Abstracts Session 1 - Room: 2A 0900-1150
Emergency Medicine Resident Driving Behaviors following Overnight Shifts
Ryan Tabor, MD; Neeraj Chhabra, MD
Background: There are numerous studies showing that sleep deprivation impairs the ability of automobile drivers to drive safely. The authors’ aim was to characterize the driving behaviors of Emergency Medicine (EM) residents following overnight shifts, the factors that influence these behaviors, and the prevalence of motor vehicle collisions.
Methods: An online survey was administered to 8 EM residency programs in one large urban center. The survey assessed knowledge of fatigued driving research, transportation methods surrounding overnight shifts in the Emergency Department (ED), and factors which may influence transportation decisions.
Results: The survey had 118 complete responses. A total of 5 respondents (4.3%) admitted to being involved in a motor vehicle collision (MVC) while driving after an overnight shift.
96% of the residents were aware of studies suggesting sleep deprivation can impair driving ability in the general population, and 86% were aware of studies that suggest working overnight shifts impairs physicians’ ability to drive safely.
79% of residents with automobiles report they “always” drive home following an overnight shift without a nap. Residents cited many factors that contributed to their decision to drive home without a nap, including: inadequate quality of call rooms (17%), inability to afford a rideshare/taxi home (11%), family obligations (9%), and a personal preference unrelated to the aforementioned factors (87%). The most commonly reported intervention that would likely facilitate safe transportation home was increasing subsidies for rideshare transportation home (51%).
Conclusions: A small, but not negligible, percentage of residents have been involved in a MVC following overnight shifts. Also, these data suggest that EM residents are largely aware of the risks of fatigued driving, but most still drive home following an overnight shift without a nap beforehand. Further education on fatigued driving, therefore, may not help alleviate this potential risk. A personal preference to sleep at home, unrelated to hospital or financial matters, is the most common motivation to drive home. These data suggest that the best way to address this issue may be to increase subsidies for taxi and rideshare transportation.
The Fast and the Furious: Focus on All-Terrain Vehicle Crashes and Estimated Speeds
Meghan Reaney, Gerene Denning, and Charles Jennissen
Background: All-terrain vehicle (ATV) crashes in the U.S. result in around 700 deaths and over 100,000 emergency department visits each year. One of the least studied risk factors is speed, because of significant barriers to data collection. The goal of this study was to better understand factors contributing to the clinical outcomes of ATV crashes.
Methods: Demographics and clinical outcomes were extracted from patient charts at the University of Iowa Hospitals and Clinics (UIHC) Emergency Department (ED) for victims of ATV crashes from 2010-2017. Additional variables were coded from patient notes. Descriptive and comparative analyses were performed on compiled data using SPSS (Statistical Package for the Social Sciences).
Results: Over the study period, 458 victims of ATV crashes were seen in the ED. The study population was 76% male, 25% were children <16 years of age, and only 18% were helmeted. Vehicle/crash characteristics included: 19% involved multiple ATV riders, 96% were recreational use, 6% were collisions with another motorized vehicle, 24% were collisions with an object, and 70% were non-collision events. Clinical outcomes included: 2% died, 25% suffered severe injuries (ISS >15), 78% were hospitalized, 21% were in the ICU at least 1 day, and 12% required ventilation. For speed, 174 records (38%) had an estimated speed, and one-third of documented cases had estimated speeds <20 mph. A greater proportion of adults than youth were traveling at high speeds (77% vs. 40%). Interestingly, there were no significant differences in the proportion hospitalized, requiring ICU care or ventilation, or having an ISS>15 when comparing crashes at low and high speeds.
Conclusions: Our studies demonstrate the serious consequences of ATV crashes that required emergency care at our institution. Although speed can increase the severity of injuries under some circumstances, even ATV crashes that were estimated to occur at 20 mph or less often resulted in serious injuries. We speculate that contributors to this observation would include lack of helmet use and being hit or pinned by the ATV, circumstances that can be seen in crashes at all speeds. There remains a continuing need to better understand ATV-related crash and injury mechanisms in order to develop effective injury prevention efforts.
Roadway to Disaster: Adult All-terrain Vehicle Crashes on Iowa’s Road
Sampson L, Stange N, Fjeld A, Denning G, and Jennissen C.
Background: Each year, U.S. all-terrain vehicle (ATV) crashes result in over 700 deaths and hundreds of thousands of injuries. The majority of these crashes involve operators over 16 years of age. Research shows that roadways are the most dangerous places to ride ATVs, but only a few studies have specifically examined the characteristics and outcomes of roadway-related ATV crashes. The goal of this study was to characterize statewide roadway crashes with adult ATV operators in a Midwest state.
Methods: Descriptive and comparative analyses (SPSS, Statistical Package for the Social Sciences) were performed on Iowa Department of Transportation data (476 crashes, 2002-2017). The study focused on crashes with adult (>18 years) operators.
Results: There was a steady increase in road-related crashes with adult operators over the study period from 104 in 2002-2005 to 144 in 2014-2017. Crash victims were 77% male and only 8% were helmeted. Almost half of crashes (47%) involved multiple riders on the ATV, 75% occurred in rural areas, one-quarter were collisions with a roadway vehicle, and 72% were on roads with speed limits >35 mph. Over 60% of crashes occurred on weekends (Friday-Sunday) and the vast majority (94%) occurred in good weather. Among all adult riders in the crash, 9% were killed and together more than half (53%) suffered severe or fatal injuries, with the majority of these deaths and injuries involved young adults 18-30 years of age. For drivers 18-60 years old, 1 in 5 were impaired by alcohol and/or drugs, whereas only 3% of drivers 60 and older were driving while impaired (p=0.011). Another age-dependent difference was in crash mechanism. The youngest (18-30 years) and oldest (>60 years) operators were more commonly involved in collisions with another vehicle or with an object, as compared to middle-aged adults.
Conclusions: Evidence shows that roadway riding is an independent risk factor for ATV-related crashes and injuries. This study further demonstrates that multiple risky behaviors by Iowa’s adult ATV operators, including riding on high speed limit roads and operating ATVs while impaired, is contributing to preventable deaths and serious injuries. Our results also suggest a critical need for additional ATV injury prevention strategies, including targeted approaches for different adult age groups.
The Dark Side of Nighttime Off-Road Vehicle Use
Stange N, Fjeld A, Sampson L, Denning G and Jennissen C.
Background: Off-road vehicles (ORVs), which include all-terrain vehicles (ATVs) and side-by-sides (SxSs), are designed for off-road use only. Iowa law restricts roadway riding to occupational purposes and limits it to daylight hours. A growing number of Iowa counties are opening roadways to recreational ORV use and many counties are choosing not to include a daylight restriction. To better understand this issue, the study objective was to compare and contrast daytime and nighttime OHV crashes on Iowa’s roads.
Methods: Analysis was performed using Iowa Department of Transportation crash data from 2002 to 2017 to analyze potential differences between daylight and nighttime crashes. Crashes at dawn and dusk were not included in the analysis. Darkness was defined as 30 minutes after sunset and ended 30 minutes before sunrise as reported by the National Weather Service. Youth were defined as <16 years of age. All analyses were performed using SPSS (Statistical Package for the Social Sciences).
Results: About one-quarter of roadway crashes included in analysis occurred in the dark, and identical proportions were observed for males and females. The proportion of nighttime crashes was higher for adults than for youth (30% vs 11%, p<0.0001). In 48% of nighttime crashes, the vehicle operator was physically or cognitively impaired in some way (e.g. alcohol use). Impairment was only observed in 11% of drivers in daytime crashes. A higher proportion of daylight versus nighttime crashes were on roads with speed limits >50 mph (57% vs. 34%, p<0.0001), still fully a third of nighttime crashes occurred on roads with highway speeds. Motor vehicle crashes were more common during the day (35%) than at night (13%), p <0.001. Fatal (15%) and major (49%) injuries occurred more frequently in nighttime crashes as compared to daytime (8% fatal, 39% major), p=0.003.
Conclusions: Operating OHVs on roads already represents a high-risk activity. The observation that a higher proportion of fatal and severe injuries occurred at night as compared to during the day suggests additional factors may contribute to the severity of crashes after dark. Targeted injury prevention strategies are clearly needed, including educating users about the dangers of roadway and nighttime operation, as well as better enforcement of state and local OHV safety laws.
The All-Terrain Vehicle Exposure and Crash Experiences of Iowa FFA Members
Cole Wymore, Gerene Denning, Nicholas Stange, Mitchell Hooyer, Pam Hoogerwerf, Lauren O’Donnell, Kristel Wetjen, Charles Jennissen
Background: All-terrain vehicles (ATVs) are used by adolescents for both recreational and occupational purposes, especially in rural areas. About 30% of all serious injuries due to ATVs in Iowa are suffered by children <16 years old. The study objective was to better understand the ATV-related exposure and crash experiences of Iowa adolescents.
Methods: Attendees of the 2017 and 2018 Iowa FFA Leadership Conference were surveyed at the Iowa ATV Safety Task Force booth. Descriptive and comparative analyses were performed on collected data.
Results: A total of 1,573 FFA members 12-19 years old participated. The vast majority (95%) had ridden an ATV. Nearly all reported having ridden as a passenger. Mean age at which respondents first rode as a passenger was 5.9 years, and as an operator was 8.8 years. Nearly 20% and about 30% reported having crashed on an ATV when riding as a passenger and as a driver, respectively. The mean age at which they first crashed as a passenger was 10.5 years and as a driver was 11.0 years. On average, males first drove ATVs about a year earlier than females. Both those that lived on farms or whose families owned an ATV were significantly younger when they first rode an ATV than those that lived elsewhere or did not own an ATV, respectively. Overall, over one-third had been in at least one ATV crash. Males and those who live outside city limits had higher percentages that had been in a crash. Fifteen percent of those in an ATV crash required getting medical attention and the mean age at the time of their first crash that required medical attention was 11.5 years.
Conclusions: Iowa FFA members reported nearly universal exposure to ATVs and commonly practice unsafe riding behaviors. Families are routinely not enforcing safe ATV practices and are allowing children to ride and drive ATVs at ages which are not developmentally appropriate and against manufacturer recommendations.
How to Increase ATV Safe Riding Behaviors in Youth: FFA Members from Across the Country Respond
Mitchell Hooyer, Nicholas Stange, Cole Wymore, Gerene Denning, Pam Hoogerwerf, Lauren O'Donnell, Charles Jennissen
Background: All-terrain vehicles (ATVs) are a significant source of injuries and deaths. In fact, more children <16 years of age die in the U.S. from ATVs than from bicycle crashes. This study’s objective was to explore the best methods to improve adolescent ATV safety practices from the target audience’s perspective.
Methods: ATV safety workshop attendees at the 2018 National FFA Convention answered a number of questions after facilitated discussions. Qualitative analysis of responses was independently performed by three research team members, and differences in coding were resolved through an iterative process.
Results: 309 FFA members from 62 clubs participated (29 states). Almost all clubs stated that one reason most youth don’t ride ATVs safely is because of personal beliefs (e.g. inconvenient/not as enjoyable to ride safely). Almost three-fourths stated that an unsafe riding behavior that young people would be most likely/willing to change was wearing a helmet; safety behaviors least likely/willing to change would be traveling at lower speeds and not carrying passengers. The majority of clubs stated that one of the best places to reach youth was at schools; the second most frequently mentioned was social media. Safety presenters that clubs felt youth would be most likely to listen to were peers and those just slightly older than themselves, followed by crash survivors and those whose loved ones had been injured or died. Presentations with real-life injury examples including videos that might create a “fear factor” and hands-on activities were thought to be most effective in promoting safe riding; the least effective methods were lengthy, non-interactive presentations and printed materials with lots of facts and statistics.
Conclusions: Youth have strong opinions regarding injury prevention information delivery, and what is likely to result in behavioral change. Our study provides important data regarding not only ATV safety information delivery, but other prevention messaging to youth as well.
Reviewing Disasters: Hospital Evacuations in the United States From 2000-2017
Aishwarya Sharma
Background: Between 2000 to 2017, there were over 150 hospital evacuations in the United States (US). Data received from approximately 35 states was primarily concentrated in California, Florida, and Texas. This analysis will provide disaster planners and administrators statistics on hazards that cause disruptions to hospital facilities. The purpose of this study is to investigate US hospital evacuations, compiling the data into external, internal, and man-made disasters; thus, creating a risk assessment for disaster planning.
Methods: Hospital reports were retrieved from Lexis Nexis, Google, and PubMed databases and categorized according to evacuees, duration, location, and type. These incidents were grouped into three classifications: external, internal, and man-made.
Results: Both partial and full evacuations were included in the study design. There were a total of 154 reported evacuations in the US. 110 (71%) were due to external threats, followed by 24 (16%) man-made threats, and 20 (13%) internal threats. Assessing the external causes, 60 (55%) were attributed to hurricanes, 21 (19%) wildfires, and 8 (7%) storms. From the internal threats, 8 (40%) were attributed to hospital fires and 4 (20%) chemical fumes. From the man-made threats, 6 (40%) were attributed to bomb threats and 4 (27%) gunmen. From the 20 total reported durations of evacuations, 9 (45%) lasted between 2 to 11:59 hours, 6 (30%) lasted over 24 hours, and 5 (25%) lasted up to 1:59 hours.
Conclusion: Over 70% of hospital evacuations in the US were due to natural disasters. Compared to 1971-1999, there was an increase in internal and man-made threats. Exact statistics on evacuees, durations, injuries, and mortality rates were unascertainable due to a lack of reporting. It is critical to implement a national registry to report specifics on incidences of evacuations to further assist with disaster and infrastructure planning.
Mortality in Nursing Home Evacuations in the United States From 1995-2017
Aishwarya Sharma
Background: There are an estimated 15,600 nursing homes with a total of 1.4 million residents in the United States. The number of residents will continue to increase due to the aging population, and the associated morbidities will make it difficult to evacuate them safely. This study is the first of its kind to provide an analysis on the number of nursing home deaths caused by external and internal events following evacuations.
Methods: Information from the databases Lexis Nexis and PubMed were compiled and limited to news articles from 1995-2017. The gathered information included the reason for evacuation, injuries, deaths, and locations within the United States.
Results: From 1995 to 2017, there was a total of 51 evacuations and 141 deaths in nursing homes. 27 (53%) evacuations were due to external events which resulted in a combined 121 (86%) deaths, and 24 (47%) evacuations were due to internal events which resulted in a combined 20 (14%) deaths. Hurricanes were responsible the majority of deaths during evacuations, followed by fires and floods. The number of evacuations and deaths increased the greatest between 2005 to 2008.
Conclusion: External events have the greatest impact on loss of life. Internal disasters are about equal in number of incidents, however external events have a much greater mortality rate. Exact numbers on injuries, morbidity, and mortality are difficult to ascertain, but it appears to be related to natural disasters. In view of the increasing likelihood of natural disasters related to global warming, a drastic improvement of standard evacuation procedures of long-term nursing homes is critical to decreasing mortality of nursing home residents. There also needs to be a national standardized method of reporting evacuations in order to better analyze data on nursing homes.
The Dangers of Off-Road Vehicles to Youths: Not Something to Kid Around About
Fjeld A, Sampson L, Stange N, Denning G, and Jennissen C.
Background: Children are not allowed to operate motor vehicles such as cars until they are 16 years old due to the risks associated with the operation of such powerful machines. Yet, the operation of off-road vehicles (ORVs) by youths under 16 years old has been largely normalized in both rural and urban communities, despite the significant safety risks involved. To better understand this issue, the goal of this study was to characterize roadway ORV crashes with youth operators, including riding behaviors and crash outcomes, in a Midwest state.
Methods: Descriptive and comparative analyses (SPSS, Statistical Package for the Social Sciences) were performed on Iowa Department of Transportation (DOT) data (115 crashes from 2002-2017). This study focused on crashes involving youth (<16 years old) operators.
Results: In Iowa’s pediatric roadway crashes from 2002-2017, 63% of victims were male and 81% were 12-15 years old. Females were more commonly passengers than were males (60% vs. 24%), as were younger (<12 years) as compared to older riders (56% vs. 26%). Only a small percentage of victims were helmeted, 24% of operators and 14% of passengers. Additionally, 73% of all roadway crashes involved multiple riders on the ATV, around 40% occurred on paved roads, and 82% occurred in rural areas. Collisions with an object or another vehicle were the mechanism in 65% of crashes. Roads with speed limits over 50 mph were the location of around half (52%) of all crashes. Among pediatric victims, 3.5% were killed in the crash and 46% of the pediatric roadway crashes resulted in either major injury or death. Moreover, a higher proportion of the fatal or incapacitating injuries were observed in adolescents (12-15 years) than in younger children (35% vs. 23%).
Conclusions: Results illustrate multiple risky behaviors are common among youth in roadway ORV crashes, including riding on high speed roads, with passengers, and/or without helmets. Adolescents (12-15 years old) are the large majority of pediatric victims, and serious injury or death resulted in almost half of all crashes. Based on these results, it is clear that multiple targeted approaches are needed for youth under 16 years old in order to prevent pediatric fatalities and severe injuries, particularly on the road.
Screening for UTIs in Febrile Children: Do We Follow the Guidelines?
Adam Rodos, MD., Jan Chang, MD., David Chestek DO, Hannah Seyller, Stacy Laurent, DO, Leah Finkel, MD.
Background: Urinary tract infections (UTIs) are a common source of unexplained fevers in children, and missed UTIs account for significant patient morbidity. Preverbal children may not be able to inform caregivers or medical professionals of urinary symptoms. Existing guidelines can help determine when to evaluate for UTI in febrile children. We wanted to determine how often we follow the guidelines when screening for UTI in one ED.
Methods: Using the Childrens’ Hospital of Philadelphia (CHOP) Febrile UTI guideline, we reviewed all charts of febrile children who presented to our urban, academic ED, staffed by a mix of PEM and non-PEM clinicians, in December 2018. The CHOP guideline stratifies patients based on the number of UTI risk factors present and categorizes them as either consider (lower risk) or recommend (higher risk) screening for UTI. We collected retrospective data regarding guideline adherence and practice variability as part of a QI project.
Results: 94 patients met inclusion criteria for chart review (febrile patients aged 3 to 36 months). 29 patients were excluded due to incomplete data regarding risk factors, leaving 65 patients in the final analysis. Out of 65 patients, 38 had risk factors that met guideline criteria for UTI screening.
In patients with the recommendation to consider UTI screening, only 24% (9/38) underwent screening. When screening was recommended, only 32% (6/19) of patients underwent screening. Under-screening was most notable among circumcised males. In patients not screened for UTI despite CHOP recommendations for screening, 100% (13/13) had alternate sources of fever identified. This overall lack of guideline adherence persisted when comparing patients cared for by PEM vs. non-PEM.
Conclusion: We identified under-screening for UTI in febrile patients aged 3 to 36 months who presented to our ED. This discrepancy existed in both genders but was most pronounced in circumcised males, suggesting that clinicians may underestimate the true risk for UTI in this population. This baseline data is a starting point to increasing adherence to published guidelines for UTI screening in febrile children. Information from providers is needed to confirm reasons for under-screening. This information can then inform the creation of an intervention to improve pediatric UTI guideline adherence.
Social workers’ determination of when a child being left home alone constitutes child neglect
Charles A Jennissen, Erin M Evans, Alycia A Karsjens, Gerene M Denning
Background: Decisions made by child welfare workers related to the determination of child neglect play an important role in promoting responsible childcare and preventing harm to children. This study’s objective was to identify factors influencing determination by social workers as to when leaving children home alone constitutes child neglect.
Methods: Email invitations to participate in an online survey were delivered Oct-Dec, 2015, to National Association of Social Workers (NASW) members designating their practice as “Child/Family Welfare” (N=4,933). Respondents were asked to indicate whether scenarios involving a child of varying age knowingly left home alone for four hours were neglect, in the presence or absence of injury to the child and the presence or absence of relevant law. Descriptive and bivariate analyses were performed.
Results: 485 social workers completed the survey; ~10% of those who received an email invitation. In the scenario where there were no relevant laws and the child was uninjured, almost 100% of experts determined this was child neglect for children 4 yrs old. For 6, 8, 10, 12, and 14 yrs of age, this was 97%, 83%, 51%, 11%, and 1%, respectively. A significantly higher percentage of social workers considered it child neglect for most ages if there was an injury versus not, and if there was a law versus not. For 14 yrs of age, the proportion went from 1% if there was no law and no injury to 51% if there was a law and the child was injured. Similarly, for 12 yrs of age, the proportion went from 11% if there was no law and no injury to 64% if there was a law and the child was injured. There were some demographic differences observed in the ages determined to be child neglect for each scenario. Ninety-four percent of participants stated that leaving a child home alone for four hours should be illegal if the child was <8 yrs old, and over 80% said it should be illegal for children <10 yrs of age.
Conclusion: Despite the risk to the child being the same, sustaining an injury and the presence of a law both increased the percentage of social workers that considered a child being left home alone for 4 hours as child neglect. These results suggest the need for guidelines and/or safety laws related to childhood supervision, as well as their uniformity across the country, in order to direct social workers in their evaluation of potential cases of child neglect and to better protect children from harm.
The Model Development, Validation and Refinement to Identify Anaphylaxis in Pediatric Patients Presenting to the Emergency Department
Kelsey Anderson, B.S.; Karisa K Harland, PhD, MPH; Sangil Lee, MD, MS
Background: The number and severity of anaphylaxis cases presenting to the Emergency Department (ED) is increasing and can create a potentially difficult diagnosis. The objective of this study was to validate the known combinations of food allergy, angioedema, hoarseness, dyspnea and nausea with clinical information to estimate a concise model for anaphylaxis diagnosis among pediatric patients.
Methods: This study was a retrospective chart review of pediatric patients (0-18 years) presenting to the ED at a large rural tertiary care center with the chief complaints of allergic reactions, food allergies, insect stings, medication reactions or anaphylaxis. Anaphylaxis was defined as a patient meeting any of the three National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria. Data collected included past medical history (PMH), demographics, suspected allergen, symptoms, medications, ED management and follow-up. Differences among variables across anaphylaxis diagnosis were tested with the Pearson Chi-Square test for categorical variables and the Student’s t-test for continuous variables. The c-statistic for the predictive ability of the model was calculated using multivariable logistic regression.
Results: A total of 475 patients were included with 54% of the sample being male (n=259). Almost one-third (n=139) of patients had a confirmed diagnosis of anaphylaxis in the ED. Of those, 15 (10.8%) had a PMH of angioedema (p <.01), 28 (20.1%) had a PMH of anaphylaxis (p < .0001), 27 (19.4%) had a PMH of asthma (p = .05) and 32 (23.0%) had a PMH of hives (p <.0001). Each of the variables for inclusion in the regression model, food allergy, angioedema (p <.01), dyspnea (p <.01), nausea (p <.0001) and hoarseness (p <.0001), were highly associated with anaphylaxis diagnosis. When combined in a regression model, these variables were highly predictive of an anaphylaxis diagnosis (c=0.87).
Conclusion: Our study indicated that the combination of food allergy, angioedema, hoarseness, dyspnea and nausea are associated with anaphylaxis diagnosis. These findings can improve accuracy of diagnosis and improve outcomes.
Procoagulant Material Released from Platelets Likely Degraded by Non-Enzymatic Process
Carleigh Hebbard, Ph D.
Background: This investigation stemmed from a DoD-funded multi-center effort to stop internal bleeding on the battlefield, where surgical intervention can be inaccessible. The group goal was to create nanoparticles that target bleeding sites and trigger coagulation locally. Years ago, the Docampo and Morrissey labs found that platelets harbored a thrombin-binding procoagulant molecule called polyphosphate (polyP). Linking polyP to targeted, threshold-switchable nanoparticles might prove useful in stopping internal bleeds. PolyP has a plasma half-life of 90 minutes (Lorenz et al 1997, Smith et al 2006). To increase the half-life of polyP-laden nanoparticles and prolong localized coagulability, we wanted to find and stop what we thought were serum polyP-degrading enzymes.
Methods: Our lab developed a 96-well formatted ELISA-like assay that lets us indirectly quantify polyP degradation. Platelet polyP are linear 60 – 100-unit phosphate chains. We chemically attach polyP to 96-well plates, submit polyP to various insults (e.g. serum), and wash the plates. Remaining polyP length depends upon the extent of polyP degradation caused by each tested condition. We bind thrombin to the remaining polyP and spectrophotometrically monitor colorimetric substrate cleaved by thrombin. Colorimetric change correlates to remaining polyP.
Results: Adding phosphatase inhibitors to serum did not slow polyP degradation. Boiling serum accelerated degradation. Removing serum metals, however, halted activity. When we depleted serum of metals and added back single metals, we found that calcium restored activity at physiologic concentrations, and we were able to approximate the rate of serum polyP decay with the in vitro conditions of pH = 7.4 and low millimolar calcium concentrations.
Conclusion: We expected to identify and stop plasma enzymes from degrading the platelet-derived procoagulant molecule, polyP. Arresting such activity would increase the half-life of polyP-laden nanoparticles targeted for internal hemorrhaging. We found instead that inherent serum metals such as calcium cause polyP decay. Removing calcium from hemorrhaging sites is a non-viable solution because calcium is needed for clotting factor membrane binding. To increase polyP's half-life in the future, we may explore substituting units within the polyP chain in order to make it less prone to decay.
Abstracts Session 2 - Room: 2B 0900-1150
Medication Refills in the Emergency Department as a Predictor for Social Need
Sarah Berg, MD
Background: The emergency department (ED) is often a point of entry for underserved patients with social need. Previous studies show that many patients use the ED as their primary source of health care, citing lack of primary care provider, financial constraints, and high burden of disease as primary reasons for utilizing the ED. We studied low acuity patients seeking medication refills in the ED to determine if social determinants of health contributed to increased ED visits for primary care complaints. We predict that patients presenting to the ED for medication refills are less likely to have health insurance or a primary care provider and are more likely to be homeless or lack adequate transportation.
Methods: The study took place at a academic, urban, 70 bed emergency department with 95,000 total annual ED visits. 221 visits from June 1 to August 31, 2017 met screening criteria: chief complaint “medication refill” or ICD-10 codes related to medication refills. Patients were included if they were over 18 years old, were ultimately discharged from the emergency department, and were not intoxicated or obtunded. The entire documented ED visit was reviewed for demographic information and reason for presenting to the emergency department.
Results: Of the 228 charts initially screened, 178 were included in the final review. 50 charts were excluded due to patient intoxication at the time of the index visit or index visit was not for medication refill. 24% of patients cited lack of access to timely outpatient appointment as their primary reason for seeking medication refill in the emergency department. 6% cited lack of access to a primary care provider, while 7% cited recent relocation as their reason for seeking medication refills.
Conclusion: Our data show that our patient population lacks access to adequate primary care resources. Lower acuity visits that are typically reserved for primary care may contributed to ED overcrowding, increased healthcare spending, and poorer continuity of care for chronically ill patients. Our study was limited by retrospective design at a single institution and relied on provider documentation for the primary outcome. More data is needed to determine specific ways that we can improve our patient’s lives and solve many of the problems plaguing academic emergency departments today.
Hospital-wide Resuscitation Quality Evaluations: How Can Medical Students Be Utilized?
Jeanette Lorme, Tarush Khurana, Errick Christian, Daniel Tauber, Christina Brown, Michelle Sergel
Background: Evaluating the quality of resuscitations that occur throughout the hospital can be a difficult undertaking due to biased retrospective self-reporting, incomplete data, and lack of a reliable workforce to objectively and reliably observe codes in real-time. Furthermore, video recording resuscitations is frequently discouraged due to legal discoverability. This study assesses the ability of pre-clinical medical students trained by video simulation, who could fill the role of objective code observer, to consistently evaluate resuscitation events in a manner similar to that of an expert physician.
Methods: A web-based instructional video simulation module was created for content delivery and data collection. 40 pre-clinical medical students and 7 attending physicians learned to use a scoring checklist based on the American Heart Association cardiopulmonary resuscitation (CPR) quality and teamwork measures in an instructional video. The assessment module included 6 resuscitation scenarios designed to be of varying CPR and teamwork quality each followed by a quiz utilizing the scoring scale (0 - 4) in the training video to evaluate the quality of the resuscitation event. A weighted kappa statistic (κ) to assess rater agreement was used to assess scores set by the simulation expert versus medical student and attending scoring.
Results: Students and attendings had higher agreement with the simulation expert on the constructs of CPR related to the technical aspects of compressions over the constructs that measured leadership and teamwork. For compression roles (team member changed every 2 minutes), students had strong agreement (κ = .8) and attendings had moderate agreement (κ = .6). For compression quality (adequate rate/depth/location), both students and attendings had weak agreement (κ = .57, .42). In the teamwork and leadership constructs (team leader’s direction, perspective, and communication) there was minimal to no agreement among students and attendings (κ < .3).
Conclusion: Medical students can evaluate objective CPR quality measures, such as compression quality, with a short video simulation training program. Medical students may require more intensive and dynamic training, particularly for measures of teamwork and leadership, to reliably provide these aspects in a real-time resuscitation.
Comparing Procedural and Patient Exposure of Medical Student Rotations at Rural and Metropolitan Emergency Departments
Connor Stephenson MS3; Jonathan dela Cruz MD; Kristin Delfino PhD; Danuta Dynda MD, MBA; James Waymack MD; Chinmay Patel DO; James Hart MD
Background: Despite an increase in medical school graduates, rural populations are still being underserved in healthcare and Emergency Medicine specifically. Many medical schools currently offer rural rotations that provide students with unique exposure to practicing in a rural environment. There is ongoing debate that rural rotations do not provide the same procedural exposure, patient acuity, or overall educational experience as their metropolitan counterparts. There has only been one prior study comparing rural and metropolitan procedural experience in residencies and no current studies observe rotations during medical school.
Methods: A retrospective review of emergency medicine clerkship logbooks was performed. Medical students at the study institution were required to rotate at one of two metropolitan sites as well as one of three rural sites. Patient encounters, admissions, and procedures (observed and performed) were tallied for comparison metropolitan versus rural sites. Calculated rates of admission and various procedures were then used to compare experiences at rural sites to those of larger metropolitan centers.
Results: Over a one month rotation, 55 students reported 4467 patient logs and 633 procedures. Students did not encounter wound care, bedside ultrasound, intubation, resuscitation, chest tube, and ‘other’ procedures at statistically significantly different rates between metropolitan and rural sites. Fracture reductions (1.13% vs 0.27%) and central line (0.83% vs 0.27%) had a statistically higher chance of exposure at metropolitan sites. Rates of procedures observed (9.00% vs 6.83%) vs performed (5.28% vs 5.31%) were not different between sites. Metropolitan sites saw higher admit rate at 28.79% than rural sites at 19.51%.
Conclusions: Students had similar procedural exposure rural vs metropolitan sites. Fracture reductions and central line rates were statistically different, however with such low procedure numbers it is unknown the educational significance. Acuity was notably higher at metropolitan sites. Possible confounding factors include the presence of residents at metropolitan sites that are absent at rural sites, varying accuracy in reports, and overall low procedure numbers. Further analysis into the distribution of presenting symptoms may provide additional insight into the differences in educational experiences.
Perceptions and Perceived Utility of Rural Emergency Department Telemedicine Services: A Needs Assessment
Sarah Oest
Background: Access to specialized medical care is often limited in rural emergency departments, and specialist consultation through telemedicine services could help increase access in low-resource areas. The objective of this study was to better understand providers’ perceptions of the anticipated impact of telemedicine in rural Midwestern emergency departments. The secondary objective was to understand differences in the perception of rural and academic providers in their views of the utility of telemedicine.
Methods: We conducted a cross-sectional survey of medical providers including physicians, physician assistants, and nurse practitioners at five rural Midwestern critical access hospitals and within six departments at a university medical center in the same region. The survey addressed opinions on telemedicine including how often it would be used and the potential to improve patient care and reduce transfers.
Results: Specialties of high perceived utility to rural providers include psychiatry, cardiology, and neurology, while academic providers viewed services in psychiatry, pediatric critical care, and neurology to be of most potential value. Academic and rural providers have differing opinions on the anticipated frequency of telemedicine use (p<0.001) and prevention of inter-hospital transfers (p=0.023). There were significant differences in perceived value by specialty.
Conclusion: There is a high demand for telemedicine consultation services in rural Midwestern hospitals, particularly in psychiatry, cardiology, and neurology. Overall, academic providers view telemedicine services as more valuable within their specialty than do rural providers. Further research should be done to investigate individualization of telehealth services based on regional needs and how disparate opinions predict telemedicine utilization.
Cardiovascular Disease (CVD), Emergency Department (ED) Use, and Social Capital Among East African Immigrants
Bjorn Westgard
Background: As the number of immigrants in the U.S. has increased, so has the prevalence of chronic illness, health disparities, and ED use related to both. We hypothesized that, among East African immigrants to the U.S., the “healthy immigrant effect” may be seen in increased CVD risks and ED use, particularly among those with low social capital.
Methods: The prevalence of CVD risks, ED use and social capital were determined in community-dwelling Somali adults at two points in time by trained community health workers. In 2001, a cluster-randomized sample of households (N=253) was surveyed, and in 2015-16, a respondent-driven sample (N=1180) was surveyed, both to approximate a random sample given known difficulties in accurately surveying the Somali community. In both efforts, we obtained anthropometric, blood sample, and survey data regarding CVD risk factors, demographics and health resource utilization, including self-reported ED use. After adjusting for sampling methodologies and age/sex weighting to the American Community Survey, we assessed the differences between the 2001 and 2015-16 results.
Results: Among Somali immigrants, there was an increasing prevalence of CVD risks, including overweight/obesity (33.9/27% to 25.7/39.7%), diabetes (15.2 to 30.2%) and hypertension (9.9 to 18.1%). Overall insurance remained high (>75%), and primary care access improved from 58.4 to 72.6%, while ED use decreased from 36.7% to 23.8%. ED use was significantly associated with the presence of CVD risk factors and changing or worsening health status, particularly among those who are older, female, less educated, unemployed, in poverty, low in English proficiency, low in trust, and/or low in social resources.
Conclusion: CVD risks among East African immigrants are increasing rapidly. ED use may be another marker of this “healthy immigrant effect,” particularly for those with persistently low social capital. EDs are essential sites for efforts to improve immigrant health through education, prevention, and social resources.
Electronic Prescribing Implementation Decreases Opiate Prescriptions in an Academic Emergency Department
Bradley Gordon
Background: The prescribing of opioid analgesics is under intense scrutiny with simultaneous pressure to move to electronic prescribing systems. At one hospital, an systems update allowed valid prescribers to transmit controlled substances to most retail pharmacies using electronic signatures (e-prescribing). Simultaneously, the hospital outpatient pharmacy changed policy to require that any electronic or handwritten prescription for a controlled substance be signed by a US Drug Enforcement Administration (DEA) registered provider rather than by a resident using a hospital-issued DEA number. The resulting changes excluded residents from independently writing prescriptions any controlled substance. We retrospectively analyzed opioid prescription rates before and after these workflow changes to better understand their impact on prescribing.
Methods: At a single high-volume academic ED, monthly census and prescribing rates were collected for two 12-month periods adjacent to, but not including, the e-prescribing implementation. Only prescriptions for short-acting oral tablet opioid analgesics were included. Graphical analysis and descriptive statistics were computed of the monthly rates.
Results: During the pre-intervention period, the mean monthly census was 7280 patients with 7.54 prescriptions per 100 patients (95% CI 6.02-9.06). In the post-implementation period the mean monthly census of 7334 patients and 4.80 prescriptions per 100 patients (95% CI 3.82-5.78). The decrease of 2.74 prescriptions per 100 patients (P < .001) represents a 36% decrease in prescribing frequency with no significant change in the overall ED census between the two periods.
Conclusions: In this academic ED, implementing new methods and policies for prescribing controlled substances was associated with a marked reduction in the frequency of prescribing short-acting oral tablet opioid analgesics. These results may guide other academic EDs working to implement e-prescribing of controlled substances and policies that mandate the use of e-prescribing over paper-based prescribing methods. We were limited by our inability to further compare prescribing rates at the provider level, which would help determine whether e-prescribing barriers or hospital pharmacy policy changes drove the observed effect in this ED.
Identification of High Efficiency Practices of Residents in an Academic Emergency Department: A Mixed Methods Study
Haley M. Egan, Morgan B. Swanson, Steven A. Ilko, Karisa K. Harland, Nicholas M. Mohr, Azeemuddin Ahmed
Background: Emergency department (ED) utilization and overcrowding are on the rise. Emergency medicine residency programs are under increased pressure to train efficient and productive residents in order to meet these demands. Specific practices associated with resident efficiency have not yet been scientifically characterized. The purpose of this study was to identify key practices associated with enhanced efficiency in emergency medicine residents.
Methods: A mixed-methods study design was utilized to identify discrete behaviors associated with resident efficiency. In Stage 1, eight emergency medicine faculty provided 61 behaviors associated with resident efficiency during semi-structured interviews, which were then distilled into eight behaviors by independent ranking. Seven behaviors from the study team were added, as well as 16 behaviors identified in a previous study on community ED provider efficiency by Bobb et al., to create a final list of 31 efficiency behaviors. Stage 2 was an observational study of 27 emergency medicine residents who were each observed for two 4-hour periods during separate clinical shifts. The timing and frequency of each of the study behaviors was recorded in minute-by-minute observation logs. In Stage 3, the association between provider efficiency and each of the 31 behaviors was tested using univariable generalized estimating equations with an identity link and clustered on resident year of training. Efficiency was measured using residents’ relative value units per hour.
Results: Eight resident practices were found to be positively associated with efficiency: average patient load, taking history with nurse, checking the board, running the board, conversations with consultants, use of dictation, text communication, and non-work tasks. Four practices were found to be negatively associated with efficiency: time in patient room, visits to patient room, reviewing electronic medical record, and utilizing ED clerks.
Conclusion: Several discrete behaviors were found to be associated with enhanced resident efficiency. By identifying these efficiency behaviors, residency programs can counsel residents on specific practices that can be implemented or developed in order to improve upon their personal efficiency throughout training.
Significant Differences in Patient Acuity Assessments Between Emergency Department Patients and Providers
Sharon Mace, MD
BACKGROUND: Prospective comparison of ED patients’ and their healthcare provider’s perception of acuity.
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing, 18-bed ED with approximately 16,000 patient visits annually. Using a survey of perceived medical acuity on a 5 point Likert scale: Level 1 Critical: Immediate Care required, Level 2 Emergent: care required within 15 minutes, Level 3 Urgent: care required within 15 – 60 minutes, Level 4 Semi-urgent: care required within 2 – 24 hours, Level 5 Non-urgent: care required within several days.
RESULTS: The majority of patients who came to the ED were female 59%, African-American35%, Caucasian60%. 44% of patients are single, 40% married, and 16% are separated, divorced or widowed. 326 patients (59.1%) have public insurance (Medicaid or Medicare) vs. 207 (37.5%) private insurance, and a minority of patients 10 (1.8%) are uninsured. 174 (31.5%) of patients are employed, 262 (47.5%) are not employed. 86 % have a primary care physician (PCP). The median acuity estimated by patients was 2- Emergent on the Likert scale vs. health care provider median estimated acuity of 4-Semi-urgent. Patients overestimated their acuity 91.1% of the time. Patients agreed only 8.9% of the time with their health care provider. No patient underestimated their acuity.
CONCLUSIONS: Patients and clinicians assessment of patient acuity were significantly different with more patients assessing their condition as being more serious or requiring immediate care 63% of the time compared to their ED providers at only 9%. An overwhelming majority of ED providers (91%) classified patient acuity urgent, semi-urgent or non-urgent, compared with 37% of patients who felt their acuity was urgent, semi-urgent or non-urgent.
Investigating Healthcare Provider Bias Toward Patients Who Use Drugs Using a Survey-Based Implicit Association Test
Authors: Rachel A. Dahl, MS; J. Priyanka Vakkalanka, ScM; Karisa K. Harland, MPH, PhD; Joshua Radke, MD
Background: When healthcare providers have implicit bias against patients who use drugs (PWUD), it may result in worse outcomes. We investigated whether implicit bias is associated with explicit bias toward PWUD at a large midwestern hospital using an online implicit association test (IAT).
Methods: We sent emails to five departments at our institution in order to recruit healthcare providers to complete an IAT via a Qualtrics® platform. We created the IAT using previously validated methods. Participants were presented with a series of on-screen stimuli or characteristics that they were instructed to match to targets (drug user or non-user) or to categories (good words or bad words) as fast as possible without making errors. A summary measure (D-score) for each participant was generated using iatgen software. A D-score [-2,+2] measures incompatibility in the timing of matching bad associations (“disgusting” with drug user/bad words) or good associations (“empathy” with drug user/good words) with the target. A score of 0 indicated no bias. A positive score indicated bias against drug users, where +2 is most biased. Participants then completed a survey about their explicit beliefs toward PWUD, including nine questions adapted from a previously validated study and five new questions. Surveys were scored on a 5-point Likert scale (1=low, 5=high). Scores were compared by demographic characteristics using univariate analyses. Explicit and implicit bias scores were measured through linear regression.
Results: Of the 44 providers who completed the study, 73% were female, 23% were from the ED, and 37% were staff physicians. About 60% of participants saw 1-10 patients with substance use disorder weekly. Total mean D-score was 0.562 (SD=0.37, p<0.001). Mean D-scores did not vary across demographic characteristics. Providers from the ED had higher explicit bias scores overall (2.27, p=0.047) and among questions regarding whether PWUD deserve healthcare (2.36, p=0.020). With each unit increase in overall explicit bias score, there was a 0.2 increase in D-scores (p=0.025).
Conclusion: We observed a positive association between implicit and explicit bias overall. Compared to other departments at our institution, ED providers may have higher explicit bias, but not implicit bias, toward PWUD. However, this study is underpowered, with potential bias due to recruitment method.
Abstracts Session 3 - Room: 2A 1400-1650
Regionalization in Emergency Time-Critical Care: Classifications, Comparisons, and Considerations
Nathan Walton and Nicholas Mohr M.D.
Background: Regionalization is the concept of organizing hospitals and providers into a system to optimize care by matching patient needs with the appropriate resources within the system. Regionalized care has been shown to improve outcomes in trauma, burn, stroke, STEMI, cardiac arrest, and NICU/OB care. The objective of this study was to conduct a comparative analysis of regionalization systems to identify common factors that can be used to refine existing systems and develop new disease-specific networks.
Methods: This study was a comparative literature review and interviews with informed organizational representatives of existing regionalization systems. We conducted a comprehensive literature review to develop a classification-based, comparative review of the existing regionalized systems of care by their components and characteristics. Then we performed a text-based analysis of the writing of the involved organizations (professional, regulatory, etc.) and interviews with the organizational leaders directly involved with regionalized systems of care. This information was incorporated into the comparison and evaluated for trends and best practices.
Results: Regionalization in the US has followed a predictable pattern of development. Systems center on the delivery of time- or volume-sensitive care that is limited due to resource, facility, or expertise scarcity. In response to lapses in care delivery and inefficient resource use, professional organizations (American College of Surgeons, Brain Attack Coalition, etc.) have published clinical guidelines and suggested regionalized tiered systems of facilities by resources and expectations of participation. These guidelines are used by government or third party-designating and certifying organizations to be established and verified in participating facilities. These efforts have been effective in establishing regionalized networks characterized by triage/transfer protocols, data registries, research, education, and performance improvement measures.
Conclusions: Regionalization in emergency care has been found to improve outcomes for several conditions despite continuing barriers in personnel, quality and processes, technology, finances, and jurisdictional politics. The best practices learned in the process hold promise to improve the existing systems and establish new ones.
A Retrospective Cross-Sectional Study Evaluating the Indications for Ultrasound in a Low Resource Emergency Department
Lanter, Patrick. Wood, Amanda. Hilbert, SueLin. Mueller, Kristen.
Background: Acute abdominal pain is one of the most common presenting symptoms in the emergency department, accounting for roughly 7-10% of all visits to US emergency department per year. In low resource settings, ultrasound provides a useful diagnostic modality to evaluate undifferentiated abdominal pain.
Methods: A retrospective cross-sectional study was performed evaluating all patients who were admitted from the emergency department at Salvador Gautier Hospital in Santo Domingo, Dominican Republic. Patient charts in January, April, May, August were reviewed, and final diagnosis was recorded. If available, patients presenting vital signs, location of pain, test results and length of stay were also recorded. Based on this data, indications for right upper quadrant, renal, aortic and pelvis ultrasounds were identified.
Results: Of 2300 patients admitted the hospital during this stay, 218 patients presented with abdominal pain. Of those charts, 107 were admitted with a chief complaint of abdominal pain. Based on final diagnosis, there were indications for 2 pelvis ultrasounds, 33 RUQ ultrasounds, 1 aortic ultrasound and 20 renal ultrasounds.
Conclusion: Based on a retrospective cross-sectional study evaluating ED admission to Salvador Gautier Hospital for abdominal pain, a total of 56 patients would have benefitted from one either a RUQ, pelvic, renal or aortic ultrasound. We hope to use this data to raise funding for an ultrasound probe at Gautier Hospital to help facilitate ultrasound training to the emergency medicine residents training at the institution.
Limitations: This study was extremely limited by the quality of data collected. Initially 218 patients were identified with abdominal pain after reviewing admission sheets. Of these, we were able to find 55 charters, 22 of which did not contain any papers leaving a total of 33. With the limitations on the data, we decided to do a secondary analysis with the admission sheets which allowed us to identify 218 patients with abdominal pain, 107 of whom carried a final diagnosis. The indications for an ultrasound were based on these final diagnoses.
Automated alerts for septic patients in the Emergency Department: A systematic review of screening test accuracy and quality measure studies
Matthew I. Hwang; Emilie S. Powell, MD, MS, MBA ; William Bond M.D., M.S.
Background: Electronic alerts are frequently implemented to improve identification and response times to sepsis. Alerts are often rule based, using a simple point system for sepsis diagnosis to notify the provider. Algorithm based alerts have been developed to incorporate additional factors, such as past medical history, lab values, and demographic.
Purpose: To review the literature of automated sepsis alert systems and establish their utility in the Emergency Department (ED) setting.
Methods: The systematic search included PubMed MEDLINE, Embase, the Cochrane library, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). Two independent reviewers selected studies with the Covidence screening and extraction tool. Eligible studies included published articles with the following: (1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock, (2) an electronic system that alerts a healthcare provider of sepsis in real or near real time, and (3) measures of diagnostic accuracy or quality of sepsis alerts. Risk of bias and quality of articles were assessed with guidance from the QUADAS-2 and GRADE rating systems.
Results: 731 articles were screened and 10 were selected for the study. 8 of these studies assessed accuracy and 6 assessed outcomes. Two studies had algorithm based alert systems, while eight had rule sets. All systems used different criteria based on systemic inflammatory response syndrome to define sepsis. Diagnostic accuracy varied greatly: sensitivity ranged from 33.3% to 100%, specificity from 78% to 99%, and PPV from 5.8% to 54%. NPV was consistently high at 99% to 100%. Process measures, such as time to antibiotic administration, showed modest improvements. Length of stay significantly improved. The only measure reported by an algorithm based study was mortality, which showed significant improvement. Rule based studies showed insignificant improvements in mortality.
Conclusions: Rule based sepsis alerts in the ED may improve process measures and length of stay. Diagnostic accuracy varies and may not correlate with outcomes. An algorithm based alert improved mortality. Further studies are needed to assess the efficacy of newer algorithmic systems.
Dextrose 10% is Safe and Effective Alternative to Dextrose 50% in Prehospital Hypoglycemia Treatment
Shaila K. Coffey, MD1; Abraham Campos, MD1
Background: Severe hypoglycemia (glucose concentration < 70 mg/dl) occurs frequently in the US and is a common emergency call for prehospital providers. Due to a recent national drug shortage, many prehospital systems have been forced to replace D50 boluses with D10 infusions to treat hypoglycemic patients. The primary aim of this study is to determine if D10 is an effective and safe alternative to D50.
Methods: This was a cross sectional study of 1073 patients suffering from hypoglycemia receiving care from a city fire department between the dates of October 2015 and March 2019. Of these patients, 1019 (95%) had complete data that was available and evaluated. For each patient encounter, the initial capillary glucose, the amount of dextrose administered, and the post dextrose capillary glucose was recorded. From this data the average initial blood glucose, post dextrose blood glucose and change in blood glucose was obtained for different dextrose loads (10g, 12.5g, 15g, 20g, 25g, and >25g). The rate of reported infiltration of dextrose and need for repeat bolus of dextrose was also explored.
Results: The median pre-dextrose capillary glucose was 34 mg/dL, with a median post-dextrose capillary glucose was 166. The median amount of dextrose administered was 18g, with the most commonly given doses being 10g, 12.5g, 15g, 20g, and 25g. After initial dextrose administration, 35 patients (3.4%) required repeat dextrose boluses, of which only 6 patients (0.6%) required more than 25g total. There were 3 (0.3%) IV infiltrations.
Conclusions: For the treatment of prehospital hypoglycemia, D10 administration was shown to be a safe and effective alternative to D50. Redosing of D10 after initial D10 bolus is rare and infiltration rate is low.
Rural Stroke Patients Have Higher Mortality: An Opportunity for Rural Emergency Medical Services (EMS)
Peter K. Georgakakos, DO; Morgan B. Swanson, BS; Azeemuddin Ahmed, MD, MBA; Nicholas M. Mohr, MD, MS
Background: Stroke is a major source of death and disability. Early recognition and prompt pre-hospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study is to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities.
Methods: This study was retrospective cohort study of 1,747,660 stroke admissions in the US from 2012 to 2016, using the Nationwide Inpatient Sample (NIS). Primary exposure was rurality of patient’s residence. Primary outcome was death during hospital encounter. Secondary outcome was discharge to a care facility or home health care. Covariates included age, sex, race, primary payer, All Patient Refined-Diagnosis Related Group (APR-DRG) mortality risk, co-morbidities, type of stroke, and admission status. Univariable and multivariable logistic regression, with purposeful model selection, estimated the odds of mortality by subject rurality among stroke subjects.
Results: Rural visits had higher mortality than non-rural visits (18.60% [95%CI 18.23 – 18.97] rural vs. 16.87% [95%CI: 16.68 – 17.06%] non-rural) and were associated with higher unadjusted odds of mortality (uOR = 1.14; 95%CI 1.11 – 1.17). After adjusting (age, sex, race, primary payer, APR-DRG mortality risk, co-morbidities, type of stroke, admission status, hospital region, rurality and teaching status, inpatient volume, control/ownership of the hospital, and year) in a logistic regression model, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95%CI 1.06 – 1.15). For the secondary outcome of discharge to home, rural stroke visits were less likely to be discharged to a care facility than non-rural stroke visits (aOR 0.94; 95%CI 0.91 – 0.97). Results were similar after adjusting for tissue plasminogen activator (tPA) administration and transfer status.
Conclusions: Rural stroke patients have higher mortality than urban counterparts likely due to their increased burden of chronic disease, lower health literacy and reduced access to prompt pre-hospital care. There may be an opportunity for pre-hospital providers to assist in managing chronic disease, increase stroke awareness for both patients and clinicians and establish response patterns to expedite emergency care.
The Varied Cost of Syncope in the Emergency Setting
Matthew Abbott
Background: Patients presenting to the emergency department with syncope may have extensive evaluations resulting in high billing costs. A direct relationship between low variation in cost and low risk of an adverse event after presenting with syncope may indicate an efficient and cost-conscious environment. This project compares the cost variability of patients presenting with syncope to the San Francisco Syncope Rule (SFSR) and Canada Syncope Risk Score (CSRS) risk stratification scales.
Methods: A retrospective chart review for patients diagnosed with syncope at a large urban emergency department between 1/01/2016 and 12/30/2016 identified 282 patients over age 18 and without traumatic syncope. A cohorted retrospective study of the discharge information for these patients examined demographics, billing data and cost calculation. Two-tailed student’s t-tests were used to determine if any patient populations’ total cost significantly differed from the mean patient total cost.
Results: Average total cost per patient was $1,239.15 with a standard deviation $1,137.26 and median cost of $843.50. Patients with an abnormal Electrocardiography (ECG) had a significantly higher average total cost ($1,993.74) than patients with a normal ECG ($1,135.70) (p<0.05). Patients that answered “yes” to one of the SFSR variables had significantly higher average total costs ($1,663.12) than those who did not ($1,107.03) (p<0.05). Patients with a history of vasovagal syncope had significantly lower average total costs ($879.22) than those without ($1,251.01) (p<0.05).
Conclusion: Comparisons of variables within the SFSR and CSRS scales indicated their respective patient populations had significantly different average costs or variability of costs. Differences may be caused by the heightened costs of advanced diagnostic testing, more thorough workups, and physician practice style that these patients required. Patients with a history of vasovagal syncope experienced a lower average cost than those without, which may be due to a decreased index of suspicion for an adverse patient event.
A Web-based survey to assess the safety of transient sportive chokes
Broc Schindler, M.D., Robert LeFevere, M.D., Jesse Corry, M.D., Thomas Menton, Samuel Stellpflug, M.D.
Background: Vascular neck restraint (VNR), known as a “choke” within the grappling community, is the practice of compressing the jugular veins and carotid arteries to threaten rendering a person unconscious by lowering cerebral perfusion pressure. It is a common maneuver practiced within the sports, police, and military combatives realms. The actual safety of VNR is unknown and underrepresented in the literature. Delineating the safety of transient VNR is crucial as it may impact the care provided to participants in the prehospital and emergency department settings. This study aimed to explore the safety of transient VNR by surveying a group of people who actively participate in this practice. The objective was to describe the level of VNR experience among respondents, symptoms related to VNR, and gauge the perception on its use in real combative interactions.
Methods: In June 2019, a convenience sample of visitors to two combat sports Internet forums (www.reddit.com/r/bjj/ and www.reddit.com/r/judo/) were invited to complete an anonymous Web-based survey. Univariate analysis (presented below), bivariate analyses, and Chi-squared tests were performed.
Results: Overall, 4421 individuals completed the survey. 114 were excluded for TBIs or strokes not related to grappling (see figure 1), leaving 4307 respondents for analysis. Of this group, 94% were male and 89.2% were between the ages of 18-44 years. 78.7% had > 1 year of grappling experience and 30% had > 5 years of experience. Of the 4307, 1443 (33.5%) reported being choked > 500 times, 3257 (75.6%) have been choked to near-syncope, and 1198 (27.8%) have been choked unconscious. 2 of the 4307 (0.05%) reported persistent symptoms from chokes; one fractured thyroid cartilage and another occasional auras. Of all responders, 94.3% felt that VNR would be a safe and effective way to control or end a street fight.
Conclusion: This descriptive data suggests that overall, transient sportive choking is safe based on a large number of participants and only 0.05% experiencing continued symptoms; even those symptoms were likely not related to brain ischemia. Further studies are necessary to support this data, potentially impacting the management of patients participating in activities involving VNR within the prehospital and emergency department settings.
Abstracts Session 4 - Room: 2B 1400-1650
Complications of Tube Thoracostomy in the Emergency Department
Arian Jahansouz
Background– Chest tube thoracostomy is a common Emergency Department (ED) procedure. How often and severe are complications of tube thoracostomy placed by Emergency Medicine residents and faculty? A previous study found a 30% complication rate in 40 patients who received tube thoracostomy in a 12-month period at a large UK teaching hospital. This study sought to determine if the rates and complications are changing and if these complications are evidence for selective reduction in the indications for tube thoracostomy in the ED.
Methods– The data was analyzed using a retrospective chart review of all patients who underwent tube thoracostomy in a 27-month period in the ED of a large Midwest teaching institution with more than 80,000 patient visits annually at two locations. 143 patients who received tube thoracostomy were identified using a query of departmental billing records. The data was analyzed using a 1-Proportion Chi-Square test.
Results– Of the 143 patients, 13 were excluded from the study due to receiving the initial thoracostomy at an outside hospital. Of the 130 total tubes placed by Emergency Medicine physicians in the ED, 7 had complications, a 5.4% complication rate. Of the 7 complications, 5 (3.8%) were related to placement or positioning and 2 (1.5%) were due to an initially kinked tube. With a sample size of 130 in this study, compared with the previous study with 50 tubes placed in 40 patients, the null hypothesis proportion is 70. The 95% CI of observed proportion is 89.22 to 97.81, with an observed proportion of 94.615, and a significance level of P <0.0001.
Conclusion– This study reveals a lower complication rate of tube thoracostomy in the ED when placed by emergency medicine physicians than previously shown in other studies. With a larger sample size and longer analysis period, this study supports the previously mentioned study's conclusion that there is no persuasive evidence to support a selective reduction in the indications for tube thoracostomy in the ED. Limitations of this study include performance of a retrospective chart review and only assessing tubes placed in the ED by emergency medicine trained physicians.
Emergency Department Patient’s Mode of Transportation and Decision Making
Sharon Mace, MD
BACKGROUND: To determine what mode of transportation patient’s use to come to the emergency department (ED), prior ED visits, preference for primary care vs. ED for current complaint and the time involved in deciding to come to the ED.
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing, 18-bed ED with approximately 16,000 patient visits annually.
RESULTS: 88% patients did notuse an ambulance to get to the ED: 47.3% got a ride from friend or family, 30.7% drove themselves, 5.5% took public transportation, 1.9% walked, and 3.5% reported other. 90.0% of patients took more than one hour to decide to come to the ED. 58% took over 24 hours. The number of ED visits in the last twelve months was (2.18 mean, range 0-≥20). The number of patients with no previous ED visits in the past twelve months was 213 (39%). Most patients preferred to visit the ED rather than see their primary care physician (PCP). Over 50% where either referred by a medical professional (24.3%) or felt the ED was more appropriate for their complaint (31.2%).
CONCLUSION: Patients deliberated several hours to days before coming to the ED suggesting that patients do not visit the ED based on an impulse or quick decision. Most patients had no prior ED visits in the past twelve months. A minority preferred to see their PCP. This may be because over half of the patients (55.5%) were either referred to the ED by their PCP or other health care professional (24.3%) or felt the ED was more appropriate for their care (24.3%). The overwhelming majority of patients drove themselves or got a ride with a friend or family member. Most patients did not use an ambulance service to visit the ED.
Factors Determining Why Patients Come To the Emergency Department
Sharon Mace, MD
BACKGROUND: There is little information about the variables influencing a patient’s decision to visit the ED. To prospectively determine factors influencing patient decisions to come to the emergency department (ED).
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing 18-bed ED with approximately 16,000 patient visits annually.
RESULTS: 552 patients (urban-348, suburban-204) from July to December 2017 were surveyed. As part of the survey, patients were asked “Why did you go to the emergency department today instead of your regular health care source?” The primary reason patients chose to visit the ED is because it is more appropriate for their condition than an office or clinic (31.2%). The second reason is because their primary provider or another medical professional referred them to the ED (24.3%). Inability to obtain a timely appointment occurred in 12.7% of the cases. Primary care provider offices were closed or not available 4.3% of the time. Thus, almost one-third of patients (30.4%) either have no access to primary care (13.6%), are unable to obtain a timely appointment (12.7%), or their primary care is closed or unavailable (4.3%). Convenience is rarely the reason for an ED visit (4%). Patients came to the ED because they believed their provider would have sent them to the ED anyway in 1.4% of cases.
CONCLUSION: It has been suggested that patients inappropriately use the ED. Based on our survey of ED patients, this appears to be an erroneous assumption. Over half (55.3%) of patients are either directly referred to the ED by a health care provider (24.3%) or need ED services that are unavailable in other medical settings (31.2%) Patients rarely use the ED for convenience, whether in the urban or suburban locale.
Patient Perception of Acuity: Does Location Matter? Urban vs. Suburban Setting
Sharon Mace, MD
BACKGROUND: Prospective comparison of ED patients in two different locations: urban vs. suburban emergency departments
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The setting was an urban, tertiary-level, teaching hospital ED that sees 63,000 patients a year and a suburban free-standing ED. Using a survey of perceived medical acuity on a 5 point Likert scale: Level 1 Critical: Immediate Care required, Level 2 Emergent: care required within 15 minutes, Level 3 Urgent: care required within 15 – 60 minutes, Level 4 Semi-urgent: care required within 2 – 24 hours, Level 5 Non-urgent: care required within several days.
RESULTS: Patients and providers agreed overall only 8.9% of the time. 91.1% of the time patients overestimated their acuity. Based on location, urban ED patients agreed with their provider only 5.2% of the time while the suburban patients agreed with the provider’s estimate of acuity 15.2% of the time. The overwhelming majority of patients overestimated their acuity with 84.8% of suburban ED patients overestimating vs. 94.8% of urban patients. Hospital admission rates were 95 (27%) for the urban setting with 251 (72%) discharges. In the suburban 32 patients were admitted (16%), 171 discharged (84%), and 3 patients (1.4%) transferred to other health care systems.
CONCLUSION: Suburban patients agreed with their provider about three times more often than their urban counterpart (15.3% vs. 5.2%). Patients in both urban vs. suburban environments almost always overestimated their acuity, over 90% when compared with their provider.
Angioedema Care in the ED: Retrospective Review of Staging Criteria as Predictor of Patient Disposition
Conor Dass; Maggie Mahaffa; Kari Harland, MPH, PhD; Ronna Campbell, MD, PhD; Zuhair Ballas, MD; Sangil Lee, MD, MS
Background: Angioedema is a non-pitting edema that can lead to airway obstruction and systemic symptoms. Airway angioedema can be fatal, and as such, having objective severity criteria would allow for quick triage and treatment. Previously, Ishoo criteria were proposed as a severity classification system based on site of swelling; however, this has not been externally validated in the era of targeted pharmacological therapy. This study aims to validate the Ishoo criteria as a method of triage based on presentation characteristics and subsequent outcome.
Methods: This study is a retrospective chart review of angioedema cases that presented to an academic emergency department between 1/2008 and 1/2018. Data was collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by a modified Ishoo criteria, which organized patients into stages based on location of swelling. These stages were defined as: stage 1, lips, face, periorbital, extremities, total body/diffuse; stage 2, soft palate, uvula, posterior pharynx; stage 3, tongue; stage 4, larynx. Predictive probability of disposition by stage was then compared.
Results: A total of 320 patients were included in this study (median age, 44; 54.4% female). Intervention with medication was used in 313 cases (97.8%) and airway intervention was required in 19 (5.9%) cases. As a whole, the majority of cases were treated as outpatient (68.4%), although 16.3% were admitted to the floor, and 15.4% were admitted the ICU. Among those admitted to the ICU, 19 (5.9%) were intubated. When disposition was correlated with stage, patients in stage 1 were more likely to be treated as outpatient (84%) compared to requiring ICU care with and without airway intervention (0.4%, 3% respectively). Conversely, patients in stage 4 were more likely to require ICU care with and without airway intervention (47%, 27% respectively) compared to outpatient treatment (13%). Patients in stage 4 were also more likely to require airway intervention (47%) compared to other stages (stage 1, 4%; stage 2, 3%; stage 3, 17%).
Conclusion: Disposition was correlated with Ishoo staging as higher stage patients were more likely to require higher levels of care, including airway intervention. As such, using this staging criteria could be of benefit to the triage and management of patients presenting with angioedema.
Right Testicular Pain and Swelling Secondary to a Pyocele
Authors: Patel, MD; Stettner, EA
Background: Testicular pain is a common complaint in the emergency department. Etiologies ranging from the relatively benign epididymo-orchitis to the emergent testicular torsion. A pyocele is a less common cause for testicular pain.
Methods: This is a single patient chart review.
Case/Results: A 61-year-old male with no past medical history presented to the Emergency Department with right testicular pain, swelling, and redness that has been worsening over one month. Vital signs were within normal limits. Physical exam was pertinent for a 5cm right testicle, tender to palpation, and less tender with scrotal elevation. Serum laboratory studies were notable for a white blood cell (WBC) count of 14.2. Urinalysis was notable for >182 WBC, 3+ leukocyte esterase, and many bacteria. Testicular ultrasound showed a large, complex hydrocele with internal irregular septations concerning for a pyocele. There was also increased vascularity in the right testicle and epididymis suggestive of acute epididymo-orchitis.
Discussion/Conclusion: Generally, scrotal pyoceles affect all age groups, and are located in the potential space that exists between the visceral and parietal tunica vaginalis. They may also extend into the inguinal canal. The condition is often associated with acute epididymo-orchitis, though rupture of a testicular abscess is also a cause. Symptoms including pain and swelling. Diagnosis is best made through testicular ultrasound. Treatment includes antibiotics and possibly surgical drainage, with orchiectomy as the ultimate method of management. If left untreated, pyoceles can progress to Fournier’s gangrene and sepsis.
In this case, urology was consulted, who recommended outpatient follow-up and oral antibiotics. Per medical records, the patient followed up with urology outpatient two days later. The patient had stated his symptoms were improving. His physical exam showed mild right testicular tenderness and swelling, with appreciation of the right hydrocele. A repeat urinalysis was unremarkable. The patient was advised to complete the course of antibiotics he had been prescribed from the emergency department. No further medical records were documented.
Migration of Orbital Silicone Oil into Subarachnoid and Cerebral Ventricular Spaces
Authors: Patel, MD; La Charité, D
Background: Silicone oil orbital injections are used in the treatment of complex retinal detachments, traumatic injuries, and diabetic retinopathy. A rare complication of silicone injection is the extravasation of silicone oil into the intracranial space.
Methods: This is a single patient chart review.
Case/Results: A 55-year-old man with a history of left eye diabetic retinopathy treated with intra-orbital silicone injection in 2011 presented to the Emergency Department after a fall at home. He reported preceding lightheadedness, with bilateral lower extremity weakness and difficulty ambulating. Vital signs were notable for a blood pressure of 185/88. Physical exam was pertinent for a sclerotic-appearing left eye and an unsteady gait. Serum laboratory studies were unremarkable. Computed tomography (CT) scan of his head showed high density material consistent with silicone oil in the subarachnoid space and lateral ventricles. A CT scan 13 days prior did not show this finding.
Discussion/Conclusion: Intra-orbital silicone injection is used to create a retinal tamponade for conditions such as severe proliferative diabetic retinopathy or retinal detachment in an effort to promote retinal reattachment and preserve visual acuity. Silicone oil may migrate through the optic nerve into the subarachnoid space and cerebral ventricles. Adverse effects are unknown, though the risks of hydrocephalus and chemical meningitis have been theorized. On imaging, intraventricular silicone oil may mimic intraventricular hemorrhage. However, whereas blood settles in the dependent portion of the ventricles, silicone oil will migrate to the nondependent regions. No previous studies have indicated surgical management of this condition.
In this case, neurology was consulted, who recommended admission to the Neurologic Intensive Care Unit for observation. Ophthalmology was consulted inpatient, who recommended outpatient follow up. The patient was ultimately transferred to a rehabilitation unit given his persistent bilateral lower extremity weakness and fall risk. No further records exist regarding ophthalmologic intervention for this case.
Acute obstruction of Laryngectomy Site by Saline Vial
Matthew Mannion
Background: Airway foreign bodies (AFB) are a common clinical occurrence in pediatric patients but can be seen in adult patients. In analyses of the populations, peak incidence of AFBs can be seen during the second year of life in children and the sixth decade of life in adults. Equally important to understanding our case is appreciating indications for laryngectomies, which include inability to undergo or failure of laryngeal sparing techniques or a non-functioning larynx.
Case: Our case features a 79-year old man with a history of T3N0M0 stage III supraglottic squamous cell carcinoma status post concurrent chemoradiation and subsequent total laryngectomy for dysfunctional larynx. While attempting to instill saline and suction his laryngectomy stoma site, the patient inadvertently dropped the saline bullet into his stoma, landing on his carina without frank airway obstruction or respiratory distress, but unable to be removed by the patient. Upon arrival to the ED, patient reported coughing up increased secretions with a blood tinge. Patient was alert and oriented with an oxygen saturation of 94 percent on room air. The ENT team was consulted, the they were able to remove the foreign body using a hemostat. Patient was discharged with instructions to hold saline bullets further away from the site and possibly obtaining larger saline bullets. This case highlights the risk for laryngectomy patients, who are often older and have less manual dexterity, irrigating and suctioning their sites using saline vials, or bullets, that are small enough to fit into their laryngectomy sites. This case also highlights a barrier to care if a patient is unable to attain larger saline bullets through insurance or home health carrier.
Conclusion: Patients with laryngectomy sites who are only able to access smaller saline vials should be educated to hold the saline bullet further away from their sites when performing routine cleaning.
Emergency Medicine Resident Driving Behaviors following Overnight Shifts
Ryan Tabor, MD; Neeraj Chhabra, MD
Background: There are numerous studies showing that sleep deprivation impairs the ability of automobile drivers to drive safely. The authors’ aim was to characterize the driving behaviors of Emergency Medicine (EM) residents following overnight shifts, the factors that influence these behaviors, and the prevalence of motor vehicle collisions.
Methods: An online survey was administered to 8 EM residency programs in one large urban center. The survey assessed knowledge of fatigued driving research, transportation methods surrounding overnight shifts in the Emergency Department (ED), and factors which may influence transportation decisions.
Results: The survey had 118 complete responses. A total of 5 respondents (4.3%) admitted to being involved in a motor vehicle collision (MVC) while driving after an overnight shift.
96% of the residents were aware of studies suggesting sleep deprivation can impair driving ability in the general population, and 86% were aware of studies that suggest working overnight shifts impairs physicians’ ability to drive safely.
79% of residents with automobiles report they “always” drive home following an overnight shift without a nap. Residents cited many factors that contributed to their decision to drive home without a nap, including: inadequate quality of call rooms (17%), inability to afford a rideshare/taxi home (11%), family obligations (9%), and a personal preference unrelated to the aforementioned factors (87%). The most commonly reported intervention that would likely facilitate safe transportation home was increasing subsidies for rideshare transportation home (51%).
Conclusions: A small, but not negligible, percentage of residents have been involved in a MVC following overnight shifts. Also, these data suggest that EM residents are largely aware of the risks of fatigued driving, but most still drive home following an overnight shift without a nap beforehand. Further education on fatigued driving, therefore, may not help alleviate this potential risk. A personal preference to sleep at home, unrelated to hospital or financial matters, is the most common motivation to drive home. These data suggest that the best way to address this issue may be to increase subsidies for taxi and rideshare transportation.
The Fast and the Furious: Focus on All-Terrain Vehicle Crashes and Estimated Speeds
Meghan Reaney, Gerene Denning, and Charles Jennissen
Background: All-terrain vehicle (ATV) crashes in the U.S. result in around 700 deaths and over 100,000 emergency department visits each year. One of the least studied risk factors is speed, because of significant barriers to data collection. The goal of this study was to better understand factors contributing to the clinical outcomes of ATV crashes.
Methods: Demographics and clinical outcomes were extracted from patient charts at the University of Iowa Hospitals and Clinics (UIHC) Emergency Department (ED) for victims of ATV crashes from 2010-2017. Additional variables were coded from patient notes. Descriptive and comparative analyses were performed on compiled data using SPSS (Statistical Package for the Social Sciences).
Results: Over the study period, 458 victims of ATV crashes were seen in the ED. The study population was 76% male, 25% were children <16 years of age, and only 18% were helmeted. Vehicle/crash characteristics included: 19% involved multiple ATV riders, 96% were recreational use, 6% were collisions with another motorized vehicle, 24% were collisions with an object, and 70% were non-collision events. Clinical outcomes included: 2% died, 25% suffered severe injuries (ISS >15), 78% were hospitalized, 21% were in the ICU at least 1 day, and 12% required ventilation. For speed, 174 records (38%) had an estimated speed, and one-third of documented cases had estimated speeds <20 mph. A greater proportion of adults than youth were traveling at high speeds (77% vs. 40%). Interestingly, there were no significant differences in the proportion hospitalized, requiring ICU care or ventilation, or having an ISS>15 when comparing crashes at low and high speeds.
Conclusions: Our studies demonstrate the serious consequences of ATV crashes that required emergency care at our institution. Although speed can increase the severity of injuries under some circumstances, even ATV crashes that were estimated to occur at 20 mph or less often resulted in serious injuries. We speculate that contributors to this observation would include lack of helmet use and being hit or pinned by the ATV, circumstances that can be seen in crashes at all speeds. There remains a continuing need to better understand ATV-related crash and injury mechanisms in order to develop effective injury prevention efforts.
Roadway to Disaster: Adult All-terrain Vehicle Crashes on Iowa’s Road
Sampson L, Stange N, Fjeld A, Denning G, and Jennissen C.
Background: Each year, U.S. all-terrain vehicle (ATV) crashes result in over 700 deaths and hundreds of thousands of injuries. The majority of these crashes involve operators over 16 years of age. Research shows that roadways are the most dangerous places to ride ATVs, but only a few studies have specifically examined the characteristics and outcomes of roadway-related ATV crashes. The goal of this study was to characterize statewide roadway crashes with adult ATV operators in a Midwest state.
Methods: Descriptive and comparative analyses (SPSS, Statistical Package for the Social Sciences) were performed on Iowa Department of Transportation data (476 crashes, 2002-2017). The study focused on crashes with adult (>18 years) operators.
Results: There was a steady increase in road-related crashes with adult operators over the study period from 104 in 2002-2005 to 144 in 2014-2017. Crash victims were 77% male and only 8% were helmeted. Almost half of crashes (47%) involved multiple riders on the ATV, 75% occurred in rural areas, one-quarter were collisions with a roadway vehicle, and 72% were on roads with speed limits >35 mph. Over 60% of crashes occurred on weekends (Friday-Sunday) and the vast majority (94%) occurred in good weather. Among all adult riders in the crash, 9% were killed and together more than half (53%) suffered severe or fatal injuries, with the majority of these deaths and injuries involved young adults 18-30 years of age. For drivers 18-60 years old, 1 in 5 were impaired by alcohol and/or drugs, whereas only 3% of drivers 60 and older were driving while impaired (p=0.011). Another age-dependent difference was in crash mechanism. The youngest (18-30 years) and oldest (>60 years) operators were more commonly involved in collisions with another vehicle or with an object, as compared to middle-aged adults.
Conclusions: Evidence shows that roadway riding is an independent risk factor for ATV-related crashes and injuries. This study further demonstrates that multiple risky behaviors by Iowa’s adult ATV operators, including riding on high speed limit roads and operating ATVs while impaired, is contributing to preventable deaths and serious injuries. Our results also suggest a critical need for additional ATV injury prevention strategies, including targeted approaches for different adult age groups.
The Dark Side of Nighttime Off-Road Vehicle Use
Stange N, Fjeld A, Sampson L, Denning G and Jennissen C.
Background: Off-road vehicles (ORVs), which include all-terrain vehicles (ATVs) and side-by-sides (SxSs), are designed for off-road use only. Iowa law restricts roadway riding to occupational purposes and limits it to daylight hours. A growing number of Iowa counties are opening roadways to recreational ORV use and many counties are choosing not to include a daylight restriction. To better understand this issue, the study objective was to compare and contrast daytime and nighttime OHV crashes on Iowa’s roads.
Methods: Analysis was performed using Iowa Department of Transportation crash data from 2002 to 2017 to analyze potential differences between daylight and nighttime crashes. Crashes at dawn and dusk were not included in the analysis. Darkness was defined as 30 minutes after sunset and ended 30 minutes before sunrise as reported by the National Weather Service. Youth were defined as <16 years of age. All analyses were performed using SPSS (Statistical Package for the Social Sciences).
Results: About one-quarter of roadway crashes included in analysis occurred in the dark, and identical proportions were observed for males and females. The proportion of nighttime crashes was higher for adults than for youth (30% vs 11%, p<0.0001). In 48% of nighttime crashes, the vehicle operator was physically or cognitively impaired in some way (e.g. alcohol use). Impairment was only observed in 11% of drivers in daytime crashes. A higher proportion of daylight versus nighttime crashes were on roads with speed limits >50 mph (57% vs. 34%, p<0.0001), still fully a third of nighttime crashes occurred on roads with highway speeds. Motor vehicle crashes were more common during the day (35%) than at night (13%), p <0.001. Fatal (15%) and major (49%) injuries occurred more frequently in nighttime crashes as compared to daytime (8% fatal, 39% major), p=0.003.
Conclusions: Operating OHVs on roads already represents a high-risk activity. The observation that a higher proportion of fatal and severe injuries occurred at night as compared to during the day suggests additional factors may contribute to the severity of crashes after dark. Targeted injury prevention strategies are clearly needed, including educating users about the dangers of roadway and nighttime operation, as well as better enforcement of state and local OHV safety laws.
The All-Terrain Vehicle Exposure and Crash Experiences of Iowa FFA Members
Cole Wymore, Gerene Denning, Nicholas Stange, Mitchell Hooyer, Pam Hoogerwerf, Lauren O’Donnell, Kristel Wetjen, Charles Jennissen
Background: All-terrain vehicles (ATVs) are used by adolescents for both recreational and occupational purposes, especially in rural areas. About 30% of all serious injuries due to ATVs in Iowa are suffered by children <16 years old. The study objective was to better understand the ATV-related exposure and crash experiences of Iowa adolescents.
Methods: Attendees of the 2017 and 2018 Iowa FFA Leadership Conference were surveyed at the Iowa ATV Safety Task Force booth. Descriptive and comparative analyses were performed on collected data.
Results: A total of 1,573 FFA members 12-19 years old participated. The vast majority (95%) had ridden an ATV. Nearly all reported having ridden as a passenger. Mean age at which respondents first rode as a passenger was 5.9 years, and as an operator was 8.8 years. Nearly 20% and about 30% reported having crashed on an ATV when riding as a passenger and as a driver, respectively. The mean age at which they first crashed as a passenger was 10.5 years and as a driver was 11.0 years. On average, males first drove ATVs about a year earlier than females. Both those that lived on farms or whose families owned an ATV were significantly younger when they first rode an ATV than those that lived elsewhere or did not own an ATV, respectively. Overall, over one-third had been in at least one ATV crash. Males and those who live outside city limits had higher percentages that had been in a crash. Fifteen percent of those in an ATV crash required getting medical attention and the mean age at the time of their first crash that required medical attention was 11.5 years.
Conclusions: Iowa FFA members reported nearly universal exposure to ATVs and commonly practice unsafe riding behaviors. Families are routinely not enforcing safe ATV practices and are allowing children to ride and drive ATVs at ages which are not developmentally appropriate and against manufacturer recommendations.
How to Increase ATV Safe Riding Behaviors in Youth: FFA Members from Across the Country Respond
Mitchell Hooyer, Nicholas Stange, Cole Wymore, Gerene Denning, Pam Hoogerwerf, Lauren O'Donnell, Charles Jennissen
Background: All-terrain vehicles (ATVs) are a significant source of injuries and deaths. In fact, more children <16 years of age die in the U.S. from ATVs than from bicycle crashes. This study’s objective was to explore the best methods to improve adolescent ATV safety practices from the target audience’s perspective.
Methods: ATV safety workshop attendees at the 2018 National FFA Convention answered a number of questions after facilitated discussions. Qualitative analysis of responses was independently performed by three research team members, and differences in coding were resolved through an iterative process.
Results: 309 FFA members from 62 clubs participated (29 states). Almost all clubs stated that one reason most youth don’t ride ATVs safely is because of personal beliefs (e.g. inconvenient/not as enjoyable to ride safely). Almost three-fourths stated that an unsafe riding behavior that young people would be most likely/willing to change was wearing a helmet; safety behaviors least likely/willing to change would be traveling at lower speeds and not carrying passengers. The majority of clubs stated that one of the best places to reach youth was at schools; the second most frequently mentioned was social media. Safety presenters that clubs felt youth would be most likely to listen to were peers and those just slightly older than themselves, followed by crash survivors and those whose loved ones had been injured or died. Presentations with real-life injury examples including videos that might create a “fear factor” and hands-on activities were thought to be most effective in promoting safe riding; the least effective methods were lengthy, non-interactive presentations and printed materials with lots of facts and statistics.
Conclusions: Youth have strong opinions regarding injury prevention information delivery, and what is likely to result in behavioral change. Our study provides important data regarding not only ATV safety information delivery, but other prevention messaging to youth as well.
Reviewing Disasters: Hospital Evacuations in the United States From 2000-2017
Aishwarya Sharma
Background: Between 2000 to 2017, there were over 150 hospital evacuations in the United States (US). Data received from approximately 35 states was primarily concentrated in California, Florida, and Texas. This analysis will provide disaster planners and administrators statistics on hazards that cause disruptions to hospital facilities. The purpose of this study is to investigate US hospital evacuations, compiling the data into external, internal, and man-made disasters; thus, creating a risk assessment for disaster planning.
Methods: Hospital reports were retrieved from Lexis Nexis, Google, and PubMed databases and categorized according to evacuees, duration, location, and type. These incidents were grouped into three classifications: external, internal, and man-made.
Results: Both partial and full evacuations were included in the study design. There were a total of 154 reported evacuations in the US. 110 (71%) were due to external threats, followed by 24 (16%) man-made threats, and 20 (13%) internal threats. Assessing the external causes, 60 (55%) were attributed to hurricanes, 21 (19%) wildfires, and 8 (7%) storms. From the internal threats, 8 (40%) were attributed to hospital fires and 4 (20%) chemical fumes. From the man-made threats, 6 (40%) were attributed to bomb threats and 4 (27%) gunmen. From the 20 total reported durations of evacuations, 9 (45%) lasted between 2 to 11:59 hours, 6 (30%) lasted over 24 hours, and 5 (25%) lasted up to 1:59 hours.
Conclusion: Over 70% of hospital evacuations in the US were due to natural disasters. Compared to 1971-1999, there was an increase in internal and man-made threats. Exact statistics on evacuees, durations, injuries, and mortality rates were unascertainable due to a lack of reporting. It is critical to implement a national registry to report specifics on incidences of evacuations to further assist with disaster and infrastructure planning.
Mortality in Nursing Home Evacuations in the United States From 1995-2017
Aishwarya Sharma
Background: There are an estimated 15,600 nursing homes with a total of 1.4 million residents in the United States. The number of residents will continue to increase due to the aging population, and the associated morbidities will make it difficult to evacuate them safely. This study is the first of its kind to provide an analysis on the number of nursing home deaths caused by external and internal events following evacuations.
Methods: Information from the databases Lexis Nexis and PubMed were compiled and limited to news articles from 1995-2017. The gathered information included the reason for evacuation, injuries, deaths, and locations within the United States.
Results: From 1995 to 2017, there was a total of 51 evacuations and 141 deaths in nursing homes. 27 (53%) evacuations were due to external events which resulted in a combined 121 (86%) deaths, and 24 (47%) evacuations were due to internal events which resulted in a combined 20 (14%) deaths. Hurricanes were responsible the majority of deaths during evacuations, followed by fires and floods. The number of evacuations and deaths increased the greatest between 2005 to 2008.
Conclusion: External events have the greatest impact on loss of life. Internal disasters are about equal in number of incidents, however external events have a much greater mortality rate. Exact numbers on injuries, morbidity, and mortality are difficult to ascertain, but it appears to be related to natural disasters. In view of the increasing likelihood of natural disasters related to global warming, a drastic improvement of standard evacuation procedures of long-term nursing homes is critical to decreasing mortality of nursing home residents. There also needs to be a national standardized method of reporting evacuations in order to better analyze data on nursing homes.
The Dangers of Off-Road Vehicles to Youths: Not Something to Kid Around About
Fjeld A, Sampson L, Stange N, Denning G, and Jennissen C.
Background: Children are not allowed to operate motor vehicles such as cars until they are 16 years old due to the risks associated with the operation of such powerful machines. Yet, the operation of off-road vehicles (ORVs) by youths under 16 years old has been largely normalized in both rural and urban communities, despite the significant safety risks involved. To better understand this issue, the goal of this study was to characterize roadway ORV crashes with youth operators, including riding behaviors and crash outcomes, in a Midwest state.
Methods: Descriptive and comparative analyses (SPSS, Statistical Package for the Social Sciences) were performed on Iowa Department of Transportation (DOT) data (115 crashes from 2002-2017). This study focused on crashes involving youth (<16 years old) operators.
Results: In Iowa’s pediatric roadway crashes from 2002-2017, 63% of victims were male and 81% were 12-15 years old. Females were more commonly passengers than were males (60% vs. 24%), as were younger (<12 years) as compared to older riders (56% vs. 26%). Only a small percentage of victims were helmeted, 24% of operators and 14% of passengers. Additionally, 73% of all roadway crashes involved multiple riders on the ATV, around 40% occurred on paved roads, and 82% occurred in rural areas. Collisions with an object or another vehicle were the mechanism in 65% of crashes. Roads with speed limits over 50 mph were the location of around half (52%) of all crashes. Among pediatric victims, 3.5% were killed in the crash and 46% of the pediatric roadway crashes resulted in either major injury or death. Moreover, a higher proportion of the fatal or incapacitating injuries were observed in adolescents (12-15 years) than in younger children (35% vs. 23%).
Conclusions: Results illustrate multiple risky behaviors are common among youth in roadway ORV crashes, including riding on high speed roads, with passengers, and/or without helmets. Adolescents (12-15 years old) are the large majority of pediatric victims, and serious injury or death resulted in almost half of all crashes. Based on these results, it is clear that multiple targeted approaches are needed for youth under 16 years old in order to prevent pediatric fatalities and severe injuries, particularly on the road.
Screening for UTIs in Febrile Children: Do We Follow the Guidelines?
Adam Rodos, MD., Jan Chang, MD., David Chestek DO, Hannah Seyller, Stacy Laurent, DO, Leah Finkel, MD.
Background: Urinary tract infections (UTIs) are a common source of unexplained fevers in children, and missed UTIs account for significant patient morbidity. Preverbal children may not be able to inform caregivers or medical professionals of urinary symptoms. Existing guidelines can help determine when to evaluate for UTI in febrile children. We wanted to determine how often we follow the guidelines when screening for UTI in one ED.
Methods: Using the Childrens’ Hospital of Philadelphia (CHOP) Febrile UTI guideline, we reviewed all charts of febrile children who presented to our urban, academic ED, staffed by a mix of PEM and non-PEM clinicians, in December 2018. The CHOP guideline stratifies patients based on the number of UTI risk factors present and categorizes them as either consider (lower risk) or recommend (higher risk) screening for UTI. We collected retrospective data regarding guideline adherence and practice variability as part of a QI project.
Results: 94 patients met inclusion criteria for chart review (febrile patients aged 3 to 36 months). 29 patients were excluded due to incomplete data regarding risk factors, leaving 65 patients in the final analysis. Out of 65 patients, 38 had risk factors that met guideline criteria for UTI screening.
In patients with the recommendation to consider UTI screening, only 24% (9/38) underwent screening. When screening was recommended, only 32% (6/19) of patients underwent screening. Under-screening was most notable among circumcised males. In patients not screened for UTI despite CHOP recommendations for screening, 100% (13/13) had alternate sources of fever identified. This overall lack of guideline adherence persisted when comparing patients cared for by PEM vs. non-PEM.
Conclusion: We identified under-screening for UTI in febrile patients aged 3 to 36 months who presented to our ED. This discrepancy existed in both genders but was most pronounced in circumcised males, suggesting that clinicians may underestimate the true risk for UTI in this population. This baseline data is a starting point to increasing adherence to published guidelines for UTI screening in febrile children. Information from providers is needed to confirm reasons for under-screening. This information can then inform the creation of an intervention to improve pediatric UTI guideline adherence.
Social workers’ determination of when a child being left home alone constitutes child neglect
Charles A Jennissen, Erin M Evans, Alycia A Karsjens, Gerene M Denning
Background: Decisions made by child welfare workers related to the determination of child neglect play an important role in promoting responsible childcare and preventing harm to children. This study’s objective was to identify factors influencing determination by social workers as to when leaving children home alone constitutes child neglect.
Methods: Email invitations to participate in an online survey were delivered Oct-Dec, 2015, to National Association of Social Workers (NASW) members designating their practice as “Child/Family Welfare” (N=4,933). Respondents were asked to indicate whether scenarios involving a child of varying age knowingly left home alone for four hours were neglect, in the presence or absence of injury to the child and the presence or absence of relevant law. Descriptive and bivariate analyses were performed.
Results: 485 social workers completed the survey; ~10% of those who received an email invitation. In the scenario where there were no relevant laws and the child was uninjured, almost 100% of experts determined this was child neglect for children 4 yrs old. For 6, 8, 10, 12, and 14 yrs of age, this was 97%, 83%, 51%, 11%, and 1%, respectively. A significantly higher percentage of social workers considered it child neglect for most ages if there was an injury versus not, and if there was a law versus not. For 14 yrs of age, the proportion went from 1% if there was no law and no injury to 51% if there was a law and the child was injured. Similarly, for 12 yrs of age, the proportion went from 11% if there was no law and no injury to 64% if there was a law and the child was injured. There were some demographic differences observed in the ages determined to be child neglect for each scenario. Ninety-four percent of participants stated that leaving a child home alone for four hours should be illegal if the child was <8 yrs old, and over 80% said it should be illegal for children <10 yrs of age.
Conclusion: Despite the risk to the child being the same, sustaining an injury and the presence of a law both increased the percentage of social workers that considered a child being left home alone for 4 hours as child neglect. These results suggest the need for guidelines and/or safety laws related to childhood supervision, as well as their uniformity across the country, in order to direct social workers in their evaluation of potential cases of child neglect and to better protect children from harm.
The Model Development, Validation and Refinement to Identify Anaphylaxis in Pediatric Patients Presenting to the Emergency Department
Kelsey Anderson, B.S.; Karisa K Harland, PhD, MPH; Sangil Lee, MD, MS
Background: The number and severity of anaphylaxis cases presenting to the Emergency Department (ED) is increasing and can create a potentially difficult diagnosis. The objective of this study was to validate the known combinations of food allergy, angioedema, hoarseness, dyspnea and nausea with clinical information to estimate a concise model for anaphylaxis diagnosis among pediatric patients.
Methods: This study was a retrospective chart review of pediatric patients (0-18 years) presenting to the ED at a large rural tertiary care center with the chief complaints of allergic reactions, food allergies, insect stings, medication reactions or anaphylaxis. Anaphylaxis was defined as a patient meeting any of the three National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria. Data collected included past medical history (PMH), demographics, suspected allergen, symptoms, medications, ED management and follow-up. Differences among variables across anaphylaxis diagnosis were tested with the Pearson Chi-Square test for categorical variables and the Student’s t-test for continuous variables. The c-statistic for the predictive ability of the model was calculated using multivariable logistic regression.
Results: A total of 475 patients were included with 54% of the sample being male (n=259). Almost one-third (n=139) of patients had a confirmed diagnosis of anaphylaxis in the ED. Of those, 15 (10.8%) had a PMH of angioedema (p <.01), 28 (20.1%) had a PMH of anaphylaxis (p < .0001), 27 (19.4%) had a PMH of asthma (p = .05) and 32 (23.0%) had a PMH of hives (p <.0001). Each of the variables for inclusion in the regression model, food allergy, angioedema (p <.01), dyspnea (p <.01), nausea (p <.0001) and hoarseness (p <.0001), were highly associated with anaphylaxis diagnosis. When combined in a regression model, these variables were highly predictive of an anaphylaxis diagnosis (c=0.87).
Conclusion: Our study indicated that the combination of food allergy, angioedema, hoarseness, dyspnea and nausea are associated with anaphylaxis diagnosis. These findings can improve accuracy of diagnosis and improve outcomes.
Procoagulant Material Released from Platelets Likely Degraded by Non-Enzymatic Process
Carleigh Hebbard, Ph D.
Background: This investigation stemmed from a DoD-funded multi-center effort to stop internal bleeding on the battlefield, where surgical intervention can be inaccessible. The group goal was to create nanoparticles that target bleeding sites and trigger coagulation locally. Years ago, the Docampo and Morrissey labs found that platelets harbored a thrombin-binding procoagulant molecule called polyphosphate (polyP). Linking polyP to targeted, threshold-switchable nanoparticles might prove useful in stopping internal bleeds. PolyP has a plasma half-life of 90 minutes (Lorenz et al 1997, Smith et al 2006). To increase the half-life of polyP-laden nanoparticles and prolong localized coagulability, we wanted to find and stop what we thought were serum polyP-degrading enzymes.
Methods: Our lab developed a 96-well formatted ELISA-like assay that lets us indirectly quantify polyP degradation. Platelet polyP are linear 60 – 100-unit phosphate chains. We chemically attach polyP to 96-well plates, submit polyP to various insults (e.g. serum), and wash the plates. Remaining polyP length depends upon the extent of polyP degradation caused by each tested condition. We bind thrombin to the remaining polyP and spectrophotometrically monitor colorimetric substrate cleaved by thrombin. Colorimetric change correlates to remaining polyP.
Results: Adding phosphatase inhibitors to serum did not slow polyP degradation. Boiling serum accelerated degradation. Removing serum metals, however, halted activity. When we depleted serum of metals and added back single metals, we found that calcium restored activity at physiologic concentrations, and we were able to approximate the rate of serum polyP decay with the in vitro conditions of pH = 7.4 and low millimolar calcium concentrations.
Conclusion: We expected to identify and stop plasma enzymes from degrading the platelet-derived procoagulant molecule, polyP. Arresting such activity would increase the half-life of polyP-laden nanoparticles targeted for internal hemorrhaging. We found instead that inherent serum metals such as calcium cause polyP decay. Removing calcium from hemorrhaging sites is a non-viable solution because calcium is needed for clotting factor membrane binding. To increase polyP's half-life in the future, we may explore substituting units within the polyP chain in order to make it less prone to decay.
Abstracts Session 2 - Room: 2B 0900-1150
Medication Refills in the Emergency Department as a Predictor for Social Need
Sarah Berg, MD
Background: The emergency department (ED) is often a point of entry for underserved patients with social need. Previous studies show that many patients use the ED as their primary source of health care, citing lack of primary care provider, financial constraints, and high burden of disease as primary reasons for utilizing the ED. We studied low acuity patients seeking medication refills in the ED to determine if social determinants of health contributed to increased ED visits for primary care complaints. We predict that patients presenting to the ED for medication refills are less likely to have health insurance or a primary care provider and are more likely to be homeless or lack adequate transportation.
Methods: The study took place at a academic, urban, 70 bed emergency department with 95,000 total annual ED visits. 221 visits from June 1 to August 31, 2017 met screening criteria: chief complaint “medication refill” or ICD-10 codes related to medication refills. Patients were included if they were over 18 years old, were ultimately discharged from the emergency department, and were not intoxicated or obtunded. The entire documented ED visit was reviewed for demographic information and reason for presenting to the emergency department.
Results: Of the 228 charts initially screened, 178 were included in the final review. 50 charts were excluded due to patient intoxication at the time of the index visit or index visit was not for medication refill. 24% of patients cited lack of access to timely outpatient appointment as their primary reason for seeking medication refill in the emergency department. 6% cited lack of access to a primary care provider, while 7% cited recent relocation as their reason for seeking medication refills.
Conclusion: Our data show that our patient population lacks access to adequate primary care resources. Lower acuity visits that are typically reserved for primary care may contributed to ED overcrowding, increased healthcare spending, and poorer continuity of care for chronically ill patients. Our study was limited by retrospective design at a single institution and relied on provider documentation for the primary outcome. More data is needed to determine specific ways that we can improve our patient’s lives and solve many of the problems plaguing academic emergency departments today.
Hospital-wide Resuscitation Quality Evaluations: How Can Medical Students Be Utilized?
Jeanette Lorme, Tarush Khurana, Errick Christian, Daniel Tauber, Christina Brown, Michelle Sergel
Background: Evaluating the quality of resuscitations that occur throughout the hospital can be a difficult undertaking due to biased retrospective self-reporting, incomplete data, and lack of a reliable workforce to objectively and reliably observe codes in real-time. Furthermore, video recording resuscitations is frequently discouraged due to legal discoverability. This study assesses the ability of pre-clinical medical students trained by video simulation, who could fill the role of objective code observer, to consistently evaluate resuscitation events in a manner similar to that of an expert physician.
Methods: A web-based instructional video simulation module was created for content delivery and data collection. 40 pre-clinical medical students and 7 attending physicians learned to use a scoring checklist based on the American Heart Association cardiopulmonary resuscitation (CPR) quality and teamwork measures in an instructional video. The assessment module included 6 resuscitation scenarios designed to be of varying CPR and teamwork quality each followed by a quiz utilizing the scoring scale (0 - 4) in the training video to evaluate the quality of the resuscitation event. A weighted kappa statistic (κ) to assess rater agreement was used to assess scores set by the simulation expert versus medical student and attending scoring.
Results: Students and attendings had higher agreement with the simulation expert on the constructs of CPR related to the technical aspects of compressions over the constructs that measured leadership and teamwork. For compression roles (team member changed every 2 minutes), students had strong agreement (κ = .8) and attendings had moderate agreement (κ = .6). For compression quality (adequate rate/depth/location), both students and attendings had weak agreement (κ = .57, .42). In the teamwork and leadership constructs (team leader’s direction, perspective, and communication) there was minimal to no agreement among students and attendings (κ < .3).
Conclusion: Medical students can evaluate objective CPR quality measures, such as compression quality, with a short video simulation training program. Medical students may require more intensive and dynamic training, particularly for measures of teamwork and leadership, to reliably provide these aspects in a real-time resuscitation.
Comparing Procedural and Patient Exposure of Medical Student Rotations at Rural and Metropolitan Emergency Departments
Connor Stephenson MS3; Jonathan dela Cruz MD; Kristin Delfino PhD; Danuta Dynda MD, MBA; James Waymack MD; Chinmay Patel DO; James Hart MD
Background: Despite an increase in medical school graduates, rural populations are still being underserved in healthcare and Emergency Medicine specifically. Many medical schools currently offer rural rotations that provide students with unique exposure to practicing in a rural environment. There is ongoing debate that rural rotations do not provide the same procedural exposure, patient acuity, or overall educational experience as their metropolitan counterparts. There has only been one prior study comparing rural and metropolitan procedural experience in residencies and no current studies observe rotations during medical school.
Methods: A retrospective review of emergency medicine clerkship logbooks was performed. Medical students at the study institution were required to rotate at one of two metropolitan sites as well as one of three rural sites. Patient encounters, admissions, and procedures (observed and performed) were tallied for comparison metropolitan versus rural sites. Calculated rates of admission and various procedures were then used to compare experiences at rural sites to those of larger metropolitan centers.
Results: Over a one month rotation, 55 students reported 4467 patient logs and 633 procedures. Students did not encounter wound care, bedside ultrasound, intubation, resuscitation, chest tube, and ‘other’ procedures at statistically significantly different rates between metropolitan and rural sites. Fracture reductions (1.13% vs 0.27%) and central line (0.83% vs 0.27%) had a statistically higher chance of exposure at metropolitan sites. Rates of procedures observed (9.00% vs 6.83%) vs performed (5.28% vs 5.31%) were not different between sites. Metropolitan sites saw higher admit rate at 28.79% than rural sites at 19.51%.
Conclusions: Students had similar procedural exposure rural vs metropolitan sites. Fracture reductions and central line rates were statistically different, however with such low procedure numbers it is unknown the educational significance. Acuity was notably higher at metropolitan sites. Possible confounding factors include the presence of residents at metropolitan sites that are absent at rural sites, varying accuracy in reports, and overall low procedure numbers. Further analysis into the distribution of presenting symptoms may provide additional insight into the differences in educational experiences.
Perceptions and Perceived Utility of Rural Emergency Department Telemedicine Services: A Needs Assessment
Sarah Oest
Background: Access to specialized medical care is often limited in rural emergency departments, and specialist consultation through telemedicine services could help increase access in low-resource areas. The objective of this study was to better understand providers’ perceptions of the anticipated impact of telemedicine in rural Midwestern emergency departments. The secondary objective was to understand differences in the perception of rural and academic providers in their views of the utility of telemedicine.
Methods: We conducted a cross-sectional survey of medical providers including physicians, physician assistants, and nurse practitioners at five rural Midwestern critical access hospitals and within six departments at a university medical center in the same region. The survey addressed opinions on telemedicine including how often it would be used and the potential to improve patient care and reduce transfers.
Results: Specialties of high perceived utility to rural providers include psychiatry, cardiology, and neurology, while academic providers viewed services in psychiatry, pediatric critical care, and neurology to be of most potential value. Academic and rural providers have differing opinions on the anticipated frequency of telemedicine use (p<0.001) and prevention of inter-hospital transfers (p=0.023). There were significant differences in perceived value by specialty.
Conclusion: There is a high demand for telemedicine consultation services in rural Midwestern hospitals, particularly in psychiatry, cardiology, and neurology. Overall, academic providers view telemedicine services as more valuable within their specialty than do rural providers. Further research should be done to investigate individualization of telehealth services based on regional needs and how disparate opinions predict telemedicine utilization.
Cardiovascular Disease (CVD), Emergency Department (ED) Use, and Social Capital Among East African Immigrants
Bjorn Westgard
Background: As the number of immigrants in the U.S. has increased, so has the prevalence of chronic illness, health disparities, and ED use related to both. We hypothesized that, among East African immigrants to the U.S., the “healthy immigrant effect” may be seen in increased CVD risks and ED use, particularly among those with low social capital.
Methods: The prevalence of CVD risks, ED use and social capital were determined in community-dwelling Somali adults at two points in time by trained community health workers. In 2001, a cluster-randomized sample of households (N=253) was surveyed, and in 2015-16, a respondent-driven sample (N=1180) was surveyed, both to approximate a random sample given known difficulties in accurately surveying the Somali community. In both efforts, we obtained anthropometric, blood sample, and survey data regarding CVD risk factors, demographics and health resource utilization, including self-reported ED use. After adjusting for sampling methodologies and age/sex weighting to the American Community Survey, we assessed the differences between the 2001 and 2015-16 results.
Results: Among Somali immigrants, there was an increasing prevalence of CVD risks, including overweight/obesity (33.9/27% to 25.7/39.7%), diabetes (15.2 to 30.2%) and hypertension (9.9 to 18.1%). Overall insurance remained high (>75%), and primary care access improved from 58.4 to 72.6%, while ED use decreased from 36.7% to 23.8%. ED use was significantly associated with the presence of CVD risk factors and changing or worsening health status, particularly among those who are older, female, less educated, unemployed, in poverty, low in English proficiency, low in trust, and/or low in social resources.
Conclusion: CVD risks among East African immigrants are increasing rapidly. ED use may be another marker of this “healthy immigrant effect,” particularly for those with persistently low social capital. EDs are essential sites for efforts to improve immigrant health through education, prevention, and social resources.
Electronic Prescribing Implementation Decreases Opiate Prescriptions in an Academic Emergency Department
Bradley Gordon
Background: The prescribing of opioid analgesics is under intense scrutiny with simultaneous pressure to move to electronic prescribing systems. At one hospital, an systems update allowed valid prescribers to transmit controlled substances to most retail pharmacies using electronic signatures (e-prescribing). Simultaneously, the hospital outpatient pharmacy changed policy to require that any electronic or handwritten prescription for a controlled substance be signed by a US Drug Enforcement Administration (DEA) registered provider rather than by a resident using a hospital-issued DEA number. The resulting changes excluded residents from independently writing prescriptions any controlled substance. We retrospectively analyzed opioid prescription rates before and after these workflow changes to better understand their impact on prescribing.
Methods: At a single high-volume academic ED, monthly census and prescribing rates were collected for two 12-month periods adjacent to, but not including, the e-prescribing implementation. Only prescriptions for short-acting oral tablet opioid analgesics were included. Graphical analysis and descriptive statistics were computed of the monthly rates.
Results: During the pre-intervention period, the mean monthly census was 7280 patients with 7.54 prescriptions per 100 patients (95% CI 6.02-9.06). In the post-implementation period the mean monthly census of 7334 patients and 4.80 prescriptions per 100 patients (95% CI 3.82-5.78). The decrease of 2.74 prescriptions per 100 patients (P < .001) represents a 36% decrease in prescribing frequency with no significant change in the overall ED census between the two periods.
Conclusions: In this academic ED, implementing new methods and policies for prescribing controlled substances was associated with a marked reduction in the frequency of prescribing short-acting oral tablet opioid analgesics. These results may guide other academic EDs working to implement e-prescribing of controlled substances and policies that mandate the use of e-prescribing over paper-based prescribing methods. We were limited by our inability to further compare prescribing rates at the provider level, which would help determine whether e-prescribing barriers or hospital pharmacy policy changes drove the observed effect in this ED.
Identification of High Efficiency Practices of Residents in an Academic Emergency Department: A Mixed Methods Study
Haley M. Egan, Morgan B. Swanson, Steven A. Ilko, Karisa K. Harland, Nicholas M. Mohr, Azeemuddin Ahmed
Background: Emergency department (ED) utilization and overcrowding are on the rise. Emergency medicine residency programs are under increased pressure to train efficient and productive residents in order to meet these demands. Specific practices associated with resident efficiency have not yet been scientifically characterized. The purpose of this study was to identify key practices associated with enhanced efficiency in emergency medicine residents.
Methods: A mixed-methods study design was utilized to identify discrete behaviors associated with resident efficiency. In Stage 1, eight emergency medicine faculty provided 61 behaviors associated with resident efficiency during semi-structured interviews, which were then distilled into eight behaviors by independent ranking. Seven behaviors from the study team were added, as well as 16 behaviors identified in a previous study on community ED provider efficiency by Bobb et al., to create a final list of 31 efficiency behaviors. Stage 2 was an observational study of 27 emergency medicine residents who were each observed for two 4-hour periods during separate clinical shifts. The timing and frequency of each of the study behaviors was recorded in minute-by-minute observation logs. In Stage 3, the association between provider efficiency and each of the 31 behaviors was tested using univariable generalized estimating equations with an identity link and clustered on resident year of training. Efficiency was measured using residents’ relative value units per hour.
Results: Eight resident practices were found to be positively associated with efficiency: average patient load, taking history with nurse, checking the board, running the board, conversations with consultants, use of dictation, text communication, and non-work tasks. Four practices were found to be negatively associated with efficiency: time in patient room, visits to patient room, reviewing electronic medical record, and utilizing ED clerks.
Conclusion: Several discrete behaviors were found to be associated with enhanced resident efficiency. By identifying these efficiency behaviors, residency programs can counsel residents on specific practices that can be implemented or developed in order to improve upon their personal efficiency throughout training.
Significant Differences in Patient Acuity Assessments Between Emergency Department Patients and Providers
Sharon Mace, MD
BACKGROUND: Prospective comparison of ED patients’ and their healthcare provider’s perception of acuity.
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing, 18-bed ED with approximately 16,000 patient visits annually. Using a survey of perceived medical acuity on a 5 point Likert scale: Level 1 Critical: Immediate Care required, Level 2 Emergent: care required within 15 minutes, Level 3 Urgent: care required within 15 – 60 minutes, Level 4 Semi-urgent: care required within 2 – 24 hours, Level 5 Non-urgent: care required within several days.
RESULTS: The majority of patients who came to the ED were female 59%, African-American35%, Caucasian60%. 44% of patients are single, 40% married, and 16% are separated, divorced or widowed. 326 patients (59.1%) have public insurance (Medicaid or Medicare) vs. 207 (37.5%) private insurance, and a minority of patients 10 (1.8%) are uninsured. 174 (31.5%) of patients are employed, 262 (47.5%) are not employed. 86 % have a primary care physician (PCP). The median acuity estimated by patients was 2- Emergent on the Likert scale vs. health care provider median estimated acuity of 4-Semi-urgent. Patients overestimated their acuity 91.1% of the time. Patients agreed only 8.9% of the time with their health care provider. No patient underestimated their acuity.
CONCLUSIONS: Patients and clinicians assessment of patient acuity were significantly different with more patients assessing their condition as being more serious or requiring immediate care 63% of the time compared to their ED providers at only 9%. An overwhelming majority of ED providers (91%) classified patient acuity urgent, semi-urgent or non-urgent, compared with 37% of patients who felt their acuity was urgent, semi-urgent or non-urgent.
Investigating Healthcare Provider Bias Toward Patients Who Use Drugs Using a Survey-Based Implicit Association Test
Authors: Rachel A. Dahl, MS; J. Priyanka Vakkalanka, ScM; Karisa K. Harland, MPH, PhD; Joshua Radke, MD
Background: When healthcare providers have implicit bias against patients who use drugs (PWUD), it may result in worse outcomes. We investigated whether implicit bias is associated with explicit bias toward PWUD at a large midwestern hospital using an online implicit association test (IAT).
Methods: We sent emails to five departments at our institution in order to recruit healthcare providers to complete an IAT via a Qualtrics® platform. We created the IAT using previously validated methods. Participants were presented with a series of on-screen stimuli or characteristics that they were instructed to match to targets (drug user or non-user) or to categories (good words or bad words) as fast as possible without making errors. A summary measure (D-score) for each participant was generated using iatgen software. A D-score [-2,+2] measures incompatibility in the timing of matching bad associations (“disgusting” with drug user/bad words) or good associations (“empathy” with drug user/good words) with the target. A score of 0 indicated no bias. A positive score indicated bias against drug users, where +2 is most biased. Participants then completed a survey about their explicit beliefs toward PWUD, including nine questions adapted from a previously validated study and five new questions. Surveys were scored on a 5-point Likert scale (1=low, 5=high). Scores were compared by demographic characteristics using univariate analyses. Explicit and implicit bias scores were measured through linear regression.
Results: Of the 44 providers who completed the study, 73% were female, 23% were from the ED, and 37% were staff physicians. About 60% of participants saw 1-10 patients with substance use disorder weekly. Total mean D-score was 0.562 (SD=0.37, p<0.001). Mean D-scores did not vary across demographic characteristics. Providers from the ED had higher explicit bias scores overall (2.27, p=0.047) and among questions regarding whether PWUD deserve healthcare (2.36, p=0.020). With each unit increase in overall explicit bias score, there was a 0.2 increase in D-scores (p=0.025).
Conclusion: We observed a positive association between implicit and explicit bias overall. Compared to other departments at our institution, ED providers may have higher explicit bias, but not implicit bias, toward PWUD. However, this study is underpowered, with potential bias due to recruitment method.
Abstracts Session 3 - Room: 2A 1400-1650
Regionalization in Emergency Time-Critical Care: Classifications, Comparisons, and Considerations
Nathan Walton and Nicholas Mohr M.D.
Background: Regionalization is the concept of organizing hospitals and providers into a system to optimize care by matching patient needs with the appropriate resources within the system. Regionalized care has been shown to improve outcomes in trauma, burn, stroke, STEMI, cardiac arrest, and NICU/OB care. The objective of this study was to conduct a comparative analysis of regionalization systems to identify common factors that can be used to refine existing systems and develop new disease-specific networks.
Methods: This study was a comparative literature review and interviews with informed organizational representatives of existing regionalization systems. We conducted a comprehensive literature review to develop a classification-based, comparative review of the existing regionalized systems of care by their components and characteristics. Then we performed a text-based analysis of the writing of the involved organizations (professional, regulatory, etc.) and interviews with the organizational leaders directly involved with regionalized systems of care. This information was incorporated into the comparison and evaluated for trends and best practices.
Results: Regionalization in the US has followed a predictable pattern of development. Systems center on the delivery of time- or volume-sensitive care that is limited due to resource, facility, or expertise scarcity. In response to lapses in care delivery and inefficient resource use, professional organizations (American College of Surgeons, Brain Attack Coalition, etc.) have published clinical guidelines and suggested regionalized tiered systems of facilities by resources and expectations of participation. These guidelines are used by government or third party-designating and certifying organizations to be established and verified in participating facilities. These efforts have been effective in establishing regionalized networks characterized by triage/transfer protocols, data registries, research, education, and performance improvement measures.
Conclusions: Regionalization in emergency care has been found to improve outcomes for several conditions despite continuing barriers in personnel, quality and processes, technology, finances, and jurisdictional politics. The best practices learned in the process hold promise to improve the existing systems and establish new ones.
A Retrospective Cross-Sectional Study Evaluating the Indications for Ultrasound in a Low Resource Emergency Department
Lanter, Patrick. Wood, Amanda. Hilbert, SueLin. Mueller, Kristen.
Background: Acute abdominal pain is one of the most common presenting symptoms in the emergency department, accounting for roughly 7-10% of all visits to US emergency department per year. In low resource settings, ultrasound provides a useful diagnostic modality to evaluate undifferentiated abdominal pain.
Methods: A retrospective cross-sectional study was performed evaluating all patients who were admitted from the emergency department at Salvador Gautier Hospital in Santo Domingo, Dominican Republic. Patient charts in January, April, May, August were reviewed, and final diagnosis was recorded. If available, patients presenting vital signs, location of pain, test results and length of stay were also recorded. Based on this data, indications for right upper quadrant, renal, aortic and pelvis ultrasounds were identified.
Results: Of 2300 patients admitted the hospital during this stay, 218 patients presented with abdominal pain. Of those charts, 107 were admitted with a chief complaint of abdominal pain. Based on final diagnosis, there were indications for 2 pelvis ultrasounds, 33 RUQ ultrasounds, 1 aortic ultrasound and 20 renal ultrasounds.
Conclusion: Based on a retrospective cross-sectional study evaluating ED admission to Salvador Gautier Hospital for abdominal pain, a total of 56 patients would have benefitted from one either a RUQ, pelvic, renal or aortic ultrasound. We hope to use this data to raise funding for an ultrasound probe at Gautier Hospital to help facilitate ultrasound training to the emergency medicine residents training at the institution.
Limitations: This study was extremely limited by the quality of data collected. Initially 218 patients were identified with abdominal pain after reviewing admission sheets. Of these, we were able to find 55 charters, 22 of which did not contain any papers leaving a total of 33. With the limitations on the data, we decided to do a secondary analysis with the admission sheets which allowed us to identify 218 patients with abdominal pain, 107 of whom carried a final diagnosis. The indications for an ultrasound were based on these final diagnoses.
Automated alerts for septic patients in the Emergency Department: A systematic review of screening test accuracy and quality measure studies
Matthew I. Hwang; Emilie S. Powell, MD, MS, MBA ; William Bond M.D., M.S.
Background: Electronic alerts are frequently implemented to improve identification and response times to sepsis. Alerts are often rule based, using a simple point system for sepsis diagnosis to notify the provider. Algorithm based alerts have been developed to incorporate additional factors, such as past medical history, lab values, and demographic.
Purpose: To review the literature of automated sepsis alert systems and establish their utility in the Emergency Department (ED) setting.
Methods: The systematic search included PubMed MEDLINE, Embase, the Cochrane library, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL). Two independent reviewers selected studies with the Covidence screening and extraction tool. Eligible studies included published articles with the following: (1) adult patients in the ED diagnosed with sepsis, severe sepsis, or septic shock, (2) an electronic system that alerts a healthcare provider of sepsis in real or near real time, and (3) measures of diagnostic accuracy or quality of sepsis alerts. Risk of bias and quality of articles were assessed with guidance from the QUADAS-2 and GRADE rating systems.
Results: 731 articles were screened and 10 were selected for the study. 8 of these studies assessed accuracy and 6 assessed outcomes. Two studies had algorithm based alert systems, while eight had rule sets. All systems used different criteria based on systemic inflammatory response syndrome to define sepsis. Diagnostic accuracy varied greatly: sensitivity ranged from 33.3% to 100%, specificity from 78% to 99%, and PPV from 5.8% to 54%. NPV was consistently high at 99% to 100%. Process measures, such as time to antibiotic administration, showed modest improvements. Length of stay significantly improved. The only measure reported by an algorithm based study was mortality, which showed significant improvement. Rule based studies showed insignificant improvements in mortality.
Conclusions: Rule based sepsis alerts in the ED may improve process measures and length of stay. Diagnostic accuracy varies and may not correlate with outcomes. An algorithm based alert improved mortality. Further studies are needed to assess the efficacy of newer algorithmic systems.
Dextrose 10% is Safe and Effective Alternative to Dextrose 50% in Prehospital Hypoglycemia Treatment
Shaila K. Coffey, MD1; Abraham Campos, MD1
Background: Severe hypoglycemia (glucose concentration < 70 mg/dl) occurs frequently in the US and is a common emergency call for prehospital providers. Due to a recent national drug shortage, many prehospital systems have been forced to replace D50 boluses with D10 infusions to treat hypoglycemic patients. The primary aim of this study is to determine if D10 is an effective and safe alternative to D50.
Methods: This was a cross sectional study of 1073 patients suffering from hypoglycemia receiving care from a city fire department between the dates of October 2015 and March 2019. Of these patients, 1019 (95%) had complete data that was available and evaluated. For each patient encounter, the initial capillary glucose, the amount of dextrose administered, and the post dextrose capillary glucose was recorded. From this data the average initial blood glucose, post dextrose blood glucose and change in blood glucose was obtained for different dextrose loads (10g, 12.5g, 15g, 20g, 25g, and >25g). The rate of reported infiltration of dextrose and need for repeat bolus of dextrose was also explored.
Results: The median pre-dextrose capillary glucose was 34 mg/dL, with a median post-dextrose capillary glucose was 166. The median amount of dextrose administered was 18g, with the most commonly given doses being 10g, 12.5g, 15g, 20g, and 25g. After initial dextrose administration, 35 patients (3.4%) required repeat dextrose boluses, of which only 6 patients (0.6%) required more than 25g total. There were 3 (0.3%) IV infiltrations.
Conclusions: For the treatment of prehospital hypoglycemia, D10 administration was shown to be a safe and effective alternative to D50. Redosing of D10 after initial D10 bolus is rare and infiltration rate is low.
Rural Stroke Patients Have Higher Mortality: An Opportunity for Rural Emergency Medical Services (EMS)
Peter K. Georgakakos, DO; Morgan B. Swanson, BS; Azeemuddin Ahmed, MD, MBA; Nicholas M. Mohr, MD, MS
Background: Stroke is a major source of death and disability. Early recognition and prompt pre-hospital care is a cornerstone of acute stroke treatment. Residents of rural areas have worse access to stroke services than urban residents. The purpose of this study is to (1) describe US trends in rural-urban stroke mortality and (2) identify possible factors associated with rural-urban stroke case-fatality disparities.
Methods: This study was retrospective cohort study of 1,747,660 stroke admissions in the US from 2012 to 2016, using the Nationwide Inpatient Sample (NIS). Primary exposure was rurality of patient’s residence. Primary outcome was death during hospital encounter. Secondary outcome was discharge to a care facility or home health care. Covariates included age, sex, race, primary payer, All Patient Refined-Diagnosis Related Group (APR-DRG) mortality risk, co-morbidities, type of stroke, and admission status. Univariable and multivariable logistic regression, with purposeful model selection, estimated the odds of mortality by subject rurality among stroke subjects.
Results: Rural visits had higher mortality than non-rural visits (18.60% [95%CI 18.23 – 18.97] rural vs. 16.87% [95%CI: 16.68 – 17.06%] non-rural) and were associated with higher unadjusted odds of mortality (uOR = 1.14; 95%CI 1.11 – 1.17). After adjusting (age, sex, race, primary payer, APR-DRG mortality risk, co-morbidities, type of stroke, admission status, hospital region, rurality and teaching status, inpatient volume, control/ownership of the hospital, and year) in a logistic regression model, patient rurality was associated with increased odds of mortality (aOR = 1.11; 95%CI 1.06 – 1.15). For the secondary outcome of discharge to home, rural stroke visits were less likely to be discharged to a care facility than non-rural stroke visits (aOR 0.94; 95%CI 0.91 – 0.97). Results were similar after adjusting for tissue plasminogen activator (tPA) administration and transfer status.
Conclusions: Rural stroke patients have higher mortality than urban counterparts likely due to their increased burden of chronic disease, lower health literacy and reduced access to prompt pre-hospital care. There may be an opportunity for pre-hospital providers to assist in managing chronic disease, increase stroke awareness for both patients and clinicians and establish response patterns to expedite emergency care.
The Varied Cost of Syncope in the Emergency Setting
Matthew Abbott
Background: Patients presenting to the emergency department with syncope may have extensive evaluations resulting in high billing costs. A direct relationship between low variation in cost and low risk of an adverse event after presenting with syncope may indicate an efficient and cost-conscious environment. This project compares the cost variability of patients presenting with syncope to the San Francisco Syncope Rule (SFSR) and Canada Syncope Risk Score (CSRS) risk stratification scales.
Methods: A retrospective chart review for patients diagnosed with syncope at a large urban emergency department between 1/01/2016 and 12/30/2016 identified 282 patients over age 18 and without traumatic syncope. A cohorted retrospective study of the discharge information for these patients examined demographics, billing data and cost calculation. Two-tailed student’s t-tests were used to determine if any patient populations’ total cost significantly differed from the mean patient total cost.
Results: Average total cost per patient was $1,239.15 with a standard deviation $1,137.26 and median cost of $843.50. Patients with an abnormal Electrocardiography (ECG) had a significantly higher average total cost ($1,993.74) than patients with a normal ECG ($1,135.70) (p<0.05). Patients that answered “yes” to one of the SFSR variables had significantly higher average total costs ($1,663.12) than those who did not ($1,107.03) (p<0.05). Patients with a history of vasovagal syncope had significantly lower average total costs ($879.22) than those without ($1,251.01) (p<0.05).
Conclusion: Comparisons of variables within the SFSR and CSRS scales indicated their respective patient populations had significantly different average costs or variability of costs. Differences may be caused by the heightened costs of advanced diagnostic testing, more thorough workups, and physician practice style that these patients required. Patients with a history of vasovagal syncope experienced a lower average cost than those without, which may be due to a decreased index of suspicion for an adverse patient event.
A Web-based survey to assess the safety of transient sportive chokes
Broc Schindler, M.D., Robert LeFevere, M.D., Jesse Corry, M.D., Thomas Menton, Samuel Stellpflug, M.D.
Background: Vascular neck restraint (VNR), known as a “choke” within the grappling community, is the practice of compressing the jugular veins and carotid arteries to threaten rendering a person unconscious by lowering cerebral perfusion pressure. It is a common maneuver practiced within the sports, police, and military combatives realms. The actual safety of VNR is unknown and underrepresented in the literature. Delineating the safety of transient VNR is crucial as it may impact the care provided to participants in the prehospital and emergency department settings. This study aimed to explore the safety of transient VNR by surveying a group of people who actively participate in this practice. The objective was to describe the level of VNR experience among respondents, symptoms related to VNR, and gauge the perception on its use in real combative interactions.
Methods: In June 2019, a convenience sample of visitors to two combat sports Internet forums (www.reddit.com/r/bjj/ and www.reddit.com/r/judo/) were invited to complete an anonymous Web-based survey. Univariate analysis (presented below), bivariate analyses, and Chi-squared tests were performed.
Results: Overall, 4421 individuals completed the survey. 114 were excluded for TBIs or strokes not related to grappling (see figure 1), leaving 4307 respondents for analysis. Of this group, 94% were male and 89.2% were between the ages of 18-44 years. 78.7% had > 1 year of grappling experience and 30% had > 5 years of experience. Of the 4307, 1443 (33.5%) reported being choked > 500 times, 3257 (75.6%) have been choked to near-syncope, and 1198 (27.8%) have been choked unconscious. 2 of the 4307 (0.05%) reported persistent symptoms from chokes; one fractured thyroid cartilage and another occasional auras. Of all responders, 94.3% felt that VNR would be a safe and effective way to control or end a street fight.
Conclusion: This descriptive data suggests that overall, transient sportive choking is safe based on a large number of participants and only 0.05% experiencing continued symptoms; even those symptoms were likely not related to brain ischemia. Further studies are necessary to support this data, potentially impacting the management of patients participating in activities involving VNR within the prehospital and emergency department settings.
Abstracts Session 4 - Room: 2B 1400-1650
Complications of Tube Thoracostomy in the Emergency Department
Arian Jahansouz
Background– Chest tube thoracostomy is a common Emergency Department (ED) procedure. How often and severe are complications of tube thoracostomy placed by Emergency Medicine residents and faculty? A previous study found a 30% complication rate in 40 patients who received tube thoracostomy in a 12-month period at a large UK teaching hospital. This study sought to determine if the rates and complications are changing and if these complications are evidence for selective reduction in the indications for tube thoracostomy in the ED.
Methods– The data was analyzed using a retrospective chart review of all patients who underwent tube thoracostomy in a 27-month period in the ED of a large Midwest teaching institution with more than 80,000 patient visits annually at two locations. 143 patients who received tube thoracostomy were identified using a query of departmental billing records. The data was analyzed using a 1-Proportion Chi-Square test.
Results– Of the 143 patients, 13 were excluded from the study due to receiving the initial thoracostomy at an outside hospital. Of the 130 total tubes placed by Emergency Medicine physicians in the ED, 7 had complications, a 5.4% complication rate. Of the 7 complications, 5 (3.8%) were related to placement or positioning and 2 (1.5%) were due to an initially kinked tube. With a sample size of 130 in this study, compared with the previous study with 50 tubes placed in 40 patients, the null hypothesis proportion is 70. The 95% CI of observed proportion is 89.22 to 97.81, with an observed proportion of 94.615, and a significance level of P <0.0001.
Conclusion– This study reveals a lower complication rate of tube thoracostomy in the ED when placed by emergency medicine physicians than previously shown in other studies. With a larger sample size and longer analysis period, this study supports the previously mentioned study's conclusion that there is no persuasive evidence to support a selective reduction in the indications for tube thoracostomy in the ED. Limitations of this study include performance of a retrospective chart review and only assessing tubes placed in the ED by emergency medicine trained physicians.
Emergency Department Patient’s Mode of Transportation and Decision Making
Sharon Mace, MD
BACKGROUND: To determine what mode of transportation patient’s use to come to the emergency department (ED), prior ED visits, preference for primary care vs. ED for current complaint and the time involved in deciding to come to the ED.
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing, 18-bed ED with approximately 16,000 patient visits annually.
RESULTS: 88% patients did notuse an ambulance to get to the ED: 47.3% got a ride from friend or family, 30.7% drove themselves, 5.5% took public transportation, 1.9% walked, and 3.5% reported other. 90.0% of patients took more than one hour to decide to come to the ED. 58% took over 24 hours. The number of ED visits in the last twelve months was (2.18 mean, range 0-≥20). The number of patients with no previous ED visits in the past twelve months was 213 (39%). Most patients preferred to visit the ED rather than see their primary care physician (PCP). Over 50% where either referred by a medical professional (24.3%) or felt the ED was more appropriate for their complaint (31.2%).
CONCLUSION: Patients deliberated several hours to days before coming to the ED suggesting that patients do not visit the ED based on an impulse or quick decision. Most patients had no prior ED visits in the past twelve months. A minority preferred to see their PCP. This may be because over half of the patients (55.5%) were either referred to the ED by their PCP or other health care professional (24.3%) or felt the ED was more appropriate for their care (24.3%). The overwhelming majority of patients drove themselves or got a ride with a friend or family member. Most patients did not use an ambulance service to visit the ED.
Factors Determining Why Patients Come To the Emergency Department
Sharon Mace, MD
BACKGROUND: There is little information about the variables influencing a patient’s decision to visit the ED. To prospectively determine factors influencing patient decisions to come to the emergency department (ED).
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The settings were an urban, tertiary-level, teaching hospital ED with 75 treatment rooms/spaces, that sees 63,000 patients a year and a suburban, free-standing 18-bed ED with approximately 16,000 patient visits annually.
RESULTS: 552 patients (urban-348, suburban-204) from July to December 2017 were surveyed. As part of the survey, patients were asked “Why did you go to the emergency department today instead of your regular health care source?” The primary reason patients chose to visit the ED is because it is more appropriate for their condition than an office or clinic (31.2%). The second reason is because their primary provider or another medical professional referred them to the ED (24.3%). Inability to obtain a timely appointment occurred in 12.7% of the cases. Primary care provider offices were closed or not available 4.3% of the time. Thus, almost one-third of patients (30.4%) either have no access to primary care (13.6%), are unable to obtain a timely appointment (12.7%), or their primary care is closed or unavailable (4.3%). Convenience is rarely the reason for an ED visit (4%). Patients came to the ED because they believed their provider would have sent them to the ED anyway in 1.4% of cases.
CONCLUSION: It has been suggested that patients inappropriately use the ED. Based on our survey of ED patients, this appears to be an erroneous assumption. Over half (55.3%) of patients are either directly referred to the ED by a health care provider (24.3%) or need ED services that are unavailable in other medical settings (31.2%) Patients rarely use the ED for convenience, whether in the urban or suburban locale.
Patient Perception of Acuity: Does Location Matter? Urban vs. Suburban Setting
Sharon Mace, MD
BACKGROUND: Prospective comparison of ED patients in two different locations: urban vs. suburban emergency departments
METHODS: Convenience sample of adult (≥ 18 years) ED, non-critical, non-pregnant, non-psychiatric, English speaking patients who provided informed consent and were prospectively surveyed. The setting was an urban, tertiary-level, teaching hospital ED that sees 63,000 patients a year and a suburban free-standing ED. Using a survey of perceived medical acuity on a 5 point Likert scale: Level 1 Critical: Immediate Care required, Level 2 Emergent: care required within 15 minutes, Level 3 Urgent: care required within 15 – 60 minutes, Level 4 Semi-urgent: care required within 2 – 24 hours, Level 5 Non-urgent: care required within several days.
RESULTS: Patients and providers agreed overall only 8.9% of the time. 91.1% of the time patients overestimated their acuity. Based on location, urban ED patients agreed with their provider only 5.2% of the time while the suburban patients agreed with the provider’s estimate of acuity 15.2% of the time. The overwhelming majority of patients overestimated their acuity with 84.8% of suburban ED patients overestimating vs. 94.8% of urban patients. Hospital admission rates were 95 (27%) for the urban setting with 251 (72%) discharges. In the suburban 32 patients were admitted (16%), 171 discharged (84%), and 3 patients (1.4%) transferred to other health care systems.
CONCLUSION: Suburban patients agreed with their provider about three times more often than their urban counterpart (15.3% vs. 5.2%). Patients in both urban vs. suburban environments almost always overestimated their acuity, over 90% when compared with their provider.
Angioedema Care in the ED: Retrospective Review of Staging Criteria as Predictor of Patient Disposition
Conor Dass; Maggie Mahaffa; Kari Harland, MPH, PhD; Ronna Campbell, MD, PhD; Zuhair Ballas, MD; Sangil Lee, MD, MS
Background: Angioedema is a non-pitting edema that can lead to airway obstruction and systemic symptoms. Airway angioedema can be fatal, and as such, having objective severity criteria would allow for quick triage and treatment. Previously, Ishoo criteria were proposed as a severity classification system based on site of swelling; however, this has not been externally validated in the era of targeted pharmacological therapy. This study aims to validate the Ishoo criteria as a method of triage based on presentation characteristics and subsequent outcome.
Methods: This study is a retrospective chart review of angioedema cases that presented to an academic emergency department between 1/2008 and 1/2018. Data was collected on location of swelling, treatment setting, and medical and procedural interventions. Cases were categorized by a modified Ishoo criteria, which organized patients into stages based on location of swelling. These stages were defined as: stage 1, lips, face, periorbital, extremities, total body/diffuse; stage 2, soft palate, uvula, posterior pharynx; stage 3, tongue; stage 4, larynx. Predictive probability of disposition by stage was then compared.
Results: A total of 320 patients were included in this study (median age, 44; 54.4% female). Intervention with medication was used in 313 cases (97.8%) and airway intervention was required in 19 (5.9%) cases. As a whole, the majority of cases were treated as outpatient (68.4%), although 16.3% were admitted to the floor, and 15.4% were admitted the ICU. Among those admitted to the ICU, 19 (5.9%) were intubated. When disposition was correlated with stage, patients in stage 1 were more likely to be treated as outpatient (84%) compared to requiring ICU care with and without airway intervention (0.4%, 3% respectively). Conversely, patients in stage 4 were more likely to require ICU care with and without airway intervention (47%, 27% respectively) compared to outpatient treatment (13%). Patients in stage 4 were also more likely to require airway intervention (47%) compared to other stages (stage 1, 4%; stage 2, 3%; stage 3, 17%).
Conclusion: Disposition was correlated with Ishoo staging as higher stage patients were more likely to require higher levels of care, including airway intervention. As such, using this staging criteria could be of benefit to the triage and management of patients presenting with angioedema.
Right Testicular Pain and Swelling Secondary to a Pyocele
Authors: Patel, MD; Stettner, EA
Background: Testicular pain is a common complaint in the emergency department. Etiologies ranging from the relatively benign epididymo-orchitis to the emergent testicular torsion. A pyocele is a less common cause for testicular pain.
Methods: This is a single patient chart review.
Case/Results: A 61-year-old male with no past medical history presented to the Emergency Department with right testicular pain, swelling, and redness that has been worsening over one month. Vital signs were within normal limits. Physical exam was pertinent for a 5cm right testicle, tender to palpation, and less tender with scrotal elevation. Serum laboratory studies were notable for a white blood cell (WBC) count of 14.2. Urinalysis was notable for >182 WBC, 3+ leukocyte esterase, and many bacteria. Testicular ultrasound showed a large, complex hydrocele with internal irregular septations concerning for a pyocele. There was also increased vascularity in the right testicle and epididymis suggestive of acute epididymo-orchitis.
Discussion/Conclusion: Generally, scrotal pyoceles affect all age groups, and are located in the potential space that exists between the visceral and parietal tunica vaginalis. They may also extend into the inguinal canal. The condition is often associated with acute epididymo-orchitis, though rupture of a testicular abscess is also a cause. Symptoms including pain and swelling. Diagnosis is best made through testicular ultrasound. Treatment includes antibiotics and possibly surgical drainage, with orchiectomy as the ultimate method of management. If left untreated, pyoceles can progress to Fournier’s gangrene and sepsis.
In this case, urology was consulted, who recommended outpatient follow-up and oral antibiotics. Per medical records, the patient followed up with urology outpatient two days later. The patient had stated his symptoms were improving. His physical exam showed mild right testicular tenderness and swelling, with appreciation of the right hydrocele. A repeat urinalysis was unremarkable. The patient was advised to complete the course of antibiotics he had been prescribed from the emergency department. No further medical records were documented.
Migration of Orbital Silicone Oil into Subarachnoid and Cerebral Ventricular Spaces
Authors: Patel, MD; La Charité, D
Background: Silicone oil orbital injections are used in the treatment of complex retinal detachments, traumatic injuries, and diabetic retinopathy. A rare complication of silicone injection is the extravasation of silicone oil into the intracranial space.
Methods: This is a single patient chart review.
Case/Results: A 55-year-old man with a history of left eye diabetic retinopathy treated with intra-orbital silicone injection in 2011 presented to the Emergency Department after a fall at home. He reported preceding lightheadedness, with bilateral lower extremity weakness and difficulty ambulating. Vital signs were notable for a blood pressure of 185/88. Physical exam was pertinent for a sclerotic-appearing left eye and an unsteady gait. Serum laboratory studies were unremarkable. Computed tomography (CT) scan of his head showed high density material consistent with silicone oil in the subarachnoid space and lateral ventricles. A CT scan 13 days prior did not show this finding.
Discussion/Conclusion: Intra-orbital silicone injection is used to create a retinal tamponade for conditions such as severe proliferative diabetic retinopathy or retinal detachment in an effort to promote retinal reattachment and preserve visual acuity. Silicone oil may migrate through the optic nerve into the subarachnoid space and cerebral ventricles. Adverse effects are unknown, though the risks of hydrocephalus and chemical meningitis have been theorized. On imaging, intraventricular silicone oil may mimic intraventricular hemorrhage. However, whereas blood settles in the dependent portion of the ventricles, silicone oil will migrate to the nondependent regions. No previous studies have indicated surgical management of this condition.
In this case, neurology was consulted, who recommended admission to the Neurologic Intensive Care Unit for observation. Ophthalmology was consulted inpatient, who recommended outpatient follow up. The patient was ultimately transferred to a rehabilitation unit given his persistent bilateral lower extremity weakness and fall risk. No further records exist regarding ophthalmologic intervention for this case.
Acute obstruction of Laryngectomy Site by Saline Vial
Matthew Mannion
Background: Airway foreign bodies (AFB) are a common clinical occurrence in pediatric patients but can be seen in adult patients. In analyses of the populations, peak incidence of AFBs can be seen during the second year of life in children and the sixth decade of life in adults. Equally important to understanding our case is appreciating indications for laryngectomies, which include inability to undergo or failure of laryngeal sparing techniques or a non-functioning larynx.
Case: Our case features a 79-year old man with a history of T3N0M0 stage III supraglottic squamous cell carcinoma status post concurrent chemoradiation and subsequent total laryngectomy for dysfunctional larynx. While attempting to instill saline and suction his laryngectomy stoma site, the patient inadvertently dropped the saline bullet into his stoma, landing on his carina without frank airway obstruction or respiratory distress, but unable to be removed by the patient. Upon arrival to the ED, patient reported coughing up increased secretions with a blood tinge. Patient was alert and oriented with an oxygen saturation of 94 percent on room air. The ENT team was consulted, the they were able to remove the foreign body using a hemostat. Patient was discharged with instructions to hold saline bullets further away from the site and possibly obtaining larger saline bullets. This case highlights the risk for laryngectomy patients, who are often older and have less manual dexterity, irrigating and suctioning their sites using saline vials, or bullets, that are small enough to fit into their laryngectomy sites. This case also highlights a barrier to care if a patient is unable to attain larger saline bullets through insurance or home health carrier.
Conclusion: Patients with laryngectomy sites who are only able to access smaller saline vials should be educated to hold the saline bullet further away from their sites when performing routine cleaning.