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Research Forum Abstracts

317

Attitudes and Practices Regarding Influenza Vaccination Among Emergency Department Personnel

Fernandez WG, Oyama L, Mitchell P, Edwards E, St. George J, Donovan J, Feldman J/Boston University School of Medicine, Boston, MA; Boston University School of Public Health, Boston, MA

Study Objectives: Prior studies have shown that influenza vaccination (FV) prevents over 50% of influenza-related complications. We sought to identify barriers to FV among ED staff that might help build support for an FV program for ED patients. Methods: In September 2005, a self-administered survey was issued to ED staff (nurses, residents, and attending physicians) at an urban, academic medical center in Boston. Using a 4-point opinion scale, responses addressed the following outcome variables: 1) likelihood of getting vaccinated themselves this year, and 2) support of an FV program for ED patients. Chi-square or Fisher’s exact tests were used to test for factors associated with outcome variables. Cochran-Mantel-Haenszel chi-square tests were used to control for provider type. All analyses were done via SAS 9.1 at alpha ⬍ 0.05. Results: Of 130 ED staff, 126 participated (97% response rate). Overall, 67% reported they were very or extremely likely to be vaccinated this year. Residents (94%) and attending physicians (82%) were significantly more likely than nurses (42%) to be vaccinated (p ⬍ 0.001). Controlling for provider type, respondents likely to be vaccinated this year were more likely to support an FV program for ED patients (80% vs 55%, p ⬍ 0.001). Respondents were more likely to get FV if they were vaccinated last year (95% vs 12%, p ⬍ 0.001), if they believed that FV is effective (67% vs 33%, p ⬍ 0.001) and that side effects of FV are uncommon (98% vs 83%, p⫽0.036). Those who heard of someone having an adverse event resulting from FV (p⫽0.003), or who did not agree that all healthcare workers should receive FV (p ⬍ 0.001) were significantly less likely to be vaccinated themselves. Conclusion: Barriers to FV among ED staff may be reduced by providing regular education on the efficacy of preventive FV therapy, and dispelling misconceptions regarding adverse effects. Widespread adoption of FV by ED providers themselves could result in support for an FV program for ED patients.

318

Etiology and Incidence of Anaphylaxis in Rochester, Minnesota: A Report From the Rochester Epidemiology Project

Decker WW, Campbell RL, St. Sauver JL, Weaver A, Luke A, Bergstralh EJ, Li JT/ Mayo Clinic College of Medicine, Rochester, MN

Study Objectives: To determine a population-based estimate of the etiology and incidence of anaphylaxis. Methods: Using the resources of the Rochester Epidemiology Project, the authors identified all residents of Rochester, Minnesota, who had a diagnosis of anaphylaxis, insect sting reaction, or food adverse effect or allergy during 1990-2000. All cases with a diagnosis of anaphylaxis were reviewed and a random sample of the remaining diagnoses were reviewed. Cases that met National Institutes of Health/Food Allergy and Anaphylaxis Network criteria for anaphylaxis were included in the study. The number of cases in each age and sex stratum was obtained after an adjustment to account for the sampling fraction used in the study design. Age- and sex-specific incidence rates were calculated with the denominator estimated using decennial census data based on the assumption that all Rochester residents during 1990-2000 were at risk. Rates were also age- and sex-adjusted to the population structure of the total United States in 2000. 95% confidence intervals (95% CI) were constructed assuming a Poisson error distribution. Results: For the time period studied, 201 cases of anaphylaxis were identified. Of those cases, 112 were female (55.7%). The mean age was 29.5, with a standard deviation of 18.3 and range of 0.8-78.2 years. The inciting allergen were as follows: Food 58 (28.9%); insect sting 39 (19.4%); medication 27 (13.4%); contrast agent 1 (0.5%); other 12 (6.0%); and indeterminate 64 (31.8%). The overall age-sex adjusted incidence rate was 49.3 (95% CI 44.6-54.1) per 100,000. Age-specific rates were highest for those ages 0-19 (70 per 100,000). Conclusion: Anaphylaxis incidence is highest in children and is most often caused by food, insect stings or medications. The incidence of anaphylaxis may be higher than previously estimated, though this is in part due to a change in definition.

S96 Annals of Emergency Medicine

319

Are Emergency Physicians Legally Obligated to Report Alcohol-Impaired Drivers?

Ripper JR, Bernard R, Platon M/Newark Beth Israel Medical Center, Newark, NJ; New York College of Osteopathic Medicine, Old Westbury, NY

Study Objectives: (1) To determine the current laws regarding the legal blood alcohol concentration (BAC) in each of the of the fifty United States and Washington D.C. and the emergency physician’s obligation of reporting the alcohol 21 impaired driver and (2) To determine how difficult it is for the emergency physician to ascertain the above laws of each State through each of the following sources: Attorney General’s Office (AGO), Department of Motor Vehicles (DMV) and the governing Medical Board (MB). Methods: A telephone survey was conducted to each legal department or legal counsel of the fifty states and Washington DC’s AGO, DMV and MB via a scripted telephone conversation with additional correspondence as requested by each office. Attempts were made to contact each office until the survey was partially or completely answered. Calls were made until five attempts to leaving messages, ten no answer/ busy signals were documented or if the state refused to comment. Results: All states define BAC of 0.08 as impaired with some sub-classifications. According to the AGO (49% response rate) two states have mandatory reporting laws, DMV (70% response rate) four states have mandatory reporting laws and MB (47% response rate) one state has mandatory reporting laws. Conclusion: There are differing reporting obligations in each state and the emergency physician must be aware of the laws where they practice. AGOs, DMVs and MBs within a state may not agree upon the reporting laws and often cannot define what the current legislation requires. This disagreement may complicate emergency physician compliance.

320

Emergency Department Discharge Without a Safety Net: Does Having Insurance Make a Difference with Follow-Up Care?

Bascom E, Takla R, Sarvpreet B, Cochran C/St John Hospital Oakland, Madison Heights, MI

Study Objectives: We aimed to measure the compliance rate of follow-up care for discharged emergency department patients, from a suburban community hospital, who were instructed to receive follow-up within 1 week by a physician, and to determine the rate of follow up visits with insured versus uninsured patients. Methods: We conducted a prospective, single center, descriptive study of adult patients, who were being discharged from the emergency department. We utilized a questionnaire to gather data at discharge -including insurance type- and instructed the patients to receive physician follow-up care within one week. A telephone interview was conducted 1 week after discharge to determine follow-up visit status. One hundred and thirty subjects were enrolled. Results: Of the one hundred and thirty patients enrolled, we reached 77 (59 %). Total patients (39%) received follow-up care as instructed. Patients with private insurance had the highest follow-up rate (46.2%), followed by those with public insurance (44.4%); the lowest rate of follow-up care was among uninsured subjects (20%). Conclusion: Uninsured patients have poor compliance with instructions for follow-up physician visits; less then one quarter visited a physician in the week after their emergency visit. Intervention is warranted for the uninsured patient. Emergency departments need to develop resources that provide a safety net of access for these at-risk patients.

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Abstract Withdrawn Building Bridges: Breast Cancer Prevention in Emergency Departments by Connecting At-Risk Women to Mammography

Bascom E, Irvin C, Corsi D, Tognacci R, Huber L, Buckley L, Olmstead M/St John Hospital and Medical Center and St John Oakland Hospital, Detroit, MI; St John Hospital and Medical Center, Detroit, MI; St John Hospital Oakland Hospital, Madison Heights, MI

Study Objectives: To identify women presenting to the emergency department (ED), who are noncompliant with the breast cancer mammography screening recommendations, and to provide these at-risk women with educational materials and

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Research Forum Abstracts referral phone numbers for free mammograms. We are measuring their compliance rate of obtaining a mammogram within one month of discharge. Methods: We are conducting a controlled, single-blinded, multi-center, prospective survey-based study. A survey regarding mammogram use is being verbally given to women over 40 in the ED, and one month later by phone. The intervention group (n⫽200 tests) is being given pamphlets about breast cancer prevention and phone numbers for free mammogram at community health departments (a program which has been established for many years). A similar group of women (n⫽200 control, call back in process) are also responding to the survey in the ED and one month later by phone, but without being given pamphlets or phone numbers. All women are being told if they need mammography. Results: We enrolled 200 women in intervention group. Of the women who need mammography (greater then 1 year) (N⫽131), we have reached (N⫽98) 74.8% on 1 month call back. Of those in need of mammography who were reached 21.4% (N⫽33), have obtained or scheduled mammography in the month following discharge. We are still calling back the control group. Of the 70 women we have called so far only 2 have obtained or scheduled mammography. Conclusion: Nearly 1/4 of the women in the intervention group who were provided with pamphlets and phone numbers have actually obtained or scheduled a mammogram within one month. These results are very promising. While we have not completed callbacks in the control group, based on historical controls it is unlikely these women will obtain mammograms. Women who utilize the ED are less likely to have access to reliable health care. We are hoping to provide a bridge to public health. EDs are in a unique position to intersect with women most in need of preventative health care. This simple and cost-effective intervention may save lives.

323

An Evaluation of Cardiopulmonary Resuscitation (CPR) Parameters in a Large Urban EMS System

Buono CJ, Aguilar S, Edwards C, Fisher R, Oakes G, Davis DP, Dunford J/ University of California, San Diego, San Diego, CA; San Diego Medical Services Enterprise, San Diego, CA

Study Objectives: To describe the specific parameters of cardiopulmonary resuscitation (CPR) in our Emergency Medical Services (EMS) system prior to the release of the new American Heart Association (AHA) guidelines including ventilation rate, chest compression rate and time on the chest in cardiac arrest during over a four month period. Also observed were the average end-tidal carbon dioxide values (ETCO2) and the rates of witnessed arrest and bystander CPR in our community. Background: The recent changes the 2005 AHA Emergency Cardiac Care recommendations emphasize the importance of optimal cardiopulmonary resuscitation, including ventilation rates. These changes are based on studies that found that the average in-hospital and out-of-hospital ventilation rates were 30 breaths per minute, significantly above the recommended 12 breaths per minute, and that the recommended rates of chest compression fall well below that of the then AHA recommendation of 100 compression per minute. Both of these are thought to lead to the poor survival rates in cardiac arrest. We sought to evaluate our system’s performance with regard to the pre-2005 AHA guidelines. Methods: Design: This was a retrospective study using data abstracted from prehospital cardiac Zoll monitors/defibrillators with digital and voice recording capabilities and the pre-hospital patient care record to evaluate the ventilation rate, chest compression rate, time on the chest, and patient demographics. Setting: A large, urban EMS system in the city of San Diego, California. Participants: All cardiac arrest patients, including pediatric and adult patients, with ventricular tachycardia and ventricular fibrillation who underwent CPR by our paramedics for which data was recorded by cardiac monitor. Results: We found 37 cases of cardiac arrest over a four month period. Overall, 71.4% were males and the age range of 3 months to 91 years. The average ventilation rate during CPR was 19.6 breaths per minute. This is 63% above the rate recommended at the time by the AHA. The average chest compression rate was 106 compressions per minute. The average time on the chest was 44.7% with a no flow ratio of 51.0% for the first three minutes. The average ETCO2 value during the first three minutes of resuscitation was 15.0 mmHg. Overall, 57.7% of cases received bystander CPR and 85.2% of cases witnessed arrests. Conclusions: Paramedics in our system performed ventilation above the rate recommended by the AHA, but less than rates reported in other systems. This is also reflected by the less than optimal ETCO2 values over the first three minutes of the resuscitation. Our paramedics performed chest compressions at the AHA recommended rate. However, our no flow ratio was significantly elevated above the

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20% threshold documented in the literature to maintain coronary perfusion pressure and improve patient outcomes. Our system will undertake training measures to improve performance of CPR.

324

An Exploratory Analysis to Assess the Potential Role for Non-Invasive Monitoring of Cerebral Oxygenation in Cardiac Arrest

Compton S, Ryder A, Medado P, Bastani A, O’Neil BJ/Wayne State University/ William Beaumont Hospital, Royal Oak, MI; William Beaumont Hospital, Royal Oak, MI; William Beaumont Hospital/ Wayne State University, Royal Oak, MI

Background: Non-invasive monitoring of cerebral oxygenation may hold potential to improve the judicious use of out-of-hospital cardiac arrest (OOHCA) interventions. Study Objective: To assess the potential utility of noninvasive monitoring of cerebral oxygenation to predict outcome in OOHCA patients. Methods: A prospective cohort study of adult OOHCA patients transported by EMS to 2 large, Midwestern community hospitals was conducted. A noninvasive cerebral oximetry device was applied by EMS personnel, blinded to the reading, while on scene, and measurements were obtained every 30 seconds during resuscitation procedures for at least 3 minutes. Oximetry measurements were dichotomized in terms of being within or outside of normal limits, and compared by outcome (death/ vegetative state or survival) using Fisher’s exact tests. Sensitivity and specificity are also reported. Results: Of 71 OOHCA patients evaluated in this study, 48 patients were excluded due to faulty lead placement or less than 3 minutes of initial monitoring time. Thus, 23 patients had complete monitoring of both the left and right cerebral hemispheres for at least 3 minutes and comprise this study population. The mean age was 70 years, 61% were male, and there were 3 (13%) survivors. Eight patients maintained normal cerebral oxygenation during the initial 3 minutes of monitoring, of whom 3 (37.5%) survived. None of the 15 patients that did not maintain normal cerebral oxygenation survived (37.5% vs 0%; p⫽0.032). Using 100% of measurements within normal range as the cutpoint to predict outcome yielded a sensitivity of 100% and specificity of 75%. Conclusions: This exploratory analysis suggests that noninvasive markers of cerebral oxygenation may possess potential utility in defining OOHCA patients that will not benefit from resuscitative therapies.

325

Histopathologic Effect of Endotracheal Drug Administration on Porcine Lung Tissue

Mencl F, Weigand J, Teermann G, Iturregui J, Rajjappannair L, Barhorst B, Evancho-Chapman M, McGuire K/Summa Health Systems, Akron, OH

Study Objectives: Advanced Cardiac Life Support (ACLS) guidelines include endotracheal drug administration (EDA) in the absence of IV access. However, little data is available on the absorption of these drugs or adverse events. We report on one of a series of studies examining EDA, done to determine whether EDA with various ACLS drugs results in lung tissue damage in a porcine model. Methods: This was a pilot, double-blind, controlled study, approved by our hospitals animal use committee. Twenty-one syringes containing one of seven weightdosed medications (epinephrine vasopressin, lidocaine, atropine, amiodarone, amiodarone [buffered to a ph of 7.4] or normal saline [as a control]) were prepared, diluted to a volume of 5 cc and identically packaged. The medications were then administered by a blinded investigator, in random order, to 21 anesthetized and intubated pigs. Each drug administration down the endotracheal tube was followed by a 5cc saline flush, and then by 5 bag-valve mask insufflations. The pigs were maintained on a ventilator using isoflourane, while vital signs and oxygen saturations were monitored according to standard protocol. Three hours after drug administration, the pigs were euthanized, the lungs were harvested, fixed with 10% formalin, and sections stained with Haemotoxylin & Eosin (H&E) for microscopic evaluation. A pathologist, blinded to the drug used, analyzed the tissue. Results: All pigs survived until euthanization. There were no significant vital sign changes, or oxygen desaturation, at any time before, during, or after the drug administration. Pathologic examination of lung tissue revealed uniform and similar changes for 3 groups, those receiving unbuffered amiodarone, epinephrine and atropine. These changes consisted of dense neutrophilic infiltration of bronchi, bronchioles and alveoli, fibrin exudates and edema, indicating severe acute tissue response. One of 3 pigs receiving lidocaine had similar changes, though the other 2 pigs had no significant histopathological changes, and none

Annals of Emergency Medicine S97