RESEARCH FORUM ABSTRACTS

sus may all be different. Further study will be needed to evaluate whether a similar protocol is significant in affecting patient outcome, patient satisfaction, and resource allocation.

21 Delays in Dint Initiation for Emergency Department Patients Impacts Clinical Outcome

Milzman D. Meyer J, Zlidenny A, Moskowitz L. Tim Janchar T/Georgetown University School of Medicine, Providence Hospital. Washington, DC

It should not require a stud)' to find that delaying enteral or parenteral n u t n t t o n

from the emergency department worsens patient's outcome. Study objective: This study mill find if delays exist for admitted ED patients until

they receive proper diets and the effect on hospital outcome. The stud)' was conducted m an urban ED with 38,000 annual visits in a community teaching hospital

Methods: A retrospective review of all ED admissions for a 30-day period excluded the following patients: those intubated on admission, those on no oral intake status, or those veith do-not-resuscitate order. The inten'al from admission until first diet order for either enteral or parental feeding was noted, and time till actual feeding adminis- tered. Intravenous fluids were not counted as feedings unless more than 150 g glucose plus supplement was administered in 24 hours. Data were analyzed using %2 Student's t test with P<05.

Results: A total of 485 ED admitted patients, excluding 8.9%, with a mean age of 64+4.8 years (52% female) waited 5.7 hours (range l to 17.8 hours) for admission and had a mean hospital stay of 6.4 days. The mean time time from admission to first diet order was 23 5 hours, with mean actual first feeding occumng in 40.3 hours; 36.4% did not receive any numtton for more than 24 hours after admission. Twemy- two percent of patients w-tth poor nutrition (albumin <2.8 mg/dL) had increased hos- pital stay: 14.8 versus 5.4 days for ED patients with normal albumin (P<.01) No difference was found for geriatric patients (>65 years) versus patients younger than 65 years for first feedings (P= NS). The 36.4% patients without diet more than 24 hours from admission had increased hospital stays versus patients first fed less than 24 hours: 8 versus 5.1 days, respectively (P<.03).

Conclusion: There exist unacceptable delays for most ED patients recetxqng an)" nutrition on hospital admission, without even consideration of diet adequacy. Poor baseline nutrition and delay in hospital nutrition affect hospital stays, and improve- menrs in ED treatments are needed.

422 EMGuidelines: A Web-Based Index of Clinical Guidelines for Emergency Medicine

Kim J J, Rothenhaus T/Boston Medical Center, Boston. MA

Clinical guidelines are powerful tools to aid clinicians in day-to-day practice. However, their dissemination and adoption have been poor Countless clinical guide- lines have been published on the lnternet, but they are difficult to find, and only a subset pertain to emergency medicine.

Stud)' objective: To perform a comprehensive survey of clinical guidelines available on the lntemet, and to create a database-backed, Web-based resource to index and make available clinical guidelines relevant to emergency medicine,

Methods: We performed a comprehensive search for clinical guidelines on the lnternet using an automated Web search tool (Copernic 99, Agents Technologies Inc, Quebec, Canada) using the search terms "clinical guidelines" and limiting the results to the 1,000 best matches. After selecting clinical guidelines relevant to emergency, we created a database (ACCESS 97, Microsoft, Inc, Redmond, WA) to catalog these guidelines by medical subject heading (MESH), emergency medicine core curriculum heading, author, and sponsoring organization, We then created an HTMk-based user interface to link this database via our department's Web server to the World Wide Web.

Results: Of 1,000 Web sites found in the search, 250 were chosen Ior their applica- bility to emergency medicine. The database provides a uniform framework for cata- loging and maintaining pointers to Web-based clinical guidelines, allowing users to browse guidelines by subject, emergency medicine core curriculum headings, author, year, and sponsoring organization. The Web site also pro,ades automated links to the National Library of Medicine's PubMed database for searching practice guidelines pub- lished in the medical literature.

Conclusion: Web-based clinical guidelines represent a heterogeneous and poorly accessible resource for emergency medicine. Our Web site provides an easy-to-use resource, making clinical guidelines readily available to emergency clinicians.

23 incorporating College Students into a Departmental Research Program

Henderson SO. Korn CS. Genna T, Esekogwu Vl/Los Angeles County-University Southern California Medical Center. Los Angeles, CA

Stud)" objective: Clinical research based in an academic en',aronment regardless of institutional size. residency affiliation, or demographic location has added the addi- tional element of required scholarly activaty to an already complex scenario We evalu- ated the increase in research productivuy in an urban emergency department by incorporating undergraduate premedical students as research associates (RAs).

Methods: A program usmg premedical undergraduate students as additional research support in the ED of a Level 1 trauma center was developed and implemented to increase research productivity Nine sophomore students from the University of Southern California were initially recruited and oriented to all issues relating to volun- teenng in the ED including an introduction to clinical research, patient confidentiality, and ethical issues Each RA served 6 hours per week performing duties ranging from patient enrollment and chart reviews, to data collection and entry. The RAs were mon- itored by the ED research facilitator and the study primary investigator and completed a questionnaire after participation in the program.

Results: Twenty-seven students have participated in the program over the past 18 months. Patient enrollment has increased from 73% to 93% over that time. Data col- lection and entry has sa;'ed 90 hours per week for the researchers and residents in departmental studies ILk satisfaction with the program was vet')" positive as reflected by their comments on the questionnaire and exit interxiew.

Conclusion An Rat program usmg premedical college students is one method by which research productiv'ity may be increased

424 A Comparison of Conscious Sedation Practices in Emergency Medicine Residency Teaching Programs

McCormick JJ. Henderson SO. Chiang L, Newton K/Los Angeles County-University of Southern California Medical Center, Los Aogeles. CA

Stud)" objectives: 1"o determine how much conscious sedation (CS) teaching is incorporated into emergency medicine cumculum and if differences exist between programs offenng formal instruction and those that do not

Methc, ds: Residency directors at 110 approved emergeno/medicine training programs received a mail sun'ey The medication options, presence or lack of formal resident training in CS. levels of monitoring used, and perceived satisfaction were analyzed

Results: Eighty-eight (80%) of the 110 programs responded. Formal didactic instruction ".','as pro',lded by 65 (74%) of the programs responding. Twemy-one (24%) of programs do not have formal CS curriculum. Medication options included midazo- lam. [entanyl, sufentanyl, etomidate, methohexital, thiopental, propofol, chloral hydrate, and Demerol. Phenergan. and Yhorazine. Monitoring options included none used. pulse oximetr), intravenous placement. ECG. end-tidal CO 2 detection, and sup- plemental oxTgen. No statistical differences were found in the number of medication choices or the level of monitoring when the 2 groups were compared. The perceived satisiaction by the residency director of CS in the groups ".','as similar and not statisti- cally different. In the didactic group, 78% (51/65) believed the CS provided to their adult population and 66% (43165) believed the pediatric CS ,,','as satisfactory. There were 2 nonrespondents in the adult group and 12 in the pediatric group. In the non- didactic group, 18 ~.86%) of 21 pro'.aded to the adults and 17 (81%) of the pediatric group believed their CS ",,,as satisfactory. There ",,,'ere no nonresponders in the adult and 1 nonrespondent in the pediamc group.

Conclusion: There was no statistical difference in reported practice, monitoring, or satisfaction of CS between programs with or without didactic training in procedural sedation, it appears that current pohcy guidelines provided by the Joint Commission on Accreditation of Heahhcare Organizations. local hospitals, and specialty societies may ensure adequate education and monitonng.

425 As.o.D~176 by Physicians and Nurses in Cases of Intentional

Houry D. Nyquist S, Pons P, Abbott J. Feldhaus K/Denver Health Medical Center, Denver. CO

Emergency department records are an important source of injury surveillance data. However, documentation regarding mechanisms of injury may be suboptimal. The purpose of this stud)" was to analyze and compare physician and nurse documentation of intentional assaults, in terms of assailant, place, and object.

Methods: The ED log of an urban Level I trauma center was retrospectively

OCTOBER 1999, PART2 34:4 ANNALS OF EMERGENCY MEDICINE $10 7

RESEARCH FORUM ABSTRACTS

reviewed to identify eligible patients presenting consecutively from November 23 to November 30, 1996. All acutely injured patients not involved in a motorized vehicle crash were included.

Results: Sixty-one patients were identified as intentional assault victims; we were able to locate both physician and nurse charts for 59 (97%). Fewer than half of the charts indicated the identity of the assailant or the date of the assault. Physicians were significantly more likely than nurses to document the identity of the assailant (29% versus 10%; P=.011), as well as the date of assault (46% versus 17%; P=.001). There was no difference between physician and nurse documentation of place of assault (14% versus 10%; P=.569). All charts had documentation of object use; however, 11 charts (9%) had a discrepancy in the type of object documented.

Conclusion: Although the ED commonly treats assaulted patients, basic surveil- lance data are often omitted from the chart. Physicians document more than nurses, but both physicians and nurses are poor overall at documennng information regarding assaults. Structured charting may provide more complete data collection.

426 Advanced Cardiac Life Support Training: Comparison of Brazilian Versus North American Student Responses

Kern KB, Timerman S, Paiva E/NCR Brazil, San Pauio, Brazil; University of Arizona, Tucson, AZ

A nationally coordinated effort has recently begun to teach advanced cardiac life support (ACLS) to health care professionals throughout Brazil. Under the direction of FUNCOR of the Brazilian Heart Foundation Society of Cardiology, these courses have carefully followed the American Heart Association's ACLS guidelines. ACtS materials (English) were available before the course for each student. Data on student prepara- tion and end of course evaluations have been prospectively gathered and comparisons made between the first 122 Brazilian students and a similar 1997 student cohort from the University of Arizona (n=31). Students evaluated the different course aspects as unsatisfactory, satisfactory, or superior. No differences in raungs concerning course schedule, course dynamics, or content were detected with both groups giving each of these categories approximately a 45% "superior" rating. Significantly more Brazilian students rated "superior" course organization (62% versus 42%; P<.02) and duration (10% versus 27%; P<.05) than did the Arizona students. Instructors were rated simi- larly high and "superior" by both student groups (57% versus 48%; P<.5). Likewise, no differences were found in course materials (56% versus 45%; P<.3) or knowledge gained (50% versus 50%; P<.9). Brazilian students did rank facilities (54% versus 26%; P<.01) and mannequin use (44% versus 20%; P<.O2) higher than the Arizona students. Both groups of students appear to prepare equally well, with 33% versus 50% reading a majority of the ACLS text before the course (P<.3). The vast majority claimed their treatment of cardiac arrest victims would be drastically altered from hav- ing attended the ALCS course (95% versus 90%; P<.4). Finally, in both countries there was unanimous agreement that the course was worthwhile and should be recom- mended for all health care professionals.

A m ) ' 7 A Breast Screening Behavior Survey in an Urban Emergency " ~ L / Department Takakuwa KM, Ernst AA, Weiss S J/University of California-Davis Medical Center, Sacramento, CA

Study objective: It is well known that screening mammography is the best way to detect early breast disease. Women themselves detect 90% of their own breast cancers. In this study, we wanted to determine whether women presenting to our emergency department practiced behaviors that might increase their rate of detecting early breast disease. Our null hypothesis is that behavior will be the same across age, race, income, and insurance type.

Methods: Between February and April 1999, we administered a 1-page convenience sampling of women in the ED treatment and waiting areas at the University of California-Davis Medical Center aged 18 and older. Participation was strictly volun- tary. During this time, 200 completed surveys were collected. We studied whether women performed breast self-examination (BSE) and if they had received a mammo- gram by age, race, income, and insurance type.

Results: A total of 68.5% of the women performed BSE. Women who were older (>40 years old) were significantly more likely to perform BSE than younger women (P<.001). Higher-income (>$20,000 per year) women were sigmficantly more likely to perform BSE than lower-income (<$20,000) women (P<.01). There were no differ- ences between races and by type of insurance.

Of the women older than 40 years, 87.8% had received a mammogram. Higher- income women were significantly more likely to receive a mammogram than lower income women (P<.01). There were no differences between race or by type of insurance.

Conclusion: BSE and mammography to detect early breast changes was higher than expected in this ED population of women. Lower-income and younger women per- formed less BSE than higher-income women and lower-income women received less mammography. The ED may be an important site to educate young and lower-income

women about BSE and mammography.

S 1 08 ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2