Methods: AdultsR21 years old presenting to an urban academic ED in Bostonwere screened by study personnel in treatment areas for the influenza vaccineaccording to CDC high risk guidelines during the hours of 12pm to 8pm, betweenNovember 25 - December 18, 2004. In light of a nationwide shortage, the CDCrestricted their ‘‘high risk’’ criteria to include only the following individuals: personsageR65 years old; residents of nursing homes; persons with chronic pulmonary orcardiovascular disorders, diabetes mellitus, renal dysfunction, immunosuppression,and pregnant women. We excluded those with egg allergy, those previouslyvaccinated this season, those who presented to the ED with a febrile illness orhospitalized patients.

Results: 469 patients were approached, and 382 (82%) agreed to be screened. Ofthose screened, 114 (30%) Caucasians, 187 (49%) blacks, 7 (2%) Asians, and 74(19%) other races. 62 (16%) were Hispanic. 284 (75%) had public insurancecoverage (Medicare, Medicaid, MassHealth, or Free Care), 65 (17%) had employer-based or private coverage and 31 (8%) had no insurance. Of those screened, 250(65%) had access to a primary care physician or a community clinic, while 110 (29%)cited the ED, urgent care, or no usual source of care. Overall, 132 (34.5%) wereidentified as ‘‘high risk’’. Of these, 79 (61%) wanted the vaccination. Some reasonsfor refusal included: vaccination is unnecessary, it doesn’t work, too many side effects,vaccination causes the flu. Among these 79 patients, the MD ordered 66 (84%) and65 received the flu vaccine. Reasons MD did not order vaccine included: patient istoo sick, didn’t know patient was eligible, vaccination may interfere with other drugtreatment, or did not order the flu-shot prior to patient disposition.

Conclusion: We identified and vaccinated adult ED patients at high risk forcomplications associated with influenza during the nationwide vaccine shortage.Patient and provider related factors reduced the efficacy of the program. Patient andstaff education, as well as modification of existing vaccination eligibility criteria, couldincrease the success of an ED-based influenza vaccination program in the future.

81 Applying Cost-Benefit Theory to Public Health Syndrome

Surveillance Programs

Roberts RR, Einstein A, Gore R, Ahmad I, Kampe LM, Cohen N, Stroger Hospital of

Cook County, Chicago, IL; Cook County Emergency Medicine Residency, Chicago,

IL; Chicago Department of Public Health - CDC, Chicago, IL

Study Objectives: Electronic ED surveillance for emerging public health threatssuch as SARS is a new priority. New questions include when to initiate epidemiologicinvestigations if an unusual occurrence is suspected. Balance must be struck betweenearly threat detection and conservation of public health resources. We postulate thatadapting receiver operating characteristic (ROC) curve decision making tools tosurveillance might clarify these issues.

Methods: Setting: A public hospital providing over 160,000 pediatric and adultvisits annually. An electronic ED surveillance system was used to examine 5 yrs ofinfluenza (ILI) and seasonal meningoencephalitis (MEE) outbreaks. Data includedage, complaints, vitals, lab, and diagnosis. Successive limited comparisons were usedto answer the questions: 1) Do different age groups increase early outbreak detection?2) Using daily ILI case-counts, is earlier detection of an outbreak associated withgreater false alarms? 3) Are different case definitions more sensitive or specific? Wedefined sensitivity as earlier detection measured in days and specificity by number ofnon-outbreak false alarms.

Results: Pediatric patients presented with ILI earlier than adults in all years andthe 2003 ILI season wouldn’t have been detectable if pediatric rates had beenexcluded. Expanded ILI definitions resulted in earlier detection, but more false alarmsin non-ILI seasons. Combining fever with temperature measuredR100 resulted insignificantly earlier detection. Sore throat alone without cough was more specific forthe ILI season. We constructed an ROC curve using progressive daily counts for ILI;the area under the curve was 0.77. Using sequential CSF protein levels to predictMEE did not generate an ROC curve with accuracy because of interference frombloody taps, and small numbers of MEE cases available.

Conclusions: These findings suggest that future work applying ROC curves tosurveillance is promising for improving our public health infrastructure. Our ultimategoal is to develop surveillance ROC that can balance the need for early diseasedetection with conserving scarce public health resources.

82 Results of a One Day Alcohol Screening Event

Sacks P, Do J, Mills L, Mills TJ, Louisiana State University Health Science Center

at New Orleans, New Orleans, LA

Objective: The purpose of this study is to report the results of an alcoholscreening event.

Methods: A one day alcohol screening event was conducted in the waiting roomof a larger, urban hospital. Participants included patients and visitors in theemergency department from 8a to 4p. Participation was voluntary. Screening resultswere anonymous. Questions addressed current and past alcohol use and familyalcohol use.

Results: One hundred seventy-two people were contacted. Fifty percent (86) ofpeople had questions but declined the survey. Fifty percent (86) completed thesurvey. Women reported a higher average number of drinks/day than men 3.8 (95%CI, 3.8G1.25 versus 1.29 drinks (95% CI, 1.29G0.76), respectively. Participantsolder than 60 years reported the highest intake of any age group with a mean of 5drinks/day (5G15.50), and 18-30 year-olds reported the least with 2.24 drinks/day(95% CI, 2.24G1.33). Caucasians reported the highest level of alcohol consumption,3.9 drinks/day (95% CI, 3.89G2.33). The same trends were found in each categorywhen the maximum number of drinks/day was compared. Women averaged a highernumber of ‘‘yes’’ responses to CAGE questions than men, 1.46 (95% CI, 1.46G0.46)versus 0.42 (95% CI, 0.42G0.38), respectively. 31-45 year-olds had the highest meanof 1.18 (95% CI, 1.18G0.62) ‘‘yes’’ answers, while theO60 age group had the lowestmean equaling 0.3 (95% CI, 0.33G1.43). Caucasian participants averaged the highestwith 1.4 (95% CI, 1.4G0.61) ‘‘yes’’ answers. Many patients who had a current or pastdrinking problem or answered positively to CAGE questions also had a family historyof alcoholism supporting the idea that alcoholism is familial.

Conclusions: Women and people over 60 years had higher incidence of positiveanswers in our survey. This may indicate that our population differs from the nationor that this method of screening is more effective for women and people over age 60.

83 Testing a Model for an Emergency Department Waiting

Room Educational Intervention

Schabowski SL, Kirchoff J, Hansen S, Anderson M, Roberts RR, Stroger Hospital

of Cook County, Chicago, IL

Emergency department (ED) overcrowding is a national crisis. ED visits exceed110 million in the US and have increased by more than 15% since 1997. At the sametime, illness and injuries caused by alcohol use resulted in up to 7.6 million visits/year. Several studies have shown remarkable outcomes associated with personalalcohol interventions in the ED but these personal interventions may be difficult toprovide as overcrowding continues to tax resources. We have designed a video modelfor a mass ED waiting room alcohol intervention that takes advantage of the increasedwaiting room times without increasing the burden on ED personnel.

Objective: To pilot test the impact of the video intervention.Methods: We designed an intervention with content derived from the opinions of

our population regarding high impact alcohol related negative outcomes, personalrisk factors for succumbing to them and suggestions for risk reduction. A conveniencesample of adults in the ED waiting room were asked to fill out a demographic survey,view the video and then provide their reaction.

Results: 35 (92.1%) of participants completed survey. 57.1% male. 60% AA,25.7% Hispanic. 60% drink alcohol. 54% would be interested in viewing the videowhile waiting. 80% stated they would recall the information. 54.2% stated they wereinspired to change their behavior regarding alcohol. After the presentation, 61.9% ofthe 21 who drink alcohol stated they were likely to reduce their alcohol intake; 38%were likely to decrease frequency; 42.9% were likely to reduce binge drinking. Of the6 who drink and drive, 4 were likely to reduce the frequency.

Conclusion: Our model for alcohol intervention has the potential to make animpact on the viewer’s relationship with alcohol and inspire a reduction in ‘‘riskybehaviors’’ related to alcohol use. This model for intervention has applications in EDswithout resources for personal interventions and as an adjunct when these services areavailable.

Research Forum Abstracts

Volume 46, no. 3 : September 2005

84 ED Overcrowding: An Opportunity to Improve Public

Health Through Education

Schabowski SL, Killey B, Roberts RR, Kampe LM, Ahmad I, Stroger Hospital of

Cook County, Chicago, IL

Study Objectives: About 50 million people in the US have hypertension andmore than 30% are undiagnosed. Of the patients who take BP medication regularly,26% still have uncontrolled HTN. If HTN is controlled, the risk of stroke andcardiac disease is reduced considerably. We assessed hypertensive awareness,treatment and control in emergency department (ED) patients in a public hospitalwhere medications are readily available. We aimed to identify the barrier(s) to bloodpressure control in this population.

Methods: Survey based pilot-study. All current adult ED patients with triageBPO140/90 were surveyed regarding access to care, BP awareness, treatment,

Annals of Emergency Medicine S25

asked to complete a survey. 199 patients completed the survey and 12 refused.Surveys were distributed over six 4 hr daytime intervals. Chi2 and independent t-testswere performed on categorical and continuous variables respectively. P\0.05 forsignificance. IRB approval was obtained.

Results: 90% [164/183; 95% CI, 85-94%] were interested in organ donationinformation through the ED. 43% [82/191; 95% CI, 36-50%] were current organdonors. The likelihood of being a current organ donor was affected by age and race(p=0.049, 0.0001 respectively) but unaffected by gender, income, being the head ofthe household, and the number of people or age of people living at home. 70% [65/109; 95% CI 60-78%] who were not current organ donors stated they would bewilling to enroll in an ED based organ donor program, and the likelihood of agreeingto be a donor was unaffected by any of the aforementioned parameters. 53% [57/108]who were not current organ donors were African-American, but 71% [35/49; 95%CI, 56-81%] would obtain an organ donor card through the ED. 69% preferred EDorgan donation information in written form, and most of the rest preferred a personalinterview/lecture.

Conclusions: Based on this pilot study, an ED organ donation enrollmentprogram would be acceptable to patients and effective, especially in capturing groupsthat currently do not have organ donor cards. A demonstration project on organdonation enrollment in the ED is warranted.

87 Use of Real-Time, Single-Operator Dynamic Ultrasound

Guidance for Internal Jugular Central Venous Cannulation:

A Randomized, Controlled Clinical Trial

Milling TJ Jr, Holden C, Melniker LA, Briggs WM, Birkhahn R, Gaeta T, New York

Methodist Hospital, Brooklyn, NY; Weill Medical College of Cornell University,

Manhattan, NY

Research Forum Abstracts

adherence and understanding of the risks of uncontrolled HTN in one-hourintervals over 10 days. Descriptive statistics were done on demographic information,triage BP and access to care and medications. Comparisons were made betweenHTN patients who adhere to medical therapy and those untreated or non-adherentregarding their awareness of the risks of uncontrolled HTN and the risk reductionassociated with BP control using Chi square analysis.

Results: Of 639 adults currently in the ED, 214 (33.5%) were identified withHTN. Of the 49.5% who did not complete the survey, 62 (57.4%) left the ED beforethey were surveyed 26 (24.5%) refused to participate and 19 (17.6%) were ineligible.Surveys were completed by 108 (50.5%); 56 (51.9%) male; mean age 50.5(SD 14.4); 65 AA (60.2%), 26 (24.1%) Hisp, 17 (15.7%) other. Having a primarymedical doctor was documented by 45 (41.7%) participants. Sixty-eight (63%)people had been told they had HTN. Fifty-eight (53.7%) responded that they werecurrently taking medication for HTN. Of those who stated they were currently takingmedications, 55 (80.9%) responded that they take their meds every day or almostevery day. Comparison of awareness of risks showed that 92.1% of adherent patientswere aware vs 56.4% of untreated or non-adherent patients (P\.0001). Comparisonregarding knowledge of associated risk reduction when BP is controlled showed90.3% of adherent were aware vs 53.9% of untreated or non-adherent (P\.0001).

Conclusion: ED is the only access to care for many people in the US. Many haveuncontrolled HTN. In our study, we found that awareness of the risks associated withuncontrolled HTN and an understanding of the risk reduction associated with BPcontrol were correlated with adherence to BP medications. We propose thatimplementing an ED educational program aimed at patients with BPO140/90 maybe expected to improve awareness, treatment, and adherence and therefore reducenegative outcomes associated with HTN. Given the increase in ED non-emergentwait times and the prevalence of HTN, this type of educational program may bepresented in the waiting room.

85 Emergency Department Physician Estimates of Patient

Literacy: How Accurate Are We?

Engel KG, Heisler M, Forman JH, Robinson CH, Smith DM, Ubel PA, University of

Michigan, Ann Arbor, MI; Ann Arbor VA Medical Center, Ann Arbor, MI

Study Objectives: Literacy significantly influences patients’ ability to understandtheir care in the emergency department (ED) and to adhere to discharge instructionsand recommendations. Thus, to facilitate appropriate and effective communication, itis important that physicians accurately assess their patients’ literacy levels. Theobjective of this study was to determine the accuracy of physicians’ estimates ofpatient literacy at the time of an ED visit and patient characteristics associated withphysician estimates.

Methods: We conducted a cross-sectional, survey based study of adult English-speaking patients following discharge from two emergency departments. Literacy wasassessed for 130 participants using the REALM (Rapid Estimate of Adult Literacy inMedicine). Physicians estimated patient literacy using broad categories, indicatingwhether a patient was below, at, or above the average for their ED population. Weused descriptive statistics and multivariate logistic regression for the analyses.

Results: Physician estimates were discordant with patient literacy scores in 25%of cases (33/130) with providers overestimating patient literacy 79% (26/33) of thetime. Notably, physicians missed 75% of cases (16/20) in which patients scoredbelow high school literacy. In multivariate analyses, physicians were most likely tooverestimate literacy for non-white males with high school or less education (femaleAOR .26, 95% CI .08-.81; non-white AOR 3.7, 95% CI 1.1-12.3; high school orless AOR 18.0, 95% CI 5.4-60.8).

Conclusions: Our findings suggest that physicians often overestimate patientliteracy and fail to recognize patients with low literacy. Inaccurate estimates of patientliteracy may undermine patient-doctor communication in the ED and, in turn,adversely affect patient outcomes following discharge. The use of brief pre-visit literacyassessment tools may enable ED providers to more accurately assess patient literacy.

86 A Pilot Study for an Emergency Department Based

Organ Donor Card Center

Cheng DC, Ku PT, Brenner BE, UAMS, Little Rock, AR; University of Arkansas

for Medical Sciences, Little Rock, AR

Objective: Many states have successful organ donation enrollment programs runby the Department of Motor Vehicles. Certain groups are under-representednationally. This study was done to determine attitudes concerning an ED-based organdonation enrollment program and whether such a program would be successful,especially in under-represented groups.

Methods: A total of 211 non-acutely-ill patients presenting to the ED of a300-bed urban, university hospital from November 2004 to December 2004 were

Background: Use of dynamic, real-time ultrasound guidance for central lineplacement generally requires two operators, one to hold the transducer and the otherto guide the needle.

Objective: We propose a single-operator technique, which requires additionaltraining, and compare it to the two-operator technique for placement of internaljugular (IJ) central venous catheters.

Methods: This was a concealed, randomized clinical trial conducted from June toSeptember 2004 in a U.S. urban teaching hospital. Enrollment packets wererandomized to dynamic single-operator (D1) and dynamic two-operator (D2) using arandom number table. The procedure was performed under real-time ultrasoundvisualization in the transverse plane. The primary outcome measure was cannulationsuccess. Secondary measures were first attempt success, number of attempts, time toplacement and complications. A complete Bayesian analysis using non-informativepriors to estimate the probability of similarity of outcomes for D1 and D2 wasperformed. All variables are reported with 95% credible intervals where appropriate.

Results: Forty-four patients were enrolled from the emergency department andintensive care unit, 23 of which randomized to D1 and 21 to D2. Cannulation successwas 96% (with 95% credible interval 85-100%) for D1 and 95% (83-100%) for D2.There is a 90% probability that the success rates of these two groups differ by less than10% of each other. First attempt success was 56% (36-75%) for D1 and 38% (20-60%)for D2. Number of attempts was 2.2 (1.5-3.0) for D1 and 2.4 (1.5-3) for D2. Timeto placement was 130s (57-203) for D1 and 180s (70-290) for D2. Complicationswere limited to two arterial punctures in D1 and one arterial puncture in D2.

Conclusions: Our one-person technique appears to be equivalent to the standardtwo-person technique for successful ultrasound-guided IJ central venouscatheterization with respect to overall success.

88 Ultrasound Evaluation of the Positional Vascular Anatomy

of the Neck: Position Optimization for Central Venous

Access

Levin A, Bair A, University of California, Davis, Sacramento, CA

Study Objectives: We sought to provide a descriptive analysis of how patient neckrotation affects the relative position of the vascular anatomy of the neck.

Methods: We used an 11 MHz linear transducer to evaluate the relative size,depth, position, and overlap of the internal jugular (IJ) vein in relation to the carotidartery in various clinically relevant patient positions. We obtained a conveniencesample of twenty adult subjects from UCDMC ED. All subjects had a series ofimages taken at standard positions on the neck with subsequent incremental neckrotation. Images of the vessels were analyzed and their relative sizes and distancesrecorded. Descriptive statistics were used with associated 95% confidence intervals.We used a generalized linear model for regression analysis with associated repeatedmeasures among subjects.

S26 Annals of Emergency Medicine Volume 46, no. 3 : September 2005