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2nd Annual SAEM Great Plains Regional Research Forum

Saturday, September 10, 2011 Farrell Learning and Teaching Center at Washington University in St. Louis School of Medicine

SAEM Great Plains Regional Research Forum Schedule of Events Time

Event

Location

7:00am - 7:45am

Continental Breakfast

FTLC 2nd Floor

7:45am - 8:00am

Welcome

Moore Auditorium (1st floor)

8:00am - 9:00am

Keynote Address

Moore Auditorium (1st floor)

John Younger, MD, University of Michigan 9:10am - 10:45am

Oral Presentation Session 1 (Abstracts #1-9)

Moore Auditorium (1st floor)

9:10am - 10:45am

Lightning Oral Presentation Session 1 (Abstracts #10-24 )

Holden Auditorium (FTLC 1st Floor)

10:45am – 11:00am

Break

11:00am – 12:00am

Oral Presentation Session 2 (Abstracts #25-30)

Moore Auditorium (1st floor)

12:00pm - 12:30pm

Lunch (pick up and bring to next event)

FTLC 2nd Floor lobby

12:00pm – 5:00pm

SimWars Competition

Holden Auditorium (FTLC 1st Floor)

12:30pm – 1:30pm

Keynote Address

Moore Auditorium (1st floor)

Past SAEM President Jeffrey Kline, MD 1:30pm – 3:30pm

Resident and Medical Student Breakout Sessions

FTLC 213A and 213B

1:40pm – 3:00pm

Lightning Oral Presentation Session 2 (Abstracts #31-45)

Moore Auditorium (1st floor)

3:00pm – 4:20pm

Poster Presentations (Abstracts #46-78)

FTLC 210 and 211

4:30pm – 5:00pm

Awards and Closing Remarks

Moore Auditorium (1st floor)

Detailed Schedule of Events 7:00am - 7:45am, Breakfast Continental breakfast will be available in the 2nd floor lobby of the Farrell Teaching and Learning Center.

7:45am – 8:00am, Welcome and Opening Remarks, Moore Auditorium 8:00am – 9:00am, Keynote Address, Moore Auditorium John Younger, MD, University of Michigan 9:10am - 10:45am, Oral Presentation Session 1, Moore Auditorium Moderator – Larry Lewis MD, Washington University in St. Louis 1. ISAR and TRST Do Not Predict Short-Term Adverse Outcomes in Geriatric Patients. Steven Abboud1 and Christopher Carpenter2. 1Saint Louis University School of Medicine, St. Louis, MO;2Washington University School of Medicine, St. Louis, MO 2. Usefulness of Pediatric Lactic Acid Screening in the Emergency Department. Antonio Cummings, Loren Reed, Jennifer Carroll, Stephen Markwell, Jarrod Wall and Myto Duong. Southern Illinois University, Springfield, IL 3. Waiting is Frustrating: A Comparison of the Emergency Severity Index to the Australasian Triage Scale for Psychiatric Patient Assessment. Andrew S Deutsch1, Leslie Zun2, LaVonne Downey3 and Trena Burke2.

1 Rosalind Franklin University of Medicine and Science / Chicago Medical School, North Chicago, IL; 2Mt. Sinai Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL 4. The Effect of Cognitive Dysfunction and Health Literacy on Patient Comprehension of ED Care among Geriatric Patients. Jessie Hu1, Owais Nadeem1, and Christopher R. Carpenter2. 1Saint Louis University School of Medicine, St. Louis, MO; 2Washington University School of Medicine, St. Louis, MO 5. Comparing Emergency Medicine Practices for Central Venous Catheter Placement to Existing ICU Checklists. Rob Klemisch and Daniel L Theodoro. Washington University School of Medicine in St. Louis, St. Louis, MO 6. Improved Interpretation of Coagulase Negative Staphylococcal Blood Culture Results Using Limited Genomic Resequencing. Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and John Younger. University of Michigan, Ann Arbor, MI 7. Evaluating Quality of Life in Cognitively Impaired Geriatric Patients in the Emergency Department. Lila S. Wahidi and Christopher R. Carpenter. Washington University School of Medicine in St. Louis, St. Louis, MO 8. Patients With Suicide Ideation Presenting To The Emergency Department: A New Characterization Of Mortality And Outcomes. David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and Nick Echevarria.

Georgetown University School of Medicine, Washington, DC 9. Comparing Urine Acetoacetate Values With Serum 3-beta-hydroxybutyrate Values In Pregnant Women With Nausea And Vomiting In The Emergency Department. Ian T Ferguson and Michael Mullins. Washington University in St. Louis, St. Louis, MO 9:10am – 10:45am, Lightning Oral Presentation Session 1, Holden Auditorium Moderator – Chris Holthaus MD, Washington University in St. Louis 10. Do Admission Check Sheets Improve Compliance with Pneumonia Core Measures? Andrew Abbeg, Sr., Steven Lorber, Preeti Dalawari and Stacy Revelle. St Louis University Hospital, St Louis, MO 11. Grip Strength as a Brief Diagnostic Test for Frailty and Pre-Frailty in Geriatric Emergency Department Patients.

Grant M. Fischer and Christopher R. Carpenter. Washington University in St. Louis School of Medicine, St. Louis, MO 12. Are They Working? The Effects Of UI And Community-Based Interventions On Thursday Night Binge Drinking.

Nicholas J Edwards and Michael Takacs. University of Iowa Carver College of Medicine, Iowa City, IA 13. Short QTc in Emergency Department Patients. Stacey House, Peta-Gay Laird and S. Eliza Halcomb.

Washington University in St. Louis, St. Louis, MO 14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs Rural Health and Safety Policy. Gerene M Denning, Kari Harland, Kevin Kremer, Charles Jennissen and Christopher Buresh. University of Iowa, Iowa City, IA

15. A Comparison of Two Hospital Electronic Medical Record Systems and Their Effects on the Relationship Between Physician Charting and Patient Contact. John Shabosky, Jonathan dela Cruz and Matthew Albrecht. Southern Illinois University School of Medicine, Springfield, IL 16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model For Training Rural Providers. Wesley Zeger1, Paul Travis2, Michael Wadman1, Carol Lomneth1, Sara Keim1 and Stephanie Vandermuelen1. 1UNMC, Omaha, NE; 2 Creighton University, Omaha, NE 17. Utilization Of Computed Tomography In Blunt Trauma: When Is Thoracic And Lumbar Imaging Warranted?

Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St. Louis University, St. Louis, MO 18. Changing Presentation Rates For Mtbi (Concussion) And Changing Imaging Rates. Han Huang1, Nick Echevarria1, David Milzman1, Carla Tilchin1 and Ronny Song2. 1Georgetown University School of Medicine, Bethesda, MD; 2Georgetown University, Bethesda, MD 19. Validity of the Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) Instrument As Predictors for Mortality, ED Revisits, Hospital Admission, Nursing Home Admission, and Functional Decline in Cognitively Normal and Cognitively Impaired Geriatric ED Patients. Dan Feng, Sophia Li and Christopher R Carpenter. Washington University School of Medicine, St Louis, MO 20. Diagnostic Accuracy of Various Health Literacy Screening Tools in the Emergency Department. Andrew Melson, Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint Louis, MO 21. "What Did You Say?” Noise: Does It Distract From Patient Care In The Emergency Department? Laurie E Byrne, Peter Anaradian and Preeti Dalawari. St. Louis University, St. Louis, MO 22. Undiagnosed Mental Illness in Children and Adolescents in the Emergency Department. Yanika Wolfe and Dane M. Doctor. Rosalind Franklin University/Chicago Medical School, North Chicago, IL 23. A Comparison of Diversion and No Diversion and the Effect on patient Safety and Outcomes in the Emergency Department. Eman Spaulding, Laurie Byrne, Eric Armbrecht and Collin Jackson. Saint Louis University, Saint Louis, MO 24. Impact Of Presence Of Third Molars On Mandible Fractures Following Facial Trauma. David Milzman1, David Weiner2 and Ryan Murray1. 1Georgetown University School of Medicine, Washington, DC; 2Georgetown University School of Medicine, Bethesda, MD 11:00am – 12:00 pm, Oral Presentation Session 2, Moore Auditorium Moderator – Dan Theodoro MD, Washington University in St. Louis 25. Mild Cognitive Impairment: A Pilot Study To Evaluate The Montreal Cognitive Assessment Screening Tool For Use In Urban Aging African Americans Who Present To The Emergency Department. Kanika A Turner and Christopher R Carpenter. Washington University School of Medicine, St. Louis, MO 26. Cardioprotection by Endogenous Fibroblast Growth Factor 2 in Cardiac Ischemia-Reperfusion Injury In Vivo.

Stacey L House, Carla Weinheimer, Attila Kovacs and David Ornitz. Washington University in St. Louis, St. Louis, MO 27. The Correlation between Health Literacy and Numeracy in the Emergency Department. Andrew Melson, Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint Louis, MO 28. Cost-Benefit Analysis of Specialized Screeners in the Emergency Department and of Memory and Aging Project Satellite Intervention. Charlene W Lai1 and Christopher R Carpenter2. 1Saint Louis University School of Medicine, St. Louis, MO; 2Washington University School of Medicine in St. Louis, St. Louis, MO 29. Ultrasound Simulation Training: Location of Central Venous Catheter Guide Wire Position. Melissa Thomas1, Charles Schmier2 and Michael Wadman1. 1University of Nebraska Medical Center, Omaha, NE; 2University of Arizona Medical Center, Tucson, AZ 30. Application of Lean Principles of the Toyota Production System Lead to Greatly Improved Door to Needle Times.

Matthew Rudy1, Andria L Ford1, Jennifer A. Williams2, Naim Khoury1, Tomoko Sampson1, Craig McCammon2, Shawn O'Connor1, Jin-Moo Lee1 and Peter Panagos1. 1Washington University, Saint Louis, MO; 2Barnes Jewish Hospital, Saint Louis, MO 12:00pm - 12:30pm Lunch Pick up lunch in 2nd floor lobby and take to your next event.

12:00pm - 4:00pm Medical Student SimWars Competition, Holden Auditorium

SimWars is a national competition pitting teams against each other solving cases using medical simulators. Midwest Regional SAEM takes a new twist on SimWars by tailoring it for medical students. This first ever Medical Student SimWars consists of two pools of 3 teams facing each other in a round-robin format. The winner of each pool will then face off in the finals where the first Medical Student SimWars Champion will be crowned.

12:30pm – 1:30pm, Keynote Address, Moore Auditorium Jeffrey Kline, MD, Past President of SAEM, Carolinas Medical Center 1:30pm – 3:30pm Medical Student and Resident Breakout Session, FTLC 213A and 213B 1:30pm-1:45 pm – Welcome and Introduction Nathan Deal, MD, President of EMRA 1:45pm-2:30pm – Post Residency EM Subspecialty and Academic Career Options Panel discussion of subspecialty fellowship training and various academic career options. Panelists include: Stacey House, MD, PhD, Washington University in St. Louis – Research Careers Preeti Delawari, MD, MSPH, St. Louis University - Research Careers Evan Schwarz, MD, Washington University in St. Louis – Toxicology William Gilmore, MD, Washington University in St. Louis – EMS Brian Wessman, MD, Washington University in St. Louis – Critical Care 2:30pm-3:30pm – Starting a Career in Academic Emergency Medicine Douglas Char, MD, Washington University in St. Louis 1:40pm – 3:00 pm, Lightning Oral Presentation Session 2, Moore Auditorium Moderator – Michael Mullins MD, Washington University in St. Louis 31. Impact Of Teaching Life Saving Procedures To First Year Medical Students. Michael Ybarra, Ryan Murray, David Weiner and David Milzman. Georgetown University School of Medicine, Bethesda, MD 32. Association of Falls with Sarcopenia and Frailty in Older Adults Presenting to The Emergency Department. Denis T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS, Charlene Lai, BA, Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika Taylor, BS, Lila Wahidi, Christopher R. Carpenter, MD, MS 33. Impact Of Airline Flight On Professional Athletes Following Minor Traumatic Brain Injury (mtbi) In Terms Of Total Games Missed Due To Injury. David Milzman1, Jeremy Altman2, Matt Milzman2, Chris Fleury2 and Carla Tilchin3. 1Georgetown University School of Medicine, Bethesda, MD; 2Georgetown University, Bethesda, DC;3Bates college, Bethesda, ME 34. Can Ambulances Be Triaged To Urgent Care Centers Based On Chief Complaint? Tina Khosla, Joseph Delucia, Ting Zhang and William Terrin. St. Louis University Hospital, St. Louis, MO 35. A Cost Benefit Analysis Of Ultrasound Programs For Central Venous Cannulation. Daniel L Theodoro.

Washington University School of Medicine in St. Louis, St. Louis, MO 36. Airway Management at a Regional Trauma Center: An Analysis of Resident Experience. Jordan Sullivan and James McClay. University of Nebraska Medical Center, Omaha, NE 37. A Comparison of 3 Forms of Procedural Sedation for the Reduction of Dislocated Total Hip Arthroplasty. Scott Burdette, Jonathan dela Cruz, Donald Sullivan, Eric Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto Duong, Steven Scaife, David Griffen and Khaled Saleh. Southern Illinois University School of Medicine, Springfield, IL 38. Knowledge of Alcohol Impairment in Boaters. Maria L Scarbrough and Preeti Dalawari. St. Louis University, St. Louis, MO 39. Got Wheels?--Adolescent Exposure to ATVs and Their Driving Practices. Charles A Jennissen1, Denning Gerene1, Hoogerwerf Pam1, Peck Jeffrey2 and Wetgen Kristel1. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2 U.S. Army Corps of Engineers, Iowa City, IA 40. Feasibility of Using Health Literacy Screening Tools in an Urban Emergency Department. Andrew Melson, Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint Louis, MO 41. Frequency and Mortality of Non-Contiguous Spine Fractures with CT Scan Use. Vijai Chauhan1, Neelaysh Vukkadala2, Howard Place1, Laura Sicking1, Lauren Segelhorst1, Eric Armbrecht2, Camelia Guild2 and Preeti Dalawari1. 1Saint Louis University SOM, Saint Louis, MO; 2Saint Louis University, Saint Louis, MO

42. Self-rated Health As A Predictor Of Emergency Department Recidivism And Functional Decline Among Geriatric Patients. Stephanie K Chang1 and Christopher R Carpenter2. 1St. Louis University, St. Louis, MO; 2Washington University in St. Louis, St. Louis, MO 43. Stroke Volume Changes in ED Patients with Shock Undergoing Serial Passive Leg Raising and Fluid Challenges.

Stephanie Charshafian1, Ashley Janssen1, Christopher Holthaus1, Brian Fuller1, Kevin Williams1, Enyo Ablordeppey1, Brian Wessman1, Daniel Theodoro1, Ronald Chang1, Jennifer Williams2, Thomas Ahrens2 and Richard Hotchkiss1. 1Washington University in St Louis, St Louis, MO; 2Barnes-Jewish Hospital, St Louis, MO 44. Seeking a Functional Definition of Drug-Seeking Behavior. Benjamin Scallon, Mark Graber, Azeemuddin Ahmed, Kari Harland and Gerene Denning. University of Iowa, Iowa City, IA. 45. Disposition Variability For Patients with Chest Pain Among Emergency Department Physicians. David J Gresback and Michael D Zwank. Regions Hospital, Saint Paul, MN 3:00pm - 4:00pm, Poster Presentations, FTLC 210 and 211 46. Characterization Of On-road ATV Crashes In Iowa From 2002-2009. Kevin Kremer, Gerene Denning, PhD and Christopher Buresh, MD. University of Iowa, Iowa City, IA 47. Differences In Perception About Access To Care Between Patients Who Choose An Urban Academic Emergency Department Over A Community-based Student-run Free Clinic For Non-urgent Care. Matthew Dettmer1, Cerrone Cohen2, Edward Jauch3, Kit N Simpson3, Brenda Walker3, Wanda Gonsalves3, Kathryn Koval3, Joshua Gray3 and Steven Saef3. 1Washington University Medical Center/Barnes-Jewish Hospital, St. Louis, MO; 2UC Davis Health System, Sacramento, CA; 3Medical University of South Carolina, Charleston, SC 48. Preliminary Report On Factors Associated With Inadequate Or Uninterpretable Cervical Spine Radiographs And Need For Ct In Cervical Spine Trauma. Richard Griffey, Betty Chen and Steven Katz. BarnesJewish/Washington University in St. Louis, Saint Louis, MO 49. All Terrain Vehicle (ATV) Crash Fatality Surveillance through Press Clipping. Gretchen McCall and Charles Jennissen, MD. University of Iowa, Iowa City, IA 50. A Quality Curriculum: A Novel Approach To Addressing The ACGME Core Competencies. Jonathan dela Cruz, Antonio Cummings, James Waymack, David Griffen and Christopher McDowell. Southern Illinois University School of Medicine, Springfield, IL 51. Emergency Department Interruptions in the Age of Electronic Health Records. Matthew Albrecht, Jonathan dela Cruz and John Shabosky. Southern Illinois University School of Medicine, Springfield, IL 52. Ct Scanning Practice In Minor Pediatric Head Injury At A Community Emergency Department. Myto Duong, Varshita Pande and Joseph Milbrandt. Southern Illinois University, Springfield, IL 53. Comparison Of Interpreters In Emergency Medicine: Video Conference Vs. In-person. Yanika Wolfe1, Leslie Zun2, LaVonne Downey3 and Trena Burke4. 1Rosalind Franklin University/Chicago Medical School, North Chicago, IL; 2Mount Sinai Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL; 4 Mount Sinai Hospital Emergency Medicine, Chicago, IL 54. Impact Of The Use Of A Standardized Order Set For Asthma Patients In The Emergency Department. Daniel D Ofori1, Leslie Zun1 and LaVonne Downey2. 1Rosalind Franklin University of Medicine and Sciences, North Chicago, IL; 2Roosevelt University, Chicago, IL 55. Same Patient. Same Overdose. Different Treatment. Different Outcome. Jon B Cole1, Heather Ellsworth2 and Samuel J Stellpflug2. 1Hennepin Regional Poison Center, Minneapolis, MN;2Regions Hospital, St. Paul, MN 56. Effect of Protocol Implementation on Emergency Department Observation Unit Length of Stay and Charges.

Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington University, St. Louis, MO 57. Retrospective Study of Underage Drinking and Emergency Department (ED) Visits: Before and After the 21 Ordinance. Christopher R Peterson and Michael Takacs. University of Iowa, Iowa City, IA 58. A Retrospective Review of the Use and Safety of Sedation for Agitated Patients with Hepatic Encephalopathy in the Emergency Department.

Jason West1 and Vijai Chauhan2. 1Albert Einstein School of Medicine, Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis University School of Medicine, St. Louis, MO 59. A Cost Comparison of Fomepizole and Hemodialysis in the Treatment of Methanol and Ethylene Glycol Toxicity.

Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy K Kim, Jon B Cole, Carson R Harris and Samuel J Stellpflug. Regions Hospital, St. Paul, MN 60. Equestrian Helmet Use in Horse Organization Promotional Material. Charles A Jennissen1 and Suleimaan Waheed2. 1University of Iowa Hospitals and Clinics, Iowa City, IA;2University of Iowa, Iowa City, IA 61. Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and Differences Between Rural and Urban Hospitals. Charles A Jennissen1, Sarah Wente2, Charmaine Kleiber2 and

Ryoko Furukawa2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa College of Nursing, Iowa City, IA 62. Characterization of Clinical Rotations in Three and Four Year Emergency Medicine Residency Training Programs. Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael Wadman. University of Nebraska Medical Center, Omaha, NE 63. Let The Good Times Roll: Computer Modeling to Investigate Risk of ATV Rollover While Turning. Charles A Jennissen1, Gerene Denning1, John Steffen2, Jonathon Marsico2, Thomas Schnell2 and Daniel McGehee2.

1 University of Iowa Hospitals and Clinics, Iowa City, IA;2University of Iowa College of Engineering, Iowa City, IA 64. A Picture’s Worth a Thousand Words: Utilizing Social Media to Better Understand ATV Crash Mechanisms.

Morgan Price1, Gerene Denning2 and Charles A Jennissen2. 1University of Iowa Emergency Department, Iowa City, IA;2University of Iowa Hospitals and Clinics, Iowa City, IA 65. Complications of Extremity Computed Tomography Angiogram Completed in Emergency Department. Emily Tilzer and Vijai Chauhan. Saint Louis University Hospital, Saint Louis, MO 66. Safety Depictions on Primetime TV: Lack of Seat belts and Helmets. David Milzman. Georgetown University School of Medicine, Bethesda, MD 67. Agreement Between Physician and CT Scan in High Energy Mechanism Stable Trauma Patients. Michael D Zwank1, Eric A Gross2, Mary J Hughes3, David J Castle3, Amanda C Miller3, William P Hughes3 and Christopher P Anderson4. 1Regions Hospital, Saint Paul, MN; 2Hennepin County Medical Center, Minneapolis, MN;3Michigan State University, East Lansing, MI;4Healthpartners Research Foundation, Bloomington, MN 68. Padding the Slider Transfer Board and Patient Comfort in the Emergency Department. Jerome R Walker1, Christopher P Anderson2 and Michael D Zwank1. 1Regions Hospital, Saint Paul, MN;2Healthpartners Research Foundation, Bloomington, MN 69. The Utility of Computed Tomography in the Diagnosis of Renal Colic in the Emergency Department. Michael D Zwank1, David J Gresback1 and Benjamin M Ho2. 1Regions Hospital, Saint Paul, MN;2University of Wisconsin, Madison, WI 70. The True Impact Of A Left Vs. A Right Shift In Assessing A White Blood Cell Count: Bacterial Viral And The True Infectious Source. David Milzman1, Anchal Ghai1, Jenika Ferritti-gallon2 and Stephan Chang1. 1Georgetown University School of Medicine, Bethesda, DC; 2Georgetown University, Washington, DC 71. Pre-Arrest Characteristics and Use of Advance Directives among Out-of-Hospital Cardiac Arrest Victims. David Milzman1, Erwin Wang2 and Han Huang3. 1Georgetown University School of Medicine, Bethesda, MD;2Georgetown University School of Medicine, Bethesda, DC;3Georgetown University School of Medicine, Washington, DC 72. Comparison of Data Collection Using Real Time Observers to Subsequent Review of Video Data for Airway Management Research. James Miner, Megan Terrebonne, Robert Reardon and John McGill. Hennepin County Medical Center, Minneapolis, MN 73. Correlation Between Exercise Levels and Medical School Board Scores. Vijai Chauhan and Sean Cavanaugh.

Saint Louis University SOM, Saint Louis, MO 74. Pain Medication Delivery In The Ed For Extremity Fractures: Correlation Of Prescribers' And Patients' Gender And Ethnicity. David Milzman1, Valerie Huckabee1, Bill Dirkes1, Julie Vieth2 and Collier Wright1. 1Georgetown University School of Medicine, Washington, DC; 2Georgetown U / Georgetown WHC EM Residency, Washington, DC 75. Protein Expression Of M2 Receptor In Atria And Ventricles Of Sham Rats. Elizabeth M Spartz, Huiyin Tu, T. Paul Tran and Yu-Long Li. University of Nebraska Medical Center, Omaha, NE 76. Rates of Selected Procedures and High-Acuity Diagnoses in Urban and Rural Emergency Departments. James Waymack, Steve Markwell and Ted Clark. Southern Illinois University, Springfield, IL. 77. Do Alcohol-Related Emergency Department (ED) Visits Mirror Police Data? A Retrospective Study. Greg Pelc, Michael Takacs and Hans House. University of Iowa, Iowa City, IA 78. Acute Disaster Response: Lessons Learned from a Small-scale Event. Kathy Lehman-Huskamp and Anthony Scalzo. Southern Illinois University, Springfield, IL; Saint Louis University, Saint Louis, MO 4:30pm – 5:00pm, Awards and Closing Remarks, Moore Auditorium.

Oral Presentation Session 1 9:10am-10:45am

1. ISAR and TRST Do Not Predict Short-Term Adverse Outcomes in Geriatric Patients

2. Usefulness of Pediatric Lactic Acid Screening in the Emergency Department

Steven Abboud1 and Christopher Carpenter2. 1Saint Louis University School of Medicine, St. Louis, MO; 2Washington University School of Medicine, St. Louis, MO

Antonio Cummings, Loren Reed, Jennifer Carroll, Stephen Markwell, Jarrod Wall and Myto Duong. Southern Illinois University, Springfield, IL

Background: Acute exacerbations of chronic illnesses cause the geriatric adult to seek emergency medicine care at constantly increasing numbers. These patients often have complex medical problems that require more time and care from emergency department (ED) staff to treat which strain available resources.

Mechanisms to focus finite resources on higher risk subsets would be of great value in this setting. Two instruments, the Identification of Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST) have been created to stratify seniors at higher risk for adverse outcomes such as death, institutionalization, functional decline, and ED revisit.

Because both instruments have validity limited to the institutions they were created at, the National Institutes of Health has prioritized research of ISAR and TRST. Objectives: To validate and compare the prognostic accuracy of the ISAR and TRST for the composite outcome of one-month ED revisit, institutionalization, death, and functional decline.

Methods: This was a prospective, observational cohort study of consenting English speaking patients ≥ 65yrs old presenting to the Barnes Jewish Hospital ED in St. Louis MO between June 1 and July 31 2011. Patients ≥ 65 years old that did not live in a nursing home or > 30 miles from the hospital were screened using ISAR and TRST. Patient follow up was at 30 days post screening. Patients were evaluated for a correlation between ISAR and TRST score and the composite outcomes of 1) unscheduled ED visit or hospital admission 2) institutionalization, defined as admission to a nursing home or chronic care hospital or assisted living facility 3) death 4) functional decline defined as ≥ 3 point decline on 28 point OARS ADL. Results: Among the 168 patients, the mean age was 74 years, 43.1% were men, and 62% were African American. Overall predictive values were summarized using ROC curves that yielded AUCs of 0.702 and 0.641 for ISAR and TRST respectively.

Conclusion: In the validation of both ISAR and TRST we found that both tests have poor predictive value for composite outcomes of ED revisit, institutionalization, death, and functional decline as indicated by unremarkable positive or negative LR‟s and the high proportion of patients identified as high risk. Future trials should evaluate these outcomes at 3 months and include ROC curves for each individual outcome.

Background: The benefits of lactic acid (LA) assays for adults in the emergency department (ED) are well known. LA has been used to monitor hydration status, acid base anomalies and in early goal directed therapy for sepsis. In pediatric patients, however, LA screening is not well established. In 2010, our ED initiated a sepsis protocol in which LA was drawn concurrently with blood cultures.

Objectives: The objective of this study was to determine the usefulness of ED LA levels in a select group of pediatric patients, assessing correlation with illness severity, laboratory tests, admission rates and outcome.

Methods: A retrospective chart review included 158 patients </=2 years old who had features of sepsis and had LA level (mmole/L) drawn from June 2010 to June 2011. This was performed in a community ED with 18000 annual pediatric visits. Data collected included: vitals, labs, cultures, length of stay, admission, and return to ED within 3 days. Descriptive statistics were examined for variables of interest and analyzed for relevance. Pearson correlation coefficients were used to examine relationships between continuous variables. To further assess the impact of having an elevated LA, patients were dichotomized into those falling above or below 75th percentile LA level. T-tests were used to compare LA groups based on age, temperature, pulse, respiratory rate (RR), white blood cell (WBC), bicarbonate level, creatinine, blood urea nitrogen, and platelet count. P<0.05 was considered significant.

Results: Mean LA was 2.26 with a standard deviation of 1.34. A statistically significant correlation was found between LA level and RR, WBC, platelet count, and rate of admission. An inverse relationship was found between LA level and age and temperature.

Admitted patients on average had a LA level of 2.65 and those not admitted 1.97 (p<0.05). There was one death (11 months old who was ventilator dependent and was discharged home without returning within 72 hours, but died 24 days later).

Conclusion: While patients with LA levels >2.7 (at or above the 75th percentile), were significantly younger, had higher RR, WBC‟s, platelets and were more likely to be admitted, the mean values for these variables were not clinically important (e.g. RR 42 and WBC 13.8 in a 9 month old is not abnormal). The usefulness of LA levels, obtained in the ED for suspicion of sepsis in children, could be predictive of hospitalization.

3. Waiting is Frustrating: A Comparison of the Emergency Severity Index to the Australasian Triage Scale for Psychiatric Patient Assessment Andrew S Deutsch1, Leslie Zun2, LaVonne Downey3 and Trena Burke2. 1Rosalind Franklin University of Medicine and Science / Chicago Medical School, North Chicago, IL; 2Mt. Sinai Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL Background: Psychiatric Emergency Department (ED) visits are increasing each year, yet there is a lack of mental health descriptors in the Emergency Severity Index (ESI) triage scale, diminishing the triage staff‟s ability to properly assess psychiatric patients. The Australasian Triage Scale (ATS) includes mental health descriptors

and has been shown to increase the competence and confidence of triage staff.

Objectives: The objective of this study is to compare the Emergency Nurses Association (ENA) 5-tier ESI to the ATS to determine which better evaluates a psychiatric patient‟s need for intervention.

Methods: This was a prospective cohort study consisting of a convenience sample of 58 medically stable consenting adults who presented with a psychiatric complaint to the level 1 trauma ED in one urban community teaching hospital during an 8 week period. As approved by the IRB, subjects were triaged according to the ESI system by the triage nurse. A second triage assessment was conducted by a research fellow using the ATS, which included observed and reported elements. Following admission to the ED, a Richmond Agitation Sedation Scale (RASS) score was assigned, and a psychiatric self-assessment was completed by each subject to determine the degree of distress and anxiety.

Results: A majority of the subjects (&gt 50%) were single, African American, and admitted with a throughput time over 4 hours. A significant correlation was identified between ATS and RASS scores (p = 0.035): however, no correlation was identified between RASS and the ESI. ATS scores predicted 6 psychiatric self-assessment questions that had to do with level of agitation, violence, and self harm (p &lt 0.05). The ESI ranked a majority (&gt 60%) of subjects as a 3-urgent and only predicted patients‟ intent on hurting themselves (p = 0.024).

Conclusion: The ESI only correlates with determining risk of harm to one‟s self, while the ATS was shown to be reliable and valid in assessing RASS and 6 core questions that determine risk of harm to self and others. Further, the ATS provided a more even distribution of triage scores, thus more appropriately coordinating patient throughput time and providing a more meaningful ranking than the ESI.

4. The Effect of Cognitive Dysfunction and Health Literacy on Patient Comprehension of ED Care among Geriatric Patients 1

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Jessie Hu , Owais Nadeem , and Christopher R. Carpenter . Saint 2 Louis University School of Medicine, St. Louis, MO; Washington University School of Medicine, St. Louis, MO Background: The rate of geriatric patients in the ED has been steadily increasing over the past several years, and this trend is expected to continue with the aging baby-boomers. Approximately one third of older patients who are discharged will return to the ED within 14 days, with 90% presenting with the same problem that prompted the first visit, making it essential to identify factors which contribute to this population‟s high rates of unnecessary recidivism.

Objectives: The objective of this study is to assess the effect of cognitive dysfunction and health literacy on comprehension of Emergency Department (ED) encounter among geriatric adults in four domains: (1) diagnosis, (2) tests and treatments in the ED, (3) prescriptions and follow-up recommendations, and (4) return instructions.

Methods: We conducted a cross sectional study on patients over the age of 65. Thirteen research assistants (RA) screened consecutive patients from June 1, 2011 to July 31, 2011 at the Barnes Jewish Hospital ED. Exclusion criteria included failure to consent, residence more than 30 miles away, residence in a nursing home, and nonEnglish speakers. The SBT, BAS, and cAD8 questionnaires were administered to assess cognitive function and the REALM-SF was used to assess health literacy. At the time of discharge, patients were also asked to rate their subjective understanding of their ED encounter for all four domains of ED care.

Results: We enrolled 165 patients. Around 47% of the patients perceived low comprehension in at least 1 domain of ED visit.

Geriatric patients seemed to most often misunderstand elements of their ED care, such as tests and treatments received. Greater cognitive

dysfunction was moderately correlated with self-rated lack of understanding of elements of ED care (Spearman r= -.393; P < .01).

Health literacy had a statistically significant effect (P < .001) on comprehension of ED care as well. When stratified by level of health literacy, 81% of patients with less than 9th grade reading level expressed a lack of understanding in this domain, whereas only 23% of patients with greater than 9th grade reading level perceived this lack of understanding.

Conclusion: Cognitive dysfunction and low health literacy in patients are significantly correlated with lower self-perceived comprehension of ED care.

5. Comparing Emergency Medicine Practices for Central Venous Catheter Placement to Existing ICU Checklists Rob Klemisch and Daniel L Theodoro. Washington University School of Medicine in St. Louis, St. Louis, MO Background: The incidence of Central Venous Catheter (CVC) insertion is increasing in the Emergency Department (ED). Checklists for CVC placement have been shown to increase adherence to best practices and reduce central line associated blood stream infections.

Though multiple checklists have been published for use in the Intensive Care Unit (ICU), none has been tailored to the ED. Objectives: Perform a pilot study to assess ED utilization of well accepted CVC checklists and determine adherence to specific checklist elements related to infection control.

Methods: This was a convenience sample of CVC insertions in an urban Level I trauma ED performed between June and August 2011.

CVC insertions by ED physicians were captured by an independent, trained observer on staggered shifts including days, evenings, and overnights. “Crash” CVC insertions (defined as placed under imminent life or death conditions) were excluded. Observed ED CVC placements were compared to elements of four non-ED checklists.

We used descriptive statistics to identify areas of high and low adherence.

Results: The CVC “bundle” was used by 19 of 19 operators (100%, 95%CI 0.83 to 1) and in 19 of 19 (100%, 95%CI 0.83 to 1) cases the included checklist was discarded. No operator completed all elements on any of the four checklists. Sterile gloves were used in 19 of 19 insertions (100%, 95%CI 0.83 to 1), sedation or local anesthetic was used in 18 of 18 (100%, 95%CI 0.83 to 1), and maintenance of a sterile field throughout the procedure was observed in 17 of 17 (100%, 95%CI 0.82 to 1). Operators wore caps and masks during 16 of 19 insertions (84%, 95%CI 0.62 to 0.94) and gowns during 18 of 19 insertions (95%, 95%CI 0.75 to 0.99). In 9 of 19 insertions (47%, 95%CI 0.27 to 0.68) patients were not draped from head to toe, 8 of 18 insertion sites (44% 95%CI 0.25 to 0.66) were not scrubbed for a full 30 seconds, 7 of 17 (41% 95%CI 0.21 to 0.64) operators did not clamp all unused lumens, and in 9 of 16 insertions Trendelenburg position was not used (56%, 95%CI 0.33 to 0.77).

Conclusion: This small pilot study demonstrated that ED physicians have not adopted CVC checklists. In addition, adherence to some aspects of established checklist practices are poor. Outcomes of ED central lines may benefit from an ED developed, structured checklist.

6. Improved Interpretation of Coagulase Negative Staphylococcal Blood Culture Results Using Limited Genomic Resequencing Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and John Younger. University of Michigan, Ann Arbor, MI Background: Coagulase-negative staphylococci are the most common cause of catheter and implanted device infection. They are also the most common cause of false positive blood cultures. Thus,

patients from whose blood these organisms are recovered often face mandatory hospitalization and broad spectrum antibiotics until the clinical significance of the culture can be determined (usually days).

Improved means of discriminating pathogenic from contaminating organisms are greatly needed.

Objectives: We examined the utility of limited genetic sequencing of bacterial isolates using multilocus sequence typing (MLST) to discriminate between known pathogenic blood culture isolates of S. epidermidis and isolates recovered from skin.

Methods: Ten blood culture isolates from patients meeting CDC criteria for clinically significant S. epidermidis bacteremia and ten isolates from the skin of healthy volunteers were studied. MLST was performed by sequencing ~ 400 bp regions of 7 genes (arc, aroE, gtR, mutS, pyr, tpiA, and yqiL). Genetic variability at these sites was compared to an international database (www.sepidermidis.mlst.net) and each strain was then categorized into a genotype on the basis of known genetic variation. The ability of the gene sequences to correctly classify strains was quantified using the support vector machine function in the statistical package R. 1,000 bootstrap resamples were performed to generate confidence bounds around the accuracy estimates.

Results: Between strain variability was considerable, with yqiL being most variable (6 alleles) and tpiA being least (1 allele). The mutS gene, responsible for DNA repair in S. epidermidis, showed almost complete separation between pathogenic and commensal strains. When the 7 genes were used in a joint model, they correctly predicted bacterial strain type with 90% accuracy (IQR 85, 95%).

Conclusion: Multilocus sequence typing shows excellent early promise as a means of distinguishing contaminant versus truly pathogenic isolates of S. epidermidis from clinical samples. Nearterm future goals will involve developing more rapid means of sequencing and enrolling a larger cohort to verify assay performance.

7. Evaluating Quality of Life in Cognitively Impaired Geriatric Patients in the Emergency Department Lila S. Wahidi and Christopher R. Carpenter. Washington University School of Medicine in St. Louis, St. Louis, MO Background: An aging population has resulted in a rising prevalence of age-related conditions, such as cognitive dysfunction, which can affect one's quality of life (QOL). It is important to study geriatric QOL in the emergency department (ED) to guide medical care in the ED and after discharge.

Objectives: To determine correlations between cognitive dysfunction and geriatric patient QOL ratings in an ED setting and to investigate the ability of cognitively impaired patients to rate their QOL by comparing self-ratings to those of a caregiver.

Methods: In this prospective, cross-sectional study at one urban academic medical center, trained researchers collected patients' responses on the Short Blessed Test (SBT) and the Quality of LifeAlzheimer's Disease (QOL-AD) Subject Report. Caregivers completed the QOL-AD Caregiver Report. Consenting subjects were non-critically ill, English-speaking, community-dwelling adults over 65 years. Spearman rho coefficient and Wilcoxon signed-rank test evaluated relationships between patient and caregiver QOL-AD scores with regard to the patients' level of cognition.

Results: Patient QOL ratings were obtained from 60 patientcaregiver pairs. QOL evaluations by patients and caregivers were more highly correlated in patients of normal cognition. Mean total QOL scores were lower for cognitively impaired patients than patients of normal cognition. The difference between mean total QOL scores for patients and caregivers was greater for patients of abnormal cognition.

Conclusion: Fewer significant correlations for cognitively impaired patients and their caregivers can explained by several reasons including patient lack of insight, denial of impairment, adaptation to

the condition, or the fact that cognitive impairment may not negatively impact quality of life. Understanding patient QOL is important for referral to multidisciplinary programs with the goal of reducing preventable hospitalizations and ED recidivism.

Patients of Normal SBT (n=27) QOL-AD

Physical health Energy Mood Living situation Memory Family Marriage Friends Self as a whole Ability to do chores Ability to do things for fun Money Life as a whole Total Score

Patients of Abnormal SBT (n=33) Wilcoxon

Patient Ratings

Caregiver Ratings

Spearman coefficient

Patient Ratings

Caregiver Ratings

Spearman coefficient

Mean (SD)

Mean (SD)

rho

p

Mean (SD)

Mean (SD)

rho

p

p

2.41 (1.01) 2.41 (1.01) 2.96 (0.90) 3.52 (0.75) 2.93 (0.96) 3.41 (0.69) 3.52 (0.58) 3.44 (0.58) 3.22 (0.51) 2.81 (1.14) 3.04 (1.02) 3.19 (1.00) 3.48 (0.58) 40.33 (7.66)

2.41 (0.97) 2.67 (0.88) 2.63 (1.08) 3.41 (0.84) 3.04 (0.81) 3.37 (0.79) 3.22 (0.93) 3.33 (0.73) 3.04 (0.90) 2.81 (1.21) 2.96 (1.02) 3.26 (0.98) 3.44 (0.75) 39.59 (9.07)

0.766 0.757 0.813 0.288 0.253 0.230 0.550 0.379 0.348 0.513 0.173 0.255 0.414 0.677

0.000 0.000 0.000 0.145 0.204 0.249 0.003 0.051 0.076 0.006 0.388 0.200 0.032 0.000

2.39 (0.97) 2.06 (1.00) 2.12 (0.93) 2.70 (0.88) 2.24 (0.87) 2.91 (0.95) 3.33 (0.89) 2.97 (0.92) 2.76 (1.03) 2.55 (1.03) 2.64 (1.06) 2.36 (1.08) 2.97 (0.85) 34.00 (8.60)

2.06 (0.86) 2.30 (1.02) 1.97 (0.88) 3.03 (0.81) 2.21 (0.74) 3.00 (0.87) 3.03 (0.88) 3.06 (0.75) 2.70 (0.88) 1.97 (0.88) 2.18 (0.81) 2.48 (0.76) 2.88 (0.74) 32.88 (7.17)

0.287 0.356 0.517 0.066 0.299 -0.017 0.349 0.044 0.292 0.269 0.169 0.309 0.149 0.351

0.106 0.042 0.002 0.715 0.091 0.926 0.047 0.808 0.099 0.129 0.348 0.080 0.406 0.045

0.012 0.120 0.531 0.174 0.686 0.127 0.059 0.175 0.128 0.256 0.812 0.276 0.071 0.112

8. Patients With Suicide Ideation Presenting To The Emergency Department: A New Characterization Of Mortality And Outcomes.

David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and Nick Echevarria. Georgetown University School of Medicine, Washington, DC Background: Psychiatric patients exhibit increased suicide risk shortly after discharge, but little is known about the fate of patients who are discharged after presentation with Suicidal Ideation (SI). In the U.S. there is furthermore a lack of supporting documentation for outcomes following admits from Emergency Department (ED) presentations for SI. Objectives: To determine if patients who present to the ED with Suicidal Ideation are at increased risk for death by suicide than those patients presenting with other acute complaints.

Methods: Setting: urban hospital, 950 patient beds, ED with 80,000 annual visits •Retrospective data collection using Azyxxi data record developed by Smith and Feeid (Microsoft, Redmond WA) •Patients included presented with triage complaint or ED diagnosis of suicide or spelling variants between 2002-2007.

•Cohort of 3742 patient records (SI Cohort) screened against Social Security Death Registry (http://ssdi.rootsweb.com/cgi-bin/ssdi.cgi) to obtain mortality statistics.

•Subcohort of 108 patients with a positive match for death on the SSNDR (Death Cohort) was identified and sociodemographics and co-morbidities were characterized.

•True suicides as primary cause of death were then ruled in by crossreferencing of this subcohort with the District of Columbia‟s Medical Examiners Office Results: 3,625 pts with SI presented to the ED during the study period over 5 years accounting for 53,217 ED visits with a mean of 13.4 visits for SI alone (95%CI: 10/5-17.1) with an overall mortality rate of 4.8%. for all comers in the ED population. The mean time to death for the 122 deaths in the suicide group was 2.9 years from the initial suicide ideation visits. for all suicidal patients, there was a mean of 11 visits and an average of 5.1 years from first ED visit( all cause) till death for those that died in the study period. 50% of the death cohort were found to abuse alcohol and/or substances and 32% were HIV positive. Only 10% of those that died during the study period were determined to have died from OD or self -inflicted wounds; this results in an overall true suicide rate of 0.5 percent for the entire suicidal patient presenting to the ED. Conclusion: SI is still a serious problem, However; the deaths for these patients presenting to the ED do not come at any increased rate in this preliminary study.

9. Comparing Urine Acetoacetate Values With Serum 3-betahydroxybutyrate Values In Pregnant Women With Nausea And Vomiting In The Emergency Department.

Ian T Ferguson and Michael Mullins. Washington University in St. Louis, St. Louis, MO Background: Nausea and vomiting affect upwards of 80% of pregnant women and are frequent causes of emergency department visits. The ED physician must distinguish between uncomplicated nausea/vomiting (â&#x20AC;&#x153;morning sicknessâ&#x20AC;?) and hyperemesis gravidarum (HG) because this affects treatments decisions, including type and quantity of IV fluids, and length of stay.

Objectives: Our aim of this study was to determine whether fingerstick 3-beta-hydroxybutryrate (BHB) predicts ketonuria in pregnant women with nausea and vomiting.

Methods: We enrolled 77 pregnant women who presented to the Barnes-Jewish Emergency Department with complaints of nausea/vomiting. All procedures were completed under IRB approval. Exclusion criteria were: 38.3°C or altered mental status, prisoners, and >1 liter of IV fluid before screening. All subjects had a fingerstick BHB test, with results reported in increments of 0.1 mmol/L. Urine ketone results were made available once reported as part of standard of care and varied from 0 (trace) to +4 values.

Results: We constructed a contingency table and receiver-operating curve for comparing the BHB values to those urine ketone values for each patient. We used a cut-off urine ketone value of +3 or +4 to sufficiently indicate severe nausea/vomiting or hyperemesis as these values necessitate aggressive fluid management to reduce ketonemia and improve ketone urine clearance.

Mean BHB was 0.435 mmol/L and median urine was +1 for the cohort as a whole. The ROC gives an area under the curve of .94. The sensitivity and specificity for a fingerstick test of >.4 mmol/L are 85% and 94% respectively. The PPV is .88 and the NPV is .92. The positive likelihood ratio is 14 and the negative likelihood ratio is .16.

Conclusion: Fingerstick BHB provides a rapid and reliable diagnostic tool to correlate ketonemia (3-beta-hydroxybutyrate) levels with ketonuria (acetoacetate) levels in pregnant women with nausea/vomiting. Fingerstick BHB results may be obtained earlier in the course of care than urine samples and as a result, may increase triage efficacy, lower length of stay times, and positively affect patient outcomes in an emergency department setting.

Lightning Oral Presentation Session 1 9:10am-10:45am 10. Do Admission Check Sheets Improve Compliance with Pneumonia Core Measures?

Andrew Abbeg, Sr., Steven Lorber, Preeti Dalawari and Stacy Revelle. St Louis University Hospital, St Louis, MO Background: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes antibiotics given within 6 hours of arrival to the emergency department (ED) for patients diagnosed with pneumonia as a performance measure. The Center for Medicaid and Medicare Services (CMS) uses this as one of its core measures to continue funding to hospitals; a 97% compliance rate is expected.

However, atypical pneumonia presentations may cause a delay in antibiotic treatment and will be considered an outlier if an explanation of the delay is not given.

Objectives: The objective of this study was to assess the monthly compliance rate with this measure before and after the institution of a checklist.

Methods: This was a review of aggregate data of ED pneumonia compliance for public reporting at an academic tertiary center. A preliminary data analysis compared 8 months before and 4 months after the checklist was instituted in March 2010 (final analysis will include 8 months post checklist). The checklist, developed by the institutional pneumonia committee, enables physicians to indicate typical versus atypical presentation, time to antibiotics, and explanations for delays in treatment. A t test for independent samples was used to analyze differences in compliance rate between groups.

Results: There were 143 reportable pneumonia cases in the preliminary time period; 88 (62%) prior to checklist and 55 (38%) after. After the institution of the checklist all pneumonia patients received timely antibiotics with 100% average monthly compliance compared to before checklist of 94.1% (p value <0.027).

Conclusion: The preliminary data suggests that using a pneumonia checklist is one way that an emergency department can improve compliance with the time to antibiotic CMS core measure.

felt exhausted in the week prior to testing, and were found to have a low physical activity level (as determined by the Stanford Brief Activity Survey). They were classified as pre-frail if they tested positive for 1 or 2 of these criteria. Grip strength values, measured by a JAMAR® Plus Hand Dynamometer, were adjusted for age and height based upon population norms for each gender. The diagnostic test characteristics of grip strength were determined using SPSS and MEDCALC. Results: Overall, 165 patients were enrolled with complete data collection. The mean age of the subjects was 74 years. 43% of the subjects were male. 27.1% of males and 11.7% of females tested below their age and height adjusted grip strength norms. Grip strength demonstrated poor diagnostic test characteristics with regards to identifying frail and pre-frail geriatric ED patients.

Diagnostic Test Characteristics of Grip Strength for Females Sen % (95% CI) Spec % (95% CI) LR+ (95% CI)

LR- (95% CI)

AUC (95% CI)

1 Fried criterion 12 (-4-27)

83 (73-94)

0.71 (0.17-3.00) 1.06 (0.85-1.31) 0.49 (0.35-0.62)

2 Fried criteria

29 (9-48)

91 (82-99)

3.14 (0.99-9.96) 0.79 (0.59-1.05) 0.47 (0.32-0.63)

3 Fried criteria

11 (-9-32)

84 (74-94)

0.69 (0.10-4.82) 1.06 (0.82-1.37) 0.49 (0.32-0.66)

Diagnostic Test Characteristics of Grip Strength for Males Sen % (95% CI) Spec % (95% CI) LR+ (95% CI)

LR- (95% CI)

AUC (95% CI)

1 Fried criterion 21 (0-43)

69 (55-83)

0.69 (0.23-2.08) 1.14 (0.81-1.60) 0.41 (0.25-0.57)

2 Fried criteria

40 (10-70)

74 (61-87)

1.53 (0.62-3.78) 0.81 (0.48-1.39) 0.48 (0.30-0.67)

3 Fried criteria

55 (25-84)

78 (66-90)

2.46 (1.14-5.29) 0.58 (0.30-1.14) 0.44 (0.25-0.63)

Conclusion: Low sensitivities and ROC AUCs indicated that grip strength poorly detected frailty and pre-frailty in geriatric ED patients. A brief, effective screening tool for frailty should still be researched to improve care for geriatric ED patients.

12. Are They Working? The Effects Of UI And CommunityBased Interventions On Thursday Night Binge Drinking Nicholas J Edwards and Michael Takacs. University of Iowa Carver College of Medicine, Iowa City, IA

11. Grip Strength as a Brief Diagnostic Test for Frailty and PreFrailty in Geriatric Emergency Department Patients Grant M. Fischer and Christopher R. Carpenter. Washington University in St. Louis School of Medicine, St. Louis, MO Background: Linda Fried et al.‟s well-established definition of frailty classifies geriatric adults as frail if they meet 3 of the following 5 criteria: unintentional weight loss, exhaustion, low grip strength, slow walking speed, and low physical activity level. It categorizes them as pre-frail if they meet 1 or 2 of these criteria. EDcase finding for frailty could offer opportunities for intervention. A brief, effective tool for identifying frailty must be developed in order for frailty-specific ED-case finding to be possible.

Objectives: The purpose of this study was to determine if grip strength could serve as a brief diagnostic test for frailty and/or prefrailty in geriatric ED patients.

Methods: An observational, cross-sectional study was conducted on a consecutive sample of eligible subjects at the ED of Barnes-Jewish Hospital (BJH). Eligible subjects included consenting Englishspeaking, community-dwelling patients at least age 65 years who presented to BJH‟s ED from June 1, 2011 to July 31, 2011 and did not reside over 30 miles from BJH. Trained geriatric technicians evaluated subjects for adherence to all of the Fried criteria except walking speed. For data analysis, subjects were considered frail if they had unintentionally lost at least 10 lbs in the year prior to testing,

Background: 2011 survey data indicates that 65% of UI students engage in binge drinking; down from 70% in 2006, but staggering when compared to 44% of college students nationwide. At this time, the impact of UI and community-based interventions on this decrease in self-reported risky drinking is unclear. Nonetheless, emergency departments (ED) continue to play an important role in injury surveillance and can capitalize on “teachable moments” during alcohol-related ED visits.

Objectives: Compare numbers of alcohol-related ED visits before and after the start of alcohol-interventions (more Friday classes, 21Only Ordinance) to determine the efficacy of these programs, with trends among students and across genders being focal points.

Methods: 18-22 year-olds, who presented to the ETC for alcoholrelated injuries on Thursday nights from Fall 2006 to Spring 2011, were eligible for this retrospective study. Data were compiled from patients‟ medical records, and FERPA-approved access to the UI Provost‟s database determined the patients‟ UI academic status. Nonstudents served as controls. Data were analyzed via chi-square and ANOVA. Results: On Thursday nights from Fall 2009-Spring 2011, 127 patients presented to the ED for alcohol related-injuries; 76 males (60%), 51 females (40%), and 78 UI-students (61%) versus 49 nonstudents (39%). 25 males presented with violence-related injuries, compared to 0 females (p<0.0001). A study of semesters before and after implementation of alcohol-interventions showed a 15% decrease in Thursday night alcohol-related ED visits following increases in

Friday classes, and a 54% decrease following onset of the 21-Only Ordinance (p<0.02 when comparing interventions). Among UIstudents, 31% and 53% decreases were seen, respectively (p<0.01 when comparing semesters).

Conclusion: Further research is indicated to effectively study correlations between alcohol-related ED visits and alcoholinterventions, as retrospective studies cannot provide direct causation for observed changes. Observed differences between male and female incidence and mechanism of injury may warrant future interventions and educational means that are gender-specific.

13. Short QTc in Emergency Department Patients Stacey House, Peta-Gay Laird and S. Eliza Halcomb. Washington University in St. Louis, St. Louis, MO Background: A short QTc interval has been shown to predispose patients to arrhythmias and sudden death. Electrolyte abnormalities, hyperthermia, and some medications are associated with shortened QTc. As the importance of short QTc has only recently been appreciated, there is limited literature describing patients with short QTc especially in the ED. Objectives: The study objective was to characterize the ED population with short QTc. Methods: This study was a retrospective review of ED patients (pts) who received an ECG from April - September 2009 at a large volume, tertiary care center. Inclusion criteria were pts with a QTc≤390ms. Exclusion criteria included pts with an ECG showing bradycardia (HR<60bpm), tachycardia (HR>100bpm), QRS>120ms, or non-sinus rhythm. ED electronic medical records were reviewed for multiple comorbid conditions, presenting symptoms, electrolyte abnormalities, medications, and disposition.

Results: 13,494 pts received ECGs during the six month period. Of these, 281 had a QTc≤390ms (2%, 95%CI 1.8-2.3%). 136 were excluded, leaving 145 eligible pts. Of these, 108 (75%) had a QTc 380-390ms, 26 (18%) had a QTc 370-379ms, and 10 (7%) had a QTc≤369ms. These pts were 39±2 years old and were predominantly male (71%, 95%CI 63-78%). Hypertension (22%), psychiatric conditions (17%), and drug abuse (22%) were the most common comorbidities. The most common symptoms were chest pain (56%), shortness of breath (40%), and dizziness (19%). 18% (95%CI 1025%) had abnormal serum potassium, and 13% (95%CI 6-19%) had abnormal serum calcium. 4% (95CI 1-7%) were hyperthermic. Only 3% (95%CI 1-5%) were on home medications which shortened QTc interval including <1% on digoxin, the most commonly described cause of medication-induced short QTc. 70% (95%CI 63-78%) were discharged from the ED. There were no significant differences among the different length QTc groups with regards to comorbidities, symptoms, electrolyte abnormalities, QTc shortening medications, or disposition.

Conclusion: Shortened QTc occurs in 1-2% of ED pts with <0.1% having a QTc<369ms. Even though hypercalcemia, hyperthermia, and digoxin therapy are commonly reported causes of shortened QTc, a very small portion of ED pts with shortened QTc had these findings. As the majority of these pts are discharged from the ED, further studies are needed to determine the cardiac event rates in ED pts with shortened QTc.

14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs Rural Health and Safety Policy Gerene M Denning, Kari Harland, Kevin Kremer, Charles Jennissen and Christopher Buresh. University of Iowa, Iowa City, IA Background: Every year, U.S. ATV crashes result in over 500 deaths, 130,000 ED visits, and $4 billion in lost life and healthcare

costs. One in three victims are under the age of 16. Because the vast majority of ATV crashes occur in or near rural communities, they represent a serious threat to rural health and safety.

Objectives: The objectives of this project were to compare Iowa ATV crashes by crash location, and to develop public policy recommendations based on these results.

Methods: Data for these studies were generated from our Iowa ATV Injury Surveillance Database (2002-2009). Proportions were compared using the chi-square test. Injury severity scores for on and off-road crashes were compared using the Mann-Whitney test.

Results: Females (23%) and children under sixteen (32%) were a higher percentage of on-road crash victims as compared to crashes in Off-Highway Vehicle (OHV) parks (females, 8%; children 10%; p < 0.05). There were also significantly higher proportions of on-road (17%) and off-road (15%) crashes that involved passengers, when compared to crashes in the parks (3.8%, p < 0.05). Monitoring and enforcement of helmet requirements in the parks appeared to increase helmet use (91%) relative to other sites (on-road, 13%; off-road, 25%; p < 0.0001); Iowa does not currently have a statewide helmet law. On-road crashes were 8-fold more likely to involve a collision with another vehicle relative to off-road crashes. On-road fatalities averaged two per year, whereas a single fatality was recorded in the parks over the 8-year period. Injury severity scores were higher for on-road crashes relative to off-road locations (p < 0.0001), and victims from on-road crashes were 3 times more likely to suffer traumatic brain injury relative to off-road victims.

Conclusion: Iowa law allows cities and counties to designate streets/roads for general ATV use; however, our data indicate that onroad ATV crashes pose a serious injury risk and traffic safety hazard.

Based on these findings, we would strongly advise policy makers against increasing ATV road use. Conversely, enforcement of OHV park regulations, including no passenger rules and required helmet use, appears to promote safer behaviors and better outcomes.

Expanding safe, controlled places for recreational riding would be a potential way to reduce ATV-related deaths and injuries.

15. A Comparison of Two Hospital Electronic Medical Record Systems and Their Effects on the Relationship Between Physician Charting and Patient Contact John Shabosky, Jonathan dela Cruz and Matthew Albrecht.

Southern Illinois University School of Medicine, Springfield, IL Background: Recent health care reform has placed an emphasis on the electronic health record (EHR). With the advent of the EHR it is common to see ED providers spending more time in front of computers documenting and away from patients. Finding strategies to decrease provider interaction with computers and increase time with patients may lead to improved patient outcomes and satisfaction.

Computerized charting adjuncts, such as voice recognition software, have been marketed as ways to improve provider efficiency and patient contact.

Objectives: We present here observational data comparing two separate ED sites, one where computerized charting is done by conventional techniques and one that is assisted with voice recognition dictation, and their effects on physican charting and patient contact.

Methods: A prospective observational quality initiative was conducted at two teaching hospitals located less than 1 mile from each other. One site primarily uses conventional computerized charting while the other uses voice recognition dictation. Four trained quality assistants observed ED physicians for 180 minutes during shifts. The tasks each physician performed were noted and logged in 30 second intervals. Tasks listed were identified from a predetermined standardized list presented at observer training. A total of 4140 minutes were logged. Time allocated to charting and that allocated to direct patient care were then compared between sites.

Results: ED physicians spent 28.6% of their time charting using conventional techniques vs 25.7% using voice recognition dictation (p=0.4349). Time allocated to direct patient care was found to be 22.8% with conventional charting vs 25.1% using dictation (p=4887).

In total, ED physicians using conventional charting techniques spent 668/2340 minutes charting. ED physicians using voice recognition dictation spent 333/1800 minutes dictating and an additional 129.5/1800 minutes reviewing or correcting their dictations.

Conclusion: The use of voice recognition assisted dictation rather than conventional techniques did not significantly change the amount of time physicians spent charting or with direct patient care.

Although voice recognition dictation decreased initial input time of documenting data, a considerable amount of time was required to review and correct these dictations.

16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model For Training Rural Providers Wesley Zeger1, Paul Travis2, Michael Wadman1, Carol Lomneth1, Sara Keim1 and Stephanie Vandermuelen1. 1UNMC, Omaha, NE; 2 Creighton University, Omaha, NE Background: In Nebraska, 80% of emergency departments have annual visits less than 10,000, the predominance are in rural settings.

General practitioners working in rural emergency medicine departments have reported low confidence in several emergency medicine skills. Current staffing patterns include using midlevels as the primary provider with non-emergency medicine trained physicians as back-up. Lightly-embalmed cadaver labs are used for resident‟s procedural training.

Objectives: To describe the impact of a lightly-embalmed cadaver workshop on physician assistant‟s (PA) reported level of confidence in selected emergency medicine procedures.

Methods: An emergency medicine procedure lab was offered at the Nebraska Association of Physician Assistants annual conference.

Each lab consisted of a 2 hour hand‟s on session teaching endotracheal intubation techniques, tube thoracostomy, intraosseous access, and arthrocentesis of the knee, shoulder, ankle, and wrist to PA‟s. IRB approved surveys were distributed pre-lab and a post-lab survey was distributed after lab completion. Baseline demographic experience was collected. Pre- and post-lab procedural confidence was rated on a 6-point likert scale (1-6) with p values calculated using the Wilcoxon Signed-Rank Test.

Results: 26 PA‟s participated in the course. All completed a pre and post-lab assessment. No PA had done any one procedure more than 5 times in their career. Pre-lab modes of confidence level were ≤ 3 for each procedure. Post-lab modes were ≥ 4 for each procedure except arthrocentesis of the ankle and wrist. However, post lab assessments of procedural confidence improvement was statistically significantly for all procedures with p values < 0.05.

Conclusion: Midlevel provider‟s level of confidence improved for emergent procedures after completion of a procedure lab using lightly-embalmed cadavers. A mobile cadaver lab would be beneficial to train rural providers with minimal experience.

17. Utilization Of Computed Tomography In Blunt Trauma: When Is Thoracic And Lumbar Imaging Warranted?

Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St. Louis University, St. Louis, MO Background: Computed tomography (CT) is becoming the standard of care for evaluating blunt trauma patients. Some clinicians argue that all level I and II trauma patients should undergo whole-body imaging even with a glascow coma score (GCS) of 15 and no clinical

evidence for spinal injury. Insufficient evidence exists to support routine use of thoracic and lumbar CT in blunt trauma.

Objectives: To explore the association between available clinical indicators and thoracolumbar fracture (TLfx) in the trauma setting and determine if utilization of thoracolumbar imaging can be modified.

Methods: This retrospective study included all level I/II blunt trauma patients with spine fracture and GCS of 13+ presenting to St. Louis University Hospital in 2009. The positive predictive values (PPV) for TLfx was determined independently for clinical indicators (no back pain and no other injury) and their combination. In addition, the association between TLfx and cervical spine fracture (CSfx) was estimated by phi coefficient of association. Subtypes of non-spinal injuries (e.g., lower extremity, upper extremity, intrathoracic) were assessed by descriptive statistics.

Results: Of the 216 adult patients with complete registry data records included in this study, 72.2% had TLfx. The PPVs (and 95% confidence interval) for clinical indicators of no back pain and no other injury were 0.58 (0.34, 0.47) and 0.60 (0.47, 0.72), respectively.

The PPV for the combination of information about back pain or injury was 0.63 (0.54, 0.71), indicating 63% of cases with no back pain or no injury had a TLfx per CT. Of the 87 cases with CSfx, 38 (or 44%) also had TLfx. By comparison, 91% of the 129 cases without CSfx had TLfx. The phi coefficient between TLfx and CSfx was 0.52 (p < 0.001), indicating a weak positive association.

Intrathoracic and upper extremity were the two most common injury subtypes associated with TLfx. Conclusion: In this study of trauma patients with GCS 13+, having no back pain was unreliable in ruling out TLfx for 59% of patients.

The overlap between TLfx and CSfx was relatively weak and unrelated to known clinical factors, such as no back pain. This study did not reveal back pain or injury as reliable clinical indicators to rule-out TLfx. The study provides no evidence against the routine use of thoracic and lumbar CT in blunt trauma patients.

18. Changing Presentation Rates For Mtbi (Concussion) And Changing Imaging Rates Han Huang1, Nick Echevarria1, David Milzman1, Carla Tilchin1 and Ronny Song2. 1Georgetown University School of Medicine, Bethesda, MD; 2Georgetown University, Bethesda, MD Background: : Minor traumatic brain injury (mTBI or concussion) has seen changes in resources devoted to education, and awareness as well as structured limitations on athletic concerns. Few studies to date have attempted to determine whether, increased occurrence is related to change in injury patterns or improvements in physician awareness and diagnosis.

Objectives: : To determine if mTBI rates are increasing faster than all trauma and whether detection is related to better diagnosis or increased occurrence including the use of advanced imaging rates related to any possible increase in detection and utility.

Methods: the Emergency Department and Trauma Center records were analyzed at ED and Trauma Centers in 2 metropolitan areas for the past decade 2000-2010. Trauma registries and the AZYXXI database (Microsoft; Redmond,WA) were analyzed for trauma admits, and mTBI rates and treatment interventions including use of radiographic study and dispositions. IRB approval and data analysis was obtained and performed, respectively.

Results: : A 10 year study found rapid rise in past 5 year with number of concussions which increased by 140% compared to ED and Trauma patients increased only by 23.9%; p< 0.02.

(Figure 1) There were also increases in use of CT for concussion: 25.8% with less than 2% of mTBI having a positive finding on Head CT and none requiring neurosurgical intervention.

Both number of concussions and admitted concussions experienced the same rate of rise as number of concussions and equal AUC.

Conclusion: There has been an effective impact on mTBI presentation and admission to our trauma centers in the past five years. CT increased in use with no improved treatment intervention.

Future studies will need to determine utility of admit compared to outpatient observation and neuropsychiatric intervention for isolated mTBI.

19. Validity of the Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) Instrument As Predictors for Mortality, ED Revisits, Hospital Admission, Nursing Home Admission, and Functional Decline in Cognitively Normal and Cognitively Impaired Geriatric ED Patients Dan Feng, Sophia Li and Christopher R Carpenter. Washington University School of Medicine, St Louis, MO Background: ED revisit and post-ED hospitalization, nursing home (NH) admission, and functional decline are key challenges for improving geriatric medical care and quality of life. The Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were developed as prognostic tools to predict suboptimal post-ED geriatric outcomes. These have only been validated in the regions where they were derived, and the NIH has recommended further research to confirm their ED applicability. In addition, TRST and ISAR are not specifically validated for cognitively impaired individuals, who comprise a majority of geriatric ED visits.

Objectives: To test the predictive validity of TRST and ISAR for mortality, ED revisit, hospitalization, NH admission, and functional decline at 30 days post ED in geriatric ED patients with 1) no cognitive impairment and 2) suspected cognitive impairment.

Methods: This was a prospective, observational cohort study of all consenting ED patients age 65 and older in a private, urban, academic hospital between June 1 and July 31, 2011. Within a larger RCT, trained geriatric technicians administered the Older American Resources and Services Activities of Daily Living (OARS-ADL) scale, Short Blessed Test (SBT) for dementia, TRST, and ISAR. At 30 days post enrollment, mortality, ED revisit, hospitalization, NH admission, functional decline (a ≥3-point decline on OARS-ADL), and the composite outcome were measured via telephone follow-up.

Participants were excluded at follow-up if they had received a cognitive intervention used in the larger RCT. ROC curves with area under the curve (AUC) and likelihood ratios were calculated for the predictive validity of TRST and ISAR in individuals with no evidence (SBT score≤4) and evidence (SBT>4) of cognitive impairment.

Results: Participants (N=168) had a mean age of 74, were 43.1% male, and 62% African-American. TRST and ISAR stratified 81% and 79% at high risk for composite outcome (score>2). TRST and ISAR had AUCs of 0.64 and 0.70 for composite outcome in all participants at 30 days, exhibiting poor and moderate validity, respectively. ISAR had moderate predictive validity for composite outcome in patients with no cognitive impairment (-LR = 0.20, N=25).

Conclusion: ISAR has some validity for suboptimal outcomes in geriatric ED patients with no cognitive impairment. Further study is necessary to verify precision.

20. Diagnostic Accuracy of Various Health Literacy Screening Tools in the Emergency Department Andrew Melson, Christopher Carpenter and Richard Griffey.

Washington University in St. Louis School of Medicine, Saint Louis, MO

Background: Health literacy is an important determinant of health outcomes that concerns how well a patient can obtain, process and understand health information needed to make appropriate health decisions. Inadequate health literacy has been linked to poor medication adherence, increased, longer hospital stays and greater emergency department (ED) utilization. A recent systematic review of health literacy and ED outcomes identified only one study using more than one screening tool. We are not aware of any studies comparing the diagnostic accuracy of various screening tools in the ED setting.

Objectives: We compare the diagnostic accuracy of commonly used health literacy screening tools in ED patients.

Methods: We performed a prospective, observational convenience sample study of adult ED patients presenting from March - July 2011 to an urban, academic ED with 97,000 annual visits. Exclusion criteria included: patients with aphasia, known dementia, mental retardation, inability to communicate, non-English speaking or too ill to interview as determined by physicians. We screened participants using the short versions of the Test of Functional Health Literacy in Adults (S-TOHFLA) and the Rapid Estimation of Adult Literacy in Medicine (REALM-R), the Newest Vital Sign (NVS) and a panel of 3 single item literacy screens (SILS) used in prior studies. Results for S-TOFHLA were dichotomized, combining marginal and low health literacy strata. Three separate Likert-style SILS questions were asked such as: How confident are you filling out medical forms by yourself? Primary outcome measures were screening test characteristics, comparing each with the S-TOFHLA as the criterion standard, based primarily on its wide use for this purpose.

Results: 262 patients participated. Participants were 55% female, 31% white, 68% black and 1% other race, with an average age of 43.8 years. The S-TOFHLA, REALM-R and NVS identified 20.2% 49.6% and 75.6% respectively as having inadequate or marginal health literacy.

Conclusion: In ED patients, when compared to the S-TOFHLA, the NVS and SILS3 had the highest sensitivity (100%) and specificity (95%) respectively in identifying low health literacy. The importance of these test characteristics depends on the goals in performing health literacy screening and must be balanced against other considerations for screening in the ED such as feasibility and usability.

Diagnostic Accuracy of Screening Tools Compared to S-TOFHLA 95% 95% Positive 95% Negative 95% Sensitivity Confidence Specificity Confidence Likelihood Confidence Likelihood Confidence Interval Interval Ratio Interval Ratio Interval REALM85% R

72-93

59%

52-66

2.1

1.7-2.5

0.25

0.13-0.5

NVS

100%

92-100

31%

25-37

1.4

1.3-1.6

0

0

SILS1

33%

21-47

86%

80-90

2.3

1.4-3.8

0.8

0.65-0.95

SILS2

51%

37-65

81%

75-86

2.7

1.8-3.9

0.6

0.46-0.80

SILS3

32%

20-46

95%

91-97

6.1

3.0-12.2

0.7

0.60-0.86

21. "What Did You Say?” Noise: Does It Distract From Patient Care In The Emergency Department?

Laurie E Byrne, Peter Anaradian and Preeti Dalawari. St. Louis University, St. Louis, MO Background: Research in critical care units have shown that noise exposure contributes to increased levels of stress and sleep deprivation in patients. Noise has also shown to negatively impact staff by increasing levels of stress and interfering with patient care.

The Environmental Protection Agency (EPA) recommends that hospital noise levels should not exceed 40 decibels (dB). Previous studies indicate that noise levels in the emergency department (ED) have consistently exceeded this level. However, no studies evaluated both ED staff and patients on the affects of noise on their care.

Objectives: The purpose of this study was to evaluate patient and staff perceptions of noise exposure and quality of care in the ED.

Methods: The study was a cross sectional survey of a convenience sample of ED patients and staff at an academic tertiary center during three standard 8 hour ED shifts (day, evening, and overnight). The questionnaire asked about perception of noise level, potential sources of noise, and how it affected the quality of care using a 10-point rating scale. A dosimeter was used to measure the noise level at the time the questionnaires were distributed. Independent t-test was used to evaluate differences in perception between staff and patients; ANOVA was used to evaluate differences among shifts.

Results: In this study, 106 people participated; 57% were patients.

There was no difference in the perception of overall noise level between patients and staff or by shift. Each group reported the noise level to be moderately loud (5 out of 10). Both groups thought the noise level interfered with patient care, but not to a significant degree (3 out of 10). Both groups cited voices from peopleâ&#x20AC;&#x;s conversations and intercom use as a leading contributor to noise. The perception of the telephone contributing to the noise level was reported by staff but not by patients (p=0.001). There was a significant difference in noise level among shifts with the evening shift noise level higher at an average dosimeter reading of 80 dB (p value < 0.05).

Conclusion: The emergency department noise level was consistently above the EPAâ&#x20AC;&#x;s recommended noise level. However, both patients and staff did not perceive any significant impact in care.

22. Undiagnosed Mental Illness in Children and Adolescents in the Emergency Department Yanika Wolfe and Dane M. Doctor. Rosalind Franklin University/Chicago Medical School, North Chicago, IL Background: Many patients present to the emergency department with undiagnosed psychiatric illness that may cause or exacerbate their presenting complaint. Pediatric and adolescent mental health concerns are also particularly unaddressed, even though they represent a key risk factor for later psychiatric problems. Early diagnosis of these illnesses may improve treatment and referral for patients with these problems.

Objectives: The objective of this study was to identify unsuspected psychiatric illness in child and adolescent patients presenting to the emergency department with non-psychiatric related complaints.

Methods: This IRB approved study involved enrolling a convenience sample of 100 patients from a level I inner city teaching emergency department, which sees 60,000 patients per year. The validated interview tool, M.I.N.I. KID (MINI International Neuropsychiatric Interview for Children and Adolescents) was administered to English speaking patients between the ages of 12-17 presenting to the emergency department with non-psychiatric complaints. Written consent was required from both the patient (minor) and parent/guardian. All consenting patients were given the MINI Neuropsychiatric interview in the emergency department. Once completed, the researcher scored the results. If the patient tested positive for any disease modules, the researcher informed the attending physician.

Results: A total of 40 patients were enrolled. The enrolled patient body was 52.5% African American, 47.5% Hispanic, and 55% Female. Overall, 40% of patients tested positive for one or more undiagnosed mental illness. Of those that did test positive for psychiatric illness based on the results of the MINI, the majority 62.5% had only one psychiatric illness. The most frequently identified disorders were Oppositional Defiant Disorder (10%), (Hypo)Manic Episodes (7.5%), ADHD (7.5%) and Hypomanic Symptoms (25.0%). Only one patient was classified by the MINI as a suicide risk. The physician and mental health crisis worker were notified and the patient was given a suicide resource pamphlet.

Conclusion: This study gives strength to the argument that there is significant undiagnosed psychiatric illness in young patients presenting to the emergency department. Additionally, the notion that

the ED may be a good place to identify undiagnosed mental health illnesses was also reinforced.

23. A Comparison of Diversion and No Diversion and the Effect on patient Safety and Outcomes in the Emergency Department Eman Spaulding, Laurie Byrne, Eric Armbrecht Jackson. Saint Louis University, Saint Louis, MO

and Collin

Background: Diversion is a controversial topic in emergency medicine that produces debate on institution-specific and regionallevel policy. Our literature review revealed no prior studies on the association between diversion and overall quality of care.

Objectives: The Emergency Department (ED) at Saint Louis University, as well as all EDs in the region, adopted a new regional zero diversion policy, effective Oct 2009. In this study we examine how ED performance measures, including left without treatment (LWOT), left without being seen (LWBS), left against medical advice (AMA), deaths, and the average length of stay, changed after the new policy.

Methods: We selected a six-month period (April through Sept) before and after the zero diversion policy change to limit effect of seasonal variation. A two-sided z-ratio was used to test the difference between hospital-option and zero diversion policy periods for LWOT, LWBS, AMA, deaths, and admission rate. Mean monthly length of stay (in minutes) was assessed by a t-test for independent samples.

Results: The total ED census during the two periods was approximately the same. During the hospital-option period, diversion was activated for an average of 7.0 hours per month. LWOT and LWBS rates were 19.4% (p < 0.001) and 18.2% (p = 0.002) lower, respectively, during zero diversion. There were no differences in observed AMA (p = 0.183) or death rates (p = 0.653). Inpatient admission rate was 4.4% higher during zero diversion (p = 0.009).

Diversion Policy Period Hospital-option (n = 18,108)

Zero (n = 18,698)

Rates (per 1,000 Census)

P

LWOT

70.8

57.1

< 0.001

LWBS

28.7

23.5

0.002

AMA

13.3

11.7

0.183

Deaths

3.5

3.2

0.653

Inpatient Admission

280.59

292.87

0.009

Length of Stay (minutes, mean + sd) Admitted

334 + 11.0 329 + 11.8

0.496

Discharged

242 + 9.0

0.015

228 + 8.0

While there was no significant difference in average monthly length of stay for admitted patients, discharged patients had faster treatment times during zero diversion (228 + 8.0 minutes) versus hospitaloption (242 + 9.0 minutes), p = 0.015.

Conclusion: Adopting a zero diversion policy was not associated with increased rates of death, AMA or overall ED length of stay. Our results revealed improvements in key performance measures, including rates of patients leaving without being seen or treated, and decreased length of stay for discharged patients.

24. Impact Of Presence Of Third Molars On Mandible Fractures Following Facial Trauma David Milzman1, David Weiner2 and Ryan Murray1. 1Georgetown University School of Medicine, Washington, DC; 2Georgetown University School of Medicine, Bethesda, MD

Background: Facial trauma is a common cause of Mandible fracture.

The majority are young men, and the mechanism of injury is often due to assault, vehicular accident, or falls.

Objectives: To determine if the presence of third molars particularly, impacted teeth create a increased risk for mandible fracture compared to persons with an already extracted third molar due to ossification and stronger mandible in that region.

Methods: Retrospective analysis of four years of consecutive presentations of mandible fractures to the emergency and trauma center was performed. Radiographic analysis by expert reviewers confirmed the presence and location of fractures and third molars as well as the angulation of the third molar.

Results: A total of 569 patients were evaluated with 34 excluded due to incomplete data. The mean age of patients was 29.6 (95% CI: 26.7 to 31.5) with 87% male, 71.5% AA and 12.1% Caucasian were included. 312 Pts were admitted for immediate fixation (54.8%).

82.4% had third molars present, with 53% impacted and 47% nonimpacted. 95.9% (513) sent for evaluation had a fracture, with 82% requiring operative repair and fixation. 62.4% of pts underwent ORIF, 52.4% were fitted with arch bars, and 36% also required extraction.

Sensitivity of third molars predicting angle fractures was 88.31%. An odds ratio of 2.4 was calculated for the presence of impacted third molars and mandible angle fractures (95% CI: 1.664-3.448). An odds ratio of 3.6 was calculated or presence of all impacted and nonimpacted third molars and mandible angle fractures (95% CI: 2.525.347) Conclusion: The presence of a third molar increases the likelihood of a mandible angle fracture following trauma. The presence of an impacted third molar results in the leading point for a fracture site.

Strong recommendations for prophylactic removal of third molars may be indicated for all student and professional athletes alike who participate in contact sports.

Oral Presentation Session 2 11:00am-12:00pm 25. Mild Cognitive Impairment: A Pilot Study To Evaluate The Montreal Cognitive Assessment Screening Tool For Use In Urban Aging African Americans Who Present To The Emergency Department Kanika A Turner and Christopher R Carpenter. Washington University School of Medicine, St. Louis, MO Background: Mild cognitive impairment (MCI) is a transitional state between normal aging and dementia with preserved activities of daily living. Detecting MCI in aging adults who present to the Emergency Department (ED) is critical for prevention and treatment of dementing illnesses. Additionally, disparities in cognitive impairments exist between aging African Americans (AA) and Caucasian Americans (CA). The Montreal Cognitive Assessment (MoCA) is a screening tool used to detect MCI. Objectives: To evaluate and compare the diagnostic accuracy between AA and CA of the MoCA in an ED setting for detection of MCI. Methods: This was a cross sectional, consecutive sampling study.

Eligible subjects were consenting English-speaking community dwelling patients over age 65. Exclusion was based on ED physician judgment, caregiverâ&#x20AC;&#x;s refusal, or residence >30 miles from hospital.

Trained researchers administered the Brief Alzheimerâ&#x20AC;&#x;s Screen (BAS), Short Blessed Test (SBT), AD8, and MoCA. MCI was defined as a MoCA score <26. Chi-square analyses were performed with MoCA scores. Diagnostic accuracy of the BAS, SBT, and AD8 to detect MoCA-defined MCI was assessed using SPSS. Results: We enrolled 165 patients: 61% AA, mean age 74 years, 39% with < 12th grade education, and 57% female. MCI was detected in 85% of patients who completed the MoCA with 97% MCI incidence in AA and 66% in CA. Conclusion: The MoCA is not an ideal MCI-screening instrument in the ED. The incidence of MCI as judged by the MoCA is unacceptably high and likely an epiphenomenon reflective of the difficulty of administering the test in ED settings, particularly for AA, but also for CA. The incidence of MCI should not be >50% in either ethnic group.

Diagnostic Test Characteristics of BAS, SBT, and cAD8 using MoCA as gold standard Positive Sensitivity Specificity Likelihood (95% CI) (95% CI) (95% CI)

Negative Likelihood Ratio (95%)

AUC-All AUC-AA AUC-CA (95% CI) (95% CI) (95% CI)

BAS, 85 (63-96) 61 (57-63) 2.2 (1.5-2.6) n=128

0.25 (0.06-0.65)

0.781 (0.6760.887)

0.906 (0.7971.00)

0.676 (0.5240.828)

SBT, 90 (69-98) 45 (41-47) 1.6 (1.2-1.8) n=127

0.22 (0.04-0.77)

0.697 (0.5990.794)

0.837 (0.6970.977)

0.559 (0.4030.714)

cAD8 67 (38-88) 49 (42-54) 1.3 (0.65-1.9) , n=61

0.68 (0.22-1.5)

0.557 (0.3870.726)

N/A

0.508 (0.3050.710)

26. Cardioprotection by Endogenous Fibroblast Growth Factor 2 in Cardiac Ischemia-Reperfusion Injury In Vivo Stacey L House, Carla Weinheimer, Attila Kovacs and David Ornitz. Washington University in St. Louis, St. Louis, MO Background: Fibroblast growth factor 2 (FGF2) has been shown to be cardioprotective in many in vitro and ex vivo models of cardiac ischemia. Limited data is available on the ability of FGF2 to protect the heart in vivo.

Objectives: The objective of this study was to determine the cardioprotective efficacy of endogenous FGF2 in a closed chest model of regional cardiac ischemia-reperfusion (IR) injury.

Methods: Mice with a targeted ablation of the Fgf2 gene (Fgf2 knockout) and wildtype controls were subjected to a closed chest model of regional cardiac IR injury to assess the cardioprotective efficacy of endogenous FGF2. In this model, mice were subjected to 90 minutes of occlusion of the left anterior descending artery followed by reperfusion for 7 days. Transthoracic echocardiography was performed on post-ischemic day 1 and day 7 to assess for cardiac function (ejection fraction) and myocardial infarct size (wall motion abnormalities). Histological analysis of myocyte cross-sectional area and vessel density and size was performed.

Results: Mice with a targeted ablation of the Fgf2 gene do not show any abnormalities in cardiac morphometry or function. When subjected to closed chest regional cardiac IR injury, Fgf2 knockout mice had significantly increased myocardial infarct size as measured by echocardiography compared to wildtype mice at both 1 day and 7 days post-IR injury (p<0.05). In addition, Fgf2 knockout animals showed significantly worsened cardiac function at 1 day and 7 days post-IR injury (p<0.05). Myocyte cross-sectional area in the periinfarct area showed no difference between Fgf2 knockout and wildtype mice suggesting no difference in post-ischemic cardiac hypertrophy. Fgf2 knockout mice have normal vessel density compared to wildtype controls in the non-injured state. After cardiac IR injury, Fgf2 knockout hearts showed significantly decreased vessel density and increased vessel diameter compared to wildtype controls (p<0.05) suggesting a defect in vascular remodeling in the Fgf2 knockout mice after IR injury.

Conclusion: Endogenous FGF2 improves cardiac function, reduces myocardial infarct size, and mediates vascular remodeling after cardiac IR injury. These data show the cardioprotective potential of endogenous FGF2 in a clinically relevant, in vivo, closed chest regional cardiac ischemia-reperfusion model which mimics acute myocardial infarction.

27. The Correlation between Health Literacy and Numeracy in the Emergency Department Andrew Melson, Christopher Carpenter and Richard Griffey.

Washington University in St. Louis School of Medicine, Saint Louis, MO Background: Although health numeracy is often considered a subset or domain of health literacy, very little research has been done showing a direct relationship between the two.

Objectives: To explore the correlation between health literacy and numeracy in an emergency department (ED) setting.

Methods: We performed a prospective, observational convenience sample study of adult ED patients presenting from March - July 2011 to an urban, academic ED with 97,000 annual visits. We enrolled 262 patients with sub-acute illness. Measurements of numeracy and health literacy consisted of 4 validated questions and 3 commonlyused screening tools (Short Test of Functional Health Literacy in Adults (S-TOFHLA), Rapid Estimate of Adult Literacy in MedicineRevised (REALM-R), and Newest Vital Sign (NVS)) respectively.

Results: Numeracy performance was universally poor, with 11/262 subjects (4.2%, 95% CI 2.3,7.5) correctly answering all questions, and a mean proportion of correct responses of 36.8%. Proportions of low or marginal health literacy as determined by the 3 screening tools varied significantly (S-TOHFLA: 20.2%, REALM-R: 49.6% , NVS: 75.6%, n=262 for all). However, correlation of each with health

numeracy was low-to-moderate (S-TOFHLA: 0.416, REALM-R: 0.363, NVS: 0.499. p<0.001).

Conclusion: We observed varying degrees of health literacy but near-universal poor performance on numeracy testing. Correlations between numeracy and health literacy were low to moderate. Insofar as numeracy is considered a subset of health literacy, our results suggest that commonly used health literacy screening tools in EDbased studies inadequately evaluate and overestimate numeracy. This suggests the need for separate numeracy screening. Providers should be sensitive to potential numeracy deficits among those who may otherwise have normal health literacy.

28. Cost-Benefit Analysis of Specialized Screeners in the Emergency Department and of Memory and Aging Project Satellite Intervention Charlene W Lai1 and Christopher R Carpenter2. 1Saint Louis University School of Medicine, St. Louis, MO; 2Washington University School of Medicine in St. Louis, St. Louis, MO Background: Cognitive dysfunction is an expensive diagnosis that is increasing in the United States. The lack of health care providers able to correctly diagnose dementia and delirium creates a missed opportunity to decrease costs and slow disease progression.

Objectives: The purpose of this study is to evaluate the costs and benefits of training screeners to detect cognitive dysfunction in older adults in the Emergency Department (ED) and the subsequent referral to the Memory and Aging Project Satellite (MAPS).

Methods: In a blinded, randomized controlled study at one urban academic medical center, geriatric screeners collected patients‟ responses to the Short Blessed Test (SBT). Consenting subjects were English-speaking adults > 65 years who lived within 30 miles of Saint Louis, MO. Subjects were excluded if they were deemed too ill to participate by the attending physician, institutionalized, and for those with cognitive impairment, lacked caregiver consent.

Abnormally scoring subjects were referred to MAPS, a free community resource that offers an in- home safety assessment, memory testing, caregiver counseling, and physician referrals. An abnormal result was defined as a score> 4 on the SBT. Followup phone calls to patients were made at a 1-month interval. Costs of ED visits, hospitalization, and institutionalization were found using the Medicare Expenditure Panel Survey, Healthcare Cost and Utilization Project, and National Health Expenditure Database. A decision analytic approach was used to analyze the data. One dimensional microsimulation and sensitivity analysis were used to test the robustness of the model and to identify critical uncertainties in the parameters.

Results: The prevalence of cognitive dysfunction in adults>65 in the ED was 52.8%. Assuming a 20% improvement in patient outcomes, screening and MAPS referral were shown to reduce the cost of patient care by $410, on average. A 40% improvement in outcomes would reduce the cost by $714, and a 10% improvement by $105.

Conclusion: Preliminary analysis indicates that screening and MAPS referral reduces cost of patient care. This study has several limitations. First, this study was conducted at a single urban academic medical center; results may not be generalizable to populations that differ significantly from the one studied. Second, cost data found was not specific to the hospital where the study was conducted.

29. Ultrasound Simulation Training: Location of Central Venous Catheter Guide Wire Position Melissa Thomas1, Charles Schmier2 and Michael Wadman1.

1 University of Nebraska Medical Center, Omaha, NE; 2University of Arizona Medical Center, Tucson, AZ

Background: Placement of a central venous catheter (CVC) is an important procedure commonly performed by Emergency Physicians (EPs). The technique of using ultrasound (US) to confirm that a guide wire is positioned in the internal jugular vein (IJ) prior to dilation and canulation has been described. To our knowledge however, no study has used a control group of guide wires incorrectly positioned in the carotid artery (CA) when assessing the effectiveness of this technique.

Objectives: Determine the accuracy of EPs in detecting the location of a CVC guide wire with the use of ultrasound on a CVC training model.

Methods: Single blinded cross-sectional study. Prior to study participant engagement, a CVC guide wire was positioned in either the IJ or CA of a Blue Phantom(TM) head and torso model designed for US guided CVC simulation training. Subjects were blinded to the position of the guide wire. Each participant used a high frequency linear probe with a Sonosite M-Turbo(TM) US system to detect the location of the guide wire. Study participants were tested twice, once with the guide wire in the IJ and once with it placed in the CA. Sensitivity and specificity were summarized using descriptive statistics with the associated 95% confidence intervals.

Results: A total of 46 US examinations were performed by 23 EPs with varying levels of experience; 14 first year residents, 4 second year residents, 4 third year residents, and one attending participated.

The guide wire was positioned in the IJ for 23 examinations and in the CA for 23 examinations. The guide wire location was correctly identified in 43 of the 46 examinations. Correctly localizing the guide wire as positioned in the IJ (occurred 21 of 23 attempts) was considered as a true positive, correctly localizing the guide wire as positioned in the CA (occurred 22 of 23 attempts) was considered as a true negative. EPs use of US yielded a sensitivity of 91% (CI 70, 98), specificity of 96% (CI 76, 99), positive predictive value of 96% (CI 75, 99), and negative predictive value of 92% (CI 72, 99).

Conclusion: EPs performed well in the use of US to localize guide wire position on a CVC training model.

30. Application of Lean Principles of the Toyota Production System Lead to Greatly Improved Door to Needle Times Matthew Rudy1, Andria L Ford1, Jennifer A. Williams2, Naim Khoury1, Tomoko Sampson1, Craig McCammon2, Shawn O'Connor1, Jin-Moo Lee1 and Peter Panagos1. 1Washington University, Saint Louis, MO; 2Barnes Jewish Hospital, Saint Louis, MO Background: Recent analysis has shown that less than a third of patients treated with intravenous tissue plasminogen activator (tPA) had door-to-needle times (DTN) within the „Golden Hour‟ recommended by current guidelines. It has been suggested that shorter DTN is associated with improved outcomes and lower inhospital mortality.

Objectives: To apply Toyota Lean manufacturing principles to improve ED DTN in acute ischemic stroke (AIS) patients receiving IV tPA. Methods: In March 2011, a prospective analysis of all AIS patients presenting to the ED were treated employing Lean manufacturing principles to improve tPA DTN. Lean techniques such as valuestream mapping, just-in-time delivery, workplace organization, reduction of systemic wastes, use of workers for quality improvement and ongoing process refinement formed the basis of modifications.

Since 2004 detailed data has been kept on all patients given tPA, including times of symptom onset, ED presentation, and tPA therapy, adverse outcomes and discharge location. Statistical analysis was performed to evaluate for reduction in DTN, adverse outcomes and discharge destination. Data was available for four months post VSA. A control group was selected with all tPA patients that presented during the four months immediately prior to the process change. In addition a four-month period exactly one year prior to the process

change was chosen for comparison to account for any seasonal variation.

Results: In the post intervention group, 37 patients received tPA with a mean DTN of 37 minutes (95% CI 28-52). Intracerebral hemorrhage (ICH) was seen in 2/37 patients. In the four months prior to change, 28 patients were treated with tPA, mean DTN of 64 minutes (95% CI, 51 -77), ICH seen in 4/28 patients. One-year prior, 14 patients were treated with tPA, mean DTN 59 minutes (95% CI, 51 - 67), ICH noted in 2/14 patients. There was a significant reduction in DTN comparing the post VSA group to both other groups, p=0.001, p=0.011 respectively. No statistically significant difference in occurrence of ICH was observed. Discharge location data was evaluated categorically, with no significant difference observed.

Conclusion: Lean-manufacturing principles utilized in the treatment of AIS can significantly improve DTN without significantly compromising safety or favorable discharge location.

Lightning Oral Presentation Session 2 1:40pm-3:00pm 31. Impact Of Teaching Life Saving Procedures To First Year Medical Students Michael Ybarra, Ryan Murray, David Weiner and David Milzman. Georgetown University School of Medicine, Bethesda, MD Background: : A fear of first year medical students involves a scenario where they are looked to for help in a medical emergency. \While students may have learned about the life saving effects of epinephrine in anaphylaxis, they may be unaware of how to administer an epinephrine auto injector.

Objectives: The purpose of our “Introduction to Life Saving Procedures” course for the first year medical students is to provide basic knowledge and practical skills such as taking a pulse, assessing respirations, caring for a choking victim, using an automatic defibrillator, and an epinephrine auto injector.

Methods: A core curriculum was developed for first year medical students and offered electively for one three hour session. A presession survey was given to students to assess for prior medical experience and knowledge of these potentially life saving sills. The same survey was given one week after the session.

Results: The pre-session survey confirmed our suspicion that most students had little knowledge of important, potentially life saving skills. Only 20% of respondents correctly stated how to assess a patient‟s respirations and 24% could correctly state the number of chest compressions needed in cardiac arrest. Sixty-two percent of respondents listed one or more appropriate critical actions items if witness to a motor vehicle collision. None of the respondents correctly stated the three-step method for using an epinephrine auto injector.

The post-session survey showed significant improvement. There was a statistically significant improvement in the number of students able to describe the method for using an epinephrine auto injector (91% of respondents, p < 0.001). There was also significant improvement in the correct responses to the number of chest compressions needed in cardiac arrest and critical action items if witness to a motor vehicle collision (p values < 0.001 and = 0.007).

Conclusion: First year medical students had a low level of knowledge and skills required of healthcare providers prior to a course “Introduction to Life Saving Procedures.” There was statistically significant improvement in nearly all categories.

Although there was no documented use in life=saving situation future studies will track the actual value of this course.

32. Association of Falls with Sarcopenia and Frailty in Older Adults Presenting to The Emergency Department Denis T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS, Charlene Lai, BA, Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika Taylor, BS, Lila Wahidi, Christopher R. Carpenter, MD, MS. Washington University in St. Louis, St. Louis, MO Objectives: Falls are an increasing and preventable source of injury in older adults presenting to the emergency department (ED). There exists a scarcity of independent ED-validated falls risk factors.

Identification of risk factors may lead to effective and resourceefficient falls prevention programs. This study‟s objective is to investigate the association of falls one month after an ED visit with grip strength and Deficit Accumulation Index (DAI) score.

Methods: In a prospective observational study at one urban academic, university-affiliated medical center, trained geriatric technicians (GTs) measured grip strength, administered the DAI, and

obtained patients‟ falls history as part of a larger study examining cognitive dysfunction in ED patients 65 or older. One month following an ED visit, GTs contacted participants by phone to identify subsequent falls. Association of grip strength and DAI with one-month fall incidence was measured using Spearman‟s rho for non-parametric data.

Results: The prevalence of low grip strength, defined as below age, sex, and height norms, among 38 participants with complete followup was 24%; falls were self-reported in 11%. Using Spearman‟s rho, no significant correlation was identified between 1-month falls and grip strength (females: rs = -0.142, p>0.4; males: rs = 0.000, p>0.90) or between 1-month falls and DAI score (females: rs = 0.107, p>0.60; males: rs = 0.336, p>0.10).

Conclusions: There exists a minimal association of 1-month falls with grip strength and sarcopenia. However, due to follow-up limitations in determining one-month falls, the number of reported falls was most likely underestimated. The study can be improved by giving participants a falls calendar, as used in other falls studies, which would improve follow-up and recollection of falls.

33. Impact Of Airline Flight On Professional Athletes Following Minor Traumatic Brain Injury (mtbi) In Terms Of Total Games Missed Due To Injury David Milzman1, Jeremy Altman2, Matt Milzman2, Chris Fleury2 and Carla Tilchin3. 1Georgetown University School of Medicine, Bethesda, MD; 2Georgetown University, Bethesda, DC; 3Bates College, Bethesda, ME Background: Air travel may be associated with unmeasured neurophysiological changes in an injured brain that may impact postconcussion recovery.

Objectives: To determine if air travel within 6-12 hours of concussion is associated with increased recovery time in professional ice hockey players (NHL) Methods: Prospective cohort study of all active-roster National Hockey League players during the 2010-2011 seasons Review of all NHL injuries and games missed based on team website and confirmed with NHL accounts via website.

Results: : During the 2010-2011 hockey season, 101 players experienced a concussion. Of these, 39 (39%) flew within 12 hours of the incident injury. The average distance flown was 1060 miles and all were in a pressurized cabin. However, the median number of games missed for head-injured NHL players who traveled by air immediately after concussion, 6.5 (IQR 3-18), was significantly higher than the median number missed for those who did not travel by air (5: IQR 3-12; p <0.01); a 30% increased missed number of games.

Conclusion: While other confounding factors must also be considered, early air travel post concussion is associated with significantly longer recovery times in professional ice hockey players.

34. Can Ambulances Be Triaged To Urgent Care Centers Based On Chief Complaint?

Tina Khosla, Joseph Delucia, Ting Zhang and William Terrin. St. Louis University Hospital, St. Louis, MO Background: Overcrowding and long waits are well known to the emergency department. This study was designed to help create a more efficient practice where people can be served their health care

needs in a faster fashion and help reduce the patient load in the emergency department.

Objectives: This study focused on developing a system for Emergency Medical Services (EMS) to take patients to an appropriate place, whether it is to an emergency department (ED) or an urgent care center based on their chief complaint.

Methods: This study was a retrospective study looking at medical records acquired in the ED at St. Louis University Hospital. We used the records of patients that were brought in by ground EMS. We excluded all special populations, including pediatric, incarcerated, pregnant, patients older than 90, and patients with cognitive impairment. We looked at the chief complaint and the disposition of the patient to see if the chief complaint can be safely triaged to urgent care centers. We determined that a chief complaint can be considered safe if there was a 95% discharge rate with minimal intervention which is defined as history and physical, lab work and plain films.

Results: We analyzed 9,620 records after exclusions and grouped them by chief complaint. We included chief complaints if there were greater than 7 of the same chief complaint. We found 10 chief complaints that were discharged with a rate greater than 95%. We then took those 10 chief complaints and investigated what treatment was completed in the emergency department. Patients with the chief complaint of toothache, insect bite, and needle stick exposure were discharged 97%, 95%, 100% respectively with minimal intervention.

Conclusion: EMS can likely safely triage patients to urgent care centers if they have a chief complaint of toothache, insect bite and needle stick exposure. This study was intended to be the beginning of an investigation to start the triage system of EMS to urgent care centers instead of coming straight to an ED to help provide patients with faster more appropriate care and secondarily decreasing overcrowding in the ED. Further studies can break down EMS gestalt, age, sex, vital signs for triaging purposes.

35. A Cost Benefit Analysis Of Ultrasound Programs For Central Venous Cannulation Daniel L Theodoro. Washington University School of Medicine in St. Louis, St. Louis, MO Background: Ultrasound (US) guidance for assistance of central venous cannulation (CVC) has widespread acceptance in teaching hospitals. Survey data suggests that penetration of US technology may lag in other hospitals. Barriers might include cost, reimbursement and physician acceptance.

Objectives: To perform a cost-benefit analysis comparing Emergency Departments (ED) with US programs to those without US programs (ED LM) from the perspective of the provider. The provider perspective was chosen to inform purchasers who may cite cost and re-imbursement issues as primary barriers.

Methods: We created a Markov decision model (TreeAge Pro 2009 Healthcare Suite, Williamstown, MA) to estimate the cost benefit of an ED US program compared to ED LM. Through literature review adverse event data was obtained on pneumothorax, central line associate blood stream infections (CLABSI), and catheter related thrombosis. Vascular complications (e.g. hematoma) were not included since little evidence suggests they have clinical consequences. Cost data regarding equipment, time-savings, and complications were obtained from the literature. Deterministic sensitivity analyses and Monte Carlo simulation for 10,000 samples were conducted to account for the uncertainty in our model.

Results: The expected cost benefit to the ED US program was $455 compared to the ED LM program with a cost of $886. There was a cost benefit to the ED US program until a threshold value of $1223 meaning that if the cost per ultrasound guided central line exceeded this, a non-ultrasound guided program would be more beneficial.

There was greater cost benefit with the ED US program across all probabilities of adverse events. The ED US program dominated the ED LM program across all costs of CLABSI. The cost benefit of the

ED US was more sensitive to changes in the cost of thrombosis and pneumothorax than CLABSI. Probabilistic sensitivity analysis also confirmed a cost benefit to the ED US program ($515 compared to $952). Tracker variables in our Monte Carlo model suggested that while a greater proportion of CLABSI may occur in the ED US program, the cost is offset by fewer thrombotic complications.

Conclusion: From the perspective of the provider, an US assisted program has more cost-benefit than a LM program. Greater cost savings may be realized avoiding thrombotic complications than infectious complications.

36. Airway Management at a Regional Trauma Center: An Analysis of Resident Experience Jordan Sullivan and James Medical Center, Omaha, NE

McClay. University of Nebraska

Background: Competency in emergency airway management is essential to the practice of emergency medicine.

Objectives: To determine emergency medicine resident airway management methods and success rates at a regional trauma center by post-graduate year (PGY) to compare to published benchmarks.

Methods: The Nebraska Medical Center (NMC) ED is a level I regional trauma center treating 50,000 patients annually. The data repository was queried to identify patients with emergency airway management from 2006 through 2010. Record for patients with emergency airway management (intubation) seen during the months of October, November, and December were manually reviewed to determine the operator, number of attempts, success or failure, and devices used. These months were chosen to represent mid-year resident skill levels. This was an IRB approved study.

Results: The NMC ED encountered a monthly average of 18.25 cases requiring emergency airway management during the study period. Emergency medicine residents performed 72% of all initial intubation attempts. The first operator was successful in 90% of cases overall with 80% (Âą 4.5% over the years studied) on the first attempt.

Success rates on the first attempt were as follows: PGY 1 = 50%, PGY 2 = 76%, PGY 3 = 84%, and attending physician = 84%.

Success rates by the first operator were as follows: PGY 1 = 50%, PGY 2 = 87%, PGY 3 = 95%, and attending physician = 97%. There was a 100% increase in the use of Video Laryngoscopes from 20062010. Success rates with Video Laryngoscope were the same as with standard laryngoscope.

Conclusion: Published benchmarks indicate that NMC resident success rates are slightly below the North American benchmarks (Sagarin et al. 2005). Success rates on initial intubation attempts increased significantly over the 3 years of residency. Senior residents (PGY3) obtained success rates nearly identical with attending physicians. The increased use of video laryngoscopes did not have an impact on intubation success rates. Intubation success was determined most directly by experience level, not device. This single center study demonstrates the success of airway management by emergency medicine residents at the NMC. Sagarin MJ, et al., Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts, Ann Emerg Med, 2005, 46(4):328-336.

37. A Comparison of 3 Forms of Procedural Sedation for the Reduction of Dislocated Total Hip Arthroplasty Scott Burdette, Jonathan dela Cruz, Donald Sullivan, Eric Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto Duong, Steven Scaife, David Griffen and Khaled Saleh. Southern Illinois University School of Medicine, Springfield, IL Background: Hip dislocations post total hip arthroplasty (TAH) are a common complaint seen in the emergency department (ED).

Patients who present to the ED most often require closed reduction under procedural sedation as their initial form of treatment.

Procedural sedation for prosthetic hip reduction commonly involves the use of an opiate/benzodiazepine combination (O/BZD), etomidate, or propofol. All three forms of procedural sedation have been documented as safe to be utilized in an ED setting, however little has been studied comparing the effectiveness of these agents in the reduction of dislocated hip prostheses.

Objectives: A retrospective review comparing TAH reduction outcomes and complications with the use of O/BZD, etomidate, or propofol as sedation agents.

Methods: A retrospective chart review was performed on 198 patients presenting to 2 academic EDs identified by CPT codes for THA dislocations. They were subsequently grouped by sedation modality. Primary outcomes measured included reduction complications with skin injury, failure of reduction, neurovascular injury, or fracture. Secondary outcomes measured included sedation complications regarding airway compromise, utilization of a reversal agent, inability to achieve sedation, and time to recover. These outcomes were than analyzed using chi-square and ANOVA. Results: 8.7% of propofol sedated patients (n=70) had reduction complications, with 7.3% having sedation complications. 24.7% of etomidate sedated patients (n=77) had reduction complications with 11.7% having sedation complications. 28.9% of O/BZD sedated patients (n=55) had reduction complications, with 21.2% having sedation complications. There were significantly less reduction complications with propofol compared to the other agents (p=0.011).

Propofol, etomidate, and O/BZD had mean recovery times of 25.1, 30.8, and 44.4 minutes. Propofol had a significantly decreased recovery time when compared to O/BZD (p=0.05).

Conclusion: Propofol, etomidate, and O/BZD are commonly used agents in the sedation of TAH reductions in the emergency department. In this small study, patients who received propofol had a trend towards reduced complication rates and improved recovery times. The use of propofol may lead to improved patient outcomes and throughput given these results.

38. Knowledge of Alcohol Impairment in Boaters Maria L Scarbrough and Preeti Dalawari. St. Louis University, St. Louis, MO Background: Alcohol is a factor in at least 60% of boating related fatalities. Prior literature has shown that 30-40% of the participants drank alcohol while boating, and they seldom knew the laws or dangers associated with alcohol ingestion while boating.

Objectives: To our knowledge, this is the first study to directly approach boaters at the dock to assess participants‟ knowledge regarding alcohol impairment while boating.

Methods: This was a cross sectional survey of a convenience sample of boaters aged 21 and older at 4 lakes in Illinois during July 2011.

Participants were asked to fill out an 8-question survey covering knowledge about alcohol use and boating. Chi square analysis was used to assess knowledge differences by demographic variables, as well as boat ownership and seating position. Kruskal-Wallis assessed differences by education level.

Results: 210 people participated. The majority of participants correctly answered 4 of the 5 knowledge questions, including 84%correctly reporting the watercraft blood alcohol legal limit. 76% admitted drinking alcohol while boating. 81% erroneously believed that it was more dangerous for the driver to be intoxicated than the passenger (N=194). There were no differences in knowledge by gender, education, boat ownership or seating position. Participants older than 40 years of age were more likely to know that being intoxicated makes one 10 times more likely to drown (p<0.05).

Younger participants (age 21-40) were significantly more likely to report drinking while boating compared to older participants (p<0.05). Older participants were also more likely to own a boat and be drivers (p<0.05).

Conclusion: A majority of participants imbibe while boating despite a basic understanding of the dangers in doing so. Public health officials may benefit from focusing education on the younger age group of boaters to help decrease alcohol related morbidity and mortality.

39. Got Wheels?--Adolescent Exposure to ATVs and Their Driving Practices Charles A Jennissen1, Denning Gerene1, Hoogerwerf Pam1, Peck Jeffrey2 and Wetgen Kristel1. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2U.S. Army Corps of Engineers, Iowa City, IA Background: All-terrain vehicle (ATV)-related injuries have almost tripled in the past decade and residents in rural communities suffer the brunt of this problem. More children die each year in the United States from ATVs than from bicycle crashes. However, the degree of adolescent exposure to ATVs is currently unknown. Education is considered an essential element of improving ATV safety, but many children receive little or no instruction.

Objectives: (1) Determine adolescent exposure to ATVs and their operating practices. (2) Educate and help adolescents understand the key principles for safely operating ATVs. Methods: A community-based multi-disciplinary ATV task force was formed and an educational program was developed highlighting our ten “Safety Tips for ATV Riders” (STARS). The program was presented at schools targeting 12-15 year olds. An audience response system was utilized to obtain demographic information, determine ATV exposure and safety knowledge, and assess knowledge acquisition.

Results: A total of 2,200 students in 13 Eastern Iowa schools received the ATV safety educational intervention. 78% reported riding on an ATV at least a few times a year and nearly 30% stated they ride an ATV at least once a week. Of those who reported having been on an ATV in the past, 92% had ridden with more than one person and 77% had been on a public road with an ATV. Nearly twothirds of those riding ATVs reported they never or almost never wear a helmet. 57% of those with riding exposure had been in an ATV crash (rolled over, fallen off, or hit something). On the three knowledge questions, pre-intervention percent correct were 52%, 27% and 46%. This increased to 93%, 80% and 79% correct postintervention. 44% said that they were likely or very likely to use the ATV safety tips they had learned during the intervention, while 36% said they were unlikely or very unlikely to do so.

Conclusion: Adolescents in Eastern Iowa have a high exposure to ATV riding. Most practice unsafe behaviors while riding ATVs and the majority of adolescents exposed to ATVs have experienced a crash. Most youth in the study demonstrated a deficiency in some ATV safety knowledge. However, our classroom educational intervention was able to increase short-term ATV safety knowledge and a significant proportion of participants felt they would use the safety information presented.

40. Feasibility of Using Health Literacy Screening Tools in an Urban Emergency Department Andrew Melson, Christopher Carpenter and Richard Griffey.

Washington University in St. Louis School of Medicine, Saint Louis, MO Background: Health literacy is an important determinant of health outcomes. Deficits have been linked to poor medication adherence and greater emergency department (ED) utilization. Validated screening tools have been developed for general use, but health care providers do not routinely perform such screening. One possible reason is the amount of time and effort such assessments can require, especially in the ED, where significant time pressures are the norm.

Lengthy screening tests not only take more time to administer but also increase the potential for confounding interruptions.

Objectives: In a separate analysis of health literacy screening tools we found the short versions of the Test of Functional Health Literacy in Adults (S-TOHFLA), the Rapid Estimation of Adult Literacy in Medicine (REALM-R), and the Newest Vital Sign (NVS) to identify 20%, 50% and 76% of ED patients as having low health literacy respectively. In the present analysis, we aimed to assess the feasibility of using these health literacy screening tools in the ED, focusing on relative time burden and test interruptions.

Methods: We performed a prospective observational study of a convenience sample of adult patients presenting during March and April 2011 to an urban, academic ED with 97,000 annual visits.

Exclusion criteria included: patients with aphasia, known dementia, mental retardation, non-English speaking or too ill to interview. We screened participants using the S-TOHFLA, the REALM-R and the NVS while documenting start and stop times as well as whether any interruptions took place during test administration.

Results: In total, 249 patients were enrolled. Among participants, 54% were female, 31% white, 67% black and 2% other race, with an average age of 43.5 years. On average, the S-TOHFLA took 5.84 (+/0.17) minutes to administer, while the NVS and REALM-R took 2.82 (+/- 0.17) and 0.64 (+/- 0.08) minutes, respectively. The S-TOHFLA, NVS and REALM-R tests were interrupted 10.4%, 6.4% and 0% of the time respectively.

Conclusion: The S-TOFHLA took on average, 3.02 minutes and 5.2 minutes longer than the NVS and REALM-R respectively. The STOFHLA and the NVS were interrupted 10.4% and 6.4% of the time respectively, with no interruptions of REALM-R. The S-TOFHLA, often used as a criterion standard, identifies a lower proportion of ED patients as having low health literacy but is lengthier and subject to interruption.

41. Frequency and Mortality of Non-Contiguous Spine Fractures with CT Scan Use Vijai Chauhan1, Neelaysh Vukkadala2, Howard Place1, Laura Sicking1, Lauren Segelhorst1, Eric Armbrecht2, Camelia Guild2 and Preeti Dalawari1. 1Saint Louis University SOM, Saint Louis, MO; 2 Saint Louis University, Saint Louis, MO Background: : Spine fractures are common in trauma patients. Noncontiguous spine fracture frequency in published studies is variable (1.6%-16.7%). The published data on the diagnosis of spine fractures commonly uses plain radiography as the imaging tool, but there are limited studies using computed tomography (CT) scan.

Objectives: The purpose of this study was to assess the incidence of non-contiguous spine fractures and the location pattern of these fractures in trauma patients who underwent CT scan imaging and, to assess the relationship between non-contiguous fractures and mortality.

Methods: : This was a retrospective chart review of trauma patients admitted between 2005-2010 at a Level 1 trauma center. All patients with spinal fractures were identified through the trauma registry.

Demographics, vertebral injury, mortality, and time to diagnosis were recorded. Delay in diagnosis, defined as greater than 60 minutes, was based upon the time delay between the first and second spine fractures being reported to the emergency department physician. Chisquare analysis was used to determine a difference in mortality between contiguous and non-contiguous fractures. Logistic regression analysis was used to examine the association between noncontiguous spine fractures and mortality after adjusting for potential confounders.

Results: There were 2,222 cases of spine fractures of which 381 (17%) were non-contiguous; while our annual incidence ranged from 16% to 19% for the time period studied. The mortality rate for noncontiguous spine fracture cases was 8.9% versus 5.5% for contiguous cases (p= .011). Compared with contiguous spine fractures, patients with a non-contiguous spine fracture had significantly higher odds for mortality (aOR= 1.73, 95% CI 1.15-2.62). Of the 364 patients who had a complete scan, the distribution of regional spine fracture patterns were, cervical and thoracic (27.6%), thoracic and lumbar (25.4.%), cervical, thoracic and lumbar (14.0 %), and cervical and lumbar (12.2%). Neither fracture pattern nor a delay in diagnosis was significantly associated with mortality.

Conclusion: According to our regional data, of those trauma patients with spine fractures, approximately 1 in 5 will have non-contiguous fractures. Non-contiguous spine fractures are associated with a higher mortality rate.

42. Self-rated Health As A Predictor Of Emergency Department Recidivism And Functional Decline Among Geriatric Patients Stephanie K Chang1 and Christopher R Carpenter2. 1St. Louis University, St. Louis, MO; 2Washington University in St. Louis, St. Louis, MO Background: Numerous cohort studies have found poor self-rated health (SRH) to be a significant risk factor for mortality and healthcare utilization. SRH assesses self-perceived health status through a single, categorical question, and is associated with mortality after adjustment for co-morbidities and functional status.

Objectives: To assess the prognostic accuracy of SRH for functional decline and ED recidivism among geriatric patients, and to examine how cognitive impairment influences the predictive value of SRH. Methods: This study was a secondary analysis of data from a randomized controlled trial, conducted within one urban academic medical center in St. Louis, Missouri. Eligible patients were community-dwelling individuals 65 years of age and older, who presented to the study site ED between June 1, 2011 and July 31, 2011. Enrollment occurred through a consecutive sampling, with the following exclusion criteria: residence outside of a 30-mile radius from the study site, inability to speak English, physician judgment of critical illness, and subject or caregiver refusal. SRH was assessed through a single question from the Quality of Life in Alzheimerâ&#x20AC;&#x;s Disease subject report, and the Short Blessed Test was utilized for cognitive screening. Information concerning ED recidivism and functional decline was collected by telephone, at 1 and 3 months following the index visit.

Results: As of July 14, 2011, 168 subjects have been enrolled, and 52 have provided 1-month follow-up data. 25 of these subjects were cognitively normal, and 27 were cognitively impaired. For the outcome of ED recidivism, sensitivity and specificity of poor/fair SRH was 65% (95% CI 53-77) and 33% (24-43) for cognitively normal patients, and 83% (42-99) and 33% (22-38) for cognitively impaired patients. For the outcome of functional decline, sensitivity and specificity of poor/fair SRH was 67% (45-87) and 42% (20-62) for cognitively normal patients, and 83% (60-97) and 40% (22-51) for cognitively impaired patients.

Conclusion: Preliminary analyses show that poor/fair SRH does not significantly predict ED recidivism or functional decline, among cognitively impaired or cognitively normal subjects. Thus, SRH

would not be a useful triaging tool for the ED. Significant limitations include a lack of external validity, and reliance on patient self-report during follow-up.

43. Stroke Volume Changes in ED Patients with Shock Undergoing Serial Passive Leg Raising and Fluid Challenges Stephanie Charshafian1, Ashley Janssen1, Christopher Holthaus1, Brian Fuller1, Kevin Williams1, Enyo Ablordeppey1, Brian Wessman1, Daniel Theodoro1, Ronald Chang1, Jennifer Williams2, Thomas Ahrens2 and Richard Hotchkiss1. 1Washington University in St Louis, St Louis, MO; 2Barnes-Jewish Hospital, St Louis, MO Background: Stroke volume index changes with passive leg raising have been shown to predict volume responsiveness.

Objectives: To estimate the positive predictive value (PPV) of Passive Leg Raising (PLR) compared to 500ml saline boluses in ED patients with shock.

Methods: This is a subset analysis of adult ED patients prospectively randomized to fluid optimization (FO) in the ED between Aug 2010Aug 2011(ClinTrials ID: NCT01128413). The study is IRB approved with informed consent and being conducted at an academic ED with 90,000 visits/yr. Inclusion criteria are vasopressor use, or SBP ≤90 or MAP ≤65 after ≥20ml/kg IV fluids, or lactate ≥2.5 mmol/L. Exclusion criteria are pulse oximetry <90% or inability to do PLR. FO consists of non-invasive bioreactance monitoring of stroke volume (Cheetah NICOM®) and PLR testing. Patients deemed volume responsive (VR) receive a 500ml saline bolus if the PLR percent change (%Δ) in stroke volume index (SVI) or cardiac index is ≥15%. PLR is repeated immediately after each bolus with repeat boluses if ≥15%. If <15%, fluids are saline locked and PLR done every 30 minutes. SVI changes are calculated as: %ΔSVI=(Maximum challenge SVI-Average baseline SVI)/Average baseline SVI. Paired Students t-Test and descriptive analysis were performed (Microsoft® Excel).

Results: 7 patients (4 male) with a median age of 60 yrs (range 4287) underwent 69 PLRs. 40 of 69 (58%) PLRs were VR and received fluid boluses. The median %ΔSVI are as follows: bolus 10% (IQR 122), pre-bolus PLR 32% (IQR 24-39), and post-bolus 26% (IQR 1136). The pre-& post PLR %ΔSVI were statistically different when compared to the bolus %ΔSVI (both p ≤ 0.01). The PPV of pre-& post bolus %ΔSVI were 38% and 22% respectively. 10/40 (25%) bolus events resulted in a negative bolus %ΔSVI. Conclusion: In this small subset analysis, pre-& post PLR SVI changes demonstrated suboptimal PPV when compared to fluid challenges. More study is needed in ED patients and quantitative incorporation of SVI changes with fluid boluses may be additionally useful in guiding fluid administration.

44. Seeking a Functional Definition of Drug-Seeking Behavior Benjamin Scallon, Mark Graber, Azeemuddin Ahmed, Kari Harland and Gerene Denning. University of Iowa, Iowa City, IA. Background. The 2005 National Institute on Drug Abuse (NIDA) Research Report on prescription drug abuse and addiction estimated that a startling 48 million Americans have used prescription medication for illicit, nonmedical purposes. Approximately 80-90% of misused prescription drugs are legally obtained through the healthcare system, most often via emergency departments (ED).

Using an open-ended question, the top five drug-seeking criteria listed by EM physicians were “multiple visits,” “multiple allergies,” “asking for a drug by name,” “abnormal behavior” and “high-risk complaint.”

Objective. The goal of this study was to determine whether top criteria were consistent using a different survey method and if these criteria or foils impacted decision-making.

Methods. ED physicians (n = 56) were randomized into three groups.

Each group was asked to evaluate three patient scenarios. Scenarios between groups varied in detail. Participants scored the likelihood that the patient was drug-seeking (10 pt scale) and indicated the amount of drugs they would prescribe. Physicians also ranked their top 5 out of 25 listed characteristics of drug-seeking behavior.

Results. Patient 1 mean scores for baseline history, history plus multiple drug allergies, and history plus allergies and requesting a specific drug were 4.3, 5.2, and 6.5 (overall p = 0.0023). Patient 2 mean scores for baseline history, history plus smoking/bad dentition, and history plus smoking/bad dentition and prison tattoos were 5.8, 6.5, and 5.2 (overall p = 0.0949). Patient 3 mean scores for baseline history, history plus stating Vicodin is ineffective, and history plus Vicodin comment and white-collar occupation were 3.8, 5.1, and 4.9 (overall p = 0.2379). For patient 1, the length of the drug prescription (days) exhibited a weak negative correlation with the score given for the likelihood of being a drug seeker (r = -0.24). The top five criteria chosen were “lying,” “multiple prescribers,” “history of drug abuse,” “acting” and “the Iowa Prescription Monitoring Program.”

Conclusions. The scenario portion suggests that ED physicians make judgments based on commonly accepted drug-seeking criteria and are, generally, unbiased against potential foils. Both survey methods provide insights into physician decision-making, however, prompting them with a list results in different selections.

45. Disposition Variability For Patients with Chest Pain Among Emergency Department Physicians David J Gresback and Michael D Zwank. Regions Hospital, Saint Paul, MN Background: Chest pain is a common presenting complaint to the emergency department (ED) with high rates of hospitalization. There is a high degree of variability in the management of these patients including ultimate disposition.

Objectives: As a quality measure, we sought to examine the variability of disposition among different emergency department physicians in an effort to understand differences between practicing pattern and as a baseline for further quality improvement initiatives.

Methods: In this retrospective chart review at an urban academic emergency department, all visits with chief complaint of chest pain from March 2011 to June 2011 were reviewed (n=1168). The charts were examined with a one month follow-up looking at: disposition, repeat visits, repeat hospitalizations and outcomes of interest. All providers with less than 10 chest pain visits were excluded from review. Outcomes of interest were defined as: unstable angina, STEMI or NSTEMI, coronary artery bypass graft, percutaneous coronary intervention or death. Acuity rate was calculated as outcomes of interest divided by total chest pain patient visits. Acuity admission index was calculated as acuity rate over admission rate.

Results: 31 out of 36 physician met inclusion criteria of at least 10 chest pain patient visits (mean=38). Mean admission rate was 0.55 (range 0.31-0.79). Outcomes of interest were seen in 77 patient visits (7%) with 2 missed outcomes (one cardiac, one non-cardiac). No provider had more than one missed outcome. Mean acuity admission index was 0.15 (SD 0.10; range 0.0-0.37). No providers with lower than the mean acuity admission index had a missed outcome. Five providers had an acuity admission index more than one standard deviation below the mean. Among these providers, 128 patients were admitted with no outcomes of interest.

Conclusion: The acuity admission index may be a way to stratify providers practice patterns in regards to disposition while accounting for the acuity of patients seen. Only 1 cardiac outcome was missed

among 1168 patient visits. Our hospital will be instituting a low-risk chest pain protocol which likely will lead to fewer admissions of lowrisk patients. This data set suggests that several providers and many patients may benefit from such a protocol. The data set only included three months of patient visits and may be limited by this.

Poster Presentations 3:00pm-4:20pm 46. Characterization Of On-road ATV Crashes In Iowa From 2002-2009 Kevin Kremer, Gerene Denning, PhD and Christopher Buresh, MD. University of Iowa, Iowa City, IA Background: All-terrain vehicle (ATV) crashes result in over 500 fatalities each year and produce similar mortality rates and higher rates of head and neck trauma as compared to motorcycles. A study in Ohio showed worse outcomes for individuals involved in on-road ATV crashes relative to crash victims at recreational parks. Iowa law allows counties and cities to designate roads for ATV use; however, the potential impact of increased on-road ATV use has not been investigated.

Objectives: To determine demographics and crash mechanisms for Iowaâ&#x20AC;&#x;s on-road ATV crashes, and to develop public policy recommendations based on these results.

Methods: The Iowa Department of Transportation (DOT) records data for all ATV crashes on Iowa roads and highways including GPS Coordinates of the location of the crash. GPS coordinates were mapped in ArcGIS 10.0 using the Universal Transverse Mercator coordinate system in zone 15N. Qualitative analysis of Iowa DOT crash data was performed to characterize on-road crashes.

Results: There were 246 on-road ATV crashes reported by the Iowa DOT from 2002 to 2009. Of these crashes, 78% of victims were male (20% female, 2% unknown), 66% were 16 years old or older (22% <16 years old, 13% unknown), and 13% involved passengers. 57% of on-road crashes were collisions; 65% of those collisions involved another vehicle. Mapping showed that on-road crashes happen in both urban and rural areas.

Conclusion: Although it is illegal to carry passengers on ATVs in Iowa, over 1 in 10 on-road crashes involved a passenger. It is also illegal to ride ATVs on public roads; however, there were 246 onroad crashes during the study period. Over 33% of these crashes involved a collision with another vehicle, thus posing a general traffic hazard. The number of on-road crashes in Iowa is alarming and some occur at a significant distance from trauma centers. Based on our findings, we would strongly recommend against counties and cities designating roads and streets for ATV recreational use. Future projects will include continuing crash surveillance and educational efforts to inform the public about the dangers of on-road ATV use.

Methods: We compared responses of uninsured patients with nonurgent complaints presenting to an urban academic level I trauma/tertiary care ED with those of a FC using a prospective, anonymous survey. Survey items evaluated patients' perceptions about access to care which might explain their choice of venue. ED patients with Emergency Severity Index (ESI) categories 4 or 5 and selected category 3 patients (ambulatory, normal mental status, skin warm and dry, no signs or symptoms of vital organ compromise) were deemed non-urgent. All patients presenting to the FC were deemed non-urgent. The study instrument was a 10 item survey addressing Desirability of a FC over the ED (DFE); Transportation Status (Access to a Car); Perceived Quality of Care; Usual Place of Care; Importance of Cost; Self-Perceived Level of Illness (SPLOI); distance to ED or FC, and patient demographics. All items were answered on a 5-point Likert Scale. Scores from like items addressing similar concerns were combined. A convenience sample of 100 patients was obtained from each site. Comparisons were made using Studentâ&#x20AC;&#x;s t-Test. Logistic regression was used to adjust for the effect of significant variables, demographics, and distance on the response to the item about DFE. Results: Differences were noted between the ED and FC patients for items regarding Cost (ED mean 4.31, FC mean 3.68; p=0.03) with ED patients showing less concern about cost; Transportation (ED mean 7.00, FC mean 8.01; p=0.003) with ED patients showing greater concern about access to a car; and SPLOI (ED mean 2.87, FC mean 3.40; p=0.01) with ED patients perceiving themselves as more ill. No difference was noted between the groups regarding DFE after adjustment (p=0.68) Conclusion: Non-urgent, uninsured patients presenting to the ED showed less concern about the cost of care, greater concern about transportation, and felt themselves to be more ill than those presenting to a FC. No difference was noted between the groups regarding DFE after adjustment.

47. Differences In Perception About Access To Care Between Patients Who Choose An Urban Academic Emergency Department Over A Community-based Student-run Free Clinic For Non-urgent Care Matthew Dettmer1, Cerrone Cohen2, Edward Jauch3, Kit N Simpson3, Brenda Walker3, Wanda Gonsalves3, Kathryn Koval3, Joshua Gray3 and Steven Saef3. 1Washington University Medical Center/BarnesJewish Hospital, St. Louis, MO; 2UC Davis Health System, Sacramento, CA; 3Medical University of South Carolina, Charleston, SC Background: Uninsured patients often choose the Emergency Department (ED) over other suitable venues for non-urgent care.

Understanding patient preferences and obstacles to non-urgent care can improve access to care.

Objectives: Characterize differences in perception about access to non-urgent care by uninsured patients who present to an urban academic ED vs. a community-based student-run free clinic (FC).

48. Preliminary Report On Factors Associated With Inadequate Or Uninterpretable Cervical Spine Radiographs And Need For Ct In Cervical Spine Trauma.

Richard Griffey, Betty Chen and Steven Katz. BarnesJewish/Washington University in St. Louis, Saint Louis, MO Background: Though cervical spine CT (CSCT) comprises an increasing proportion of initial cervical spine (c-spine) imaging in trauma, patients at low to moderate risk of injury often undergo radiography (xrays) as the initial imaging modality. Initial screening with CSCT in trauma has been demonstrated only to be cost-effective for patients meeting specific high-risk criteria who are undergoing concomitant head CT. For patients not meeting these criteria, identification of patients likely to have inadequate or uninterpretable c-spine xrays, requiring subsequent CT would aid in an evidence-

based approach in determining initial imaging modality and improve upon imaging efficiency.

Objectives: To identify risk factors associated with inadequate evaluation with xrays as a first step in further distinguishing which patients would benefit from primary CT. Methods: Setting: Academic, urban, level 1 trauma center with 87,000 visits. Participants: Trauma patients >18 years old with cspine xrays followed by CSCT in the ED. Design: Retrospective observational study from March 2008-2010. We performed explicit chart review of an electronic medical record for comorbidities, medications and other features likely to result in inadequate xrays, and noted the reasons for performing CT. Results: Among 8752 visits with c-spine imaging, there were 4838 with CT, and 616 with xrays and CT. The latter had a mean age of 46 were 55% male and 52% black. Common mechanisms were motor vehicle collision (282) and fall (177) and assault (50) with Emergency Severity Index scores of 3 (358) and 2 (195). Arrival was by ambulance in 405(65%). 5.7% of patients had chronic neck pain or prior c-spine surgery. 5.7% of patients also had arthritis or bone disease. 10% of patients were taking a steroid or a medication for osteoporosis, and 9.4% were either unable to cooperate or had an upper extremity injury. CT after xray was most often performed for inadequate xrays (53%), degenerative disease (36%), and malalignment (25%).

Conclusion: This preliminary review identifies chronic neck pain, prior c-spine surgery, arthritis, osteoporosis, steroid use, and behavioral issues as potential risk factors for inadequate or uninterpretable c-spine xrays. Further study in a larger cohort of control patients is underway to determine whether significant differences warrant development of a clinical decision rule.

49. All Terrain Vehicle (ATV) Crash Fatality Surveillance through Press Clippings Gretchen McCall and Charles Jennissen, MD. University of Iowa, Iowa City, IA Background: ATV crashes are a growing source of injuries and deaths, particularly in rural communities. Every year, ATV crashes result in over 700 deaths and more than 130,000 ED visits. ATV injury surveillance is extremely challenging and crash data must be collected from many sources. Newspaper reports are an untapped resource to investigate the factors and variables surrounding ATV crashes.

Objective: The objective of this study was to use press clippings for nine states (IA, IL, KS, MN, MO, ND, NE, and SD) as a source for studying fatal ATV crashes.

Methods: A retrospective study of 2009 and 2010 ATV press clippings was performed and clippings for fatal crashes were identified. Descriptive analyses were done for demographics and crash mechanisms. The number of press clippings for fatal and nonfatal crashes was compared using the Mann-Whitney test.

Results: Press clippings captured over 90% of state fatalities as reported by the Consumer Product Safety Commission (CPSC); and the number of press clippings for fatal crashes was significantly higher than for non-fatal crashes (median 2.0 vs. 1.0). Demographic variables (e.g., gender) were well documented (93-100%). ATVrelated fatalities were 84% males and 16% of victims were children under 16 years of age. Approximately 1 in 4 victims (24%) were wearing a helmet. Documentation of crash circumstances (e.g., surface type) was variable (20-97%). The majority of crashes occurred at dusk/dark (52%). More than 1 in 10 fatal crashes involved vehicle-vehicle collisions (15%) or being pinned by the vehicle (11%). Vehicle-related parameters (e.g., vehicle model) were poorly documented (12-30%). Annual fatality rates were higher than the overall average of 1.0 deaths/100,000 rural population for MN (1.2), MO (1.3), NE (1.4), and ND (1.4). Rates for IL (1.0) and WI (0.9) were at or near the average, and IA (0.6), KS (0.8), and SD (0.6)

were below average. There did not appear to be an association between mortality rate and number of ATV laws.

Conclusions: Press clippings are a valuable resource for ATV fatality surveillance because they comprehensively capture fatalities in multiple states and they provide information not readily available from other sources. They also contribute additional insights as part of our integrated ATV surveillance database.

50. A Quality Curriculum: A Novel Approach To Addressing The ACGME Core Competencies Jonathan dela Cruz, Antonio Cummings, James Waymack, David Griffen and Christopher McDowell. Southern Illinois University School of Medicine, Springfield, IL Background: Of the ACGME core competencies, application of practice-based learning and improvement, and systems-based practice have been difficult to assess in emergency medicine (EM) residency curriculum. ABEM has now required attestation to a quality improvement (QI) activity for continued certification. It is important that EM residents are fluent in their core competencies and are exposed to QI principles.

Objectives: We present here a formalized curriculum in quality to assess resident understanding of ACGME core competencies while providing them with a skill set in QI. Methods: A class of 6 EM residents participated in a 3 part lecture series on QI principles during core didactics. Using a previous hospital QI project as a model, the residents learned the application of statistical process control. Residents then became members of an interdisciplinary QI project team intervening on the reversal of coagulopathic ICH. Each resident was required to advance different areas of the project. Their progress was tracked through periodic meetings with the QI project leader and time was allotted during core conferences for them to present their tasks. Presentations included basic science didactics on the coagulation cascade, literature reviews on current treatments, and a focused audit of the yearâ&#x20AC;&#x;s previous ICH data. Understanding of the ACGME core competencies was evaluated by core faculty during resident presentations and during their meetings with the QI project team leader who also was a core faculty member.

Results: All residents engaged in the process and showed an improved understanding of the ACGME core competencies and QI principles. This knowledge was demonstrated through their presentation of didactic lectures, integration with an interdisciplinary QI project team, and successful implementation of a new treatment protocol. The QI project continues to be monitored and the outcomes of the process changes are to be followed longitudinally.

Conclusion: A quality curriculum surrounding resident involvement in a QI project seems feasible and promising. Involvement in a QI project enhanced understanding of ACGME core competencies.

Further observation of resident project involvement and data collection of QI project outcomes need to be performed to fully assess the potential this curriculum has on resident education.

51. Emergency Department Interruptions in the Age of Electronic Health Records Matthew Albrecht, Jonathan dela Cruz and John Shabosky.

Southern Illinois University School of Medicine, Springfield, IL Background: Interruptions of clinical care in the emergency department (ED) have been correlated with increased medical errors and decreased patient satisfaction. Studies have also shown that most interruptions happen during physician documentation. With the advent of the electronic health record and computerized documentation, ED physicians now spend much of their clinical time

in front of computers and are more susceptible to interruptions. Voice recognition dictation adjuncts to computerized charting boast increased provider efficiency, however, little is known about how data input of computerized documentation affects physician interruptions.

Objectives: We present here observational interruptions data comparing two separate ED sites, one that uses computerized charting by conventional techniques and one assisted by voice recognition dictation technology.

Methods: A prospective observational quality initiative was conducted at two teaching hospital EDs located less than 1 mile from each other. One site primarily uses conventional computerized charting while the other uses voice recognition dictation computerized charting. Four trained observers followed ED physicians for 180 minutes during shifts. The tasks each ED physician performed were noted and logged in 30 second intervals.

Tasks listed were selected from a predetermined standardized list presented at observer training. Tasks were also noted as either completed or placed in queue after a change in task occurred. A total of 4140 minutes were logged. Interruptions were noted when a change in task occurred with the previous task being placed in queue.

Data was then compared between sites.

Results: ED physicians averaged 5.33 interruptions/hour with conventional computerized charting compared to 3.47 interruptions/hour with assisted voice recognition dictation (p=0.0165).

Conclusion: Computerized charting assisted with voice recognition dictation significantly decreased total per hour interruptions when compared to conventional techniques. Charting with voice recognition dictation has the potential to decrease interruptions in the ED allowing for more efficient workflow and improved patient care.

52. Ct Scanning Practice In Minor Pediatric Head Injury At A Community Emergency Department Myto Duong, Varshita Pande and Joseph Milbrandt. Southern Illinois University, Springfield, IL Background: Pediatric head injury (HI) is responsible for >7400 deaths, 60,000 admissions and 600,000 emergency department (ED) visits annually. Over 50% of minor pediatric HI will get a head CT scan. Head CT scans has doubled between 1995 and 2005.

Objectives: The objective of our study was to determine the overall rate of head CT use in children with minor HI and to evaluate the appropriateness of head CT use based on Kuppermann et al recommendations in 2009.

Methods: A retrospective chart review was performed for patients <18 years old presenting to the ED with a HI in 2008 and 2009.

Patients were identified using ICD codes. Information collected included age, gender, mechanism of injury, clinical findings, imaging studies on initial presentation, any clinically significant HI finding on head CT, number of repeat head CT related to initial injury with a limit of 1 month post-injury.

Results: A total of 654 charts were reviewed. 383 (59%) patients had a head CT scan. Out of 654 HI, 352 were minor and 165 (47%) had a CT scan. Of these 165 head CT scans, 123 met criteria for a scan.

Only 10 of the 123 (8%) had abnormalities. 42 of the 352 (12%) minor HI had a scan when they did not meet criteria (all were negative except 2 -neither required any intervention). We identified 62 (18%) HI with no scan but did meet criteria for a head CT scan.

Conclusion: Even before head CT scanning guidelines for minor pediatric HI were available, the overall rate of head CT use in children with minor HI (47%) in our community ED was below the national average for adult ED but high compared to pediatric EDs in the United States. The percentage of pediatric patients with minor HI who met criterias for the head CT scan was 53% but only 35% of the minor HI who met criteria had a CT scan. Eighteen percent of patients with minor HI met criteria for a head CT scan but did not

have one. Although there are other urgent cares and ED in our community, our hospital is the only children‟s hospital in the community who would admit patients with HI complications. Based on return visits data to our hospital, none of these patients required further evaluation or hospitalization. Although the algorithm previously suggested for CT scan utilization was designed to decrease pediatric head CT scanning, the algorithm identified a large number of patients who had negative CT findings. In addition, we identified overutilization of head CT scans in 12% of minor pediatric HI in our ED.

53. Comparison Of Interpreters In Emergency Medicine: Video Conference Vs. In-person Yanika Wolfe1, Leslie Zun2, LaVonne Downey3 and Trena Burke4.

1 Rosalind Franklin University/Chicago Medical School, North Chicago, IL; 2Mount Sinai Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL; 4Mount Sinai Hospital Emergency Medicine, Chicago, IL Background: Many studies have shown the benefits of using professional interpreters for patients with limited English proficiency.

Despite this, interpreters are still underutilized within the ED. This fact is attributable to the lack of available interpreters, cost and time constraints. Only a few studies have examined the impact of using videoconference interpretation method in the ED. Objectives: The purpose of this study is to compare the effectiveness of video conference (IVIN-Illinois Video Interpreter Network) and in-person (LIVE) interpretation methods in ED setting with regards to patient and staff satisfaction, cost, and throughput times.

Methods: This was an IRB approved, prospective cohort study consisting of a convenience sample of 100 medically stable Spanish speaking patients, 18 years and older, presenting to the level 1 trauma ED of an urban teaching hospital. Each patient was assigned to receive either IVIN or LIVE interpreter. At the end of treatment, patient was given a survey which assessed the patient‟s satisfaction of the communication quality with staff and patient‟s level of understanding of what was explained. A survey was also given to the health care provider to assess whether or not language barrier issues were addressed.

Results: 25 patients were enrolled, 15 in LIVE interpreter and 7 in IVIN group. Majority of both cohorts listed elementary school as their highest level of education and was currently unemployed. In regards to patient‟s satisfaction of the quality of communication with hospital staff, 93% LIVE interpreter users reported that they were either very satisfied or somewhat satisfied, compared to 100% of IVIN users. 80% LIVE interpreter users reported that they could understand very or mostly easily things that were explained to them, compared to 71% of IVIN users. Most healthcare providers felt that language issues were adequately addressed by using the LIVE interpreter (87%) or IVIN (85%).

Conclusion: This preliminary data suggests that video-conference interpreters performs as well as in-person interpreters in ED setting with regards to the patient and provider‟s satisfactions. This preliminary result warrants further data collection. Potential differences in throughput times between these two interpretation methods will also be considered and further analyzed as part of the second phase of the study.

54. Impact Of The Use Of A Standardized Order Set For Asthma Patients In The Emergency Department Daniel D Ofori1, Leslie Zun1 and LaVonne Downey2. 1Rosalind Franklin University of Medicine and Sciences, North Chicago, IL; 2 Roosevelt University, Chicago, IL

Background: Order set use is on the rise. Order sets combine evidence-based orders for specific diagnosis into concise, easy to use formats. How beneficial is this in the E.D for asthma patients?

Objectives: To investigate the impact of the use of a standardized order set list for patients presenting to the E.D with asthma exacerbation, on treatment throughput time, outcome, length of stay, cost and patient return to the E.D. Methods: An IRB-approved randomized chart review was conducted on patients presenting to the E.D. of a Midwest, inner city, level 1 trauma hospital between December 2003 and June 2011. The study compared patients for whom an asthma order set was used (users) to those for whom an asthma order was not used (non-users). The data was analyzed using SPSS frequency descriptive, one-way anova and crosstabulations.

Results: 101 patients were enrolled: 52 male and 49 female.

Ethnicities included 91 African-American, 8 Hispanic and 2 unknown. 28 patients were 17 years old or younger, with 73 older than 17 years. Most patients were brought in by the fire department.

E.D priority ratings were 55 urgent, 23 non-urgent, 20 acute and 1 critical. 62 patients were on publicaid, 28 uninsured/self-pay and 8 on private insurance. Asthma order sets were used for 34 patients; order sets were not used for 55 patients; order set use/non-use could not be verified for 12 patients. 49 patients returned to the E.D within 30 days of discharge. Significant difference between order set users and non-users were found for: 1) Length of stay: sig value of 0.015 and F value of 6.164 for 37 patients (13 users vs. 24 non-users) staying for 1 day; 2) Total treatment time: sig value of 0.010 and F value 7.028 for 18 patients (6 users vs. 12 non-users) with 2.5-4 hours, 18 patients (6 users vs. 12 non-users) with 5-7 hours; 3) Total throughput time: sig value of 0.014 and F value of 6.342 for 12 patients (3 users vs. 9 non-users) with 2.5-3.5 hours, 19 patients (6 users vs. 13 non-users) with 5-7 hours; 4)E.D. charges: sig value of 0.001 and F value of 12.948 for 19 patients (all non-users) with $0-$1,000, 16 patients (6 users vs. 10 non-users) with $2,000-$5,000.

Conclusion: The study showed that using a standardized order set for asthma patients in the E.D. resulted in fewer patients with long treatment and throughput times, thus expediting patient care delivery.

55.

Same Patient. Same Overdose. Different Treatment.

Different Outcome.

Jon B Cole1, Heather Ellsworth2 and Samuel J Stellpflug2. 1Hennepin Regional Poison Center, Minneapolis, MN; 2Regions Hospital, St. Paul, MN Background: Intravenous Fat Emulsion (IFE) is a promising therapy for Poison-Induced Cardiogenic Shock (PICS). An American College of Medical Toxicology position statement asserts that IFE is â&#x20AC;&#x153;a reasonable consideration for therapy, even if the patient is not in cardiac arrest.â&#x20AC;?

Objectives: We present a case series of a single patient who overdosed on two separate occasions with diltiazem (D), metoprolol (M), and amiodarone (A). She received IFE both times with different outcomes.

Methods: This is a retrospective review of a 2-case series; the same patient was the subject in both cases.

Results: Case 1: A 30 yo woman with hypertrophic cardiomyopathy and an AICD presented with an overdose (OD) of D, M, and A. Initial vital signs showed BP 89/46 and HR 73. Over 3 hrs the BP and HR dropped to 64/41 and 70, and she was confused. ECG showed paced rhythm. Normal saline (NS) 4L IV and 27 mEq IV Ca2+ were given, and a high dose insulin (HDI) infusion escalated to 10U/kg/hr.

She remained hypotensive and confused. The CVP was 20 and an Echo showed low EF. IFE (20%) was given as a 100mL bolus and an infusion of 1.5L over 1 hr. Within 15 min of the bolus the BP was 110/60 and confusion improved. She had no negative sequelae.

Serum levels from the ED were D: 1449 ng/mL (nl 130-190), M: 388 ng/mL (30-300), A: 2.7 mg/L (0.5-2).

Case 2: The same patient presented with an OD of D, M, and A 4 months later. She was treated with NS, but became hypotensive and suffered a cardiac arrest treated with glucagon and pressors unsuccessfully. IFE was given with return of spontaneous circulation.

She received HDI at 1U/kg/hr, a Ca2+ infusion, dopamine, phenylephrine and vasopressin. She improved clinically and was noted to be alert and following commands. Shortly thereafter she suffered a second cardiac arrest and died. Post-mortem drug levels were D: 4,500 ng/mL, M 162 ng/mL, and A: 1.9 mg/L. Conclusion: Early IFE in the setting of refractory Poison-Induced Cardiogenic Shock may be preferable to waiting for cardiac arrest. In case 1 the patient got IFE while declining clinically but had a pulse; she had rapid improvement and a good outcome. In case 2 IFE was delayed; though she clearly responded, she ultimately died. In this patient it appears early IFE was associated with a better outcome. We recognize that in case 2 the concentration of D was higher than case 1, and pressors were included in the treatment of case 2; both factors may have affected the outcome.

56.

Effect of Protocol Implementation on Emergency Department Observation Unit Length of Stay and Charges Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington University, St. Louis, MO Background: Emergency Department-based observation units are becoming increasingly used for the assessment and treatment of patients who may not require inpatient management or monitoring.

Objectives: To determine if implementation of Emergency Department Observation Unit (EDOU) care pathways (CP) impacted EDOU patient length of stay (LOS) and total ED (professional plus facility) charges.

Methods: In June of 2009, 21 CP were implemented in a 12 bed EDOU. Data from a 2 week period (12/1-14/2008) 6 months preimplementation were retrospectively compared to a 2 week period (12/1-14/2009) 6 months post-implementation. EDOU LOS and total charges were compared for all EDOU patients, those admitted to the hospital, and those discharged from the EDOU. Boarding patients (ED patients admitted to the hospital waiting in the EDOU for an inpatient bed) were excluded from the analysis. EDOU LOS and total charges were analyzed using medians and interquartile ranges (IQ) (25th and 75th %tiles). Statistical significance was analyzed using Wilcoxon Rank Sum. Results: 171 pre-implementation and 192 post-implementation patient visits met inclusion criteria with 3 visits excluded because of incomplete billing data. The overall median EDOU patient LOS was 15 minutes shorter after the implementation of CP (658 vs 643 mins; P=0.89). The LOS of EDOU patients who required inpatient hospitalization decreased 287 minutes post-implementation (1027 vs 740 mins; P=0.10); whereas those discharged from the EDOU only decreased 9 minutes (620 vs 611 mins; P=0.74). Median overall charges for the entire cohort were $755 higher post-CP implementation ($4,863 vs $5,618; P=0.13); and were $53 higher for EDOU patients who required inpatient hospitalization ($10,857 vs $10,910; P=0.74). Total charges decreased $179 for patients who were discharged from the EDOU ($4,173 vs $4,352; P=0.13).

Conclusion: Implementation of EDOU CP decreased the overall LOS for EDOU patients. LOS was also decreased for patients those who required inpatient hospitalization or were discharged from the EDOU. EDOU CP also increased total ED billing. Future multicenter research is needed to validate these findings.

57. Retrospective Study of Underage Drinking and Emergency Department (ED) Visits: Before and After the 21 Ordinance Christopher R Peterson and Michael Takacs. University of Iowa, Iowa City, IA

Background: Excessive consumption of alcohol and dangerous drinking behaviors continue to be a growing concern in Iowa City. A 2009 study reported that 70% of UI students had engaged in high-risk drinking in the last two weeks as compared to 44% nationally. The Iowa City Council sought to curtail underage alcohol consumption by passing the 21-Only Ordinance on 6/1/2010, banning people under 21 from bars after 10:00 pm. There has been much debate in the community as to the effectiveness of this measure - whether it would reduce dangerous drinking, or simply shift drinking to house parties where supervision and police presence would be minimal.

Objectives: The objective of our study was to determine whether the rate of alcohol-related ED visits among 18-20 year olds decreased following implementation of the 21-Only Ordinance.

Methods: A retrospective study of 18-20 year olds presenting to the ED for alcohol-related reasons from 6/1/2009 to 5/31/2011 was performed. Medical record data were compiled, including age, blood alcohol content (BAC), date and time of visit, complaint and diagnosis. Data were analyzed using Pearson‟s chi-square test.

Results: In the year prior to the 21-Only Ordinance, there were 1685 visits to the ED by 18-20 year old patients; 272 of these visits were for alcohol related reason (16.3/100 patients). In the year following, there were 206 alcohol visits out of 1608 total visits (12.4/100 patients), suggesting overall decline (23.8%) in alcohol-related visits among the study population (p<.01).

Alcohol-related ED visits by 18-20 year old UI students decreased from 8.72% to 6.16% (p<.01).

Alcohol-related visits involving violence decreased from 2.85% of total visits in the year prior to 1.43% after (p<.01). Similarly, the proportion of visits involving a mental or emotional condition, such as depression or suicidal ideations, decreased from 2.20% to 1.06% (p=.01).

Conclusion: Retrospective studies can reveal trends within a given population over time, but are unable to provide causation for these trends. Thus, while this study suggests a significant decline in 18-20 year old alcohol-related visits to the ED in the year after the 21-Only Ordinance, additional studies are needed to determine the sustainability of these changes.

58. A Retrospective Review of the Use and Safety of Sedation for Agitated Patients with Hepatic Encephalopathy in the Emergency Department Jason West1 and Vijai Chauhan2. 1Albert Einstein School of Medicine, Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis University School of Medicine, St. Louis, MO Background: Patients with hepatic encephalopathy may present with a wide range of alterations in mental status including delirium, agitation, and aggression. There are no consensus guidelines to recommend a standard agent for sedation in patients with hepatic encephalopathy or hepatic failure in the emergency department (ED).

Objectives: We intended to compare and characterize the use of intravenous midazolam, lorazepam, and haloperidol for the sedation of agitated patients with hepatic encephalopathy and end-stage liver disease (ESLD) in the ED. Methods: This was a retrospective chart review set in a university hospital ED. The ED database was queried to identify patients admitted with hepatic encephalopathy 2005-2009, and further chart review was performed if the patient received sedation for agitation.

We analyzed the adequacy of sedation, adverse events, and disposition.

Results: Of the 401 patients presenting with hepatic encephalopathy or ESLD, 8 received sedation for agitation in the ED. 7 patients recieved lorazepam, and 1 patient received both haloperidol and lorazepam. One patient recieving both drugs required active airway management and intubation for respiratory depression. No patients were reported to have post-sedation hypotension, arrhythmia,

vomiting, or significant Glasgow Coma Scale changes. All patients were adequately sedated at the time of disposition and were more likely to require admission to intensive care units.

Conclusion: Agitated patients with hepatic encephalopathy given lorazepam were adequately sedated but may be at increased risk of requiring active airway management.

59. A Cost Comparison of Fomepizole and Hemodialysis in the Treatment of Methanol and Ethylene Glycol Toxicity Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy K Kim, Jon B Cole, Carson R Harris and Samuel J Stellpflug.

Regions Hospital, St. Paul, MN Background: Fomepizole (F), alone or in combination with hemodialysis (HD), may be used in the treatment of toxic alcohol exposures such as methanol (M) and ethylene glycol (EG). There is a paucity of data regarding the financial cost of each treatment.

Objectives: Using patient charge estimates specific to our institution, we present an analysis comparing cost effectiveness of F and HD for treatment of M and EG levels of 50 mg/dL. Methods: Patient charges associated with treatment of EG and M exposures in 2010 at our institution were reviewed and averaged with respect to the cost of the following: F dose, HD session, and daily rates of a general care (GC) and intensive care unit (ICU) beds. All other costs were assumed comparable irrespective of treatment received. Based on available pharmacokinetic (PK) data for M and EG in the presence of F, the duration of treatment was projected.

Results: The average patient charge for a dose of F was $1,267, HD session $765, GC bed (daily rate) $915, and ICU bed (daily rate) $1,524. For an EG or M level of 50 mg/dL treated with HD, the patient charge would approximate $4,823 (2 doses of F, 1 HD session, 1 day of hospitalization in the ICU). In contrast, the estimated cost associated with treatment of an EG level of 50 mg/dL with F only, based on a t½ of 12.9 h, to an endpoint of <20 mg/dL was $5,631 (based on a treatment duration of 25.8 h, 3 doses of F, 2 days of hospitalization in a GC bed). Similarly, for a M level of 50 mg/dL treated with F only, with an estimated t½ of 54 h, the estimated cost was $17,245 (administration of 10 doses of F and 5 days of hospitalization in a GC bed).

Conclusion: Hemodialysis is a more cost effective approach to the management of methanol and ethylene glycol toxicity than alone if levels exceed 50 mg/dL. This is especially true for M, which has a significantly longer t½ than EG. Limitations include not accounting for the cost of complications related to HD such as vascular injury, infection, and thrombosis (data suggest these complications are rare).

Another limitation is the failure to account for individual variability with respect to PK as well as patient weight, which may influence the number and volume of F doses required. Accounting for these parameters could make the cost difference between F and HD even more favorable for HD, considering reports of extremely long EG and M t½'s treated with F alone.

60. Equestrian Helmet Use in Horse Organization Promotional Material Charles A Jennissen1 and Suleimaan Waheed2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa, Iowa City, IA Background: Equestrian helmet use is an effective method to prevent head injuries in horse-related events. However, rates of protective head gear use while riding or working around horses is still low. The media can have a great impact on injury prevention both positively and negatively by their portrayal of protective safety equipment or lack thereof.

Objectives: To determine the equestrian helmet use by individuals pictured in horse organization promotional materials.

Methods: Literature was requested from horse organizations through email and/or mail, with the inquiring investigator posing as a horse enthusiast. Organizations contacted included national horse agencies, breed registries and all state equine councils. Photographs in materials received were reviewed for equestrian helmet use along with the age and activity of individuals depicted in photographs.

Results: 113 of 335 organizations responded and 95 organizations sent published material. A total of 2,004 photos with 2,738 people were evaluated. The highest equestrian helmet use was by children, and teen helmet use was generally portrayed more frequently than in adults. The lowest rate were in those that appeared elderly (14.6%).

Helmet use was highest in photos that depicted competition-jumping (87.9%). Competition-riding and pleasure-riding helmet use was only 30.0% and 34.5%, respectively. Equestrian helmet use was low in all portrait categories--photos where pictured individuals were formally posing for the camera. No one who was pictured while working on, with or while on a horse was shown with an equestrian helmet; nor was anyone in a parade. Adults riding with children did have a significantly higher rate of wearing an equestrian helmet than adults who were pleasure-riding in general (44.2% vs. 23.2%).

Conclusion: Photographs in horse organization literature often show people not wearing helmets during equine-related activities. Horse organizations have an excellent opportunity to define injury prevention practices as normative behavior. One way this may be accomplished is by portraying people always wearing equestrian helmets in the photos they use in their published material.

Developing a culture of safe equestrian practices including helmet use will decrease the number of serious head injuries experienced by horse enthusiasts.

61. Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and Differences Between Rural and Urban Hospitals Charles A Jennissen1, Sarah Wente2, Charmaine Kleiber2 and Ryoko Furukawa2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2 University of Iowa College of Nursing, Iowa City, IA Background: Children‟s pain management in the Emergency Department (ED) remains inadequate. Available evidence-based practice (EBP) guidelines for pediatric pain management exist, but are currently under utilized in managing pediatric pain in EDs. Objectives: To determine the factors that nurses identify as facilitating the use of EBP in the management and prevention of pediatric pain in the ED and whether these factors are different for rural versus urban hospitals.

Methods: All nurses working in hospital EDs in the state of Iowa were invited to participate in a confidential survey regarding EBP of pediatric pain treatment and included the question “What would facilitate the use of EBP pediatric pain management in your ED?” Qualitative responses were analyzed using Nvivo software to identify patterns and themes. Researchers reviewed the responses independently and then discussed the coding, resolving any discrepancies.

Results: Of 1171 returned surveys, 735 contained responses to the study question. Data fell into five nodes: knowledge, staff aspects, hospital system, treatment, and patient/family issues. Knowledge and staff aspects appear to be key facilitators for EBP in EDs. The knowledge node revealed several themes including the desire for specific types of training and education, information sharing, and for examples of guidelines and policies. Staff aspects included the need for more collaboration with physicians, and more openness and motivation to change. Critical access hospital ED nurses more frequently reported a need for education and guidelines/standing orders than nurses from larger hospital EDs. Nurses from rural facilities also reported wanting more exposure to pediatric patients

and asked for processes for the sharing of information from other facilities, including larger hospitals with pediatric expertise. Nurses from all hospital sizes reported the need for “proof” of effectiveness of pain management practices.

Conclusion: Most strategies to increase evidence-based pediatric pain management in EDs can be utilized in hospitals of all sizes.

However, rural hospitals may benefit more from networking and information sharing with other hospitals, including examples of guidelines and standing orders. It will be important all strategies stress effectiveness and positive impact on the patient.

62. Characterization of Clinical Rotations in Three and Four Year Emergency Medicine Residency Training Programs Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael Wadman. University of Nebraska Medical Center, Omaha, NE Background: Emergency medicine (EM) currently recognizes 3 training formats: PGY 1-3, 2-4, and 1-4. EM program requirements proscribe that „no less than 50% of the clinical experience take place under the supervision of emergency medicine faculty‟, that there must be „at least two months of critical care rotations,‟ and if less than 16% of all ED encounters are pediatric patients, some pediatric rotations are required. Little is known about the content of the remaining rotations in EM programs.

Objectives: To describe the similarities and differences in clinical rotations between three and four year EM residency programs.

Methods: EM residency programs were identified on the SAEM website during November, 2010. Information was abstracted from individual program websites regarding the types and duration of rotations during residency. Rotations were grouped into EM, critical care (CC), surgery (surg), medicine (IM), pediatrics (peds), other or (s)elective clinical categories. The median/interquartile range for the number of blocks in each category were calculated for PGY 1-3 and PGY 1-4 programs and compared by Mann-Whitney Rank Sum Test.

Results: We identified 152 programs: 113 PGY 1-3, 35 PGY 1-4 and 4 PGY 2-4. Within the PGY 1-3 programs there were 44 with 39 four week blocks and 69 with 36 month blocks. Within the 35 PGY 1-4 programs there were 25 with 52 four week blocks and 10 with 48 month blocks. In comparing 52 and 39 block programs, there were significant differences in EM: 34(32.2, 36) vs 26(24.5, 27.1) p<0.001, other: 7(5.4,7.8) vs 4(3, 5.4) P<0.001 and (s)elective 4(2,4.5) vs 2(1,2) p<0.001. There were no differences in CC: 4(3,5) vs 4 (3,4.4) p=0.653, surg: 2.5(1.4,3) vs 2(1.25,3) p=0.389, IM: 1(0.75,2) vs 1(0,1) p=0.115, and peds 0(0,1) vs 0(0,0) p=0.081. In comparing 48 and 36 block programs, there were significant differences in EM: 29.5(28, 30) vs 23(22, 24.6) p<0.001, other: 5.4(4,7) vs 3.5(3,4)p<0.001, and (s)elective: 4.25(3,6.5) vs 2(1,2) p<0.001. There were no differences in CC: 4(3,5) vs 4 (3,4) p=0.988, surg: 3(2,4.5) vs 2(1.4,3) p=0.054, IM: 2(1,3) vs 1(0,2) p=0.051, and peds 0(0,1) vs 0(0,1) p=0.685.

Conclusion: Of the additional 13 or 12 blocks in four year programs, there are an additional 8 or 6.5 EM blocks, 3 or 1.9 other blocks, and 2 or 2.25 elective blocks respectively.

63. Let The Good Times Roll: Computer Modeling to Investigate Risk of ATV Rollover While Turning Charles A Jennissen1, Gerene Denning1, John Steffen2, Jonathon Marsico2, Thomas Schnell2 and Daniel McGehee2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa College of Engineering, Iowa City, IA Background: Rollovers are the most common all-terrain vehicle (ATV) crash mechanism. Most field research of ATV rollovers is limited due to the risk of subject injury. Computer modeling is a

potential tool to safely investigate ATV crash mechanisms and risk factors.

Objectives: To explore how various factors might affect the likelihood of an ATV rollover while turning including velocity, surface friction, turning radius, passenger and ATV center of gravity, and wheelbase dimensions Methods: Vehicle specifications for a convenience sampling of utility ATVs were compiled. A computerized free body diagram was constructed of an ATV with passenger(s), and the risk of sliding or rollover with turning was assessed for multiple parameters while keeping ATV size specifications constant. The relative rollover risk of various ATV models was also determined.

Results: Surfaces with higher friction coefficients (i.e. dry pavement) increase the likelihood of a rollover while turning. Even a typical dirt trail (friction coefficient of 0.3) would require a 16.4 mph limit to avoid a slide with an average adult male driver making a 60 ft. radius turn. A slide may not result in a rollover but will reduce the operators control over the ATV. The risk of rollover increases significantly with tighter turns. If the operator simply takes more gradual turns at higher speeds, roll-overs can be avoided entirely. The minimum turning radius for most ATVs was around 8 ft. which only allows a maximum speed of around 10 mph to avoid a rollover on high friction surfaces. As the combined operator/passenger weight increases from 85 lbs to 365 lbs, the vehicle speed needs to be reduced approximately 4 mph in order to prevent a rollover at the same turning radius. There was a difference, albeit relatively small, in the speed at which ATVs from different manufacturers will rollover.

Conclusion: Surface friction, total rider mass, velocity and turning radius are rollover determinants that are terrain and rider decision dependent. Education of operators, enforcement of strict no passenger rules, and speed limiters for younger drivers may be important to affect these factors and prevent rollover crashes. Manufacturers could engineer better rollover protection by optimizing ATV width and lowering its center of gravity, and/or producing ATVs with roll bars and safety belts.

64. A Picture’s Worth a Thousand Words: Utilizing Social Media to Better Understand ATV Crash Mechanisms Morgan Price1, Gerene Denning2 and Charles A Jennissen2.

1 University of Iowa Emergency Department, Iowa City, IA; 2 University of Iowa Hospitals and Clinics, Iowa City, IA Background: Over the last decade, all terrain vehicle (ATV) crashes, injuries and deaths have risen more than 400%, with over 800 deaths and 130,000 ED visits every year. Rollovers have been reported as the most common mechanism. However, most injury surveillance sources provide limited data on the sequence of events during an ATV crash. This limitation provides the rationale to investigate less traditional sources such as social media sites like YouTube.

Objectives: The study‟s objective was to compile a video library of ATV crashes and to review these videos in order to achieve insights regarding the crash mechanisms and contributing factors of ATV crashes on uphill inclines.

Methods: A retrospective search of videos posted on YouTube between April 2006 and July 2011 was performed. Videos were compiled and coded according to occupant, crash, vehicle, and video parameters. Uphill incline crashes were identified and reviewed creating a highly detailed account of the crash sequence, moment by moment, for every vehicle and person involved.

Results: One hundred eighty three ATV crash videos have been downloaded to date and 52 uphill incline crashes were reviewed.

Almost all ATV operators in the videos were males and 81% were adults. Helmet use was 73%. All crashes involving adolescents occurred on adult-sized vehicles. 75% of vehicles were sports ATVs and 25% were single-person utility ATVs. Major surface types shown in the videos were dirt (72%), mud (10%), and solid rock (6%).

Overall, forty-three of the uphill crashes (83%) resulted in rollovers,

68% of these rollovers were backwards. A major contributor in the majority of these crashes was loss of momentum followed by inappropriate acceleration. A difference between sports and utility ATVs was noted in which utility ATVs during a slower velocity backward rollover would veer to the side once the metal rack on the back hit the ground.

Conclusion: Videos from social media sites are a rich source of ATV crash mechanism information. Analysis of these videos yields significant details that are not available through any other data source. Our ATV crash video library will serve as both an important educational and research tool.

65. Complications of Extremity Computed Angiogram Completed in Emergency Department

Tomography

Emily Tilzer and Vijai Chauhan. Saint Louis University Hospital, Saint Louis, MO Background: Computed Tomography Angiography (CTA) is increasingly used as a imaging modality for extremity vascular pathology in patients presenting to the Emergency Department. From limb trauma to acute arterial blockage, CTA is noninvasive and frequently immediately available (1). However, the procedure still requires intravenous contrast, which can cause adverse events, such as anaphylactoid reactions or acute kidney injury.

Objectives: The objective of this study was to analyze the frequency of adverse reactions related to CTA studies ordered for Emergency Department patients.

Methods: This was a retrospective chart review of patients age 18-90 who received a CTA from July 2009 to August 2010 at an academic medical center. A list of all CTA studies ordered from the Emergency Department was cross referenced with patient‟s creatinine, admission status, documented reactions, and time-to and type-of intervention.

Results: This is preliminary study data on 20 of approximately 60 subjects. These 20 patients had no documented adverse reaction to the intravenous contrast or increase in creatinine.

Conclusion: As a modality that is becoming more common for evaluation of extremity vascular pathology, CTA did not have an increase in complications when ordered from the Emergency Department. Further studies are needed to with larger number of patient‟s who receive a CTA to detect any possible complications.

66. Safety Depictions on Primetime TV: Lack of Seat belts and Helmets David Milzman. Georgetown University School of Medicine, Bethesda, MD Background: A 1998 Mich St. U study recorded prime time TV portrayal of 25% seatbelt usage when actual national usage was 65% that year.. in 13 years, since the US national usage had inc. to 85%.

Objectives: Compare Primetime TV traffic/safety exposures with USDOT NHTSA figures and Compare to Past TV representations.

Methods: Researchers watched a total of 53 non-news, non realityTV totaling 53 programs across 10 weeks of Spring 2011 primetime (8-11 PM EST)from the following networks: ABC, CBS, NBC, FOX and CW. Commercials were excluded. All instances of seat belt usage (driver and passenger) , helmets (bikes and motorcycle) and miscellaneous pedestrian and vehicular traffic infractions were also recorded.

Results: total of 273 of prime time tV was viewed with an overall rate for proper seat belt usage in 37.6% (95% CI: 32.4-42.9) of drivers, 22.3% (95% CI:18.5-26.0) passengers. Proper seating and childseat usage , not noted in original 1998 study was only 14%.

Helmet were used by 15.9% of bicyclists, 70.3%of motorcyclists.

There was 17% rate of Pedestrian and 22% vehicular traffic violations, also. Overall proper 2011 restraint use was 30.1%

(95%CI: 25.4- 34.6). This figure represent only a 4.2% rise and NS increase since the prior study. Portrayal of Primetime TV seatbelt usage rose a 4.8% (p â&#x2030;¤ 0.11) from 1998 to 2011 while actual US seatbelt use increased a significant 20%.(p â&#x2030;¤ 0.03) helmet use did increase for both bike by 32% to 15.9% and motorcycle by 20% to 70.3%.

Conclusion: Recent studies have found traffic safety behaviors continue to increase in Us population; however, major TV network programs have not incorporated such simple safety changes into current programming despite prior study into these deficiencies. A poor example continues to be set.

67. Agreement Between Physician and CT Scan in High Energy Mechanism Stable Trauma Patients Michael D Zwank1, Eric A Gross2, Mary J Hughes3, David J Castle3, Amanda C Miller3, William P Hughes3 and Christopher P Anderson4.

1 Regions Hospital, Saint Paul, MN; 2Hennepin County Medical Center, Minneapolis, MN; 3Michigan State University, East Lansing, MI; 4Healthpartners Research Foundation, Bloomington, MN Background: Computed tomography (CT) is a vital adjunct in the evaluation and care of trauma patients. While its usefulness is undisputable, this benefit comes with radiation related risk given the relatively high doses of ionizing radiation that are used. This concern has generated a debate over the proper role of CT in stable trauma patients. While several studies have promoted liberal CT use, to date there has been no well designed prospective study to examine this practice in this patient population.

Objectives: This study assessed how closely physician assessment and CT scan results agree in the alert stable patient who has experienced high energy trauma. Can physicians reliably detect severe injuries in this select patient population?

Methods: This is a prospective cohort study conducted at three Level I trauma centers. A convenience sample was enrolled when study personnel were available. Patients were included if they met the inclusion criteria: blunt trauma, trauma team activation, Glasgow Coma Score 15, systolic blood pressure on arrival > 100, age between 18 and 65. Trauma team leaders completed a survey regarding the reliability of the patient and suspicion of any injury and severe injury in various body regions (head, neck, chest, abdomen, pelvis and extremities). The patientâ&#x20AC;&#x;s chart was later abstracted for outcome and injuries detected on x-ray or CT. Major injuries were defined a priori.

Results: 150 patients were enrolled. Mean age was 43 (SD=17.6).

Mechanisms of injury were primarily motor vehicle accident and fall.

46% of patients were deemed unreliable mostly because of intoxication or distracting injury. Among the reliable patients (n=81), there were 4 major injuries that were not detected by the provider.

The negative predictive value of physician assessment ranged from 0.97 to 1 (CI 0.85 to 1). Sensitivity of physician assessment to the presence of major injury ranged from 0.67 to 1 (CI 0.09-1).

Conclusion: Clinicians can reliably detect major injuries in alert stable trauma patients who are deemed reliable. There were only four major injuries that were missed. None of these injuries required intervention beyond observation. Attention needs to be given to patients who are intoxicated or otherwise deemed unreliable and to patients with significant distracting injuries. These patients may benefit from increased CT scan utilization.

68. Padding the Slider Transfer Board and Patient Comfort in the Emergency Department Jerome R Walker1, Christopher P Anderson2 and Michael D Zwank1.

1 Regions Hospital, Saint Paul, MN; 2Healthpartners Research Foundation, Bloomington, MN

Background: A slider board (SB) is a rigid thin plastic board that facilitates the movement of a patient from an emergency department (ED) gurney to a radiology imaging table such as CT scan or x-ray.

Often patients who have experienced trauma are placed on a SB immediately on arrival in the ED with the anticipation of needs for imaging.

Objectives: The primary objective of this study is to compare patient comfort when using a padded versus an unpadded SB. Secondary objectives including number of imaging tests ordered and dose of analgesics.

Methods: This was a randomized controlled trial involving adults age 18-65 arriving to the ED on pre-hospital EMS backboard who were expected to be on a SB for greater than 30 minutes. Patients were excluded if: trauma team activation, pregnant, hemodynamically unstable, GCS < 14. Patients were randomized to standard care of slider board versus slider board padded by 3 inch egg crate overlay foam. Pain scores were measured using visual analog scale (VAS) measured in centimeters at 0, 30, 60, 90, 120 minutes.

Frequency/dosage of analgesics and number/type of imaging tests ordered were recorded. Variables were analyzed descriptively with means, medians, standard deviations and ranges. The outcome of pain (as measured by VAS) was evaluated for normality using the Kolmogorov-Smirnov test. The association between pain time and the use of a padded board was quantified using linear mixed-effects regression.

Results: 39 patients were enrolled (16 women, 23 men; 18 assigned to control, 21 padded). Mean age was 42. Mean time on the slider board was 107 minutes and mean number of imaging studies was 1.7.

Mean pain score in the control group was 6.73 and in the padded group was 5.45 (p=0.047). Pain ratings diminished in both groups over time. The time on the slider board, total amount of analgesics and number of imaging studies ordered was similar in both groups.

Conclusion: Padding the slider board led to decreased discomfort but not decreased amount of analgesics or number of imaging studies.

The difference in VAS scores is not likely to be clinically significant.

Since the conclusion of this study, our hospital has instituted a policy of only using the slider board when needed - not placing any patient on a slider board in anticipation of imaging studies.

69. The Utility of Computed Tomography in the Diagnosis of Renal Colic in the Emergency Department Michael D Zwank1, David J Gresback1 and Benjamin M Ho2.

1 Regions Hospital, Saint Paul, MN; 2University of Wisconsin, Madison, WI Background: Patients with renal colic commonly present to the emergency department and are usually treated with analgesics, antiemetics and rehydration. Rarely to these patients require more acute care or hospitalization. A very common approach to evaluating patients with suspected renal colic in 2011 is to use computed

tomography (CT) scan which carries a heavy burden in both radiation exposure and expense.

Objectives: Does CT scan change management, diagnosis or disposition in patients with suspected renal colic?

Methods: In this observational study, a convenience sample of 35 (ongoing enrollment, goal=100) clinically stable patients between the age of 18 and 50 with chief complaint of abdominal/back/flank pain and renal colic as the most likely diagnosis were enrolled. Exclusion criteria were: history of previous kidney stone, history of chronic kidney disease (CR >2.0), urinary tract infection, recent CT (<6 mo) or history of nephrectomy or renal transplant. Pre-CT and Post-CT surveys were completed by the treating provider. Descriptive statistics were used.

Results: 35 patients were enrolled in the study to date. The discharge diagnosis was renal colic in 24 patients (69%). 10 cases had change of diagnosis from renal colic: 4 muscular back pain, 3 abdominal pain, 1 ovarian cyst seen on CT, 1 ovarian mass seen on CT, 1 testicular torsion not seen on CT. 4 cases had changed disposition after CT-scan: 3 were diagnosed with renal colic/ureterolithiasis and admitted for further care and 1 was taken to the operating room for surgical management of testicular torsion. 10 patients were given tamsulosin only after confirmation of ureterolithiasis. In the pre-CT survey, providers thought that CT scan would/might be useful in 15 cases. In this group, 8/15 cases (53%) resulted in either changed diagnosis or disposition. Conversely, in cases where no perceived value would come from CT scan, 0/6 cases (0%) resulted in changed diagnosis or disposition.

Conclusion: CT scans with high perceived value prior to completion changed diagnosis or disposition in 53% of these patients while CT scans with no perceived value did not change diagnosis or disposition. There were a significant number of diagnosis and disposition changes after completion of CT. These results are limited by small patient numbers to date.

70. The True Impact Of A Left Vs. A Right Shift In Assessing A White Blood Cell Count: Bacterial Viral And The True Infectious Source David Milzman1, Anchal Ghai1, Jenika Ferritti-gallon2 and Stephan Chang1. 1Georgetown University School of Medicine, Bethesda, DC; 2 Georgetown University, Washington, DC Background: The complete blood cell count and differential, have been used f as a diagnostic tool for acute bacterial infections. it has always been taught that an increase in WBC accompanied by a specific increase in neutrophils especially immature neutrophils, referred to as a left shift, are associated with a bacterial infection. In contrast an increase in WBC, specifically lymphocytes, referred to as a right shift, is associated with a viral disease.

Objectives: This study will compare proven viral and bacterial infections and the finding of right and left WBC shifts with the respective infectious causation.

Methods: The study was completed at a level 1 trauma center urban teaching ED with 87,000 annual visits. A retrospective cohort study of all ED patients presenting between Jan 1 2009 and Jan 1 2011with a full white blood cell count and differential performed on admission with necessary supporting medical record info obtained through the Azyxxi( Smith, M and Microsoft, Redmond, WA) EMR. Viral disease was confirmed with a positive viral swab and bacterial infection was confirmed with positive blood culture.

Results: a total of 107 viral infections and 205 bacterial infections meeting strict criteria were discovered. There was a difference for age and gender between the two groups with mean age for viral 44.5 and bacterial 62.2 with viral having 65% female and bacterial : 51% female P 10000 neutrophils was 79% accurate compared to accuracy for a right shift finding a viral infection was 34%.

Conclusion: Although the total WBC was greater in bacterial VS viral infection the finding of the "classic" shifts in lymphocyte

predominance for viral infections was not accurate and that of bacterial infection was found to be a better marker.

71. Pre-Arrest Characteristics and Use of Advance Directives among Out-of-Hospital Cardiac Arrest Victims David Milzman1, Erwin Wang2 and Han Huang3. 1Georgetown University School of Medicine, Bethesda, MD; 2Georgetown University School of Medicine, Bethesda, DC; 3Georgetown University School of Medicine, Washington, DC Background: Several factors have Early recognition of an arrest improves survival, as every delay in initiating treatment reduces likelihood of survival (Larsen, 1993) demonstrated to improve CA survival rates.

Objectives: to determine the true survival to hospital discharge in a major urban city with a documented less than 5% survival rate from out-of hospital cardiac arrest and to evaluate the value of implementing advanced directives from the prehospital side.

Methods: A two year prospective data collection and scene investigation study of all cardiac arrest victims who presented to a 87, 000 Annual ED visit urban teaching hospital was completed b/w 2009-2010. Utstein criteria and Demographic information including age, gender, and ethnicity Medical information: Location of cardiac arrest Incidence of pre-existing disease EMS response time Presenting cardiac rhythm Interventions by EMS, family m Results: Initially, 199 cases were identified and 53 were excluded according to Utstein criteria: of the 146 included study patients there was an overall 6/6 % survival to hospital discharge. CA was most frequently reported from home with a 8.6% survival rate vs. skilled nursing facility 1.8% survival. P < 0.03. SNF patients were older, had lower SF-36 scores for independent living and actually had only 2/ 66 with Advanced directives in place.

Conclusion: Advanced directives do not coincide with low independent functionality in this urban city with very low cardiac arrest survival even from V Fib. Improvements in education and acceptance of not only DNR orders but bystander CPR are needed to improve outcomes and correct expectations.

72. Comparison of Data Collection Using Real Time Observers to Subsequent Review of Video Data for Airway Management Research James Miner, Megan Terrebonne, Robert Reardon and John McGill. Hennepin County Medical Center, Minneapolis, MN Background: The optimal method of data collection for clinical airway research is unknown.

Objectives: To compare data collected by a real-time observer to data obtained by subsequent review of video of the same procedure by a different observer.

Methods: This was a prospective observational study of patients undergoing endotracheal intubation at an urban level one trauma center where all emergency intubations are recorded using video devices from three distinct angles with the cardiac monitor information recorded alongside these images. Observers at the bedside collected information regarding vital signs, airway maneuvers, method of intubation, number of breaths delivered by bag-valve-mask, number of intubation attempts, the duration of each maneuver and attempt, and any adverse events including oxygen saturations <93%. The same procedure was subsequently reviewed for the same data using the video recordings of the procedure using a different observer. Data describing the occurrence of hypoxia, the number of bag-valve-mask breaths given, the number of intubation

attempts, and the time to successful intubation recorded for each procedure were compared between the real time assessment and the video assessment. Data were compared using descriptive statistics.

Results: Twenty patients were included. The number of breaths given by bag-valve mask prior to intubation was different between the two groups in 8 cases. More breaths were detected by video than by real time in 6 cases (median difference 6, range 1 to 17). The device used was recorded the same in both groups (13 laryngoscope, 7 CMAC). The drugs given and the doses were recorded the same in both groups. The lowest oxygen saturation was recorded the same in both groups. The number of attempts was the same in both groups.

The time to intubation was recorded the same in 14 cases. In one case the time to intubation could not be determined from the video. In 4 cases it was longer in the video group (median difference 45 seconds, range 22 to 95); in 1 case it was longer in the real-time group (difference 2 minutes).

Conclusion: There were significant discrepancies between the data collected from real-time observers and from review of video. It is possible that a combination of video and real-time data collection may improve research accuracy.

73. Correlation Between Exercise Levels and Medical School Board Scores Vijai Chauhan and Sean Cavanaugh. Saint Louis University SOM, Saint Louis, MO Background: Medical education is recognized as a stressful undertaking and coping strategies of students impact their performance and wellbeing. It is accepted that the demanding workload often prevents students from a steady exercise schedule, and as they progress through their medical training, good health habits and health status decline. A few studies with adolescents have strongly suggested a positive relationship between physical fitness and academic achievement, although the causation may be unclear.

However none have examined a relationship between levels of exercise and academic performance in medical students.

Objectives: This study sought to find a correlation between exercise levels and academic performance as indicated by student US Medical Licensing Examination (USMLE) Step 1 test scores.

Methods: This IRB-approved study involved two anonymous surveys of a midwestern medical school class of 2012. The first survey was administered at the beginning of 2nd year and the second survey at beginning of the 3rd year of medical school. Surveys asked height, weight & exercise practices. The second survey included specific questions about weekly exercise practices over the preceding year, and also a 10-digit range of USMLE Step 1 score.

Results: A total of 28 students responded to the second survey, 46% male, with a mean age of 24.8 and mean BMI of 22.6. Two groups were designated according to USMLE score range of 226-265 or 186225. Those in the lower score group had a higher BMI of 23.5 versus the higher score group with BMI of 21 (p=0.110). Exercise practices of these two groups were examined by comparing the self-reported average number of hours of exercise per week over the previous year, 3.42 for the 186-225 group versus 4.13 for the 226-265 group (p=0.431). The group that exercised more had a higher incidence of reporting running/jogging and weight training as their preferred modes of exercise.

Conclusion: This small study suggests an association between a higher USMLE Step 1 score with increased exercise activity and lower BMI, although calculated p-values did not indicate statistical significance. Both factors suggest a motivated individual. Further study involving more respondents is necessary to better characterize the validity of this association.

74. Pain Medication Delivery In The Ed For Extremity Fractures: Correlation Of Prescribers' And Patients' Gender And Ethnicity David Milzman1, Valerie Huckabee1, bill dirkes1, Julie Vieth2 and collier Wright1. 1Georgetown University School of Medicine, Washington, DC; 2Georgetown U / Georgetown WHC EM Residency, Washington, DC Background: There is great debate on timing of pain medication in the ED and especially if there may be bias based on patient selection factors such as age, gender and ethnicity. No study has really investigated the role of the physician prescriber own demographic factors in relation to that of the patient.

Objectives: Primary: To determine if bias exists in analgesic prescribing practices based solely on patients' gender and ethnicity Secondary: To determine if the gender and ethnicity of the physician relative to that of the patient influenced pain management Methods: A 5 year review of patients presenting to an Urban, Teaching Hospital ED with 80,000 annual visits.

Inclusion criteria: Adult patients with long-bone fractures but without other distracting diagnoses Caucasian, African American, Latino or American Indian Primary Outcome: Administration of analgesia in the ED based on patient gender and ethnicity.

Secondary Outcome: Gender/ethnicity of prescribing physician and type of medication Results: 782 patients met inclusion criteria. Mean age was 50.9 years, 60.7% were female, 191 identified as Caucasian, 562 as African-American, 95 as Latino/Hispanic Physician prescriber incidents: 79% male and 55% White, 29% African American and 14% Asian.

There was no outlier group with regard to physician and patients when looking at timing of pain medication delivery and narcotic VS non narcotic medication selection. Although overall ED physician performance was delayed with mean time to medication > 30 min in 68% of cases without bias and overall, all groups tended to administer less medication to women VS men and Older > 65 yrs received less mediation than younger patients without bias based on physician prescribing.

Conclusion: No observed bias based on patient gender nor ethnicity No observed bias based on physician gender nor ethnicity Type of pain medication prescribed and delay to medication delivery in minutes were independent of the race and gender of patients and physicians

75. Protein Expression Of M2 Receptor In Atria And Ventricles Of Sham Rats Elizabeth M Spartz, Huiyin Tu, T. Paul Tran and Yu-Long Li. University of Nebraska Medical Center, Omaha, NE Background: Autonomic dysfunction is being recognized as an important pathogenic cause of increased morbidity and mortality in many disease states, including chronic heart failure (CHF) and diabetes mellitus (DM). The dysfunction is caused by an imbalance between the sympathetic tone, which of left ventricle, right ventricle, left atria, and right atria were harvested, homogenized, and protein levels for M2 receptors were measured using western blotting.

Results: See graph (attached).

Conclusion: Cardiac function is profoundly affected by neural activation. While activation of the sympathetic system increases heart rate, contractility and conduction velocity, activation of the parasympathetic system (PNS) has the opposite effects; PNS is concerned with rest, conservation, and restoration of energy via reduction of heart rate and blood pressure. Of the five muscarinic subtypes, only M2 receptors appear to be clinically relevant in mammalian cardiac physiology. Although a body of data established

that PNS outflow is reduced in disease states such as CHF and DM, it is not clear whether the reduction in PNS outflow occurs at the ICG level or the PNS terminal level. This preliminary study is part of our larger study to answer the question if the reduction in PNS outflow in CHF/DM is caused by a dysfunction in ICG or a reduction in M 2 receptor at the cardiac tissue. Consistent with data obtained through other methods, our data suggest that most of the M2 receptors localize in the cardiac atria in this rodent model.

76. Rates of Selected Procedures and High-Acuity Diagnoses in Urban and Rural Emergency Departments James Waymack, Steve Markwell and Ted Clark. Southern Illinois University, Springfield, IL. Background: EM workforce studies show relatively low rates of board certified/residency-trained emergency physicians practicing in rural EDs. Rural ED rotations for EM residents may lead to increased numbers of residency-trained EM providers in rural areas, as well as provide unique training experience. There is concern, however, that residents trained in rural environments will not get sufficient procedural experience or patient acuity.

Objectives: To compare the rates of selected procedures and highacuity diagnoses at rural and urban EDs in the US. Methods: Procedures and high-acuity diagnoses were selected based on ACGME guidelines and were identified in the Nationwide Emergency Department Sample (NEDS) database by ICD9 Code.

The rates of procedures and diagnoses, reported as a percentage of all visits, are compared between two categories. The urban category (U) includes hospitals that are in counties defined as large or small metropolitan; the rural category (R) includes hospitals that are in counties defined as metropolitan or non-metropolitan.

Results: Procedure rates are lower for rural EDs. (R%, U%) Fracture reduction - 0.25, 0.46; chest tube - 0.06, 0.13; cricothyrotomy - 0.01, 0.07; intubation - 0.27, 0.55; lumbar puncture - 0.13, 0.33; pericardiocentesis - 0.002, 0.007; thoracotomy - 0.002, 0.006. Highacuity diagnosis rates are lower for rural EDs. (R%, U%) Acute MI 0.53, 0.68; cardiac arrest - 0.19, 0.24; cardiac dysrhythmia - 3.50, 4.36; pneumothorax - 0.04, 0.05, intracranial bleeding - 0.10, 0.15; ischemic CVA - 0.73, 0.88; acute appendicitis - 0.19, 0.29; ectopic pregnancy - 0.02, 0.05; pulmonary embolism - 0.12, 0.19; aortic aneurysm - 0.13, 0.17; aortic dissection - 0.01, 0.02; testicular torsion - 0.01, 0.02.

Conclusion: The lower rates of procedures and high-acuity diagnoses in rural EDs confirms the concern that residents receiving a substantial portion of their training in rural EDs may not get sufficient experience in certain procedures or diagnoses. The benefits of a rural ED rotation must be weighed against the risk of lower procedure and high-acuity diagnosis rates. The impact of a 1-3 month rotation in a rural ED on overall procedural competency and clinical experience cannot, however, be extrapolated, and further study is required to quantify this effect.

77. Do Alcohol-Related Emergency Department (ED) Visits Mirror Police Data? A Retrospective Study Greg Pelc, Michael Takacs and Hans House. University of Iowa, Iowa City, IA Background: A 2011 self-reported survey at the University of Iowa (UI) indicates that 64.5% of UI students engaged in binge drinking in the past two weeks, exceeding the national average of 44%. The UI has recently supported a number of programs to address this problem, including AlcoholEdu, more Friday classes, Red Watch Band Program, the under 21-Ordinance, and increased late-night programming. Measures to identify the effectiveness of these interventions are needed to determine their worth. Police data and alcohol-related ED visits are two measures for adverse consequences of alcohol use.

Objectives: The study was designed to examine the relationship between alcohol-related visits at the UI ED with Iowa City Police Department (ICPD) and University of Iowa Police Department (UIPD) records. Does the level of alcohol-related ED visits reflect the number of alcohol-related incidents documented by police?

Methods: ED medical records for patients 18-22 years of age presenting between 6:00 pm and 6:00 am were retrospectively examined from June 2008 to May 2011. Patient data (including age, date and time of visit, and diagnosis) was compiled for any subject with an alcohol-related illness or injury. ICPD and UIPD records were obtained and compiled into categories for common offenses.

Monthly totals for alcohol-related ED visits were then compared to police data using correlation tests.

Results: From June 2008 to May 2011, there were 1,258 alcoholrelated ED visits. In the same period, the aggregate police data indicated the following number of charges: 3,335 Public Intoxication (PI), 2,937 Possession of Alcohol Under Legal Age (PAULA), 1,572 Operating While Intoxicated (OWI), 1,143 Disorderly Conduct (DC), and 784 Interference with Official Acts (IOA). A weak positive correlation exists between alcohol-related ED visits and alcoholrelated police charges, with correlation coefficients for ED visits versus PI, PAULA, and IOA charges of 0.61, 0.55, and 0.51, respectively.

Conclusion: The weak positive correlation between alcohol-related ED visits and police charges tracks the general trends of college-age alcohol abuse, with rises and falls cyclically based on student life in Iowa City. Both ED and police data are worthwhile measures of college-age alcohol abuse in Iowa City, as they are not mutually dependent upon one another.

78. Acute Disaster Response: Lessons Learned from a Smallscale Event Kathy Lehman-Huskamp and Anthony Scalzo. Southern Illinois University, Springfield, IL; Saint Louis University, Saint Louis, MO Background: In August 2008, the St. Louis area experienced an incident involving nine individuals who were illegally entering a waste dumpster at a repackaging facility in East St. Louis, IL. The men were inadvertently exposed to nitroaniline. Within hours, the individuals began having symptoms and presented by either private car or ambulance to hospitals in St. Louis, MO. This event ultimately resulted in the temporary closing of two Emergency Departments and one Intensive Care Unit.

Objectives: To illustrate critical lessons learned with disaster response involving a small-scale event.

Methods: A retrospective analysis was performed on publicly available records of a real-time event. This project was determined to be exempt from review of the Institutional Review Board.

Results: Eight significant lessons regarding disaster response were derived from this experience.

Conclusion: Disaster response plans cannot solely be based on mass casualty events. Small scale events such as this case study have a higher probability of occurrence in any given response area.

Consequently, disaster planning must be flexible in its response scale at both the emergency responder and hospital level.

Medical Student SimWars Competition Kansas University Medical Center Jeremy Cook, MS2 Patrick Harper, MS2 Elspeth Pearce, MS2 Julianne Schwerdtfager, MS2

St. Louis University, School of Medicine Team 1 Stephen Gregory, MS4 Sarah Kuehnle, MS3 Stefan Law, MS3 Andrew Jung, MS2 Neil Kalsi, MS3 (alternate)

St. Louis University, School of Medicine Team 2 Cory Cheatham, MS3 Matthew Fellin, MS3 Jeff Scott, MS3 Kamran Hussaini, MS2 Jacinta Robenstine, MS3 (alternate)

Southern Illinois University, School of Medicine Jennifer Carroll, MS3 Loren Reed, MS3 Matt Albrecht, MS4 Dan O‟Keefe, MS4 Mike O‟Keefe, MS4 (alternate)

Washington University in St. Louis, School of Medicine Team 1 Rob Klemisch, MS2 Akshay Ganju, MS2 Clark Smith, MS4 Sara Manning, MS4

Washington University in St. Louis, School of Medicine Team 2 Austin Wesevich, MS1 Dylan Kluck, MS1 Amelia Lucisano, MS1 Shelley Forbes, MS1

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