Urban Community Emergency Department Research Articles

Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Nurses.

Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study.

In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2. Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle. The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles. This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

Manual Palpation vs. Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation in the Emergency Department: A Pilot Study.

Manual palpation (MP) is frequently employed for pulse checks, but studies have shown that trained medical personnel have difficulty accurately identifying pulselessness or return of spontaneous circulation (ROSC) using MP. Any delays in identifying pulselessness can lead to significant delays in starting or resuming high-quality chest compressions. This study explored whether femoral arterial Doppler ultrasound (FADU) decreases pulse check duration during cardiopulmonary resuscitation (CPR) compared with MP among patients in the emergency department (ED) receiving CPR directed by emergency medicine physicians who had received minimal additional didactic ultrasound training. We performed a prospective observational cohort study from October 2018 to May 2019 at an urban community ED. Using convenience sampling, we enrolled patients arriving at our ED or who decompensated during their ED stay and received CPR. For continuous data, median (interquartile range [IQR]) were calculated, and medians were compared using Kruskal-Wallis test. Fifty-two eligible patients were enrolled and 135 pulse checks via MP and 35 via FADU were recorded. MP observations had a median (IQR) of 11.00 (7.36-15.48) s, whereas FADU had a median (IQR) of 8.98 (5.45-13.85) s. There was a difference between the two medians of 2.02 s (p = 0.05). In this study, the use of FADU was superior to MP in achieving shorter pulse check times. Further research is needed to confirm the accuracy of FADU for identifying ROSC as well as to determine whether FADU can improve clinical outcomes.

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study.

International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Using Emergency Department Data to Inform Specialty Strategy: Analyzing the Distribution of 13,777 Consecutive Immediate Orthopaedic Consults in an Urban Community Emergency Department

Introduction:Although an estimated 20% of emergency department (ED) visits are musculoskeletal in nature, it is unclear which of these require urgent orthopaedic consultation and which orthopaedic subspecialties are best suited for these consults. When an ED's internal staff does not have necessary orthopaedic coverage, transfer to other facilities is required. However, transfers pose major inconveniences and financial burdens to patients and can lead to long ED wait times, hospital financial loss from walk outs, decreased patient safety, and decreased staff morale. Therefore, it is beneficial for a hospital to have the appropriate staff readily available for consults. Data can be used to assess the orthopaedic needs of an ED. We evaluated the nature of urgent ED consults requesting the timely presence of an orthopaedic provider.Methods:Between the years 2008 and 2017, the Orthopaedics Department of this Health System saw 13,777 patients from the ED requesting immediate consult from an orthopaedic provider. We retrospectively analyzed the distribution of anatomic areas and nature of these injuries for these visits.Results:Hand, foot, and ankle consults comprised 75% of the volume. Knee, hip, and spine accounted for 15% of consults. Most injuries were fractures. Infections and sprains were also common.Discussion:By determining and understanding this distribution, orthopaedic departments can improve their organization to better respond to urgent ED consults, allowing for the proper delivery of orthopaedic point-of-care service to patients, increased revenue for the hospital, proper availability of core competencies, and increased value to the healthcare delivery system as a whole. We also believe that the trends observed in our data are largely generalizable to EDs serving urban communities similar to ours. Thus, these results can help inform a synergistic strategy for the system comprising EDs, urgent care clinics, and orthopaedic surgeons servicing them.

The Effect of a Rapid Assessment Zone on Emergency Department Operations and Throughput

We examine the effects of a front-end flow model designated the rapid assessment zone on multiple emergency department (ED) operational metrics. This was a retrospective, before-after study of consecutive patient visits at an urban community ED. Six-month periods were compared before and after an intervention in 2017 that changed patient flow and the intake process. A lead nurse role splits patient flow immediately on patient arrival according to only age and chief complaint, allowing direct bedding without the bottlenecks of vital sign measurement, full triage assessment, or Emergency Severity Index assignment. A new patient care area (designated rapid assessment zone) preferentially expedites treatment of patients likely to remain ambulatory and serves as flexible acute care space when needed by individual cases and the ED. The outcomes measured were ED length of stay, arrival-to-provider time, the rate of leaving before treatment completion, and the rate of leaving before being seen. Data were analyzed with nonparametric testing, χ2 analysis, and multiple linear regression, controlling for patient visit characteristics, ED daily census volumes, and measurements of boarding patients. We analyzed 43,847 visits in the preintervention and 44,792 visits in the postintervention periods. The intervention was associated with the following changes: median ED length of stay from 203 to 171 minutes (-15.8%), median arrival-to-provider time from 28 to 13 minutes (-53.6%), leaving before treatment completion from 1.0% to 0.8% (-20%), and leaving before being seen from 3.1% to 0.5% (-84%). Regression analysis accounting for multiple confounders demonstrated that the reduced length of stay after rapid assessment zone implementation persisted across Emergency Severity Index levels 2 to 5 and all ED daily census levels. The rapid assessment zone model aims to decrease front-end bottlenecks and minimize serial intake assessments at a high-volume, urban ED. It was associated with improved patient throughput and decreased early patient departure. It may represent a useful model for similar centers.

326 Manual Palpation Versus Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation

The two critical components of effective cardiopulmonary resuscitation (CPR) are high-quality chest compressions and minimizing interruptions in chest compressions. While cardiac point-of-care ultrasound (POCUS) is frequently used during pulse checks, a recent study showed that employing cardiac POCUS nearly doubled the maximum recommended 10-second pause during pulse checks. Manual palpation (MP) is frequently employed for pulse checks, but prior studies have shown that trained medical personnel can only identify pulselessness using MP accurately 55% of the time. Femoral arterial doppler ultrasound (FADU) in contrast, has the benefit of avoiding the critical area of the neck and the airway, as well as avoiding the precordium where CPR is performed. There is sparse data supporting the use of FADU for pulse checks during CPR. The objective of this study was to observe emergency physicians during resuscitations in the emergency department (ED) while CPR was performed to assess the length of pulse checks with comparison of MP and FADU techniques. A prospective blinded observational study was conducted from October 2018 to May 2019 at an urban community emergency department with approximately 42,000 visits per year. Using convenience sampling, patients arriving at the emergency department who received CPR, or patients who decompensated during their ED stay and received CPR were enrolled in our study. Patients under the age of 18, patients with leg amputations, patients who had arterial lines already in place, or patients with abnormal femoral anatomy met exclusion criteria. A trained research assistant, who passed a CPR pretest module with a minimum inter-observer agreement with Cohen’s kappa>0.7, observed each code and recorded the length of each pulse check with a stopwatch, as well as the modality used to look for a pulse. Prior to the start of the study, an email with best practice CPR recommendations was sent to our faculty, including details on how to perform both femoral color and spectral doppler ultrasound to identify pulsatile arterial flow in the femoral artery. Faculty and research assistants were blinded to the primary outcomes of our study. Our ED faculty includes 23 full-time physicians and 7 part-time physicians. For continuous data means and confidence intervals (CI) were calculated, and means were compared using an unpaired Student’s t-test. During this 8-month observation period 56 eligible patients were enrolled. 125 pulse checks via MP and 35 via FADU were recorded. MP observations had a mean of 13.6 seconds (95% CI 11.9-15.4) while FADU had a mean of 10 seconds (95% CI 8.1-11.9). There was a difference between the two means of 3.6 seconds (95% CI 0.1-7.2 p<0.05). Of our sample, only one patient survived to be discharged from the hospital. In this small observational study, the use of FADU was superior to MP towards reducing pulse check times. Further research is needed to confirm the accuracy of FADU for confirming ROSC in patients receiving CPR in the ED as well as to determine if FADU can provide a significant improvement in clinical outcomes.

P061: Preventable adverse drug events in Canadian emergency departments

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.

LO91: Repeat exposures to culprit drugs contribute to adverse drug events in emergency department patients

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million annual emergency department (ED) visits in Canada. Australian data indicate that 27% of ADEs requiring admission are events caused by re-exposure to drugs that previously caused harm. Our objective was to estimate the frequency of repeat ADEs. Methods: We reviewed the charts of ADE patients who had been enrolled in 1 of 3 prospective studies conducted in 2 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal association between the drug regimens and patient presentations. After completion of the parent studies, a research pharmacist and a physician independently reviewed the charts of ADE patients, abstracted data using electronic forms, and searched that hospital’s records for previously recorded ADEs. The main outcome was a repeat ADE, defined as a same or same-class drug re-exposure, or repeat inappropriate drug withdrawal, causing a same or similar presentation as a prior ADE. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 614 ED patients diagnosed with 655 ADEs. Of these, 20% (133/665, 95%CI 17.0-23.0%) were repeat events. Most repeat ADEs were moderate (61%) or severe (32%) in nature, and 33% (95%CI 25.1-41.1%) required hospital admission. The most commonly implicated drugs were warfarin (10%), hydrochlorothiazide (4%) and insulin (4%), and the most commonly implicated drug classes were antithrombotics (17%), psychotropics (12%) and analgesics (9%). Repeat ADEs commonly required clinical monitoring (59%), additional medications to treat the ADE (50%) and follow-up lab testing (35%). Overall, 61% (95%CI 51.3-70.7%) of culprit drug re-exposures were deemed potentially or definitely inappropriate. Conclusion: Inappropriate re-exposures to previously harmful medications cause a substantial number of recurrent ADEs, and may represent an ideal target for prevention. We were unable to search for repeat ADEs in the records of other hospitals that our patients may have visited, and could not detect ADEs that were not documented in the medical record. As a result, we likely underestimated the frequency of repeat ADEs.

LO92: Factors contributing to the development of adverse drug events treated in emergency departments

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, commonly cause or contribute to emergency department (ED) presentations. Understanding provider, patient and system factors that contribute to their development may assist in developing effective preventative strategies. Our objective was to identify factors that contributed to the development of ADEs that caused ED presentations. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal associations between the drug regimens and patient presentations. Subsequently, a research pharmacist and physician independently reviewed the charts of ADE patients from these cohorts, abstracting data using electronic forms. Reviewers recorded patient, provider and system factors that contributed to the development of ADEs. The main outcome was the presence of at least one contributing factor in the development of an ADE. We used descriptive statistics with appropriate measures of variance. The sample size was determined by enrolment into the primary studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We identified ≥1 contributing factors in 62% (95%CI 58-65%) of ADEs. Multiple contributing factors were present in 17% of ADEs (95%CI 13-20%). The most common contributing factors were inadequate patient counseling or instructions about medication use (15%), insufficient laboratory monitoring or follow-up of monitoring tests (12%), lack of staff education (7%), lack of provider adherence with recommended treatment guidelines (7%), and delayed or inadequate clinical reassessment after a medication change (6%). Provider errors in drug administration contributed to 0.3% of ADEs (95%CI 0.0-0.7). Conclusion: Contributing factors were identified for most ADEs. They were often related to inadequate counseling and follow-up, and were rarely the result of errors. Further research is required to understand how communication of medication instructions can be improved. Investments in technologies to reduce provider errors may not significantly reduce the numbers of ADE patients presenting to EDs.

Patterns of Ketorolac dosing by emergency physicians.

Ketorolac tromethamine is a non-steroidal anti-inflammatory drug (NSAIDs) that is widely used in the emergency department (ED) for the treatment of moderate-to-severe pain. Ketorolac, like other NSAIDs, exhibits an analgesic ceiling effect and previous research suggests that 10 mg is possibly the ceiling dose. Do the patterns of ketorolac dosing by emergency physicians follow its analgesic ceiling dose? This was a single center retrospective, descriptive study to characterize patterns of ketorolac administration in ED patients. Data for all patients who received ketorolac during the ten year study period from January 1, 2003 to January 1, 2013 were collected from the electronic medical record of an urban community ED with an annual volume of 116 935 patients. There were 49 605 ketorolac administrations during the study period; 38 687 (78%) were given intravenously, 9 916 (20%) intramuscularly, and 1 002 (2%) orally. Through the intravenous route, 5 288 (13.7%) were 15 mg, 32 715 (84.6%) were 30 mg, 15 (0.03%) were 60 mg, and 669 (1.7%) were other varying doses. Through the intramuscular route, 102 (1.0%) were 15 mg, 4 916 (49.6%) were 30 mg, 4 553 (45.9%) were 60 mg, and 345 (3.5%) were other varying doses. The most common diagnoses at discharge were renal colic (21%), low back pain (17%) and abdominal pain (11%). The data show that ketorolac was prescribed above its ceiling dose of 10 mg in 97% of patients who received intravenous doses and in 96% of patients receiving intramuscular doses.

PL003: Impact of process improvements on measures of emergency department efficiency

Introduction: The objective was to study the operational impact of an intervention comprised of simultaneous process improvements to triage, patient inflow, and physician scheduling patterns on emergency department (ED) patient flow. The intervention did not require any increase in ED resources or expenditures. Methods: A 36-month pre-/post-intervention retrospective chart review at an urban community emergency department from January 2010 to December 2012. The ED process improvements started on June 6, 2011 and involved streamlining triage, parallel processing, flexible nurse-patient ratios, flexible exam spaces, and flexible physician scheduling. The main outcomes were ED length-of-stay (LOS). Secondary outcomes included time to physician-initial-assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed on Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether there were changes in the trend between pre-intervention and post-intervention segments. Results: 251,899 patients attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.64 hours (p&lt;0.001), and 90th-percentile LOS by 0.81 hours (p=0.024). When separated by acuity and disposition, there were reductions in LOS for non-admitted CTAS 2 (-0.58 hours, p &lt;0.001), 3 (-0.75 hours, p &lt;0.001), 4 (-0.32 hours, p=0.002), and 5 (-0.28 hours, p=0.008) patients. For secondary outcomes, there was a decrease in overall average PIA by 43.81 minutes (p&lt;0.001), and 90th-percentile PIA by 91.39 minutes (p&lt;0.001). LWBS and LAMA rates decreased by 35.2% (p&lt;0.001) and 61.9% (p&lt;0.001), respectively. Conclusion: A series of process improvements meant to optimize flow in the ED without the addition of resources was associated with clinically significant reductions in LOS, PIA, LWBS and LAMA rates for non-resuscitative patients.

LO009: Impact of physician navigators on measures of emergency department efficiency

Introduction: The Physician Navigator (PN) is a novel position created to manage patient flow in real-time at a very-high volume emergency department (ED). When paired with an emergency physician, PNs actively track patient wait times, and direct the physician to see and re-assess patients in a particular order to improve measures of emergency department efficiency, and maximize patient flow. Anecdotal evidence has shown that PNs decrease length-of-stay times for non-resuscitative patients in the setting of increased patient volumes, and without additional nursing or physician hours. The objective was to study the operational impact of PN on emergency department patient flow. Methods: A 48-month pre-/post-intervention retrospective chart review at an urban community emergency department from September 2011 to September 2015. The PN program started on March 1, 2013. The main outcome is emergency department length-of-stay (LOS). Secondary outcomes include time to physician-initial-assessment (PIA), left-without-being-seen rates (LWBS), left-against-medical-advice (LAMA), and physician satisfaction rates. Autoregressive integrated moving average models were generated for Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether the impact was sustained over time. Results: Interim results are provided. 399,958 patients attended the ED during the study period. Daily patient volumes increased 11.2% during the post-intervention period. There were no significant increases in the number of physicians shifts/day, and physician hours/day during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.04 hours/PN (p&lt;0.05), and 90th-percentile LOS by 0.14 hours/PN (p&lt;0.05). For secondary outcomes, there was a decrease in overall average PIA by 6.37 minutes/PN (p&lt;0.05), and 90th-percentile PIA by 8.29 minutes/PN (p&lt;0.05). LWBS rates decreased by 40.8% (p&lt;0.05). There were no significant changes in LAMA rates. Conclusion: The implementation of Physician Navigators is associated with significant reductions in LOS, PIA, and LWBS rates for non-resuscitative patients at a very-high volume emergency department.

Pediatric Caregiver Attitudes and Technologic Readiness Toward Electronic Follow-Up Communication in an Urban Community Emergency Department

Follow-up of pediatric patients after an emergency department (ED) visit is important for monitoring changes in patient health and informing patients of test results conducted during the visit. The telephone has been the standard method of communication, but contact rates are poor. We conducted a survey to assess pediatric caregiver attitudes toward and access to alternate electronic communication modalities after a pediatric ED encounter. Participants (n=102) were recruited from an urban community ED and completed a 35-item questionnaire in this cross-sectional study. The majority of pediatric caregivers have Internet access in their home (72%), although less than half check e-mail daily (46%). A larger percentage owns a cell phone (90%) and checks text messages daily (87%). The majority agree that more doctors should communicate by e-mail (70%), and nearly half (45%) would like to receive test results by text message. Caregivers of children have access to the Internet and mobile phone technologies, and many would be interested in communicating with healthcare providers following an ED visit. Cell phone and text-messaging technologies appear to be more available than e-mail and may serve as an underutilized contact method. A combination of modalities directed by caregiver preferences may improve ED follow-up contact rates.

277: The Association Between Length of Emergency Department Boarding and Mortality: A Multicenter Study

Study Objectives Emergency department (ED) boarding has been associated with several negative patient-oriented outcomes, from dissatisfaction to higher inpatient mortality rates. The current study evaluates the association between length of ED boarding and outcomes at three distinct hospital settings. We hypothesized that prolonged ED boarding of admitted patients would be associated with higher mortality rates and longer hospital length of stay, but that this effect may differ across hospital settings. Methods Study Design-Retrospective cohort study. Setting-one suburban and one urban academic ED, and one urban community ED with a combined annual ED census of 160,000. Subjects-Consecutive patients visiting the suburban ED from 9/05-9/08 and the other two facilities from 1/04-12/06. Measures and Outcomes-An electronic medical record system was used to extract patient demographics, ED disposition (discharge, admit to floor), ED and hospital length of stay (LOS), and inhospital mortality. Boarding was defined as ED LOS >2 hrs after calling in admission. Data Analysis-descriptive statistics were used to evaluate the association between length of ED boarding and hospital LOS, subsequent transfer to an ICU, and mortality controlling for disease/injury severity. Results There were 15546 admissions in the suburban ED, 9536 in the urban academic ED, and 7350 in the urban community ED. In the suburban setting, mortality generally increased with increasing boarding time from 4.9% in patients boarded less than 2 hours to 6.3% in patients boarding 24 or more hours (p < .001). Hospital LOS also showed an increase with boarding time (p < .001). The increases were still apparent after adjustment for co-morbid conditions and other factors. In Research Forum Abstracts contrast, mortality and hospital LOS in the urban settings were not associated with length of boarding. Conclusion The association between length of ED boarding and hospital mortality varies from hospital to hospital. Efforts to mitigate the effect of ED boarding on outcomes should be tailored to local hospital settings.

Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more "palliative care triggers" on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services.

Use of aspirin and heparin for treatment of stroke in a community hospital emergency department in the 21st century

Study objectives: Stroke is the third leading cause of death in the United States and the leading cause of adult disability. The International Stroke Trial and Chinese Acute Stroke Trial demonstrated decreases in mortality, disability, and recurrent stroke for patients who received early administration of aspirin. A systematic review by the Cochrane Collaboration and the Heparin in Acute Embolic Stroke Trial (HAEST) study, both published in early 2000, found no benefit from heparin in the management of any subgroup of acute stroke patients. No study has been published that surveys the frequency of aspirin and heparin use in the early management of acute stroke in a community emergency department (ED). One study published a survey of frequency of heparin and aspirin administration during a hospitalization for acute stroke and found a 10% and 44% rate, respectively. Our study characterizes the frequency of aspirin and heparin use by emergency physicians in managing strokes in the 21st century to discover whether the recent evidence supporting aspirin and discouraging heparin use has affected practice. We determine the use of aspirin and heparin for treatment of acute stroke in an urban community ED in 2000 to 2001. Methods: We performed a retrospective chart review for aspirin and heparin use in patients with a primary ED diagnosis of cerebrovascular accident from January 2000 to May 2001. Review methodology previously recommended was implemented and included a single chart reviewer who used a standardized abstraction form. Additionally, a second reviewer reabstracted a sample of charts to measure interpreter reliability. Computerized order-entry records and physician dictations were reviewed to quantify the rate of aspirin and heparin use, as well as the frequency of aspirin contraindications (allergic reactions, previous antiplatelet use on day of treatment, active bleeding). Results: Five hundred eighty-five patients were diagnosed with acute cerebrovascular accident during the 17-month study period. Two hundred fifty-one patients received aspirin, which represented 43% (95% confidence interval [CI] 39% to 47%) of patients who were candidates for aspirin therapy. Fifty-nine patients (10%; 95% CI 8% to 12%) received heparin. Conclusion: We found that aspirin is underused and heparin is overused in the early management of acute stroke in a community ED in the 21st century. Efforts should be made to increase awareness of the beneficial effects of aspirin and nonbeneficial effects of heparin in the early treatment of stroke patients.

Do emergency physicians save time when locating a live intrauterine pregnancy with bedside ultrasonography?

To determine whether patients presenting to the emergency department (ED) with first-trimester pregnancy complications have a decreased length of stay (LOS) when a live intrauterine pregnancy (IUP) is diagnosed by emergency physicians (EPs). This study was performed at an urban community ED with a residency program and an annual census of 65,000. A retrospective chart review from October 1995 to August 1998 identified 1,419 patients who received ultrasound examinations confirming live IUP in the first trimester with pain and/or bleeding. Two hundred seventy-seven of these patients received their ultrasound examinations from EPs; 1, 142 patients received a study from radiology and were not scanned by EPs. The LOSs for the two groups were compared and defined as the time from being placed into a room to discharge from the ED. Significance was determined using a two-tailed t-test. Median times with confidence intervals were calculated. When patients had a live IUP confirmed by an EP, the median LOS was 21% (59 min) less than those who received an ultrasound examination by radiology (p = 0.0001; 95% CI = 49 min to 1 hr 17 min). When evaluated by time of day, patients who presented after hours (6 PM to 6 AM) and were scanned by EPs spent 28% (1 hr 17 min) less time in the ED (p = 0.0001; 95% CI = 55 min to 1 hr 37 min). Emergency physicians identifying live IUP with bedside ultrasonography significantly decreased patients' LOSs in the ED. The decrease in LOS was most apparent for patients presenting during evening and nighttime hours.