Research Forum Abstracts

rating with 82% being lower. The higher the initial suspicion, the more likely thesuspicion was lowered after the thoracic ultrasound examination (P<.0003).

Conclusions: This study suggests that thoracic ultrasound can have a significanteffect on medical decisionmaking in the out-of-hospital evaluation of patients withthoracic trauma. By correctly lessening clinical suspicion of a pneumothorax,unnecessary thoracic procedures may be avoided in the out-of-hospital setting.

Family as a Barrier and a Boon to Diabetes Self-Care in

85 Emergency Department Patients: A Qualitative AnalysisBurner E, Menchine M, Arora S/Keck School of Medicine of USC, Los Angeles, CA

Study Objectives: Diabetes and its complications result in over 2 millionemergency department (ED) visits annually in the United States. This burden onpatients, communities and the health care system is particularly pronounced in safety-net hospitals. Understanding the barriers faced by patients with diabetes is necessary toinform ED-based interventions to improve glycemic control. The objective of thisstudy was to identify barriers to diabetes management among low-income, inner-cityLatinos receiving care in the ED.

Methods: We conducted 5 focus groups in Spanish and English with a total of 24participants who had received a comprehensive mobile health diabetes intervention.We imported verbatim transcripts into a computerized qualitative analysis program,Dedoose. A rigourous text-based coding system was used. Transcripts were analyzed inan iterative process, reexamining the earlier transcripts with the new codes derived fromeach round of analysis until saturation was reached. Broad categorical themes arosefrom the initial codes and were developed into a paradigm of barriers and strategies tomanagement of diabetes.

Results: Family was an important motivator to patients; patients wanted to stayalive and healthy enough to enjoy their loved ones, and also were encouraged andcoached by loved ones to improve their diet and exercise choices.

“What motivates me is my children. To take care of them and myself, too.” (translatedfrom Spanish)

“My son is 25 and we were talking. about getting a job so he was like, you know thateffort when you got laid off, you just knew you was getting a job and you got another one. Hesaid, well, you need to use that same effort on your diabetes.”

Patients also identified family events and pressure as detrimental to healthy foodchoices.

“I have a big family. We have birthday parties, barbecues,/ if I’m gonna have a piece ofthat cake, I knowwhat it’s gonna do tome/I have to choose.What poison do I want?Do I wantthe barbecue sauce that’s full of seasonings and sugar and all that other-or do I want the cake?”

“When I feel bad, that they see that I am kind of emotionally off, they immediatelybring a chocolate so that I can eat it and get better.” (Translated from Spanish)

Additionally, patients expressed that their loved ones were sometimes misinformed.“They [family members] know they want to help you but at the same way, they’re not

helping because they don’t understand it.”“Withmy family, I’ll buy a bag of candy and the first thing they’ll do is, ‘Ohno you can’t have

that. That’s sweet.’And I said, ‘Oh yes I can. Becausewhenmy blood sugar goes down, I need it.’”Conclusion: Family members play an important role in motivating Latino patients

with diabetes to improve diabetes care. However, physicians should be aware thatpatient’s loved ones often provide patients with incorrect advice regarding diabetesmanagement and that family events are potential sources of dietary indiscretions. Aspatients often present to the ED with family members, this may provide anopportunity to engage and educate these potentially influential social supporters.Family members may also be an important resource to incorporate into ED-basedinterventions aimed at improving diabetes self-care.

Trends in Tissue Plasminogen Activator Delivery forIschemic Stroke

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Sharp AL, Sauser K, Sangha N, Ajani Z, Neil W, Newton T, Gould M/KaiserPermanente Souther California, Pasadena, CA; University of Michigan, Ann Arbor, MI;Kaiser Permanente Southern California, Los Angeles, CA; Kaiser PermanenteSouthern California, San Diego, CA; Kaiser Permanente Southern California, Irvine,CA; Kaiser Permanente Southern California, Pasadena, CA

Background: Acute ischemic stroke is a common reason for hospitalization and theleading cause of severe disability. Despite clear guidelines the majority of acute strokepatients do not receive treatment consistent with best practice guidelines. There is littleknown regarding performance of integrated health systems, and smaller communityhospitals in delivering tissue plasminogen activator (t-PA) for ischemic stroke patients.

Volume 64, no. 4s : October 2014

Study Objectives: This study describes patterns of acute ischemic stroke care deliverywithin an integrated health system comprising 14 emergency departments (EDs).

Study Objectives: (1) To describe the proportion of acute ischemic stroke patientsreceiving t-PA and to examine how this proportion has changed from 2009 to 2013;(2) To identify variation in t-PA utilization attributable to patient characteristics; (3)To identify factors associated with likelihood of t-PA receipt.

Design: A retrospective, observational study using existing structured data from anelectronic health record. Our primary outcome was t-PA receipt among all ischemicstroke patients. We used chi-square tests to compare proportions and multivariablelogistic regression methods to describe variation and identify factors associated withlikelihood of t-PA receipt.

Setting: Fourteen EDs within Kaiser Permanente Southern California.Participants: We included all adults with a diagnosis of acute ischemic stroke

(identified by International Classification of Diseases, Ninth Revision codes 433.xx,434.xx, or 436). Exclusions were age <18 years, and those with a primary or secondarystroke diagnosis in the 3 months prior to the ED visit.

Results: A total of 18,762 ischemic strokepatients presented to our 14EDs from2009-2013 and 571 of them received t-PA (3%). In our sample median age was 74 (IQR 64-82),50.1% were female, 51.2% white and 37.8% arrived by ambulance. The proportion ofpatients receiving t-PA has increased from 1.9% to 4.9% (P value for trend ¼ <0.0001)over the 5-year study. In multivariable regression analysis, the following variables wereshown to improve the odds of receiving t-PA: female sex (OR¼1.24, 95%CI 1.02-1.50),Asian or Pacific Islander race (OR¼1.37, 95% CI 1.00-1.86) and arrival by ambulance(OR¼1.99, 95% CI 1.64-2.41). We also found that older age (OR¼0.98, 95% CI 0.97-0.99) andBlack race (OR0.68, 95%CI0.50-0.92) decreased the chances of receiving t-PA.

Conclusion: In an integrated health system comprised of 14 community EDsabout 5% of patients with ischemic stroke receive t-PA. Trends show significantimprovement over the study period, but racial and sex disparities exist.

Prioritizing Conditions for Which to Compare Emergency

87 Department Admission RatesLin MP, Weissman J, Sinnette C, Greenwood Erickson M, Bernard KR, Ma J, Schuur JD/Brigham and Women’s Hospital, Boston, MA

Background: Inpatient hospital care accounts for one third of national healthexpenditures, and emergency department (ED) visits are a growing source of hospitaladmissions. ED admission rates vary across medical conditions and EDs, but there isno consensus regarding which conditions or settings to prioritize to reduce EDadmissions and improve quality.

Study Objective: To review methods for comparing ED admission rates, prioritizeconditions for quality improvement, and review criteria to identify hospitals with bestpractices in Massachusetts. Reducing ED admission rates may have unintended qualityconsequences, which need to be “balanced” against the goal of admission reduction.

Methods: We assembled a multidisciplinary technical expert panel (TEP) with keystakeholders in the ED admission process to participate in a modified Delphi consensusprocess. The panel consisted of 2 academic and 2 community-based emergencyphysicians, a hospitalist, a primary care physician, a surgeon, a case manager, andrepresentatives from an insurer, risk management and patient advocacy. The TEP wasco-chaired by an academic emergency physician and an expert methodologist.Conditions were selected based on detailed data analysis of all-payer Massachusetts EDadmission data over 4 conference calls and rounds of voting. In round 1, the TEPidentified conditions with unexplained variation in ED admissions amenable toreduction through process improvement. In round 2, conditions were scored on 1-5Likert scales in 3 domains: evidence to support outpatient care, feasibility of outpatientcare, and contribution to health costs. In round 3, the conditions were ranked, and“balancing” measures including revisit and readmission rates were discussed. In round4, three final conditions were selected, and 6 hospitals with low admission rates werechosen for site visits.

Results: All TEP members voted in all rounds. Round 1 identified 19 conditions;subsequent rounds narrowed to 10, 5 and finally 3 conditions, one of which receivedunanimous support. The Table lists the top conditions with priority rankings. TEPdiscussions revealed several themes: contribution to cost was of primary concern, as werediffering motivations to admit, such as fear of a rare adverse outcome (chest pain), socialdeterminants of health (asthma) and clinical severity (diverticulitis). Members prioritizedcertain conditions for which non-clinical factors such as outpatient follow-up andmedication adherence, often perceived as outside the role of the emergency physician,may influence the decision to admit. TEP members felt qualitative methods for site visitsshould focus on the effect of clinical protocols and performance measures for individual

Annals of Emergency Medicine S31