Research Forum Abstracts

Results: The study identified plans for 50/50 States, 29/50 had no EMSspecified section, 4/50 had an EMS section �10 % of the total document, theremainder had � 10% focused on EMS. SHSPs varied in length from 1 page to�120 pages. EMS representation was not identified on all SHSP developmentcommittees. In SHSPs with an EMS section, categories addressed were notconsistent across plans. Some focused on EMS training, dispatch and response,others on funding or other issues. One plan in addition to focusing on issues ofdispatch and training also had a specific section focused on the safety of EMSproviders during transport and on the scene of a highway emergency. No field ofEMS focus was common to all plans.

Conclusion: The State SHSPs evaluated reflected a varied involvement ofEMS representatives, identification of diverse EMS priorities, and varied EMS-related highway safety issues. Although regional variation is expected,involvement of key EMS stakeholders should be standard in the basicdevelopment of SHSP. Consideration of uniform recommendations for the coreaspects of EMS SHSP components could enhance a more substantive role of EMSin these State plans.

370 National Patterns in Emergency DepartmentAntibiotic Prescribing for Elderly Patients WithUrinary Tract Infections, 1996-2005

Weed S, Caterino JM, Espinola JA, Camargo Jr CA/Duke University College ofMedicine, Raleigh-Durham, NC; The Ohio State University, Columbus, OH;Massachusetts General Hospital, Boston, MA

Study Objectives: Due to the high prevalence of antibiotic resistance in elderlypatients with a urinary tract infection (UTI), current practice guidelines recommendtreatment with fluoroquinolones and avoidance of trimethoprim-sulfamethoxazole(TMP-SMX) monotherapy in patients 65 and over. To determine theappropriateness of current prescribing practices in emergency department (ED) elderswith UTI, we sought to identify rates and trends in prescribing fluoroquinolones andTMP-SMX over the past decade in the elderly as compared to younger adults.

Methods: We performed a retrospective analysis utilizing the 1996-2005National Hospital Ambulatory Medical Care Survey. We included patients aged18 or older with an ICD-9-CM diagnosis of urinary tract infection orpyelonephritis. Pregnant patients were excluded. Patients were divided in agegroups of 18-64 years (“adults”) and 65 years and older (“elders”) for analysis.The primary outcomes were prescription of either TMP-SMX monotherapy orthe prescription of a fluoroquinolone. National Drug Code Directory DrugClasses and Codes were used to identify type of antibiotic prescribed. Estimatedvisit totals and rates with 95% confidence intervals (CIs) of each outcome werecalculated for the entire population and by age group. We analyzed trends usingweighted linear and logistic regression, with two-tailed p�0.05 consideredstatistically significant.

Results: From 1996-2005, there were an estimated 26.3 million (95% CI,23.9-28.6 million) ED visits diagnosed with a UTI or pyelonephritis, accountingfor 3.3% (95% CI, 3.2-3.5%) of all ED visits. 7.5 million (95% CI, 6.7-8.4million) were ��65 years old, an estimated 4.8% (95% CI, 4.5-5.1%) of EDvisits by elders. The percentage of ED visits for UTI in both age groups increasedduring the study period (p for trend �0.001). Overall, an estimated 9.4% (95%CI, 7.9-11%) of elders received TMP-SMX monotherapy as compared to 23%(95% CI, 21-25%) of adults. Both groups demonstrated a trend for decreasingrates of TMP-SMX monotherapy (p for trend in elders �0.031 and in adults�0.001). An estimated 39% of elders (95% CI, 36-42%) and 31% (95% CI,30-33%) of adults received a fluoroquinolone. Rates in both groups increasedover the study period (p for trend �0.001 for both). The percentage of eldersreceiving a fluoroquinolone increased from 26% (95% CI, 17-36%) in 1996 to52% (95% CI, 44-61%) in 2005.

Conclusion: Elders presenting to the ED with a UTI are less likely to receiveTMP-SMX monotherapy than other adults. The percentage of elders receiving TMP-SMX prescriptions has significantly decreased over the past decade. Fluoroquinolonetherapy has increased in both elderly and other adult patients; however, elderscontinue to receive fluoroquinolones more commonly than other adults. EDprescribing trends for elders with UTI are consistent with national guidelines,

although complete compliance has not been achieved.

Volume , . : October

371 Appropriately Screened Geriatric Chest PainPatients May Be Appropriate for an EmergencyDepartment Observation Unit

Bledsoe J, Bossart P, Sugerman, PA-C S, Bernhisel K, Cheng M, Mataoa T,Madsen T/University of Utah, Salt Lake City, UT

Study Objective: Observation units may exclude geriatric patients due to the highrate of observation failure (admission to an inpatient unit) among these patients. Weevaluated whether geriatric patients (age � 65) on a chest pain protocol are admittedto an inpatient unit from an emergency department (ED) observation unit at a higherrate than non-geriatric patients at our 35,000 visits/year ED.

Methods: This was a retrospective chart review of all patients admitted to the EDobservation unit at the University of Utah Medical Center over the 14-month periodfrom April 2006-June 2007. The observation unit did not exclude geriatric patients,nor did it exclude patients with a history of coronary disease; patients were admittedper the discretion of the attending emergency department physician. Patientinformation, including age, date of admission, history of coronary disease (defined asa previous myocardial infarction, stent, or coronary artery bypass graft), andadmission to an inpatient unit from the observation unit, were recorded. Results wereanalyzed using chi-square statistics.

Results: 134 geriatric patients were admitted to the ED observation unit forchest pain during the study period. 17% of these patients were admitted to aninpatient unit from the observation unit vs. 10.7% of the 394 chest pain patientswho were under age 65 (p�0.048). Geriatric patients were more likely to havecoronary disease (31.3%) than non-geriatric patients (20.8%, p�0.013). Wethen performed a subanalysis of the 404 patients (92 geriatric, 312 non-geriatric)who had no history of coronary disease. Geriatric patients without a history ofcoronary disease had a 12% inpatient admission rate from the observation unitvs. a 7.7% admission rate for non-geriatric patients without a history of coronarydisease (p�0.2).

Conclusion: Geriatric patients without a history of coronary artery disease wereadmitted to an inpatient unit at a rate consistent with a generally acceptedobservation failure rate of 10%. When screened appropriately, these patients may beappropriate for chest pain evaluation in the ED observation unit.

372 Nursing Home-Acquired Pneumonia: Demographics,Outcomes and Antibiotic Usage

Kass-Shamoun R, Anderson S, Robinson D, Medado P, Haque N, Zervos MJ,O’Neil BJ/William Beaumont Hospitals, Royal Oak, MI; Henry Ford Hospital,Detroti, MI

Study Objectives: Pneumonia is a leading cause of hospitalization and mortalityamong the elderly in nursing homes with an estimated 1.9 million episodes by 2010.NHAP pathogens are not well defined; however, the IDSA and ATS in 2005recommend treatment in NHAP like health care-acquired pneumonia. Despite itsprevalence, little is known regarding NHAP pts admitted through the ED. Ourobjective is to investigate the demographics, outcomes and appropriate use ofantibiotics (ABX) in NHAP. A retrospective chart review of ED nursing homepatients with a final diagnosis of pneumonia was performed at 2 large hospitals. Datawas abstracted pre and post the IDSA guidelines. Data abstraction followed theguidelines of Gilbert and Lowenstein. Patient demographics, test results, length ofstay, (LOS), treatment and final outcomes were abstracted. Data was analyzed withstudent t test.

Methods: A retrospective chart review of ED nursing home patients with afinal diagnosis of pneumonia was performed at 2 large hospitals. Data wasabstracted pre and post the IDSA guidelines. Data abstraction followed theguidelines of Gilbert and Lowenstein. Patient demographics, test results, lengthof stay, (LOS), treatment and final outcomes were abstracted. Data was analyzedwith student t test.

Results: 302 patients were enrolled with a mean age of 78.3 with 50% males.16.5% of patients were intubated and 20% died on the initial visit, additionally 7.9%died at 1 yr follow-up. The immunization rate for influenza A was 11.9%, forpneumonia was 15.2% and 27.8% of patients were on ABX at EC visit. Bloodcultures were performed on 89% of patients, 17.8% of these had growth and of these52% were contaminants. Sputum culture was obtained in 27.5% of patients, 85.5%grew bacteria, none of which correlated to blood pathogens. Before and after theIDSA guidelines NHAP was treated 59.4% v 41.3% appropriately, 26.1% v 18.7%

as CAP and 46.4% and 33.3% with a single antibiotic, respectively, all had a p �

Annals of Emergency Medicine S155