confirmed recorded procedures 104.5 and 147.2 respectively , p-value<.005). Data analysis in satisfaction survey showed that most faculty members and residents prefer using web-based over paper-based logbook.

Conclusions: Our study showed that web-based logbooks can influence on quantity of recorded activities in residency program. Moreover, it is possible to record activities at any time in any place by residents and to verify by their teachers online in web based logbook system. Evaluation of the electronic system is more accurate and very time-saving than paper based system. It is crucial to evaluate effect of web-based systems on quality of residency programs in future.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Academics / Resident Education

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INNOVATIVE PPOCEDURAL TRAINING CURRICULUM IN EMEREGENCY MEDICINE

J. Riordan 1, P. Targonski 1

1

University Of Virginia, Charlottesville, Usa

Background: “Flipping the classroom” is an increasing common teaching approach, but little data exist regarding resident trainee preferences for this style of learning. We examined resident preferences in procedural training.

Methods: First year Emergency Medicine residents were surveyed annually from 2011-2014 after completing mandatory airway education curricula using a “flipped” model: independent instructional podcast viewing and online knowledge quiz, followed by 1:1 airway skills assessment with instructor. The survey included six 5-level Likert-scaled questions, unlinked to quiz performance, regarding comfort/impression of curricular structure.

Results: 24/ 30 respondents (80%) preferred at least half of all procedural topics should be taught with the novel educational experience. 27/33 respondents (82%) agreed or strongly agreed that they enjoyed the flexibility of online lectures. 5/ 33 respondents (15%) agreed or strongly agreed that they preferred podcasts to face-to-face lectures and 13/ 33 (39%) agreed or strongly agreed that they preferred face-to-face lectures to podcasts. 15/ 33 (46%) were neutral. Those who preferred or strongly preferred podcasts were significantly more likely to prefer individual instruction (Mantel Haenszel Chi-Square=4.21, p=0.04) although data were sparse. Those preferring face-to face lectures had 7.5-fold higher odds for enjoying the structure associated with sequential face-to-face lectures (Mantel-Haenszel Chi-Square p=0.018) and 4.86-fold higher odds of preferring group procedure labs to individual procedure instruction (Mantel-Haenszel Chi-Square p=0.053). There was a significant trend (Chi-square=11.89, p=0.0078) towards respondents preferring podcasts also preferring a higher percentage of procedural topics being taught utilizing the ‘novel educational experience’.

Conclusions: Our observations support learner approval for procedural education utilizing a “flipped classroom”.

Most residents enjoy the flexibility of online lectures. However, the content may dictate which types of learning are more conducive to this approach. Learners who prefer podcasts seem to prefer individual instruction and a higher percentage of ‘novel’ instruction. The preferences of learners may be changing as many students favored newer technologies in the learning environment. Further study is required to determine performance characteristics and achievement of competence associated with matched learning styles and preferences.

MEMC - GREAT Rome (Italy), 05/09/2015 - 09/09/2015 Topic: Patient Flow / Throughput Management

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HIGH LEVEL TRIAGE, INNOVATION BEYOND IMAGINATION:

A. Habib 1, F. Khan 1

1

Doncaster Royal Infirmary, Doncaster, United Kingdom

Background: Objective: Meeting Targets and delivering quality care at the same time is a significant challenge faced by all EDs in UK. We innovated a system which will not only deliver high quality timely care but also help in meeting targets.

Methods: Methods: We are among the busiest Trust in the country. We were struggling to meet ED targets and were un able to meet the quality indicators set by the CEM for walk in patients.

We developed a “New System” of Triage called “High Level Specialist Triage” (HST).

This HST is run by band 7 Nurses 24/7. HST starts from the point of registration called “Streaming”.

The reception staff categorized patients into 2 categories. a) Minor Injury b) HST. Minor injuries directed to be seen by ENPs in ED. HST patients are assessed by Band 7 Nurse with in 10 mins of arrival.

Patients after initial assessment than streamlined into 2 areas.

1GP in ED 2ED Doctors Results: Results: Waiting time to be seen by Doctor in Unplanned Care Centre reduced from 52 mins to 29 mins and Trust’s 4 hr target improved from 85% to 96%.

Conclusions: Conclusion: Introduction of HST has resulted in significant improvement to the Trust and Departmental performance Statistically as well as Clinically