ED Arrival Research Articles

Abstract 2811: Effects of EMS Routing to Stroke Centers and Participation in a Prehospital Neuroprotective Trial on Door to Needle Times for IV tPA

Introduction: IV tPA is an effective therapy for acute ischemic stroke and better outcomes occur with earlier lytic start. Prehospital initiation of neuroprotective therapies may stabilize penumbral tissue until reperfusion occurs. Prehospital neuroprotective treatments might modify start times of thrombolysis, including accelerating start by galvanizing receiving stroke teams or delaying start by requiring greater care time in the field. Door to needle (DTN) times are a target of improving stroke care nationwide with a goal of <60 minutes according to guidelines. Hypothesis: Participating in prehospital research does not delay appropriate thrombolysis and may actually improve treatment times by focusing attention and local resources on eligible patients. We expect primary stroke centers (PSC) to have shorter DTN times. Methods: We analyzed consecutive patients enrolled in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG), phase 3, NIH-sponsored trial of magnesium sulfate started prehospital within 2h of symptom onset. Parameters examined in IV tPA treated patients included: time from ED arrival to IV tPA start (DTN), type of hospital (PSC/non PSC), enrollment before and after start of LA EMS policy routing patients directly to PSCs, and arrival in ED within 60 minutes of last known well time (LKWT). Results: Among the first 1324 enrollments, 300 received IV tPA and 292 had complete data of LKWT’s and tPA initiation times. Mean DTN was 88.7 minutes with 290 (99%) treated in the 3h and 2 (1%) treated in the 3-4.5 hour time window. Overall, DTN <60 minutes was 17% and 55% received tPA ≤ 90 minutes from ED arrival. DTN times were faster (79 vs. 96 min, p<0.0001) and a greater proportion received treatment ≤ 90 minutes (72% vs. 46%, p<0.0001) in hospitals that were PSCs at the time of enrollment. DTN within 60 minutes in PSC vs. non PSC was 27% vs 11%, P=0.001. Overall onset to tPA initiation was reduced at PSC hospitals (147 vs. 156 min p=0.046). Trialwide, DTN times were reduced after implementation of a countywide PSC triage system in November of 2009(84 vs. 92 min, p=0.024). Conclusions: Acute stroke patients can be enrolled in a prehospital treatment trial without delaying start of IV tPA compared with national norms. Compared with non-PSC hospitals, certified hospitals achieved shorter door to needle times and faster overall onset to needle times when administering thrombolytic stroke therapy.

Abstract 195: Beneficial Impact of EMS Routing to Certified Stroke Centers on Door to Imaging Times

Background Effective acute interventions for ischemic and hemorrhagic stroke are time-critical, making rapid brain imaging an important component of high quality stroke care. National guideline recommendations are that initial brain imaging be performed within 25 minutes of ED arrival. Direct EMS routing of acute stroke patients to certified Stroke Centers has the potential to increase the proportion of patients receiving high quality care, including more rapid post arrival brain imaging. Methods Data collected in the ongoing, region-wide NIH FAST-MAG trial permitted analysis of the impact of EMS implementation of a stroke center routing policy on door to imaging (DTI) times. FAST-MAG is an NIH, multicenter trial of prehospital initiation of neuroprotective therapy conducted in 228 ambulances transporting patients to 51 adult receiving hospitals in Los Angeles County. In November 2009, the LA EMS Agency instituted a policy of preferentially routing acute stroke patients to Approved Stroke Centers that had been certified by the Joint Commission. Data on patients from all sites was analyzed from 2005-2010. Results Among the first 1000 patients enrolled, mean age was 70 (SD 14), 41%were female, median NIHSS was 9 (IQR 3, 17) and onset to door time was 71 (SD 55) minutes. Throughout the 5 year period analyzed, patients cared for at hospitals that would become Approved Stroke Centers (ASCs) had shorter door to imaging times than patients cared for at non-ASCs. Comparing the 9 inaugural ASCs with the 42 others, 34.4 vs 42.3 minutes (0.001). Comparing the 23 eventual ASCs with the 28 non-ASCs, 35.5 vs 46.5 minutes (<0.0001). Preferential EMS routing of patients to ASCs resulted in a reduction of DTI times among the entire cohort: enrollments across all sites before vs after implementation of the routing policy: 44.9 vs 32.0 minutes (<0.0001). With implementation of the routing system, the proportion of patients meeting the 25 minute DTI goal increased from 25% vs 47%, p<0.0001. Conclusions Direct EMS routing to certified Stroke Centers reduced times from ED arrival to initial brain imaging, and more than doubled frequency of achievement of the national DTI target. These results support wide national dissemination of regionally organized stroke critical care systems.

Abstract 65: Field Neuroprotective Therapy Followed by Intravenous Thrombolysis in a Phase 3 Clinical Trial

Background: A highly promising treatment strategy for acute cerebral ischemia is 1) administration of neuroprotective therapy in the field to stabilize the penumbra, followed by 2) intravenous thrombolytic recanalization therapy to restore blood flow and rescue threatened tissue. The NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study is the first phase 3 RCT testing field initiation of neuroprotective therapy and enrollees are permitted to undergo FDA or national guideline approved recanalization therapies upon hospital arrival when clinically indicated. Objective: To characterize rates of utilization of intravenous (IV) thrombolysis with tissue plasminogen activator (TPA) in ischemic stroke patients enrolled in a prehospital study. Methods: In FAST-MAG, patients within 2 hours of last known well time transported by 353 ambulances to 59 hospitals are randomized to prehospital-initiated magnesium sulfate vs. placebo. Results: Among 1206 consecutive enrolled subjects, final diagnosis of the presenting event was acute cerebral ischemia in 861 (71.4%), intracranial hemorrhage (ICH) in 295 (24.5%), and stroke mimic in 48 (4%). IV TPA was used in 320 patients, 37% of those with a final diagnosis acute cerebral ischemia (ACI, stroke or TIA). Among the ACI patients, none had intracerebral hemorrhage (ICH) on initial imaging study. Among the ACI patients, compared with patients not treated with TPA, TPA-treated patients had worse stroke deficits both in the field (Los Angeles Motor Scale Score 4.2 v 3.35, p<0.0001) and on ED arrival (NIHSS 14 v 7, p<0.0001); and had shorter onset to paramedic evaluation (28 v 43 min, p=0.001) and onset to door (62 v 78 min, p=0.002); and more frequently had a history of HTN (83% v 77%, p = 0.034). TPA treated and non-treated patients were similar in age (71 v 71, p=0.960), sex (female in 47% v 44%, p=0.559), Hispanic ethnicity, race, prehospital and ED systolic and diastolic blood pressures, and other vascular risk factors. Conclusions: More than 1 in 3 acute ischemic stroke patients enrolled in the FAST-MAG trial are receiving IV TPA following their field initiation of study agent. When completed, FAST-MAG will have substantial power to evaluate whether there is a synergistic benefit of prehospital neuroprotection and early postarrival thrombolytic reperfusion therapy on clinical outcomes.

Abstract 2940: Arrival in the Emergency Department on Nights and Weekends Results in Delayed Administration of Intravenous Thrombolysis for Ischemic Stroke

Background: Reduced time to administration of intravenous thrombolysis for acute ischemic stroke (AIS) is associated with improved functional outcomes. Less than one-third of AIS patients receive IV rt-PA with a door-to-needle (DTN) ≤ 60 minutes with only modest improvements reported over time. We investigated factors that may adversely prolong DTN time including reduced resident physician experience, low stroke severity on presentation, patient presentation time (day, evening, night) and day of week. Methods: A consecutive series of 258 patients with AIS received IV rt-PA at an academic comprehensive stroke center with a developed process for IV rt-PA administration and a neurology training program. Patient presentation times in the emergency department were divided into shifts defined as 07:00-14:59 (day), 15:00-22:59 (evening) and 23:00-06:59 (night). Neurology resident experience level was grouped as July-December (less experienced) vs. January-June (more experienced). Day of the week was grouped into weekday (Monday-Friday) and weekend (Saturday-Sunday). Variables associated with DTN time were assessed by t-test, ANOVA and by logistic regression. Results: The group had a mean age of 70.7±14.3 years, NIHSS score 13.3±6.8, DTN time 70.0±28.1 minutes, onset to ED arrival time 77.5±38.0 minutes. Patients presenting during evening and night hours had prolonged DTN times, day=65.5, evening=71.8 and night=78.3 minutes (p=0.05) by ANOVA. Patients arriving on weekends also had prolonged DTN times weekdays= 66.6 vs. weekends=77.2 minutes (p=.01). Increased time from onset to ED arrival was also associated with reduced DTN time (p<0.001). Age, gender, race, stroke severity on presentation, and resident experience level were not related to DTN time. Both presentation time by shift and day of week were predictive of prolonged DTN time by multivariable analysis (p<0.01). Conclusions: Presentation time during the evening and night hours and weekends is associated with prolonged DTN times. Reduced staffing and support on nights and weekends may adversely affect DTN time.

Abstract 3122: Delays in Warfarin Reversal following Intracerebral Hemorrhage: A Population-Based Study

Introduction: Warfarin anticoagulation worsens outcomes following intracerebral hemorrhage (ICH), in part by increasing risk of hematoma expansion. Prompt reversal of warfarin anticoagulation is therefore imperative. We documented patterns of anticoagulant reversal following ICH in a large, population-based stroke study. Methods: As part of the Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study, we identified all patients who presented with an ICH to an emergency room in the five-county Greater Cincinnati/Northern Kentucky region from July 2008 through December 2009. Patients from outside the five-county region were excluded. We recorded all INRs, medications used to reverse coagulopathy, and mortality. For patients with warfarin-associated ICH and initial INR > 1.4, we determined the time from presentation to initiation of warfarin reversal and time to achievement of INR ≤ 1.4. We also compared times to warfarin reversal in centers with and without emergency medicine residency training programs (“academic” vs. “community” hospitals). Results: There were 403 cases of ICH identified at 13 local hospitals, including 67 cases of warfarin-associated ICH. After exclusion of patients with INR < 1.4 upon arrival, patients with stroke in the hospital, and patients who were made “comfort-care” within one hour of arrival, there were 53 cases of warfarin-associated ICH for analysis. Times of anticoagulation reversal are displayed in the table . Cryoprecipitate was given to one patients and platelets to two patients. No patients received promthrombin complex concentrates or recombinant activated factor VII. Use of FFP did not differ between academic hospitals and community hospitals, nor did time to FFP administration. Among 31 patients with documented reversal of anticoagulation to INR ≤ 1.4, time from FFP administration to INR normalization was less at academic centers, but this may have been a function of frequency of INR testing. Thirty-day mortality among the 53 analyzed cases was 49%. Conclusions: Reversal of coagulopathy was significantly delayed in our population, with a median time of > 3 hours from ED arrival to initiation of FFP. Only 31 of 53 analyzed cases had documented reversal of INR to ≤ 1.4, and this took a median of 11 hours. Improvements in time to warfarin reversal via streamlined systems or alternative medications such as prothrombin complex concentrates may improve patient outcomes.

Abstract 3543: Imaging Correlates of Early Neurologic Deterioration among Patients with Intracerebral Hemorrhage

Background: Early neurologic deterioration (END) occurs commonly in intracerebral hemorrhage (ICH) patients being transported by EMS ambulances, but the imaging correlates of END have not been previously delineated. Methods: We analyzed consecutive ICH patients in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) Trial, a phase 3, multicenter of paramedic-initiated magnesium sulfate vs. placebo for stroke patients presenting within 2 hours of symptom onset. END was defined as a 2-point or greater decrease in the Glasgow Coma Scale (GCS) from paramedic evaluation to ED evaluation. Baseline imaging studies were independently analyzed by 2 neurologists for ICH location, volume, presence of intraventricular hemorrhage (IVH), heterogeneity (defined as >20 point difference in Hounsfield units), irregular hematoma borders, multilobulated appearance, and substantial edema (defined as >0.5cm thickness). Leukoaraiosis was graded using the Fazekas scale for periventricular and deep white matter changes (0-3 for each). Results: Among 127 patients, mean age was 66 (SD 14) years, 34% were women, 35% were Hispanic ethnicity, 83% white, and 84% had a history of HTN. Patients were evaluated by paramedics a median of 23 (IQR 16, 39) minutes after last known well time (LKWT). At that time, the median GCS was 15 (IQR 15-15) and mean SBP/DBP was 177/95 (SD 34/22). Initial post-arrival brain imaging was performed a median of 94 (IQR 77, 117) min after LKWT. Post-arrival study GCS scores were obtained at a median of 108 (IQR 70, 144) min after LWKT. Early neurologic deterioration occurred in 37 (29%) patients. Among these patients, median first ED GCS was 3 (IQR 3-10). On first imaging, compared with neurologically stable patients, END patients had larger hematoma volume (33 cc v 16 cc, p<0.0001), and more frequent presence of intraventricular extension (45% v 20%, p=0.003), midline shift (58% v 22%), substantial edema (54% v 26%, p=0.038), heterogeneous density (50% v 22%, p=0.006), multilobulated appearance (44% v 18%, p=0.002), and irregular border (39% v 14%, p=0.010). Leukoaraiosis and cortical v subcortical location did not affect rates of END. In multivariate analysis, hematoma volume and presence of IVH were imaging findings independently associated with early neurologic deterioration. Conclusions: About 3 in 10 patients with hyperacute ICH neurologically deteriorate during the prehospital and early emergency department course, often before neuroimaging is obtained. Patients with early neurologic deterioration have larger hematoma volume and occurrence of IVH on initial imaging. These findings suggest hematoma expansion prior to ED arrival drives early neurologic deterioration in ICH and emphasize the need for prehospital interventions.

Abstract 98: Initiation of Large-Volume, Ice-Cold Saline Infusion During Initial Resuscitation Attempts for Out-of-Hospital Cardiac Arrest Results in Near-Target Temperatures for Therapeutic Hypothermia Upon Emergency Department Arrival

Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol in the New York City 9-1-1 System on August 1, 2010 that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume, pressure infused, ice-cold saline administration. Purpose: We sought to assess the effects of the intra-arrest initiation of an infusion of up to 30cc/kg of ice-cold saline on core body temperature for out-of-hospital cardiac arrest (OOHCA). Methods: A convenience sample of out-of-hospital cardiac arrest patients for whom core temperature monitoring via esophageal temperature probes was available were analyzed. Results: There were a total of 78 patients for whom core temperature (esophageal) data was available both at the time hypothermia induction and upon ED arrival. Eight patients (10.3%) were reported to have developed clinical signs of pulmonary edema during the infusion and were excluded from this analysis due to the discontinuation of the large-volume infusion. Among the remaining 70 patients, an average of 1,361mls of ice-cold saline was administered prior to emergency department arrival. The average initial temperature for these patients at the time hypothermia induction was 35.1 o C (range 32.7-38.0 o C). The average temperature reduction as a result of the large-volume, ice-cold saline infusion was -0.92 o C, with an average core temperature upon emergency department arrival of 34.2 o C. Conclusion: Large volume, ice-cold saline infusion during initial resuscitation efforts allows patients to arrive in the emergency department with a core temperature near the target range for therapeutic hypothermia. Further study is needed to assess the effects of early induction of hypothermia on immediate and long-term survival.

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

The Birth Cohort Effect and Helicobacter pylori: Evidence for Stabilized Colonization Rates in Childhood in a Developed Country

impaction (90% vs. 79%; p=0.007). Conclusions: The majority of patients with EFBI at our institution between 2005 and 2009 presented to the ED. Medical management was largely ineffective, and a therapeutic procedure was required to clear the EFBI in most patients. Time of ED arrival made no difference in time-to-procedure, indicating that GI and ENT specialists recognize and address the urgency of treating EFBI regardless of time of day.

018 Cold mountain: do delays to hospital increase the risk of hypothermia in mountain casualties?

IntroductionUK mountain casualties are at risk of hypothermia year-round. Mountain Rescue personnel are often taught that pre-hospital treatment of hypothermia cannot reverse cooling of casualties and so delays in evacuation...

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Factors Associated With Prolonged Emergency Department Length of Stay for Admitted Children

To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

Doctor on board? What is the optimal skill-mix in military pre-hospital care?

BackgroundIn a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the...

The Impact of Time from ED Arrival to Surgery on Mortality and Hospital Length of Stay in Patients With Traumatic Brain Injury

The previous studies examining the benefits of timely surgery in patients with traumatic brain injury (TBI) have yielded inconsistent conclusions. This study examined how time from ED arrival to surgery in patients with TBI influenced two patient outcomes: hospital mortality and length of hospital stay. Using a multivariate and cross-sectional research design, the study sample included 493 patients from the 17 level I and II trauma centers that met inclusion criteria in the National Trauma Data Bank 4.0. The patient characteristics (eg, age, Glasgow Coma Scale score, Injury Severity score, and ED arrival time) and trauma center characteristics (eg, ownership, designation type, and center level) were examined. Student t test, χ² test, analysis of variance, and multilevel regression models were used to analyze data. Patients who underwent craniotomy or drainage of hematoma within 4 hours of arrival had half the likelihood of mortality when compared with those who underwent surgery more than 4 hours after ED arrival (odds ratio = .49; 95% confidence interval = .24 to .99). When patients had surgery within 4 hours of arrival, they had a significantly shorter length of hospital stay than did patients who had surgery more than 4 hours after arrival in the emergency department (Estimate = -.10, 95% confidence interval = -.19 to -.01). Based on the results of this study using a large sample from multiple centers and advanced statistics, benefits of early clinical assessment and quick access to neurosurgical surgery are substantiated in patients with TBI.

Early Anticoagulation Is Associated With Reduced Mortality for Acute Pulmonary Embolism

Acute pulmonary embolism (PE) may be rapidly fatal if not diagnosed and treated. IV heparin reduces mortality and recurrence of PE, but the relationship between survival and timing of anticoagulation has not been extensively studied. We studied 400 consecutive patients in the ED diagnosed with acute PE by CT scan angiography and treated in the hospital with IV unfractionated heparin from 2002 to 2005. Patients received heparin either in the ED or after admission. Time from ED arrival to therapeutic activated partial thromboplastin time (aPTT) was calculated. Outcomes included in-hospital and 30-day mortality, hospital and ICU lengths of stay, hemorrhagic events on heparin, and recurrent venous thromboembolism within 90 days. In-hospital and 30-day mortality rates were 3.0% and 7.7%, respectively. Patients who received heparin in the ED had lower in-hospital (1.4% vs 6.7%; P = .009) and 30-day (4.4% vs 15.3%; P < .001) mortality rates as compared with patients given heparin after admission. Patients who achieved a therapeutic aPTT within 24 h had lower in-hospital (1.5% vs 5.6%; P = .093) and 30-day (5.6% vs 14.8%; P = .037) mortality rates as compared with patients who achieved a therapeutic aPTT after 24 h. In multiple logistic regression models, receiving heparin in the ED remained predictive of reduced mortality, and ICU admission remained predictive of increased mortality. We report an association between early anticoagulation and reduced mortality for patients with acute PE. We advocate further study with regard to comorbidities to assess the usefulness of modifications to hospital protocols.

Emergency Department Hyperglycemia as a Predictor of Early Mortality and Worse Functional Outcome after Intracerebral Hemorrhage

We have previously reported the association of hyperglycemia and mortality after ischemic stroke. This study attempts to answer the hypothesis, if hyperglycemia at arrival, is associated with early mortality and functional outcome in patients with acute non-traumatic intracerebral hemorrhage (ICH). The study cohort consisted of 237 patients who presented to the ED with ICH and had blood glucose measured on ED presentation. The presence of hyperglycemia on presentation was correlated with outcome measures including volume of hematoma, intraventricular extension of hematoma (IVE), stroke severity, functional outcome at discharge, and date of death. Of the cohort of 237 patients, a total of 47 patients had prior history of Diabetes Mellitus (DM). Median blood glucose at presentation was 140 mg/dl (Inter-quartile range 112-181 mg/dl). DM patients had higher glucose levels on arrival (median 202 mg/dl for DM vs. 132.5 mg/dl for non-DM, P < 0.0001). Higher blood glucose at ED arrival was associated with early mortality in both non-diabetics and diabetics (P < 0.0001). Higher blood glucose was associated with poor functional outcome in non-DM patients(P < 0.0001) but not in DM patients (P = 0.268). In the logistic regression model, after adjustment for stroke severity, hematoma volume, and IVE of hemorrhage, higher initial blood glucose was a significant predictor of death (P = 0.0031); as well as bad outcome in non-DM patients (P = 0.004). Hyperglycemia on presentation in non-diabetic patients is an independent predictor of early mortality and worse functional outcome in patients with intracerebral hemorrhage.

How public ambulance arrivals impact on Emergency Department workload and resource use

Objectives: To examine patient’s characteristics associated with ED arrival mode, and to determine EMS impact on ED clinical resource use, workload and crowding. Methods: This is a retrospective study of patients seen at Sant’Andrea Hospital ED. Comparison focused on visit characteristics, and on resource use. Results: The use of EMS ambulance confirms association to older age, higher rate of hospital admission, longer length of stay, and severity of injury. Moreover our data show that ambulance referred patients are triaged into a higher acuity category and have a greater intensive care unit admission. Conclusion: Ambulance arrivals have a significant impact on ED resource use, workload and crowding.

Relationship of Insurance Status to Hospital Length of Stay after Traumatic Injury: Patients with Publically Funded Insurance Have the Longest Lengths of Stay and Uninsured Patients Are Discharged the Earliest

Introduction: Research has consistently shown that insurance status significantly impacts health care, including resource use, morbidity, and mortality. Data from several medical specialties demonstrate that patients without insurance have fewer physician visits, receive fewer procedures, and have shorter lengths of hospital stay leading to worse clinical outcomes. Uninsured hospitalized trauma patients are also known to have worse mortality outcomes; however, the impact of insurance on hospital stay in trauma is unknown. Objective: To examine the impact of insurance status on hospital length of stay (LOS) in the setting of acute trauma. Methods: Trauma patients, age 18-64, included in the National Trauma Data Bank (NTDB) between 2002-2006 were analyzed. Patients were categorized in three insurance groups: 1) Private insurance (HMO, PPO, MCO, Workers Comp, No Fault, and other commercial plans), 2) Publically funded insurance (Medicaid & Medicare), and 3) Uninsured (self pay or private charity). In unadjusted analyses Student's t-test were applied to determine the bi-variate relationship between insurance and LOS. In order to control for differences in injury severity and case mix between insurance groups, generalized linear models, an extension of multiple linear regression, were used, and adjusted estimates of LOS calculated. Covariates adjusted for included: age, gender, race, injury severity score (ISS), presence of shock (SBP<90) on ED arrival, GCS motor score, mechanism of injury (motor vehicle collision, motorcycle collision, fall, etc), type of injury (blunt vs. penetrating), intention of injury, presence of severe head and/or extremity injury, and year of admission. Results: 542,171 patients in the NTDB met inclusion criteria and had complete data for analysis. Unadjusted median hospital LOS for Uninsured patients was 2 days. Private and Publically insured patients had a median LOS of 3 days (respective mean LOS: 4.4, 5.3, and 6.9, p<0.001). After adjusting for covariates, mean length of stay for Uninsured patients was the lowest followed by Private insurance and then Publically insured patients (see figure). On analysis of patients with moderate to severe injuries (ISS>9), LOS for Uninsured, Privately insured, and Publically insured patients were 12.7, 13.5, and 15.7 days, respectively. Similarly among the most severely injured patients (ISS>15), the respective LOS were 13.3, 14.6, and 17.7 days. The differences between adjusted LOS for each insurance group were significant (p<0.001) across all injury severities. Conclusion: The ability to pay is directly linked to length of hospital stay in acute trauma patients. Those without insurance are discharged the earliest whereas those with publically funded insurance are kept in hospital the longest. These disparities in LOS are even more pronounced among the more severely injured patients with even longer hospital stays. These data become increasingly important given the current debate over health care reform. As a next step towards improving health care disparities after trauma, the relationship between LOS, quality of care, and outcomes needs to be further explored.

Patterns of analgesia for fractured neck of femur in Australian emergency departments

Fractured neck of femur is a common ED problem and poor pain management in this patient group can contribute significantly to their morbidity. The present study aims to describe current practices for managing pain in patients with fractured neck of femur in Australian ED and to identify real or potential barriers to providing analgesia. Hospitals were invited to participate in a retrospective medical chart audit of patients with fractured neck of femur. At each site, 20 cases were randomly selected from the previous 12 months. Patient demographics, timing, type and method of analgesia in ED, use of pain scales and perceived barriers to analgesia were extracted from the medical chart. Data on 646 patients were collected from 36 hospitals in five Australian states. Most patients were elderly with a preponderance of women. One hundred and eighty-five (28.6%) patients had no record of analgesia administration in the ED and almost half of these had also not received prehospital analgesia. Intravenous morphine was the most frequently used analgesic and only 45 patients received a nerve block in the ED. The median time to first analgesia was 75 min after ED arrival. The most commonly reported barriers reported were cognitive impairment and language difficulties. Oligoanalgesia for fracture neck of femur in Australian ED is common and time to analgesia tends to be relatively slow. Regional techniques are infrequently used despite their recognized efficacy. Strategies for improving pain management in this cohort of ED patients need to be explored.

Factors Affecting Morbidity/Mortality of Emergency General Surgery

Introduction/Background: Emergency status has been documented as adversely affecting the outcome of general surgery. However, the predictors of increased morbidity and mortality of emergency general surgery (EGS) are unclear, including the possibility of modifying these factors. This study aims to determine the predictive factors for postoperative complications of EGS. Methods: A retrospective study of all randomly selected Brigham and Women's Hospital (BWH) American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients who had an EGS procedure from January 1, 2007 to December 31, 2008 were selected for this study. BWH IRB approved this study. The study applied the inclusion and exclusion criteria as defined by ACS NSQIP using select preoperative and all postoperative data variables. Additional non-ACS NSQIP data points were added and analyzed as possible predictors of poor outcomes. These included blood glucose levels closest to the time of surgical incision, length of time from ED arrival to incision, total volume of intravenous fluids (IVF) administered within 24 hours prior to incision, and time of antibiotic administration prior to incision. Our primary outcomes were whether or not the patient had experienced any of the pre-defined ACS NSQIP postoperative occurrences within 30 days and/or died while hospitalized for the target emergency procedure. Univariate statistical analyses were done using Wilcoxon signed rank sum test for continuous variables and Chi square test/Fisher Exact test for categorical variables. Multivariate analyses were done to identify independent predictors using logistic regression. Results: We identified 263 cases. 46.4% were male. 60 (22.8%) had complications, and 25 (9.5%) died within 30 days. Those without complications had a mean age of 51 years while those with complications had a mean age of 66 years. The most common procedures were appendectomies (22.4%), colectomies (18.6%) and enterectomies (17.1%). The most common postoperative occurrences were prolonged ventilator support>48hrs (12%), unplanned intubations (6%), and superficial incisional infections (5%). In univariate analyses, age (p<0.0001), male gender (p<0.001), length of operation (p<0.0001), preoperative blood transfusion (p<0.001), elevated blood glucose (p=0.026), elevated BUN (p<0.0001), functional health status (p=0.007), ASA (p<0.001), presence of COPD (p=0.002), and history of smoking (p=0.009) were found to be significant predictors of postoperative complications. Length of time from ED arrival to time of incision (p=0.42), total volume of IVF administered within 24 hours prior to incision (p=0.19), and time of antibiotic administration prior to incision (p=0.74) were not found to be significant. Multivariate analyses using stepwise logistic regression found male gender (OR 2.01, 95% CI 1.05, 4.10), smoking (OR 2.69, 1.15, 6.26), elevated BUN (OR 1.04, 95% CI 1.02, 1.06), and length of operation time (OR 1.001, 95% CI 1.000, 1.003) to be independent predictors for postoperative complications. Conclusions: Emergency general surgery patients who develop postoperative complications are more likely to be male, smokers, have a higher preoperative BUN, and experience longer operative times. Preoperative fluid resuscitation to address elevated BUN and experienced surgical teams to decrease operative times are potential targets to improve outcomes in emergency general surgery patients.