POSTER PRESENTATIONS:
Control Number: 3161
Title: Epidemiology and Geospatial Analysis of All-Terrain Vehicle Crashes in Iowa
Topic: Disease/Injury Prevention
Author Block: Evelyn Qin, Gerene Denning. University of Iowa, Iowa City, IA
Abstract:
Background: Each year in the United States, there are over 700 deaths, more than 400,000 injuries, and in excess of $22 billion dollars in costs related to all-terrain vehicle (ATV) crashes. The long-term goal of our research is to prevent ATV-related deaths and injuries using education, engineering and public policy approaches.
Objectives: Describe the epidemiology, crash mechanisms, clinical outcomes and geographic pattern of ATV crashes in Iowa.
Methods: A retrospective cross sectional study was performed using a unique statewide ATV injury surveillance database (2002-2013). SPSS statistical software was used to perform descriptive and comparative analysis. ArcGIS was used to map the location and characteristics of ATV crashes in the state.
Results: The statewide database included a total of 1,951 crashes, 2,308 vehicles, and 2,330 riders in Iowa. Crash victims were 79% males, 30% under 16 years of age, and 4% of crashes resulted in fatalities. Thirty-six percent of all crashes were on the road, despite strong warnings against roadway riding. The vast majority (91%) of all crashes were non-collision events (i.e. vehicle rollovers). GIS mapping demonstrated that ATV crashes occurred in both rural and urban areas, including downtown Des Moines. Mapping also provided striking visual patterns demonstrating the following: the proportion of fatal crashes was twice as high on the road than off, further evidence for the danger of roadway riding; for roadway crashes, a large majority were not traffic-related, contrary to beliefs that low traffic volume roads are “safe”; and ATV crashes are occurring in remote rural areas with highly limited access to emergency medical services (EMS). The latter is a growing problem, as access to EMS services in rural areas of our state is decreasing.
Conclusion: GIS represents a powerful tool for ATV safety education and for public awareness. Dispelling many misperceptions about ATV safety is vital to creating a safety culture around the vehicle. Results from this study will be used in our safety programming, as well as to inform public health and public policy makers, in order to promote evidence-based ATV safety laws.
Control Number: 3178
Title: Billing and Coding Shift for Emergency Medicine Residents: A Win-Win-Win Proposition
Topic: Education
Author Block: Michael Takacs, Joshua Stilley. University of Iowa, Iowa City, IA
Abstract:
Background: Effective teaching of coding has been well known to be deficient in emergency medicine (EM) residencies.
Objectives: Our primary objective was to create an effective teaching method for coding education in an EM medicine residency. Secondary objectives were to improve the efficiency and job satisfaction of our coders and to increase revenue in the department.
Methods: We conducted a one-on-one interprofessional workshop with our lead coder. From September, 2014 to March, 2015 and during their EM 4 week rotation between days 11 and 18 of their 28 day rotation. This consisted of a one hour interactive lecture, followed by a 1-2 hour exercise of residents coding a set of standardized charts followed by a feedback session. We surveyed the residents to assess the quality of this experience as a measure of our primary objective. We surveyed the coders in April, 2015 as a measure of our secondary objectives.
Results: 17 of 26 emergency medicine residents (65%) completed the interprofessional workshop and 14 of 17 residents (82%) completed the post-workshop self-assessment survey. A paired t-test on a 5 point scale comparing knowledge gained before and after the workshop showed an improvement from 3.4 to 4.3, p < 0.001. All residents were able to identify mistakes they commonly make. Other resident results are shown in the table. Residents made additional comments of being thoroughly satisfied with this experience and requesting it to be required for next year. Secondary results were obtained from the 4 of 4 coders (100%) completing their survey. Coders noted better documentation of required elements, improved job satisfaction with better charts, improvements in prior years, and the ability to process more charts with better coding.
Conclusion: A coding interprofessional shift is an effective teaching method for emergency medicine residents. Improvements in documentation also led to an increase in job satisfaction and efficiency of coders. Future work in this area may show an increase in department revenue creating a win for resident education, a win for coders, and a win for the department.
Control Number: 3180
Title: Child Welfare Professionals’ Determination of When Certain Unsafe Activities and Lack of Child Protection Constitutes Child Neglect
Topic: Pediatrics - General
Author Block: Erin Evans1, Resmiye Oral2, Alycia Karsjens3, Charles A. Jennissen4. 1University of Iowa Carver College of Medicine, Iowa City, IA; 2University of Iowa Departmet of Pediatrics, Iowa City, IA; 3University of Iowa Hospital and Clinics Social Patient and Family Services, Iowa City, IA; 4University of Iowa Departmet of Emergency Medicine, Iowa City, IA
Abstract:
Background: Although laws provide guidelines for the evaluation of possible child abuse and neglect cases, the language and substance of child safety laws and guidelines varies greatly among states.
Objectives: To identify factors that influence the determination of child neglect by child welfare experts, and develop some consensus regarding what constitutes child neglect with respect to child safety issues.
Methods: A survey was developed and distributed to members of the American Academy of Pediatrics Section on Child Abuse and Neglect (SOCAN). Respondents were requested to decide whether a particular scenario was child neglect with varying age of the child involved, and then with alterations in the scenario regarding the presence of injury to the child and the legality of the situation.
Results: Of 523 members, 152 have completed surveys to date. In a child left at home alone scenario, respondents were significantly more likely to declare child neglect for those 8-14 years of age if the child had been injured. In addition, for 10-14 year olds, SOCAN members were significantly more likely to declare child neglect if leaving that aged child at home alone was against the law. In a scenario where a loaded firearm was allowed to be accessible to children, the legality of the situation significantly affected the determination of child neglect for every age category. For a child who had possession of a loaded firearm in their home’s yard, 100% of the experts believed the situation constituted child neglect for those 4-8 years of age, and over 85% thought it was child neglect for children 10-14 years. No significant differences in child neglect determination were seen by sex, age, ethnicity, or child abuse and neglect certification possession.
Conclusion: Age of the child, presence of injury, and the legality of a situation affect how experts view a case of potential child neglect. This suggests that such cases may be evaluated differently across the nation due to varying state child safety laws, even though the risk to the child is the same. Moreover, a vast majority of experts indicated certain scenarios warranted child neglect designation, even when no current state laws regulated those particular situations. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and to better protect the safety of children.
Control Number: 3184
Title: Inter-rater Concordance in Variable Coding of Off-Highway Vehicle Park Photographic Data
Topic: Disease/Injury Prevention
Author Block: Eilis Baranow1, Charles A. Jennissen2, Emily Robinson1, Benjamin Wilkinson1, Gabe Greene2, Kristel Wetjen3, Pam Hoogerwerf4, Gerene Denning2. 1University of Iowa, Iowa City, IA; 2University of Iowa Department of Emergency Medicine, Iowa City, IA; 3University of Iowa Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 4University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Safety behaviors of all-terrain vehicle (ATV) riders at off-highway vehicle (OHV) parks may be better than those riding off-road elsewhere. A previous study of trauma patients from Iowa OHV parks were significantly more likely to have been helmeted, and less likely to have been a passenger than those injured off-road outside of parks. Motion-activated cameras were utilized to photographically capture riders entering OHV parks in order to determine park census and the types of vehicles using the parks, as well as the demographics and safety behaviors of park users.
Objectives: To determine the concordance in variable coding among investigators evaluating photos obtained at OHV parks for the purpose of study methodology validation.
Methods: Fourteen motion-activated cameras were placed at the entrances of the eight public OHV parks in Iowa. Four investigators did photo image analysis and coding for demographic, vehicle, and safety behavior variables on photos taken on June 21, 2014. Comparative analysis was performed on the entered data.
Results: A total of 206 vehicles with 215 riders were analyzed by all four photo analysts. Vehicle related variables such as vehicle type, vehicle size, number of vehicle wheels and the carrying of loads, had very strong concordance among evaluators. Safety behavior variables such as helmet use, presence of passengers, and use of safety belts in side-by-side vehicles were also extremely consistent among coders. Demographic variables (such as age and sex) and many personal protective equipment variables (such as goggles/face shield, chest protection, gloves and boots) were more likely to be evaluated differently. The number of discrepancies noted per photo varied some among cameras reflecting that the camera placement in some instances may not have been as optimal to achieve the best photos of riders.
Conclusion: Concordance of variable coding of study photos was high among evaluators, especially safety behavior and vehicle-related variables. Demographic variables (especially age) were more likely to vary between coders, and were more frequently indeterminate than other study variables. This study helps validate the methodology of photo evaluation to determine safety behaviors of OHV park users.
Control Number: 3187
Title: All-Terrain Vehicle Safety Knowledge and Riding Behaviors of Farm Progress Show Attendees
Topic: Disease/Injury Prevention
Author Block: Karisa Harland1, Gerene Denning1, Kristel Wetjen2, Pam Hoogerwerf3, Charles A. Jennissen1. 1University of Iowa Hospitals Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Hospitals Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 3University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: All-terrain vehicles have become very popular in rural areas for both recreation and work purposes. The epidemiology of agricultural-related all-terrain vehicle (ATV) use is largely unknown.
Objectives: The study objective was to describe the epidemiology of ATV use, riding behaviors, crash history and safety knowledge among visitors to the nation’s largest outdoor farm show.
Methods: Farm Progress Show attendees in 2012 (Boone, Iowa) and 2013 (Decatur, Illinois) were surveyed on ATV use (excluded side-by-sides) and their history of safety behaviors at the Iowa ATV Safety Task Force tent. Descriptive and comparative analyses were performed.
Results: 1,036 visitors completed the survey. Nearly two-thirds of those surveyed were male; one-fifth were under 16 years of age. Just over one-half of participants lived on a farm, with nearly another 20% living in the country but not on a farm. Overall, more than 90% had ridden an ATV. Males were significantly more likely to be riders (p<0.0001), as were those that lived on farms (p<0.01). One in 10 riders was over the age of 65 with the majority of riders being 31-65 years of age. Among riders, 61% rode at least once a week with 39% riding almost daily. Regarding unsafe behaviors, over 80% had ridden with a passenger, and 65% had ridden on a public road. Nearly one-half never or almost never wore a helmet, and only 24% stated they always or almost always wore one. Nearly 40% had been in a crash, defined as having hit something, rolled over, or fell/thrown from the vehicle. Males were more likely to have been in a crash (p<0.0001). Those having been in a crash were more likely to have reported riding with passengers and on the road (both p<0.0001). Safety knowledge did not necessarily correspond with safer behaviors. For example, 80% of those who knew you should only have one rider on an ATV still had ridden with passengers.
Conclusion: ATV use is prevalent in rural populations but few riders report safe riding behaviors. Study and input from rural community members and agricultural producers is needed to understand how to increase safety behaviors among this population. ATV safety education and training programs should be developed to target agricultural workers.
Control Number: 3200
Title: Risk Factors For Anaphylaxis Recurrence Among Olmsted County Residents
Topic: Toxicology/Environmental
Author Block: Curtis Bashore1, Ronna L. Campbell1, Dante Lucas S. Souza1, M Fernanda Bellolio1, Erik H. Hess1, Sangil Lee2. 1Mayo clinic, Rochester, MN; 2Mayo Clinic Health System, Mankato, MN
Abstract:
Background: The incidence and potential factors leading to recurrent anaphylaxis are poorly understood.
Objectives: To identify the rate of and risk factors for recurrent anaphylaxis in a population-based epidemiology cohort in Olmsted County, Minnesota.
Methods: We used the Rochester Epidemiology Project, a comprehensive medical records linkage system to obtain multicenter records of 371 Olmsted County residents who presented to their health care providers with at least one episode of anaphylaxis defined by anaphylaxis diagnostic criteria from January 2001 to December 2010. Charts were reviewed for identification of recurrent anaphylactic reactions during the 10 year period. We tested association of each independent risk factor with recurrence as the outcome and built a multiple logistic regression, followed by a secondary Cox-proportional hazard model. Results were reported as odds ratios (OR) and 95% confidence intervals (CI).
Results: Among the 371 patients who had an episode of anaphylaxis, 37 (10%) experienced at least one recurrence. The median time for first recurrence was 0.5 years. In univariate analysis, a history of asthma (OR 2.2 [95% CI 1.1-4.7]; p=0.04), prior anaphylaxis (OR 2.4 [95% CI 1.1-5.2]; p=0.03), atopic dermatitis (OR 1.2 [95% CI 1.4-17.3]; p=0.02), and the symptom of cough on first visit (OR 3.5 [95% CI 1.4-8.9]; p=0.006) were associated with recurrence. A multiple logistic regression analysis adjusted for asthma, prior anaphylaxis, atopic dermatitis and symptom of cough showed that history of atopic dermatitis (OR 4.9 [95% CI 1.2-17.3]; p=0.03) and the symptom of cough (OR 3.5 [95% CI 1.2-9.1]; p=0.02) remained statistically significantly associated with recurrence. A Cox regression model showed similar findings.
Conclusion: Ten percent of the patients developed recurrent anaphylaxis over the 10 year study periods. The median time to recurrence was 0.5 years. Those with past medical history of atopic dermatitis or initial symptom of cough were more likely to experience a recurrence.
Control Number: 3211
Title: T/QRS and ST/T Ratios are Significantly Greater in Patients with Left Bundle Branch Block and Acute Coronary Occlusion
Topic: Cardiovascular – Clinical Research
Author Block: Kendra D. Elm1, Kenneth W. Dodd2, Stephen W. Smith2. 1University of Minnesota, Minneapolis, MN; 2Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background: Hyperacute T-waves and ST segment deviation can occur in ECGs of AMI in normal conduction. In LBBB without AMI, T-waves are normally discordant to the majority of the QRS complex and ST deviation is present but not necessarily indicative of ACO.
Objectives: To investigate the T-wave changes in patients with left bundle branch block (LBBB) and acute coronary occlusion (ACO), including absolute T-wave amplitude (TWA), concordant ST/T ratio, and discordant T/QRS ratio. We hypothesize that these parameters will be greater in LBBB patients with ACO than in those without ACO.
Methods: Retrospectively, ECGs of ED patients with LBBB and ischemic symptoms were obtained. STEMI, NSTEMI, and no-MI groups consisted of 33, 24, and 105 patients respectively. “STEMI” patients had 1) angiographically proven ACO or 2) lesion and troponin I ≥ 10 ng/ml. “NSTEMI” patients had clinically diagnosed AMI without ACO. Control patients had negative serial troponins. Measurements obtained were S- or R-wave amplitude, ST deviation at the J point and TWA to the nearest 0.5 mm relative to the PQ junction. The T-wave was concordant if the majority was in the same direction as the majority of the QRS.The maximum ratio in any lead was used in calculations for both T/QRS and ST/T statistics. Any ST/T wave ratios calculated to be greater than 1.0 were reviewed. Statistics were by Kruskal-Wallis test and McNemar’s test.
Results: The median TWA was 9 mm [IQR 6.5-11] for STEMI and 8.5 mm [IQR 6.5-11.5] for all other patients (p = NS). The T/QRS ratio was significantly larger for STEMI versus all other patients but not between NSTEMI and no-MI patients (Table 1). For STEMI, the sensitivity and specificity of T/QRS ratio of > 1.25 was 45% (95% CI 29-63) and 93% (95% CI 87-97).
Similarly, the ST/T ratio was significantly increased for STEMI versus all other patients but not for NSTEMI patients compared to no-MI patients (Table 1). A ST/T ratio of > 0.80 in any lead has a sensitivity and specificity of 76% (95% CI 57-88) and 59% (95% CI 50-67) respectively for STEMI.
Conclusion: The ratio of discordant T/QRS is significantly increased in ACO and a cutoff of T/QRS > 1.25 has high specificity for ACO in LBBB. Additionally, concordant ST/T is significantly increased in ACO, which parallels what has been previously described in the Sgarbossa and Smith modified Sgarbossa criteria.
Control Number: 3189
Title: A Safer Place to Ride: Regulations and DNR enforcement in OHV Parks Increases Safety Behaviors
Topic: Disease/Injury Prevention
Author Block: Jessica Waters1, Charles A. Jennissen2, Nathaniel Johnson3, Brandon Johnson3, Emily Robinson3, Eilis Baranow3, Gabe Greene2, Benjamin Wilkinson3, Pam Hoogerwerf4, Gerene Denning2, Karisa Harland2. 1University of Iowa Carver College of Medicine, Iowa City, IA; 2University of Iowa Department of Emergency Medicine, Iowa City, IA; 3University of Iowa, Iowa City, IA; 4University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Iowa off-highway vehicle (OHV) parks have regulations regarding youth users and helmet use that do not apply outside of parks, and have Department of Natural Resources (DNR) personnel who patrol the parks and provide enforcement. In previous studies, we found Iowa all-terrain vehicle (ATV) crash victims at OHV parks had better safety behaviors as compared to off-road crashes outside the parks.
Objectives: To determine the demographics and prevalence of safety behaviors among OHV park users, and how regulations and enforcement affect rider safety behaviors.
Methods: From May to September of 2014, motion-activated cameras captured photos of users at the entrances of Iowa’s eight OHV parks. Riders were coded by vehicle type, estimated age, sex, and safety behaviors. Descriptive and multivariable logistic regression analyses were performed.
Results: A total of 6,718 vehicles and 9,083 riders were analyzed. Riders on ATVs comprised 44% of OHV park users, 51% were on dirt bikes and 5% were on side-by-sides (SxSs). Helmet use was 94.4% overall. Just 6% of single-rider ATVs and 0.8% of dirt bikes had passengers. While only 11% of park users on ATVs were <16 years old, 59% of the child operators were driving adult sized ATVs. Of those riding SxSs, 64% were not using their restraints. Multivariate modeling controlling for important covariates showed that in comparison with young adults (16-39 years) on ATVs, children were nearly 6 times as likely to wear a helmet, whereas middle aged adults (40-60 years old) were half as likely to wear one. When DNR officers were patrolling the parks, there was a 3.6 times higher likelihood of helmet use and a 40% lower likelihood of passengers on dirt bikes and ATVs.
Conclusion: Regulated safety behaviors such as helmet use and riding without passengers were highly practiced by OHV park users. However, unregulated behaviors such as children only driving youth sized vehicles and restraint device use in SxSs had lower compliance. Moreover, regulated safety behaviors were significantly increased when the parks were patrolled by DNR officers. This study shows that a combination of regulation and enforcement is effective in ensuring compliance with rider safety behaviors in OHV parks. The establishment of similar safety regulation and enforcement outside of parks would likely have a more far-reaching effect on decreasing OHV-related deaths and injuries.
Control Number: 3214
Title: Electrocardiographic Diagnosis of Acute Right Coronary Artery Occlusion in Left Bundle Branch Block
Topic: Cardiovascular – Clinical Research
Author Block: Kenneth W. Dodd1, Erin M. Dodd2, Kendra D. Elm2, Stephen W. Smith1. 1Hennepin County Medical Center, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN
Abstract:
Background: The Sgarbossa criteria for diagnosing acute myocardial infarction in LBBB are (concordant ST elevation ≥1 mm, concordant ST depression of ≥ 1 mm in leads V1 to V3, or ≥ 5 mm discordant ST elevation). However, a QRS axis ≤ -30 degrees indicates negative QRS complexes in all of leads II, III, and aVF and such patients cannot have concordant ST elevation. Moreover, the relatively low voltages in the inferior leads make it difficult for patients to meet a 5 mm ST elevation cutoff. Therefore, we hypothesized that the Sgarbossa criteria have a low sensitivity for diagnosis of inferior ST-elevation myocardial infarction (STEMI).
Objectives: Here we characterized patients with inferior STEMI with regards to their QRS axis and compared the Sgarbossa and Smith criteria for diagnosing inferior STEMI in LBBB.
Methods: Retrospectively, ED patients were identified with LBBB and ischemic symptoms but no evidence of myocardial infarction (no-MI), with LBBB and non-ST elevation myocardial infarction (NSTEMI), and with LBBB and angiographically-proven acute coronary occlusion (STEMI). Measurements included ST segment at the J-point as well as S- and R-wave amplitude. The QRS axis was recorded as printed on the ECG and checked by examining leads I and aVF. If abnormalities were identified, the QRS axis was re-calculated by hand. Statistics were by two-tailed Student’s t-test, Mann-Whitney U test, and McNemar’s test.
Results: The STEMI, NSTEMI and no-MI groups consisted of 33, 24, and 105 patients. There were 9 STEMI patients with right coronary artery occlusion (i.e. inferior STEMI). Mean and median QRS axis was similar for all groups (p = NS). There were 0 patients with QRS axis ≤ -30 degrees who met Sgarbossa’s first criterion in the inferior leads. There were also 0 patients that met Sgarbossa’s third criterion (≥ 5 mm discordant ST elevation) in the inferior leads. In the diagnosis of inferior STEMI, Smith ST/QRS ≤ -0.25 ratio rule had sensitivity of 100% (95% CI 89-100) as compared to 56% (95% CI 39-74) for the Sgarbossa criteria (p < 0.05).
Conclusion: The Smith ST/QRS ratio rule is significantly more sensitive for diagnosing inferior STEMI as compared to the traditional Sgarbossa criteria. This is due to the fact that the Smith ST/QRS ratio rule allows for “excessively discordant” ST elevation that is proportional to the voltage of the inferior leads and is not limited by the QRS axis.
Control Number: 3218
Title: ATV and SxS Safety Training for Agricultural Workers: Short Term Results of a Safety Workshop Piloted with Iowa Farmers
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Karisa Harland1, Andrew Winborn2, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2Rural Health and Safety Clinic of Greater Johnson County, Iowa City, IA
Abstract:
Background: All-terrain vehicles (ATVs) and side-by-sides (SxSs) have become increasingly popular for agricultural work purposes. There are few occupational ATV/SxS safety education resources, and it is unclear how many operators have received training.
Objectives: To develop and evaluate a workshop that provides farmers education on the safe occupational use of ATVs and SxSs, and determine the ATV/SxS safety behaviors, knowledge, and crash experiences of workshop participants.
Methods: Evidence-based safety information was used to develop an educational workshop for agricultural workers and piloted. Demographic information, safety behaviors, crash experiences, and safety knowledge was collected prior to training. The reported likelihood of using the workshop information and short-term knowledge gain was assessed.
Results: Forty-three subjects participated; mean age was 30 years (range 18-65 years) and 80% were men. About half were owners/operators or family members, while 42% were employees. Only eight had previously received any ATV/SxS education and only one had received formal hands-on training. Nearly all (91%) had used ATVs for occupational purposes with almost 40% reporting daily use. About 60% of occupational ATV users reported daily or weekly use on public roadways, and 82% reported having ridden with passengers. The vast majority never wore a helmet. Most (72%) reported using SxSs for occupational purposes, with about 50% reporting daily use. Of occupational SxS users, almost half reported daily or weekly public roadway use and 65% reported never using the restraint device. Seven (16%) had an occupational crash in the prior year. No difference in baseline knowledge scores were found by age, farming operation role, or riding frequency. Mean knowledge scores pre-workshop were 7.1 (range 2-17) and post-workshop 13.4 (range 6-19). Mean change was 6.3 (95% CI 5.2-7.4, p<0.0001). Nearly all subjects reported they were very likely (43%) or likely (48%) to use the safety information presented.
Conclusion: Agricultural workers frequently use ATVS/SxSs for occupational purposes. Of workshop participants, few had received previous training and most practiced unsafe behaviors. The safety training employed in this study increased short term safety knowledge and a high percentage of participants stated they would use the information provided.
Control Number: 3219
Title: What Is The Frequency Of Radiographic Detection Of Foreign Bodies After Snake Bites?
Topic: Diagnostic Technologies/Radiology
Author Block: Jarrod Dornfeld, David Edelman, Michael E. Mullins. Washington University in St. Louis School of Medicine, St. Louis, MO
Abstract:
Background: A recent study proposed the use of ultrasound for detecting retained foreign bodies in snakebite patients based upon simulation using a fang or a tooth embedded in a gelatin model. It is not known whether our patient population would be appropriate for studying this new technique.
Objectives: Determine the frequency of retained foreign bodies seen in radiographs of snakebite patients in Missouri
Methods: This is an IRB-approved, retrospective chart review using a previously collected database of snakebite consult patients. We identified patients who presented in Barnes-Jewish Hospital or St. Louis Children’s Hospital from 2001-2011 with snakebites and radiographs or radiographic reports. We calculated the frequency of positive retained foreign bodies was calculated in our patient population.
Results: 121 patients were consulted for a snakebite over the 11 year period of the study. Of these 87 patients meet the study criterion of an documented radiologic study of the bitten extremity. None (0%, 95%CI 0%-3.4%) of these patients had positive radiographs of retained foreign bodies.
Conclusion: None of the patients in our population had a retained foreign body and the rate of encounters per year was low in our population (mean of 11 patients per year). It is unlikely that we would encounter a retained foreign body from a snakebite in the near future. Given the low probability of encountering a retained foreign body among our patient population, we determined that it was not feasible to study a new ultrasound method for the detection of retained foreign bodies following snakebite in our hospitals.
Control Number: 3220
Title: Snowmobile-Related Injuries In The Ed Population 2002-2013
Topic: Disease/Injury Prevention
Author Block: Christopher R. Peterson, Ryan A. Peterson, Charles A. Jennissen. University of Iowa, Iowa City, IA
Abstract:
Background: Snowmobiling is a popular form of recreation in the winter, but adverse events can lead to significant injury. There are no recent studies which have looked at national data on snowmobile-related ED visits.
Objectives: To determine the demographics and risk factors for snowmobile-related injuries.
Methods: ED visits related to snowmobiles were identified through the National Electronic Injury Surveillance System (NEISS) database which collects information from a national probability sample of hospitals in the U.S., and is maintained by the Consumer Product Safety Commission. Injuries that did not occur during snowmobile operation were excluded. Descriptive and statistical analyses were performed.
Results: After exclusions, a total of 1944 snowmobile-related injuries were identified in the NEISS database from 2012-2013. This corresponds to a national estimate of 135,032 snowmobile-related ED visits during the study period. There was a trend of decreasing injuries over time with a national estimate of 12,862 in 2002 and 9,270 in 2013 (average decrease of 499 per year, 95% CI 89.9-907.7). Most commonly injured were 19-29 year olds, accounting for 30.0% of the total; 19% were pediatric patients. About three-fourths were male. The most common mechanisms of injury involved falling off (22.4%), striking a stationary object (16.2%), and rolling/flipping the vehicle (12.5%). Mechanisms that had the greatest admission rates include events involving a drop-off/cliff (50.0%), ejections from the snowmobile (24.7%), and collisions with a motorized vehicle (21.8%). Helmet use was reported in 11.4% of cases. Patients wearing a helmet had 63% reduced odds of requiring inpatient admission compared to those without a helmet (p=0.03). Speed was reported in only 6.6% of cases. Those operating at speeds estimated ≥35 mph had 1.74 times greater odds of admission compared to lower speeds (p=0.27, probably not statistically significant due to small samples), and a 1.93 times greater odds of admission compared to those with unreported speed (p=0.03).
Conclusion: Snowmobilers who either did not wear helmets or were operating at high speeds were more likely to require hospital admission. Snowmobilers should be especially wary of terrain changes, other vehicles in the area, and being ejected, as these mechanisms accounted for a higher rate of injuries requiring inpatient treatment.
Control Number: 3222
Title: Everyone’s Nightmare: Agitation During Procedural Sedation In Children
Topic: Airway/Anesthesia/Analgesia
Author Block: Ana Castaneda-Guarderas1, Henrique A. Puls2, Patricia Barrionuevo1, Waqas I. Gilani1, Waqas I. Gilani1, Jana L. Anderson1, Patricia J. Erwin1, M. Hassan Murad1, Erik P. Hess1, M. Fernanda Bellolio1. 1Mayo Clinic, Rochester, MN; 2Federal University of Health Sciences Of Porto Alegre, Porto Alegre, Brazil
Abstract:
Background: Procedural sedation and analgesia (PSA) is routinely performed in the Emergency Department (ED) to facilitate potentially painful procedures by alleviating pain, anxiety and suffering, this involves the use numerous classes and combinations of short acting analgesic and sedative medications with heterogeneous adverse events which adds to the challenge of performing safely in children.
Objectives: We conducted a systematic review and metaanalysis to evaluate the incidence of agitation in the ED during PSA in the pediatric population.
Methods: We searched multiple electronic databases including Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Ovid CENTRAL, Ovid Cochrane Database of Systematic Reviews, Web of Science and Scopus from inception through June 2014 without language restrictions. Randomized controlled trials and observational studies of procedural sedations in the ED were included. Data were extracted by independent pairs of reviewers and risk of bias was assessed using the Cochrane risk of bias tool for trials and the Newcastle-Ottawa Scale for observational studies. Meta-analysis was performed using a random-effects model and reported as incidence rate and 95% confidence intervals (CI).
Results: A total of 1,177 studies were retrieved for title and abstract screening and 258 of them were selected for full-text review. Forty two studies reporting on 13,975 procedural sedations in 13,968 children were included. Agitation was reported in 18.2 per 1,000 sedations (95% CI 12.5 to 23.9). Midazolam alone had the highest incidence of agitation at 181.2 per 1,000 sedation, followed by ketamine in combination with another drug (55.5 - 63.6 per 1,000 sedations) and ketamine alone (24.1 per 1,000 sedations). Nitrous oxide and propofol had a very low incidence of agitation (7.9 and 3.3 per 1,000 respectively). Only 6 out of 1,171 children were treated for their agitation (3.1 per 1,000 sedations).
Conclusion: Agitation causes discomfort to the child, parents and healthcare providers. Overall, is an uncommon effect of medications used for sedation, with a frequency lower than 2%. Most episodes will not require treatment.
Control Number: 3181
Title: Pre-Hospital Notification of Suspected Acute Ischemic Stroke Can Improve Common Reported Time Benchmarks.
Topic: Neurology
Author Block: Michael D. Zwank, Carol J. Droegemueller. Regions Hospital, Saint Paul, MN
Abstract:
Background: Ischemic stroke continues to be a cause of significant morbidity and mortality in the United States. Great efforts have been aimed at improving stroke care by both standardizing the management and improving the efficiency of care of patients with suspected stroke. In May of this year, we implemented a quality improvement program at our urban tertiary care stroke center with a pre-hospital notification system for EMS providers to alert the hospital of an incoming patient with suspected stroke. As part of the new protocol, providers meet the EMS personnel in the hallway after arrival and assess the patient. Unless the provider assesses that acute stroke is unlikely, the patient is registered, received an IV catheter and is taken directly to the CT scanner.
Objectives: e sought to determine if this quality improvement project improved the standard reporting measures of 'door to CT' time and 'door to IV tPA administration' time.
Methods: We analyzed a cohort of patients from 2015 that included approximately five months of patients arriving before the process change and three months of patients arriving after the change. Data was available from time stamps in the electronic medical record. While this is primarily a descriptive assessment, we analyzed the data for statistical significance using unpaired student t-tests assuming equal variance.
Results: 126 patients were assessed from January to August of 2015 with suspected acute stroke. 75 patients arrived before the process change and 51 arrived after. Door to CT scanner time decreased from 19 minutes to 8 minutes (p=0.001). 37 patients were treated with tPA (23 before, 14 after). Door to IV tPA administration showed a trend of decrease from 1:13 to 53 minutes. This was not statistically significant (p=0.13).
Conclusion: Pre-hospital notification at an urban tertiary care stroke center improved door to CT time. There was a non-significant trend towards faster tPA administration. Future analysis will include a larger data set and will include patient outcomes.
Control Number: 3236
Title: Does an Electronic Medical Record Alert Improve Recognition of Elevated Blood Pressure Prior to Discharge?
Topic: Cardiovascular – Clinical Research
Author Block: Michael D. Zwank, Katie Cicolello, Kendal Farrar. Regions Hospital, Saint Paul, MN
Abstract:
Background: It is well known that untreated or undertreated hypertension (HTN) is dangerous. Because of this, recognition of abnormal elevated blood pressure (EBP) during ED encounters is very important. At our tertiary care hospital, we implemented an EMR alert which generates a notification to providers at the time of discharge if a patient’s blood pressure has exceeded 140/90 during their visit. The alert also prompts the clinician to provide the patient with a diagnosis of EBP or HTN, a primary care referral, and/or HTN specific discharge instructions.
Objectives: We sought to determine if the alert led to improved patient notification of EBP and ultimately to improved primary care referral and follow-up.
Methods: We conducted a retrospective chart review of 883 charts (400 pre- and 483 post-intervention). Data was abstracted from the electronic medical record by two trained research assistants.
Results: A total of 79 patients received a referral to primary care in the pre-intervention group, compared to 114 after the intervention. Of these referrals, only 12 and 13 respectively were specifically for EBP. Post-intervention, a total of 51 patients who were not previously diagnosed with HTN were given a new discharge diagnosis of EBP compared with 5 patients pre-intervention (p<0.05). There was no difference in the number of patients receiving HTN specific discharge instructions, with 29 patients in each group. Following their ED visit, a total of 255 post-intervention patients were seen in follow up at some point in the next six months versus 218 in the pre-intervention group. Of these, new antihypertensive medications or changes to an existing regimen were prescribed for 49 post-intervention patients, versus 21 pre-intervention patients.
Conclusion: The EMR alert produced mixed results. While more patients were referred to primary care after the intervention, a similar number of patients were referred specifically for EBP. It is unclear if the increase in general referrals may have been related to the alert. However, many more patients were discharged from the ED with a new diagnosis of EBP and more patients had HTN medication changes at the follow-up appointment.
Control Number: 3237
Title: Electronic Medical Record Workflow Affects Bedside Ultrasound Ordering and Documentation Compliance
Topic: Ultrasound
Author Block: Michael D. Zwank. Regions Hospital, Saint Paul, MN
Abstract:
Background: Point-of-care ultrasound (POCUS) has become standard care of many patients in the ED. There is large variation in many aspects of POCUS across the country. As part of a quality improvement project, we standardized POCUS at our hospital including a new workflow that emphasized orders for all POCUS in the electronic medical record (EMR) as well as new alerts to complete documentation.
Objectives: We wanted to determine if the new standardized workflow would affect POCUS numbers in the ED including numbers of ultrasounds ordered, documented and billed.
Methods: We conducted a retrospective review of the EMR three months before the intervention and three months after, with specific focus on POCUS. Data was queried by trained EMR programmers and billers.
Results: A total of 2,112 ultrasounds were ordered during the 6 month period (917 before and 1,195 after). Of these, 480 and 1054 respectively had an interpretation note completed. This represented an average of 52.4% with documentation before and 88.40% with documentation after the intervention. A total of 364 ultrasounds were billed before and 669 were billed after the intervention. This demonstrated that the rate of billing increased from 39.70% to 56.40%. All of the increases after the intervention were statistically significant (p's<0.05).
Conclusion: A change in EMR workflow resulted in dramatic increases in the number of ultrasounds ordered, documented and billed. While there may have been unforeseen confounders during the period of evaluation, it is doubtful that any could have produced these dramatic results.
Control Number: 3243
Title: Comparison of Amnesia and Respiratory Depression during Moderate versus Deep Procedural Sedation with Propofol in the Emergency Department (ED)
Topic: Airway/Anesthesia/Analgesia
Author Block: Alexandra Schick1, Erik Fagerstrom2, Johanna Moore3, James Miner3. 1University of Minnesota, Minneapolis, MN; 2Minnesota Medical Research Foundation, Minneapolis, MN; 3Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background:
Objectives: Moderate and deep procedural sedations are common in the ED, but little data exists
comparing the efficacy and safety of these two approaches. Therefore, it is unclear whether one depth of sedation is superior to the other. Our objective was to determine whether there was a difference in amnesia and respiratory depression (RD) between moderate and deep sedation.
Methods: This was a prospective, randomized, controlled study of consenting adults undergoing
procedural sedation with propofol from 3/5/15 - 8/1/15. The observer’s assessment of alertness/sedation (OAAS) score, vital signs, propofol doses, and end tidal CO2 (ETCO2) were monitored continuously during the procedure and recorded every 30 seconds. To assess memory, a standardized image was shown every 30 seconds starting several minutes before the sedation until the end of
sedation. Recall and recognition of the images was assessed 10 minutes after the end of the sedation. RD was defined as SaO2 <92%, a change in ETCO2 >10 mm Hg, or absent ETCO2 at any time during the sedation. Data were analyzed with description statistics.
Results: We enrolled 23 subjects: 12 in the moderate group, and 11 in the deep group. The
median propofol dose (mg/kg) in the moderate group was 1.5 (range 1.0-2.0, IQR 0.5) and was 2.0 (range 0.9-3.6, IQR 0.8) for deep. The median lowest OAAS for moderate sedation was 1.5 (range 1-3, IQR 1) and was 1 (range 1-2, IQR 1) for deep. RD was observed in 8/12 in the moderate group and 8/11 in the deep group. However, 4 patients in the moderate group actually received deep sedation, and these subjects all had RD. RD was observed in 4/9 that received moderate sedation, and 12/14 those with deep sedation (difference -41.3%, 95% CI -2.6 to -68.8%). The percentage correctly recognized
after sedation was 72.6% for those that received moderate sedation and 45.4% for those that received deep (difference 27.2%, 95% CI 9.4 to 45%). The difference between recalled images was not significant.
Conclusion: The incidence respiratory depression between the randomization groups was not significantly different, but there was a significant difference when comparing those that actually received moderate and deep sedation. Those that received moderate sedation are able to recognize more images from during the procedure than the deep group, but had no difference in image recall.
Control Number: 3151
Title: Use of a Multi-Location, Interprofessional In-Situ Simulation of a Patient Presenting With Symptoms of Ebola Virus Infection (EVI) to Evaluate Hospital Bioemergency Preparedness.
Topic: Clinical Operations – Processes
Author Block: Daniel G. Miller, Beth Hanna, Julie Lindower, Maria Lofgren, Thomas Persoon, Christina Spofford, Jeffrey Vande Berg, Emily Wynn. University of Iowa, Iowa City, IA
Abstract:
Background: Highly contagious bioemergencies present significant challenges to a hospital, these include: prompt patient recognition and isolation, effective use of personal protective equipment by hospital staff, and performance of multiple handoffs between healthcare teams and units without degradation of information accuracy. Failure mode and effects analysis (FMEA) is a systematic qualitative observational technique originally developed in the 1950s to identify system failures and their downstream effects in military systems.
Objectives: We hypothesized that our standing policies and procedures for handling a bioemergency patient had unknown performance gaps that we could identify by performing an in-situ simulation of a patient presenting to the Emergency Department with symptoms of EVI and using FMEA techniques to monitor the patient’s entire clinical course.
Methods: We enlisted representatives from the ED, the ICU, hospital security, and the Decedent Care Center (DCC) to design an in-situ simulation of a patient presenting to the ED with symptoms of EVI who required admission to our biohazard containment unit and eventually died, requiring removal of his remains through our DCC. This involved 5 locations of care and 4 transitions of care. We identified 8 major and 15 minor objectives as well as 35 possible failure modes and enlisted a team of trained observers to observe patient care and handoffs. A panel of trained debriefers, who were not involved in the design of the scenarios, debriefed the participants. An FMEA template was developed and used to evaluate performance on the objectives and identify additional learning points.
Results: Through structured observation we identified 3 major and 13 minor objectives that required process improvement. Through debriefing and observation we identified an additional 101 individual learning points.
Conclusion: Applying FMEA to a Multi-Location, Interprofessional In-Situ Simulation allowed us to identify unexpected latent risks to patients and staff in the case of a bioemergency.
Control Number: 3168
Title: Rapid Response Systems, Healthcare Utilization And Mortality In Patients Admitted Through The Emergency Department
Topic: Health Services Research
Author Block: Marc N. Olive, Shawna D. Bellew, James M. Walston, Daniel Cabrera, Christine M. Lohse, M. Fernanda Bellolio. Mayo Clinic, Rochester, MN
Abstract:
Background: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration.
Objectives: We aimed to compare the healthcare utilization and outcomes of patients that had a RRT activation within 12 hours of admission.
Methods: We conducted a case-control study of patients presenting from Jan-2009 to Dec-2013 to a tertiary ED who subsequently had RRT activations within 12 hours of admission. The medical records of patients 18 years and older admitted to a non-Intensive Care Unit (ICU) setting were reviewed. Controls were matched 1:1 on age, gender, and diagnosis.
Results: A total of 948 patients were included (474 cases and 474 controls). Criteria for RRT activation were as follows: acute and persistent declining oxygen saturations < 90%, heart rate: 130, systolic blood pressure <90 mmHg, change in respiratory rate 28 per minute, change in conscious state, acute chest pain suggestive of ischemia, new onset of symptoms suggestive of stroke, or a staff member is worried about the patient.
Having an RRT activation corresponded to increased utilization of healthcare with increased ICU admission within 72 hours (OR 38.49, 95%CI 19.03-77.87), invasive interventions (OR 5.49, 95%CI 3.82-7.89), mortality at 72 hours (OR 4.24, 95%CI 1.60-11.24), and mortality at 1 month (OR 4.02, 95%CI 2.44-6.62).
Conclusion: After matching for age, gender and ED diagnosis, patients with RRT activations had higher mortality at 72 hours and 1 month, higher need for invasive interventions and increased ICU admission.
Control Number: 3183
Title: Why The Need For Speed?-- ATVs, Speed and Brain Injuries
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Joshua Godding2, Karisa Harland1, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Carver College of Medicine, Iowa City, IA
Abstract:
Background: Head trauma is the leading cause of death and serious injury from all-terrain vehicle (ATV) crashes. There are few studies that have specifically discussed how ATV speed affects crash injury. Present manufacturer guidelines for youth size ATVs allow vehicles for children aged 10 years and over to travel up to 30 mph, and for those 14 years and older to travel up to 38 mph.
Objectives: The study objective was to better understand the relationship between speed and ATV crash-related brain injuries.
Methods: A retrospective chart review was performed of trauma registry patients with ATV-related injuries at the University of Iowa from 2002-2013. Descriptive and comparative analyses were performed.
Results: 560 cases were identified; 77% were male and 32% were children <18 years of age. Rollovers (45%) were most common, followed by striking an object (22%) and ejection/fall (13%). Collisions with a motorized vehicle occurred in 8% of patients. Speeds >20 mph were associated with higher Max Head Abbreviated Injury Scale (AIS) scores than those ≤20 mph (p=0.05). Crashes with speeds >30 mph had higher Max Head AIS scores than those ≤30 mph (p=0.014). Higher speeds were also associated with a trend towards lower patient Glasgow Coma Scale (GCS) scores. Only about 20% of victims overall were wearing a helmet. Competitive racers, although helmeted, had more severe head injuries than all other victims. Competitive racers had lower GCS scores than their helmeted non-racing peers (p<0.05). Non-racers without helmets had lower GCS scores than their helmeted peers (p=0.003).
Conclusion: Higher speed appears associated with greater head injury risk in ATV crashes. The increasing speeds of today’s ATVs are likely contributing to more serious injuries, including more severe head injuries. Although helmets are protective, there may be ATV crash speeds or mechanisms of brain injury at higher speeds that reduce helmet effectiveness. This study suggests that the present maximum speed limitations for many youth size ATVs are not safe and puts the child at increased risk for head injury. All ATVs should have a code-protected, tamper-proof speed governor. This would particularly assist parents and employers in protecting youth and employees from the serious risks associated with high operating speeds.
Control Number: 3213
Title: Repolarization Parameters are Significantly Prolonged in Many Patients with Left Bundle Branch Block and Acute Myocardial Infarction
Topic: Cardiovascular – Clinical Research
Author Block: Kenneth W. Dodd1, Kendra D. Elm2, Erin M. Dodd2, Stephen W. Smith1. 1Hennepin County Medical Center, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN
Abstract:
Background: In patients with normal conduction, prolongation of repolarization parameters such as the QTc interval, JTc interval, and T-wave peak to end (Tpe) interval are associated with cardiac ischemia, ventricular tachydysrhythmias, and sudden cardiac death. We are unable to find published manuscripts that report these parameters in LBBB patients. Furthermore, it has been proposed that the Bazett correction formula for QTc and JTc overestimates repolarization in patients with conduction disturbances.
Objectives: Here we report the QTc, JTc, and Tpe intervals in ED patients with LBBB with and without MI. We also compared common correction formulas.
Methods: Retrospectively, ED patients were identified with LBBB and ischemic symptoms but no evidence of MI (no-MI), with LBBB and NSTEMI, and with LBBB and angiographically-proven acute coronary occlusion (STEMI). The QT, JT, and Tpe intervals were measured manually in leads II, V3, and V5; the longest of each was used. QTc and JTc intervals were calculated by Bazett’s, Hodges’ and Framingham formulas. Statistics were by two-tailed Student’s t-test and Mann-Whitney U test.
Results: The no-MI, NSTEMI, and STEMI groups consisted of 105, 24 and 33 patients, respectively. The mean Tpe for the STEMI and no-MI groups was 104 ms and 87 ms, respectively (p < 0.0001). In the STEMI group, 24.3% of patients had Tpe ≥ 120 ms compared to 4.8% of no-MI patients (p < 0.001). The mean QTc by Bazett’s was 484 ms, compared to Hodges’ 461 ms (p < 0.0001) and Framingham 451 ms (p < 0.0001). The mean JTc for Bazett’s, Hodges’, and Framingham were 307 ms, 312 ms, and 302 ms, respectively (p = NS). By Hodges’ formula, 53.1% of patients with LBBB had QTc ≥ 450 ms and 12.3% had JTc ≥ 340 ms. There was no significant difference in QTc or JTc between the STEMI, NSTEMI, or no-MI groups (see Dodd Table 1).
Conclusion: Repolarizaton parameters are prolonged in many patients with LBBB. The Tpe interval, which has been proposed as a marker of transmural repolarization heterogeneity due to ischemia, is significantly prolonged in patients with STEMI and LBBB when compared to no-MI patients. Using either the Hodges’ or Framingham correction formulas to calculate the QTc, or evaluating the JTc, may give a more accurate measure of LBBB patients’ repolarization intervals.
Control Number: 3188
Title: Occupational Side-by-Side Vehicle Exposure, Safety Behaviors, and Crash Experiences of Farm Progress Show Attendees
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Karisa Harland1, Kristel Wetjen2, Pam Hoogerwerf3, Lauren O'Donnell3, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 3University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Side-by-sides (SxSs), including both utility-task vehicles (UTVs) and recreational off-highway vehicles (ROVs), have become increasingly popular for performing work-related tasks and for recreation in rural areas. No studies have examined the safety issues and experiences of agricultural workers and their families while driving SxSs.
Objectives: The study objective was to better understand the epidemiology, safety behaviors, and crash experiences of SxS riders.
Methods: Visitors to the 2014 Farm Progress Show, the nation’s largest outdoor farm show, in Boone, Iowa, were surveyed on their SxS use at the Iowa ATV Safety Task Force tent. Descriptive and comparative analyses were performed.
Results: 227 surveys were completed. Respondents were 66% male. Average age was 39 years (8-80 years), and 77% were involved in agricultural work. About one-third currently owned a SxS in their family. Of respondents, 72% had driven or ridden a SxS in the past year. Of these, over three-quarters had used one for occupational purposes. Participants whose family owned a SxS were significantly more likely to have driven or ridden one in the past year (92% vs. 60%, p<0.0001). Respondents reported more frequent occupational than recreational use, with 59% of SxS users reporting occupational use at least once a week. Occupational SxS uses included transportation (94%), checking fields (68%), hauling loads (54%) and spraying (44%). Nearly all occupational users had driven on roadways, with 32% and 49% reporting driving at least once a week on paved and unpaved roads, respectively. Over 50% stated they never wear a helmet and 26% said they never use the safety belt/harness when using a SxS for work. During their lifetime, an occupational crash was reported by 15% of occupational SxS users. Of these, 37% occurred in the past year (6% of occupational users). Occupational crashes more frequently involved rollovers, and had a higher percentage of victims that sought medical attention than those in recreational crashes.
Conclusion: Farmers frequently own and use SxSs for occupational purposes. Transportation is a frequent occupational use, and driving on roadways is exceedingly common. Many SxS users are not wearing the restraint device which is critical to stay within the rollover protective structure if in a crash.
Control Number: 3232
Title: Time to Antibiotic Administration in Oncology Patients with Neutropenic Fever
Topic: Infectious Diseases
Author Block: Courtney Moors1, Rebecca Zadroga2, Heather Rhodes2. 1University of Minnesota, Minneapolis, MN; 2Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background: The ASCO guidelines recommend antibiotic administration within 1 hour of an oncology patient presenting with a neutropenic fever. The IDSA recommends that these patients receive empiric antibiotics urgently (< 2 hours).
Objectives: The goal of this study was to determine the extent to which Hennepin County Medical Center (HCMC) is meeting the above recommendations, and to compare the time to antibiotic administration in oncology patients who presented to the emergency department (ED) versus those who were directly admitted to the hospital from clinic.
Methods: We performed a retrospective chart review of all adult oncology patients who presented with febrile neutropenia that were admitted to HCMC between July 1, 2011, and June 30, 2014. Initial chart review identified patients based on DRG codes at hospital discharge. Data collected and analyzed included: length of hospital stay, mortality, time from admission to antibiotic administration, time from labs reported to antibiotic administration, antibiotic administered, type of malignancy and staging, and factors contributing to antibiotic administration delay. Comparisons were made between ED admissions and direct admissions from clinic. Febrile neutropenia was defined as a temperature >38.3C once or consistently above 38C for greater than one hour AND an ANC <500 cells/mm3 or expected to fall to less than <500 within 48 hours of admission. A T-test was used to compare differences between the two means of the ED versus direct admission data.
Results: 45 patients met inclusion criteria (25 ED, 20 direct admit). Mean time to antibiotic administration from when labs were reported was 1 hour in the ED compared to clinic where that time was 5 hours and 31 minutes (p<0.05). There was no statistically significant difference in length of hospital stay or mortality between these two populations.
Conclusion: The time to antibiotic administration is significantly shorter in the ED compared to a direct admission from clinic (4 hours and 31 minute difference) for oncology patients presenting with neutropenic fever at HCMC. Length of time until the patient hit the floor from clinic and delays in antibiotic administration on the floor were the two greatest factors contributing to this time difference between the clinic and the ED. These patients should be sent to the ED from clinic to decrease the time to receipt of antibiotics.
Control Number: 3161
Title: Epidemiology and Geospatial Analysis of All-Terrain Vehicle Crashes in Iowa
Topic: Disease/Injury Prevention
Author Block: Evelyn Qin, Gerene Denning. University of Iowa, Iowa City, IA
Abstract:
Background: Each year in the United States, there are over 700 deaths, more than 400,000 injuries, and in excess of $22 billion dollars in costs related to all-terrain vehicle (ATV) crashes. The long-term goal of our research is to prevent ATV-related deaths and injuries using education, engineering and public policy approaches.
Objectives: Describe the epidemiology, crash mechanisms, clinical outcomes and geographic pattern of ATV crashes in Iowa.
Methods: A retrospective cross sectional study was performed using a unique statewide ATV injury surveillance database (2002-2013). SPSS statistical software was used to perform descriptive and comparative analysis. ArcGIS was used to map the location and characteristics of ATV crashes in the state.
Results: The statewide database included a total of 1,951 crashes, 2,308 vehicles, and 2,330 riders in Iowa. Crash victims were 79% males, 30% under 16 years of age, and 4% of crashes resulted in fatalities. Thirty-six percent of all crashes were on the road, despite strong warnings against roadway riding. The vast majority (91%) of all crashes were non-collision events (i.e. vehicle rollovers). GIS mapping demonstrated that ATV crashes occurred in both rural and urban areas, including downtown Des Moines. Mapping also provided striking visual patterns demonstrating the following: the proportion of fatal crashes was twice as high on the road than off, further evidence for the danger of roadway riding; for roadway crashes, a large majority were not traffic-related, contrary to beliefs that low traffic volume roads are “safe”; and ATV crashes are occurring in remote rural areas with highly limited access to emergency medical services (EMS). The latter is a growing problem, as access to EMS services in rural areas of our state is decreasing.
Conclusion: GIS represents a powerful tool for ATV safety education and for public awareness. Dispelling many misperceptions about ATV safety is vital to creating a safety culture around the vehicle. Results from this study will be used in our safety programming, as well as to inform public health and public policy makers, in order to promote evidence-based ATV safety laws.
Control Number: 3178
Title: Billing and Coding Shift for Emergency Medicine Residents: A Win-Win-Win Proposition
Topic: Education
Author Block: Michael Takacs, Joshua Stilley. University of Iowa, Iowa City, IA
Abstract:
Background: Effective teaching of coding has been well known to be deficient in emergency medicine (EM) residencies.
Objectives: Our primary objective was to create an effective teaching method for coding education in an EM medicine residency. Secondary objectives were to improve the efficiency and job satisfaction of our coders and to increase revenue in the department.
Methods: We conducted a one-on-one interprofessional workshop with our lead coder. From September, 2014 to March, 2015 and during their EM 4 week rotation between days 11 and 18 of their 28 day rotation. This consisted of a one hour interactive lecture, followed by a 1-2 hour exercise of residents coding a set of standardized charts followed by a feedback session. We surveyed the residents to assess the quality of this experience as a measure of our primary objective. We surveyed the coders in April, 2015 as a measure of our secondary objectives.
Results: 17 of 26 emergency medicine residents (65%) completed the interprofessional workshop and 14 of 17 residents (82%) completed the post-workshop self-assessment survey. A paired t-test on a 5 point scale comparing knowledge gained before and after the workshop showed an improvement from 3.4 to 4.3, p < 0.001. All residents were able to identify mistakes they commonly make. Other resident results are shown in the table. Residents made additional comments of being thoroughly satisfied with this experience and requesting it to be required for next year. Secondary results were obtained from the 4 of 4 coders (100%) completing their survey. Coders noted better documentation of required elements, improved job satisfaction with better charts, improvements in prior years, and the ability to process more charts with better coding.
Conclusion: A coding interprofessional shift is an effective teaching method for emergency medicine residents. Improvements in documentation also led to an increase in job satisfaction and efficiency of coders. Future work in this area may show an increase in department revenue creating a win for resident education, a win for coders, and a win for the department.
Control Number: 3180
Title: Child Welfare Professionals’ Determination of When Certain Unsafe Activities and Lack of Child Protection Constitutes Child Neglect
Topic: Pediatrics - General
Author Block: Erin Evans1, Resmiye Oral2, Alycia Karsjens3, Charles A. Jennissen4. 1University of Iowa Carver College of Medicine, Iowa City, IA; 2University of Iowa Departmet of Pediatrics, Iowa City, IA; 3University of Iowa Hospital and Clinics Social Patient and Family Services, Iowa City, IA; 4University of Iowa Departmet of Emergency Medicine, Iowa City, IA
Abstract:
Background: Although laws provide guidelines for the evaluation of possible child abuse and neglect cases, the language and substance of child safety laws and guidelines varies greatly among states.
Objectives: To identify factors that influence the determination of child neglect by child welfare experts, and develop some consensus regarding what constitutes child neglect with respect to child safety issues.
Methods: A survey was developed and distributed to members of the American Academy of Pediatrics Section on Child Abuse and Neglect (SOCAN). Respondents were requested to decide whether a particular scenario was child neglect with varying age of the child involved, and then with alterations in the scenario regarding the presence of injury to the child and the legality of the situation.
Results: Of 523 members, 152 have completed surveys to date. In a child left at home alone scenario, respondents were significantly more likely to declare child neglect for those 8-14 years of age if the child had been injured. In addition, for 10-14 year olds, SOCAN members were significantly more likely to declare child neglect if leaving that aged child at home alone was against the law. In a scenario where a loaded firearm was allowed to be accessible to children, the legality of the situation significantly affected the determination of child neglect for every age category. For a child who had possession of a loaded firearm in their home’s yard, 100% of the experts believed the situation constituted child neglect for those 4-8 years of age, and over 85% thought it was child neglect for children 10-14 years. No significant differences in child neglect determination were seen by sex, age, ethnicity, or child abuse and neglect certification possession.
Conclusion: Age of the child, presence of injury, and the legality of a situation affect how experts view a case of potential child neglect. This suggests that such cases may be evaluated differently across the nation due to varying state child safety laws, even though the risk to the child is the same. Moreover, a vast majority of experts indicated certain scenarios warranted child neglect designation, even when no current state laws regulated those particular situations. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and to better protect the safety of children.
Control Number: 3184
Title: Inter-rater Concordance in Variable Coding of Off-Highway Vehicle Park Photographic Data
Topic: Disease/Injury Prevention
Author Block: Eilis Baranow1, Charles A. Jennissen2, Emily Robinson1, Benjamin Wilkinson1, Gabe Greene2, Kristel Wetjen3, Pam Hoogerwerf4, Gerene Denning2. 1University of Iowa, Iowa City, IA; 2University of Iowa Department of Emergency Medicine, Iowa City, IA; 3University of Iowa Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 4University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Safety behaviors of all-terrain vehicle (ATV) riders at off-highway vehicle (OHV) parks may be better than those riding off-road elsewhere. A previous study of trauma patients from Iowa OHV parks were significantly more likely to have been helmeted, and less likely to have been a passenger than those injured off-road outside of parks. Motion-activated cameras were utilized to photographically capture riders entering OHV parks in order to determine park census and the types of vehicles using the parks, as well as the demographics and safety behaviors of park users.
Objectives: To determine the concordance in variable coding among investigators evaluating photos obtained at OHV parks for the purpose of study methodology validation.
Methods: Fourteen motion-activated cameras were placed at the entrances of the eight public OHV parks in Iowa. Four investigators did photo image analysis and coding for demographic, vehicle, and safety behavior variables on photos taken on June 21, 2014. Comparative analysis was performed on the entered data.
Results: A total of 206 vehicles with 215 riders were analyzed by all four photo analysts. Vehicle related variables such as vehicle type, vehicle size, number of vehicle wheels and the carrying of loads, had very strong concordance among evaluators. Safety behavior variables such as helmet use, presence of passengers, and use of safety belts in side-by-side vehicles were also extremely consistent among coders. Demographic variables (such as age and sex) and many personal protective equipment variables (such as goggles/face shield, chest protection, gloves and boots) were more likely to be evaluated differently. The number of discrepancies noted per photo varied some among cameras reflecting that the camera placement in some instances may not have been as optimal to achieve the best photos of riders.
Conclusion: Concordance of variable coding of study photos was high among evaluators, especially safety behavior and vehicle-related variables. Demographic variables (especially age) were more likely to vary between coders, and were more frequently indeterminate than other study variables. This study helps validate the methodology of photo evaluation to determine safety behaviors of OHV park users.
Control Number: 3187
Title: All-Terrain Vehicle Safety Knowledge and Riding Behaviors of Farm Progress Show Attendees
Topic: Disease/Injury Prevention
Author Block: Karisa Harland1, Gerene Denning1, Kristel Wetjen2, Pam Hoogerwerf3, Charles A. Jennissen1. 1University of Iowa Hospitals Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Hospitals Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 3University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: All-terrain vehicles have become very popular in rural areas for both recreation and work purposes. The epidemiology of agricultural-related all-terrain vehicle (ATV) use is largely unknown.
Objectives: The study objective was to describe the epidemiology of ATV use, riding behaviors, crash history and safety knowledge among visitors to the nation’s largest outdoor farm show.
Methods: Farm Progress Show attendees in 2012 (Boone, Iowa) and 2013 (Decatur, Illinois) were surveyed on ATV use (excluded side-by-sides) and their history of safety behaviors at the Iowa ATV Safety Task Force tent. Descriptive and comparative analyses were performed.
Results: 1,036 visitors completed the survey. Nearly two-thirds of those surveyed were male; one-fifth were under 16 years of age. Just over one-half of participants lived on a farm, with nearly another 20% living in the country but not on a farm. Overall, more than 90% had ridden an ATV. Males were significantly more likely to be riders (p<0.0001), as were those that lived on farms (p<0.01). One in 10 riders was over the age of 65 with the majority of riders being 31-65 years of age. Among riders, 61% rode at least once a week with 39% riding almost daily. Regarding unsafe behaviors, over 80% had ridden with a passenger, and 65% had ridden on a public road. Nearly one-half never or almost never wore a helmet, and only 24% stated they always or almost always wore one. Nearly 40% had been in a crash, defined as having hit something, rolled over, or fell/thrown from the vehicle. Males were more likely to have been in a crash (p<0.0001). Those having been in a crash were more likely to have reported riding with passengers and on the road (both p<0.0001). Safety knowledge did not necessarily correspond with safer behaviors. For example, 80% of those who knew you should only have one rider on an ATV still had ridden with passengers.
Conclusion: ATV use is prevalent in rural populations but few riders report safe riding behaviors. Study and input from rural community members and agricultural producers is needed to understand how to increase safety behaviors among this population. ATV safety education and training programs should be developed to target agricultural workers.
Control Number: 3200
Title: Risk Factors For Anaphylaxis Recurrence Among Olmsted County Residents
Topic: Toxicology/Environmental
Author Block: Curtis Bashore1, Ronna L. Campbell1, Dante Lucas S. Souza1, M Fernanda Bellolio1, Erik H. Hess1, Sangil Lee2. 1Mayo clinic, Rochester, MN; 2Mayo Clinic Health System, Mankato, MN
Abstract:
Background: The incidence and potential factors leading to recurrent anaphylaxis are poorly understood.
Objectives: To identify the rate of and risk factors for recurrent anaphylaxis in a population-based epidemiology cohort in Olmsted County, Minnesota.
Methods: We used the Rochester Epidemiology Project, a comprehensive medical records linkage system to obtain multicenter records of 371 Olmsted County residents who presented to their health care providers with at least one episode of anaphylaxis defined by anaphylaxis diagnostic criteria from January 2001 to December 2010. Charts were reviewed for identification of recurrent anaphylactic reactions during the 10 year period. We tested association of each independent risk factor with recurrence as the outcome and built a multiple logistic regression, followed by a secondary Cox-proportional hazard model. Results were reported as odds ratios (OR) and 95% confidence intervals (CI).
Results: Among the 371 patients who had an episode of anaphylaxis, 37 (10%) experienced at least one recurrence. The median time for first recurrence was 0.5 years. In univariate analysis, a history of asthma (OR 2.2 [95% CI 1.1-4.7]; p=0.04), prior anaphylaxis (OR 2.4 [95% CI 1.1-5.2]; p=0.03), atopic dermatitis (OR 1.2 [95% CI 1.4-17.3]; p=0.02), and the symptom of cough on first visit (OR 3.5 [95% CI 1.4-8.9]; p=0.006) were associated with recurrence. A multiple logistic regression analysis adjusted for asthma, prior anaphylaxis, atopic dermatitis and symptom of cough showed that history of atopic dermatitis (OR 4.9 [95% CI 1.2-17.3]; p=0.03) and the symptom of cough (OR 3.5 [95% CI 1.2-9.1]; p=0.02) remained statistically significantly associated with recurrence. A Cox regression model showed similar findings.
Conclusion: Ten percent of the patients developed recurrent anaphylaxis over the 10 year study periods. The median time to recurrence was 0.5 years. Those with past medical history of atopic dermatitis or initial symptom of cough were more likely to experience a recurrence.
Control Number: 3211
Title: T/QRS and ST/T Ratios are Significantly Greater in Patients with Left Bundle Branch Block and Acute Coronary Occlusion
Topic: Cardiovascular – Clinical Research
Author Block: Kendra D. Elm1, Kenneth W. Dodd2, Stephen W. Smith2. 1University of Minnesota, Minneapolis, MN; 2Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background: Hyperacute T-waves and ST segment deviation can occur in ECGs of AMI in normal conduction. In LBBB without AMI, T-waves are normally discordant to the majority of the QRS complex and ST deviation is present but not necessarily indicative of ACO.
Objectives: To investigate the T-wave changes in patients with left bundle branch block (LBBB) and acute coronary occlusion (ACO), including absolute T-wave amplitude (TWA), concordant ST/T ratio, and discordant T/QRS ratio. We hypothesize that these parameters will be greater in LBBB patients with ACO than in those without ACO.
Methods: Retrospectively, ECGs of ED patients with LBBB and ischemic symptoms were obtained. STEMI, NSTEMI, and no-MI groups consisted of 33, 24, and 105 patients respectively. “STEMI” patients had 1) angiographically proven ACO or 2) lesion and troponin I ≥ 10 ng/ml. “NSTEMI” patients had clinically diagnosed AMI without ACO. Control patients had negative serial troponins. Measurements obtained were S- or R-wave amplitude, ST deviation at the J point and TWA to the nearest 0.5 mm relative to the PQ junction. The T-wave was concordant if the majority was in the same direction as the majority of the QRS.The maximum ratio in any lead was used in calculations for both T/QRS and ST/T statistics. Any ST/T wave ratios calculated to be greater than 1.0 were reviewed. Statistics were by Kruskal-Wallis test and McNemar’s test.
Results: The median TWA was 9 mm [IQR 6.5-11] for STEMI and 8.5 mm [IQR 6.5-11.5] for all other patients (p = NS). The T/QRS ratio was significantly larger for STEMI versus all other patients but not between NSTEMI and no-MI patients (Table 1). For STEMI, the sensitivity and specificity of T/QRS ratio of > 1.25 was 45% (95% CI 29-63) and 93% (95% CI 87-97).
Similarly, the ST/T ratio was significantly increased for STEMI versus all other patients but not for NSTEMI patients compared to no-MI patients (Table 1). A ST/T ratio of > 0.80 in any lead has a sensitivity and specificity of 76% (95% CI 57-88) and 59% (95% CI 50-67) respectively for STEMI.
Conclusion: The ratio of discordant T/QRS is significantly increased in ACO and a cutoff of T/QRS > 1.25 has high specificity for ACO in LBBB. Additionally, concordant ST/T is significantly increased in ACO, which parallels what has been previously described in the Sgarbossa and Smith modified Sgarbossa criteria.
Control Number: 3189
Title: A Safer Place to Ride: Regulations and DNR enforcement in OHV Parks Increases Safety Behaviors
Topic: Disease/Injury Prevention
Author Block: Jessica Waters1, Charles A. Jennissen2, Nathaniel Johnson3, Brandon Johnson3, Emily Robinson3, Eilis Baranow3, Gabe Greene2, Benjamin Wilkinson3, Pam Hoogerwerf4, Gerene Denning2, Karisa Harland2. 1University of Iowa Carver College of Medicine, Iowa City, IA; 2University of Iowa Department of Emergency Medicine, Iowa City, IA; 3University of Iowa, Iowa City, IA; 4University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Iowa off-highway vehicle (OHV) parks have regulations regarding youth users and helmet use that do not apply outside of parks, and have Department of Natural Resources (DNR) personnel who patrol the parks and provide enforcement. In previous studies, we found Iowa all-terrain vehicle (ATV) crash victims at OHV parks had better safety behaviors as compared to off-road crashes outside the parks.
Objectives: To determine the demographics and prevalence of safety behaviors among OHV park users, and how regulations and enforcement affect rider safety behaviors.
Methods: From May to September of 2014, motion-activated cameras captured photos of users at the entrances of Iowa’s eight OHV parks. Riders were coded by vehicle type, estimated age, sex, and safety behaviors. Descriptive and multivariable logistic regression analyses were performed.
Results: A total of 6,718 vehicles and 9,083 riders were analyzed. Riders on ATVs comprised 44% of OHV park users, 51% were on dirt bikes and 5% were on side-by-sides (SxSs). Helmet use was 94.4% overall. Just 6% of single-rider ATVs and 0.8% of dirt bikes had passengers. While only 11% of park users on ATVs were <16 years old, 59% of the child operators were driving adult sized ATVs. Of those riding SxSs, 64% were not using their restraints. Multivariate modeling controlling for important covariates showed that in comparison with young adults (16-39 years) on ATVs, children were nearly 6 times as likely to wear a helmet, whereas middle aged adults (40-60 years old) were half as likely to wear one. When DNR officers were patrolling the parks, there was a 3.6 times higher likelihood of helmet use and a 40% lower likelihood of passengers on dirt bikes and ATVs.
Conclusion: Regulated safety behaviors such as helmet use and riding without passengers were highly practiced by OHV park users. However, unregulated behaviors such as children only driving youth sized vehicles and restraint device use in SxSs had lower compliance. Moreover, regulated safety behaviors were significantly increased when the parks were patrolled by DNR officers. This study shows that a combination of regulation and enforcement is effective in ensuring compliance with rider safety behaviors in OHV parks. The establishment of similar safety regulation and enforcement outside of parks would likely have a more far-reaching effect on decreasing OHV-related deaths and injuries.
Control Number: 3214
Title: Electrocardiographic Diagnosis of Acute Right Coronary Artery Occlusion in Left Bundle Branch Block
Topic: Cardiovascular – Clinical Research
Author Block: Kenneth W. Dodd1, Erin M. Dodd2, Kendra D. Elm2, Stephen W. Smith1. 1Hennepin County Medical Center, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN
Abstract:
Background: The Sgarbossa criteria for diagnosing acute myocardial infarction in LBBB are (concordant ST elevation ≥1 mm, concordant ST depression of ≥ 1 mm in leads V1 to V3, or ≥ 5 mm discordant ST elevation). However, a QRS axis ≤ -30 degrees indicates negative QRS complexes in all of leads II, III, and aVF and such patients cannot have concordant ST elevation. Moreover, the relatively low voltages in the inferior leads make it difficult for patients to meet a 5 mm ST elevation cutoff. Therefore, we hypothesized that the Sgarbossa criteria have a low sensitivity for diagnosis of inferior ST-elevation myocardial infarction (STEMI).
Objectives: Here we characterized patients with inferior STEMI with regards to their QRS axis and compared the Sgarbossa and Smith criteria for diagnosing inferior STEMI in LBBB.
Methods: Retrospectively, ED patients were identified with LBBB and ischemic symptoms but no evidence of myocardial infarction (no-MI), with LBBB and non-ST elevation myocardial infarction (NSTEMI), and with LBBB and angiographically-proven acute coronary occlusion (STEMI). Measurements included ST segment at the J-point as well as S- and R-wave amplitude. The QRS axis was recorded as printed on the ECG and checked by examining leads I and aVF. If abnormalities were identified, the QRS axis was re-calculated by hand. Statistics were by two-tailed Student’s t-test, Mann-Whitney U test, and McNemar’s test.
Results: The STEMI, NSTEMI and no-MI groups consisted of 33, 24, and 105 patients. There were 9 STEMI patients with right coronary artery occlusion (i.e. inferior STEMI). Mean and median QRS axis was similar for all groups (p = NS). There were 0 patients with QRS axis ≤ -30 degrees who met Sgarbossa’s first criterion in the inferior leads. There were also 0 patients that met Sgarbossa’s third criterion (≥ 5 mm discordant ST elevation) in the inferior leads. In the diagnosis of inferior STEMI, Smith ST/QRS ≤ -0.25 ratio rule had sensitivity of 100% (95% CI 89-100) as compared to 56% (95% CI 39-74) for the Sgarbossa criteria (p < 0.05).
Conclusion: The Smith ST/QRS ratio rule is significantly more sensitive for diagnosing inferior STEMI as compared to the traditional Sgarbossa criteria. This is due to the fact that the Smith ST/QRS ratio rule allows for “excessively discordant” ST elevation that is proportional to the voltage of the inferior leads and is not limited by the QRS axis.
Control Number: 3218
Title: ATV and SxS Safety Training for Agricultural Workers: Short Term Results of a Safety Workshop Piloted with Iowa Farmers
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Karisa Harland1, Andrew Winborn2, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2Rural Health and Safety Clinic of Greater Johnson County, Iowa City, IA
Abstract:
Background: All-terrain vehicles (ATVs) and side-by-sides (SxSs) have become increasingly popular for agricultural work purposes. There are few occupational ATV/SxS safety education resources, and it is unclear how many operators have received training.
Objectives: To develop and evaluate a workshop that provides farmers education on the safe occupational use of ATVs and SxSs, and determine the ATV/SxS safety behaviors, knowledge, and crash experiences of workshop participants.
Methods: Evidence-based safety information was used to develop an educational workshop for agricultural workers and piloted. Demographic information, safety behaviors, crash experiences, and safety knowledge was collected prior to training. The reported likelihood of using the workshop information and short-term knowledge gain was assessed.
Results: Forty-three subjects participated; mean age was 30 years (range 18-65 years) and 80% were men. About half were owners/operators or family members, while 42% were employees. Only eight had previously received any ATV/SxS education and only one had received formal hands-on training. Nearly all (91%) had used ATVs for occupational purposes with almost 40% reporting daily use. About 60% of occupational ATV users reported daily or weekly use on public roadways, and 82% reported having ridden with passengers. The vast majority never wore a helmet. Most (72%) reported using SxSs for occupational purposes, with about 50% reporting daily use. Of occupational SxS users, almost half reported daily or weekly public roadway use and 65% reported never using the restraint device. Seven (16%) had an occupational crash in the prior year. No difference in baseline knowledge scores were found by age, farming operation role, or riding frequency. Mean knowledge scores pre-workshop were 7.1 (range 2-17) and post-workshop 13.4 (range 6-19). Mean change was 6.3 (95% CI 5.2-7.4, p<0.0001). Nearly all subjects reported they were very likely (43%) or likely (48%) to use the safety information presented.
Conclusion: Agricultural workers frequently use ATVS/SxSs for occupational purposes. Of workshop participants, few had received previous training and most practiced unsafe behaviors. The safety training employed in this study increased short term safety knowledge and a high percentage of participants stated they would use the information provided.
Control Number: 3219
Title: What Is The Frequency Of Radiographic Detection Of Foreign Bodies After Snake Bites?
Topic: Diagnostic Technologies/Radiology
Author Block: Jarrod Dornfeld, David Edelman, Michael E. Mullins. Washington University in St. Louis School of Medicine, St. Louis, MO
Abstract:
Background: A recent study proposed the use of ultrasound for detecting retained foreign bodies in snakebite patients based upon simulation using a fang or a tooth embedded in a gelatin model. It is not known whether our patient population would be appropriate for studying this new technique.
Objectives: Determine the frequency of retained foreign bodies seen in radiographs of snakebite patients in Missouri
Methods: This is an IRB-approved, retrospective chart review using a previously collected database of snakebite consult patients. We identified patients who presented in Barnes-Jewish Hospital or St. Louis Children’s Hospital from 2001-2011 with snakebites and radiographs or radiographic reports. We calculated the frequency of positive retained foreign bodies was calculated in our patient population.
Results: 121 patients were consulted for a snakebite over the 11 year period of the study. Of these 87 patients meet the study criterion of an documented radiologic study of the bitten extremity. None (0%, 95%CI 0%-3.4%) of these patients had positive radiographs of retained foreign bodies.
Conclusion: None of the patients in our population had a retained foreign body and the rate of encounters per year was low in our population (mean of 11 patients per year). It is unlikely that we would encounter a retained foreign body from a snakebite in the near future. Given the low probability of encountering a retained foreign body among our patient population, we determined that it was not feasible to study a new ultrasound method for the detection of retained foreign bodies following snakebite in our hospitals.
Control Number: 3220
Title: Snowmobile-Related Injuries In The Ed Population 2002-2013
Topic: Disease/Injury Prevention
Author Block: Christopher R. Peterson, Ryan A. Peterson, Charles A. Jennissen. University of Iowa, Iowa City, IA
Abstract:
Background: Snowmobiling is a popular form of recreation in the winter, but adverse events can lead to significant injury. There are no recent studies which have looked at national data on snowmobile-related ED visits.
Objectives: To determine the demographics and risk factors for snowmobile-related injuries.
Methods: ED visits related to snowmobiles were identified through the National Electronic Injury Surveillance System (NEISS) database which collects information from a national probability sample of hospitals in the U.S., and is maintained by the Consumer Product Safety Commission. Injuries that did not occur during snowmobile operation were excluded. Descriptive and statistical analyses were performed.
Results: After exclusions, a total of 1944 snowmobile-related injuries were identified in the NEISS database from 2012-2013. This corresponds to a national estimate of 135,032 snowmobile-related ED visits during the study period. There was a trend of decreasing injuries over time with a national estimate of 12,862 in 2002 and 9,270 in 2013 (average decrease of 499 per year, 95% CI 89.9-907.7). Most commonly injured were 19-29 year olds, accounting for 30.0% of the total; 19% were pediatric patients. About three-fourths were male. The most common mechanisms of injury involved falling off (22.4%), striking a stationary object (16.2%), and rolling/flipping the vehicle (12.5%). Mechanisms that had the greatest admission rates include events involving a drop-off/cliff (50.0%), ejections from the snowmobile (24.7%), and collisions with a motorized vehicle (21.8%). Helmet use was reported in 11.4% of cases. Patients wearing a helmet had 63% reduced odds of requiring inpatient admission compared to those without a helmet (p=0.03). Speed was reported in only 6.6% of cases. Those operating at speeds estimated ≥35 mph had 1.74 times greater odds of admission compared to lower speeds (p=0.27, probably not statistically significant due to small samples), and a 1.93 times greater odds of admission compared to those with unreported speed (p=0.03).
Conclusion: Snowmobilers who either did not wear helmets or were operating at high speeds were more likely to require hospital admission. Snowmobilers should be especially wary of terrain changes, other vehicles in the area, and being ejected, as these mechanisms accounted for a higher rate of injuries requiring inpatient treatment.
Control Number: 3222
Title: Everyone’s Nightmare: Agitation During Procedural Sedation In Children
Topic: Airway/Anesthesia/Analgesia
Author Block: Ana Castaneda-Guarderas1, Henrique A. Puls2, Patricia Barrionuevo1, Waqas I. Gilani1, Waqas I. Gilani1, Jana L. Anderson1, Patricia J. Erwin1, M. Hassan Murad1, Erik P. Hess1, M. Fernanda Bellolio1. 1Mayo Clinic, Rochester, MN; 2Federal University of Health Sciences Of Porto Alegre, Porto Alegre, Brazil
Abstract:
Background: Procedural sedation and analgesia (PSA) is routinely performed in the Emergency Department (ED) to facilitate potentially painful procedures by alleviating pain, anxiety and suffering, this involves the use numerous classes and combinations of short acting analgesic and sedative medications with heterogeneous adverse events which adds to the challenge of performing safely in children.
Objectives: We conducted a systematic review and metaanalysis to evaluate the incidence of agitation in the ED during PSA in the pediatric population.
Methods: We searched multiple electronic databases including Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, Ovid CENTRAL, Ovid Cochrane Database of Systematic Reviews, Web of Science and Scopus from inception through June 2014 without language restrictions. Randomized controlled trials and observational studies of procedural sedations in the ED were included. Data were extracted by independent pairs of reviewers and risk of bias was assessed using the Cochrane risk of bias tool for trials and the Newcastle-Ottawa Scale for observational studies. Meta-analysis was performed using a random-effects model and reported as incidence rate and 95% confidence intervals (CI).
Results: A total of 1,177 studies were retrieved for title and abstract screening and 258 of them were selected for full-text review. Forty two studies reporting on 13,975 procedural sedations in 13,968 children were included. Agitation was reported in 18.2 per 1,000 sedations (95% CI 12.5 to 23.9). Midazolam alone had the highest incidence of agitation at 181.2 per 1,000 sedation, followed by ketamine in combination with another drug (55.5 - 63.6 per 1,000 sedations) and ketamine alone (24.1 per 1,000 sedations). Nitrous oxide and propofol had a very low incidence of agitation (7.9 and 3.3 per 1,000 respectively). Only 6 out of 1,171 children were treated for their agitation (3.1 per 1,000 sedations).
Conclusion: Agitation causes discomfort to the child, parents and healthcare providers. Overall, is an uncommon effect of medications used for sedation, with a frequency lower than 2%. Most episodes will not require treatment.
Control Number: 3181
Title: Pre-Hospital Notification of Suspected Acute Ischemic Stroke Can Improve Common Reported Time Benchmarks.
Topic: Neurology
Author Block: Michael D. Zwank, Carol J. Droegemueller. Regions Hospital, Saint Paul, MN
Abstract:
Background: Ischemic stroke continues to be a cause of significant morbidity and mortality in the United States. Great efforts have been aimed at improving stroke care by both standardizing the management and improving the efficiency of care of patients with suspected stroke. In May of this year, we implemented a quality improvement program at our urban tertiary care stroke center with a pre-hospital notification system for EMS providers to alert the hospital of an incoming patient with suspected stroke. As part of the new protocol, providers meet the EMS personnel in the hallway after arrival and assess the patient. Unless the provider assesses that acute stroke is unlikely, the patient is registered, received an IV catheter and is taken directly to the CT scanner.
Objectives: e sought to determine if this quality improvement project improved the standard reporting measures of 'door to CT' time and 'door to IV tPA administration' time.
Methods: We analyzed a cohort of patients from 2015 that included approximately five months of patients arriving before the process change and three months of patients arriving after the change. Data was available from time stamps in the electronic medical record. While this is primarily a descriptive assessment, we analyzed the data for statistical significance using unpaired student t-tests assuming equal variance.
Results: 126 patients were assessed from January to August of 2015 with suspected acute stroke. 75 patients arrived before the process change and 51 arrived after. Door to CT scanner time decreased from 19 minutes to 8 minutes (p=0.001). 37 patients were treated with tPA (23 before, 14 after). Door to IV tPA administration showed a trend of decrease from 1:13 to 53 minutes. This was not statistically significant (p=0.13).
Conclusion: Pre-hospital notification at an urban tertiary care stroke center improved door to CT time. There was a non-significant trend towards faster tPA administration. Future analysis will include a larger data set and will include patient outcomes.
Control Number: 3236
Title: Does an Electronic Medical Record Alert Improve Recognition of Elevated Blood Pressure Prior to Discharge?
Topic: Cardiovascular – Clinical Research
Author Block: Michael D. Zwank, Katie Cicolello, Kendal Farrar. Regions Hospital, Saint Paul, MN
Abstract:
Background: It is well known that untreated or undertreated hypertension (HTN) is dangerous. Because of this, recognition of abnormal elevated blood pressure (EBP) during ED encounters is very important. At our tertiary care hospital, we implemented an EMR alert which generates a notification to providers at the time of discharge if a patient’s blood pressure has exceeded 140/90 during their visit. The alert also prompts the clinician to provide the patient with a diagnosis of EBP or HTN, a primary care referral, and/or HTN specific discharge instructions.
Objectives: We sought to determine if the alert led to improved patient notification of EBP and ultimately to improved primary care referral and follow-up.
Methods: We conducted a retrospective chart review of 883 charts (400 pre- and 483 post-intervention). Data was abstracted from the electronic medical record by two trained research assistants.
Results: A total of 79 patients received a referral to primary care in the pre-intervention group, compared to 114 after the intervention. Of these referrals, only 12 and 13 respectively were specifically for EBP. Post-intervention, a total of 51 patients who were not previously diagnosed with HTN were given a new discharge diagnosis of EBP compared with 5 patients pre-intervention (p<0.05). There was no difference in the number of patients receiving HTN specific discharge instructions, with 29 patients in each group. Following their ED visit, a total of 255 post-intervention patients were seen in follow up at some point in the next six months versus 218 in the pre-intervention group. Of these, new antihypertensive medications or changes to an existing regimen were prescribed for 49 post-intervention patients, versus 21 pre-intervention patients.
Conclusion: The EMR alert produced mixed results. While more patients were referred to primary care after the intervention, a similar number of patients were referred specifically for EBP. It is unclear if the increase in general referrals may have been related to the alert. However, many more patients were discharged from the ED with a new diagnosis of EBP and more patients had HTN medication changes at the follow-up appointment.
Control Number: 3237
Title: Electronic Medical Record Workflow Affects Bedside Ultrasound Ordering and Documentation Compliance
Topic: Ultrasound
Author Block: Michael D. Zwank. Regions Hospital, Saint Paul, MN
Abstract:
Background: Point-of-care ultrasound (POCUS) has become standard care of many patients in the ED. There is large variation in many aspects of POCUS across the country. As part of a quality improvement project, we standardized POCUS at our hospital including a new workflow that emphasized orders for all POCUS in the electronic medical record (EMR) as well as new alerts to complete documentation.
Objectives: We wanted to determine if the new standardized workflow would affect POCUS numbers in the ED including numbers of ultrasounds ordered, documented and billed.
Methods: We conducted a retrospective review of the EMR three months before the intervention and three months after, with specific focus on POCUS. Data was queried by trained EMR programmers and billers.
Results: A total of 2,112 ultrasounds were ordered during the 6 month period (917 before and 1,195 after). Of these, 480 and 1054 respectively had an interpretation note completed. This represented an average of 52.4% with documentation before and 88.40% with documentation after the intervention. A total of 364 ultrasounds were billed before and 669 were billed after the intervention. This demonstrated that the rate of billing increased from 39.70% to 56.40%. All of the increases after the intervention were statistically significant (p's<0.05).
Conclusion: A change in EMR workflow resulted in dramatic increases in the number of ultrasounds ordered, documented and billed. While there may have been unforeseen confounders during the period of evaluation, it is doubtful that any could have produced these dramatic results.
Control Number: 3243
Title: Comparison of Amnesia and Respiratory Depression during Moderate versus Deep Procedural Sedation with Propofol in the Emergency Department (ED)
Topic: Airway/Anesthesia/Analgesia
Author Block: Alexandra Schick1, Erik Fagerstrom2, Johanna Moore3, James Miner3. 1University of Minnesota, Minneapolis, MN; 2Minnesota Medical Research Foundation, Minneapolis, MN; 3Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background:
Objectives: Moderate and deep procedural sedations are common in the ED, but little data exists
comparing the efficacy and safety of these two approaches. Therefore, it is unclear whether one depth of sedation is superior to the other. Our objective was to determine whether there was a difference in amnesia and respiratory depression (RD) between moderate and deep sedation.
Methods: This was a prospective, randomized, controlled study of consenting adults undergoing
procedural sedation with propofol from 3/5/15 - 8/1/15. The observer’s assessment of alertness/sedation (OAAS) score, vital signs, propofol doses, and end tidal CO2 (ETCO2) were monitored continuously during the procedure and recorded every 30 seconds. To assess memory, a standardized image was shown every 30 seconds starting several minutes before the sedation until the end of
sedation. Recall and recognition of the images was assessed 10 minutes after the end of the sedation. RD was defined as SaO2 <92%, a change in ETCO2 >10 mm Hg, or absent ETCO2 at any time during the sedation. Data were analyzed with description statistics.
Results: We enrolled 23 subjects: 12 in the moderate group, and 11 in the deep group. The
median propofol dose (mg/kg) in the moderate group was 1.5 (range 1.0-2.0, IQR 0.5) and was 2.0 (range 0.9-3.6, IQR 0.8) for deep. The median lowest OAAS for moderate sedation was 1.5 (range 1-3, IQR 1) and was 1 (range 1-2, IQR 1) for deep. RD was observed in 8/12 in the moderate group and 8/11 in the deep group. However, 4 patients in the moderate group actually received deep sedation, and these subjects all had RD. RD was observed in 4/9 that received moderate sedation, and 12/14 those with deep sedation (difference -41.3%, 95% CI -2.6 to -68.8%). The percentage correctly recognized
after sedation was 72.6% for those that received moderate sedation and 45.4% for those that received deep (difference 27.2%, 95% CI 9.4 to 45%). The difference between recalled images was not significant.
Conclusion: The incidence respiratory depression between the randomization groups was not significantly different, but there was a significant difference when comparing those that actually received moderate and deep sedation. Those that received moderate sedation are able to recognize more images from during the procedure than the deep group, but had no difference in image recall.
Control Number: 3151
Title: Use of a Multi-Location, Interprofessional In-Situ Simulation of a Patient Presenting With Symptoms of Ebola Virus Infection (EVI) to Evaluate Hospital Bioemergency Preparedness.
Topic: Clinical Operations – Processes
Author Block: Daniel G. Miller, Beth Hanna, Julie Lindower, Maria Lofgren, Thomas Persoon, Christina Spofford, Jeffrey Vande Berg, Emily Wynn. University of Iowa, Iowa City, IA
Abstract:
Background: Highly contagious bioemergencies present significant challenges to a hospital, these include: prompt patient recognition and isolation, effective use of personal protective equipment by hospital staff, and performance of multiple handoffs between healthcare teams and units without degradation of information accuracy. Failure mode and effects analysis (FMEA) is a systematic qualitative observational technique originally developed in the 1950s to identify system failures and their downstream effects in military systems.
Objectives: We hypothesized that our standing policies and procedures for handling a bioemergency patient had unknown performance gaps that we could identify by performing an in-situ simulation of a patient presenting to the Emergency Department with symptoms of EVI and using FMEA techniques to monitor the patient’s entire clinical course.
Methods: We enlisted representatives from the ED, the ICU, hospital security, and the Decedent Care Center (DCC) to design an in-situ simulation of a patient presenting to the ED with symptoms of EVI who required admission to our biohazard containment unit and eventually died, requiring removal of his remains through our DCC. This involved 5 locations of care and 4 transitions of care. We identified 8 major and 15 minor objectives as well as 35 possible failure modes and enlisted a team of trained observers to observe patient care and handoffs. A panel of trained debriefers, who were not involved in the design of the scenarios, debriefed the participants. An FMEA template was developed and used to evaluate performance on the objectives and identify additional learning points.
Results: Through structured observation we identified 3 major and 13 minor objectives that required process improvement. Through debriefing and observation we identified an additional 101 individual learning points.
Conclusion: Applying FMEA to a Multi-Location, Interprofessional In-Situ Simulation allowed us to identify unexpected latent risks to patients and staff in the case of a bioemergency.
Control Number: 3168
Title: Rapid Response Systems, Healthcare Utilization And Mortality In Patients Admitted Through The Emergency Department
Topic: Health Services Research
Author Block: Marc N. Olive, Shawna D. Bellew, James M. Walston, Daniel Cabrera, Christine M. Lohse, M. Fernanda Bellolio. Mayo Clinic, Rochester, MN
Abstract:
Background: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration.
Objectives: We aimed to compare the healthcare utilization and outcomes of patients that had a RRT activation within 12 hours of admission.
Methods: We conducted a case-control study of patients presenting from Jan-2009 to Dec-2013 to a tertiary ED who subsequently had RRT activations within 12 hours of admission. The medical records of patients 18 years and older admitted to a non-Intensive Care Unit (ICU) setting were reviewed. Controls were matched 1:1 on age, gender, and diagnosis.
Results: A total of 948 patients were included (474 cases and 474 controls). Criteria for RRT activation were as follows: acute and persistent declining oxygen saturations < 90%, heart rate: 130, systolic blood pressure <90 mmHg, change in respiratory rate 28 per minute, change in conscious state, acute chest pain suggestive of ischemia, new onset of symptoms suggestive of stroke, or a staff member is worried about the patient.
Having an RRT activation corresponded to increased utilization of healthcare with increased ICU admission within 72 hours (OR 38.49, 95%CI 19.03-77.87), invasive interventions (OR 5.49, 95%CI 3.82-7.89), mortality at 72 hours (OR 4.24, 95%CI 1.60-11.24), and mortality at 1 month (OR 4.02, 95%CI 2.44-6.62).
Conclusion: After matching for age, gender and ED diagnosis, patients with RRT activations had higher mortality at 72 hours and 1 month, higher need for invasive interventions and increased ICU admission.
Control Number: 3183
Title: Why The Need For Speed?-- ATVs, Speed and Brain Injuries
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Joshua Godding2, Karisa Harland1, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Carver College of Medicine, Iowa City, IA
Abstract:
Background: Head trauma is the leading cause of death and serious injury from all-terrain vehicle (ATV) crashes. There are few studies that have specifically discussed how ATV speed affects crash injury. Present manufacturer guidelines for youth size ATVs allow vehicles for children aged 10 years and over to travel up to 30 mph, and for those 14 years and older to travel up to 38 mph.
Objectives: The study objective was to better understand the relationship between speed and ATV crash-related brain injuries.
Methods: A retrospective chart review was performed of trauma registry patients with ATV-related injuries at the University of Iowa from 2002-2013. Descriptive and comparative analyses were performed.
Results: 560 cases were identified; 77% were male and 32% were children <18 years of age. Rollovers (45%) were most common, followed by striking an object (22%) and ejection/fall (13%). Collisions with a motorized vehicle occurred in 8% of patients. Speeds >20 mph were associated with higher Max Head Abbreviated Injury Scale (AIS) scores than those ≤20 mph (p=0.05). Crashes with speeds >30 mph had higher Max Head AIS scores than those ≤30 mph (p=0.014). Higher speeds were also associated with a trend towards lower patient Glasgow Coma Scale (GCS) scores. Only about 20% of victims overall were wearing a helmet. Competitive racers, although helmeted, had more severe head injuries than all other victims. Competitive racers had lower GCS scores than their helmeted non-racing peers (p<0.05). Non-racers without helmets had lower GCS scores than their helmeted peers (p=0.003).
Conclusion: Higher speed appears associated with greater head injury risk in ATV crashes. The increasing speeds of today’s ATVs are likely contributing to more serious injuries, including more severe head injuries. Although helmets are protective, there may be ATV crash speeds or mechanisms of brain injury at higher speeds that reduce helmet effectiveness. This study suggests that the present maximum speed limitations for many youth size ATVs are not safe and puts the child at increased risk for head injury. All ATVs should have a code-protected, tamper-proof speed governor. This would particularly assist parents and employers in protecting youth and employees from the serious risks associated with high operating speeds.
Control Number: 3213
Title: Repolarization Parameters are Significantly Prolonged in Many Patients with Left Bundle Branch Block and Acute Myocardial Infarction
Topic: Cardiovascular – Clinical Research
Author Block: Kenneth W. Dodd1, Kendra D. Elm2, Erin M. Dodd2, Stephen W. Smith1. 1Hennepin County Medical Center, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN
Abstract:
Background: In patients with normal conduction, prolongation of repolarization parameters such as the QTc interval, JTc interval, and T-wave peak to end (Tpe) interval are associated with cardiac ischemia, ventricular tachydysrhythmias, and sudden cardiac death. We are unable to find published manuscripts that report these parameters in LBBB patients. Furthermore, it has been proposed that the Bazett correction formula for QTc and JTc overestimates repolarization in patients with conduction disturbances.
Objectives: Here we report the QTc, JTc, and Tpe intervals in ED patients with LBBB with and without MI. We also compared common correction formulas.
Methods: Retrospectively, ED patients were identified with LBBB and ischemic symptoms but no evidence of MI (no-MI), with LBBB and NSTEMI, and with LBBB and angiographically-proven acute coronary occlusion (STEMI). The QT, JT, and Tpe intervals were measured manually in leads II, V3, and V5; the longest of each was used. QTc and JTc intervals were calculated by Bazett’s, Hodges’ and Framingham formulas. Statistics were by two-tailed Student’s t-test and Mann-Whitney U test.
Results: The no-MI, NSTEMI, and STEMI groups consisted of 105, 24 and 33 patients, respectively. The mean Tpe for the STEMI and no-MI groups was 104 ms and 87 ms, respectively (p < 0.0001). In the STEMI group, 24.3% of patients had Tpe ≥ 120 ms compared to 4.8% of no-MI patients (p < 0.001). The mean QTc by Bazett’s was 484 ms, compared to Hodges’ 461 ms (p < 0.0001) and Framingham 451 ms (p < 0.0001). The mean JTc for Bazett’s, Hodges’, and Framingham were 307 ms, 312 ms, and 302 ms, respectively (p = NS). By Hodges’ formula, 53.1% of patients with LBBB had QTc ≥ 450 ms and 12.3% had JTc ≥ 340 ms. There was no significant difference in QTc or JTc between the STEMI, NSTEMI, or no-MI groups (see Dodd Table 1).
Conclusion: Repolarizaton parameters are prolonged in many patients with LBBB. The Tpe interval, which has been proposed as a marker of transmural repolarization heterogeneity due to ischemia, is significantly prolonged in patients with STEMI and LBBB when compared to no-MI patients. Using either the Hodges’ or Framingham correction formulas to calculate the QTc, or evaluating the JTc, may give a more accurate measure of LBBB patients’ repolarization intervals.
Control Number: 3188
Title: Occupational Side-by-Side Vehicle Exposure, Safety Behaviors, and Crash Experiences of Farm Progress Show Attendees
Topic: Disease/Injury Prevention
Author Block: Charles A. Jennissen1, Karisa Harland1, Kristel Wetjen2, Pam Hoogerwerf3, Lauren O'Donnell3, Gerene Denning1. 1University of Iowa Department of Emergency Medicine, Iowa City, IA; 2University of Iowa Department of Surgery, Division of Pediatric Surgery, Iowa City, IA; 3University of Iowa Children's Hospital, Iowa City, IA
Abstract:
Background: Side-by-sides (SxSs), including both utility-task vehicles (UTVs) and recreational off-highway vehicles (ROVs), have become increasingly popular for performing work-related tasks and for recreation in rural areas. No studies have examined the safety issues and experiences of agricultural workers and their families while driving SxSs.
Objectives: The study objective was to better understand the epidemiology, safety behaviors, and crash experiences of SxS riders.
Methods: Visitors to the 2014 Farm Progress Show, the nation’s largest outdoor farm show, in Boone, Iowa, were surveyed on their SxS use at the Iowa ATV Safety Task Force tent. Descriptive and comparative analyses were performed.
Results: 227 surveys were completed. Respondents were 66% male. Average age was 39 years (8-80 years), and 77% were involved in agricultural work. About one-third currently owned a SxS in their family. Of respondents, 72% had driven or ridden a SxS in the past year. Of these, over three-quarters had used one for occupational purposes. Participants whose family owned a SxS were significantly more likely to have driven or ridden one in the past year (92% vs. 60%, p<0.0001). Respondents reported more frequent occupational than recreational use, with 59% of SxS users reporting occupational use at least once a week. Occupational SxS uses included transportation (94%), checking fields (68%), hauling loads (54%) and spraying (44%). Nearly all occupational users had driven on roadways, with 32% and 49% reporting driving at least once a week on paved and unpaved roads, respectively. Over 50% stated they never wear a helmet and 26% said they never use the safety belt/harness when using a SxS for work. During their lifetime, an occupational crash was reported by 15% of occupational SxS users. Of these, 37% occurred in the past year (6% of occupational users). Occupational crashes more frequently involved rollovers, and had a higher percentage of victims that sought medical attention than those in recreational crashes.
Conclusion: Farmers frequently own and use SxSs for occupational purposes. Transportation is a frequent occupational use, and driving on roadways is exceedingly common. Many SxS users are not wearing the restraint device which is critical to stay within the rollover protective structure if in a crash.
Control Number: 3232
Title: Time to Antibiotic Administration in Oncology Patients with Neutropenic Fever
Topic: Infectious Diseases
Author Block: Courtney Moors1, Rebecca Zadroga2, Heather Rhodes2. 1University of Minnesota, Minneapolis, MN; 2Hennepin County Medical Center, Minneapolis, MN
Abstract:
Background: The ASCO guidelines recommend antibiotic administration within 1 hour of an oncology patient presenting with a neutropenic fever. The IDSA recommends that these patients receive empiric antibiotics urgently (< 2 hours).
Objectives: The goal of this study was to determine the extent to which Hennepin County Medical Center (HCMC) is meeting the above recommendations, and to compare the time to antibiotic administration in oncology patients who presented to the emergency department (ED) versus those who were directly admitted to the hospital from clinic.
Methods: We performed a retrospective chart review of all adult oncology patients who presented with febrile neutropenia that were admitted to HCMC between July 1, 2011, and June 30, 2014. Initial chart review identified patients based on DRG codes at hospital discharge. Data collected and analyzed included: length of hospital stay, mortality, time from admission to antibiotic administration, time from labs reported to antibiotic administration, antibiotic administered, type of malignancy and staging, and factors contributing to antibiotic administration delay. Comparisons were made between ED admissions and direct admissions from clinic. Febrile neutropenia was defined as a temperature >38.3C once or consistently above 38C for greater than one hour AND an ANC <500 cells/mm3 or expected to fall to less than <500 within 48 hours of admission. A T-test was used to compare differences between the two means of the ED versus direct admission data.
Results: 45 patients met inclusion criteria (25 ED, 20 direct admit). Mean time to antibiotic administration from when labs were reported was 1 hour in the ED compared to clinic where that time was 5 hours and 31 minutes (p<0.05). There was no statistically significant difference in length of hospital stay or mortality between these two populations.
Conclusion: The time to antibiotic administration is significantly shorter in the ED compared to a direct admission from clinic (4 hours and 31 minute difference) for oncology patients presenting with neutropenic fever at HCMC. Length of time until the patient hit the floor from clinic and delays in antibiotic administration on the floor were the two greatest factors contributing to this time difference between the clinic and the ED. These patients should be sent to the ED from clinic to decrease the time to receipt of antibiotics.