low risk for serious complications and could be managed in an outpatient setting.There are no validated US guidelines to aid the emergency physician in determiningwhich patients can be safely discharged from the ED. The United Kingdom (UK) hasdeveloped a scoring system, the Glasgow-Blatchford bleeding score (GBS), whichaccurately predicts which patients are low-risk for 7-day complications and can havean outpatient evaluation. The objective of this study is to evaluate the usefulness ofthe GBS in determining if admitted low-risk ED patients with upper gastrointestinalbleeding experience serious adverse events.

Methods: We conducted a retrospective chart review of adult patients admitted tothe hospital from the ED with upper gastrointestinal bleeding over a 3-year period.Charts were selected using ICD-9 code for GI bleed. Subjects with a GBS of zero(low-risk) were evaluated for complications. A GBS of zero was assigned ifBUN�18.2, hemoglobin �13.0(male) or �12.0 (female), systolic blood pressure�110, pulse�100, the patient had no complaints of melena or syncope, and had nohistory of hepatic disease or congestive heart failure. A serious adverse event wasdefined as endoscopic treatment, blood transfusion, or surgery. The setting was a76,000 visit ED community hospital with an emergency medicine residency program.

Results: Five hundred sixty-seven presentations of upper gastrointestinal bleedingwere screened. Four hundred sixty-four of these patients were admitted to thehospital with a diagnosis of upper gastrointestinal bleeding. Twenty-one (4.5%, 95%CI: 3.0-6.8%) of these were low-risk (GBS score of 0). Nine of the 21 patientsunderwent UGI endoscopy in the hospital. Serious adverse events were as follows: 0blood transfusions, 0 surgeries, and 1 endoscopic treatment (hemorrhagic gastricpolyp banded), 4.8%, (95%CI: 0.1-26.5).

Conclusion: Very few (4.5%) of our low-risk upper gastrointestinal bleedingpatients were admitted to the hospital. Of the 21 low-risk patients admitted, only 1had an adverse event (4.8%). The GBS may not be applicable to the US health caresystem, due to the already low percent of low-risk upper gastrointestinal bleedingpatients admitted. The reason might be more stringent admission criteria and therapid availability of outpatient endoscopy. More low-risk patients need to be followedto determine safety of outpatient management.

412 Profitability of Patients Discharged From anEmergency Department

Henneman PL, Nathanson BH, Haiping L, Tomaszewski A, Lemanski MJ/Tufts-Baystate Medical Center, Springfield, MA; OptiStatim, LLC, Longmeadow, MA;Baystate Medical Center, Springfield, MA

Study Objectives: To determine the contribution margin per bed hour by facilitybilling level for patients seen and discharged from a busy urban academic emergencydepartment (ED).

Methods: Billing and demographic data for patients seen and discharged from anED with �110,000 annual visits between 2003 and 2009 were collected from EDand hospital decision support databases. Contribution margin per case wasdetermined at the individual patient level by subtracting direct clinical costs fromcontractual net revenue. Overhead and physician revenue and expenses were notincluded. Admitted patients were not included. Costs were allocated at the patientlevel using an institution specific relative value units. CM was then divided by thetime from bed placement to ED discharge. Level 1 patients are the lowest acuity andlevel 5 are the highest acuity (not including critical care). Values are expressed aspercentages or medians.

Results: 588,514 patients were discharged from the ED between 2002 and 2009.17% had no insurance, 54% had private/commercial insurance, 17% had Medicaid, and12% had Medicare. 46,508 (8%) left the ED without being seen and were not billed,leaving 542,006 for analysis. The table shows results by facility billing level.

Conclusion: In our institution, median contribution margin per case per ED bedhour by facility billing decreases with increasing billing level. Among patients dischargedfrom the ED, lower acuity patients are more profitable than higher acuity patients.

Table. Results by Facility Billing Level

FacilityBillingLevel

# of EDOutpatients from

2003-2009

MedianCharge

percase

MedianNet

Revenueper Case

MedianDirect

Cost PerCase

ContributionMargin per

Case

ContributionMargin/Hour

per Case

MedianLOS in

hours perCase

Level 1 6,326 (1.1%) $179 $106 $34 $71 $138 0.6Level 2 93,614 (15.9%) $275 $164 $58 $107 $111 0.9Level 3 243,498 (41.4%) $635 $306 $121 $190 $112 1.6Level 4 160,234 (27.2%) $1,602 $636 $298 $315 $88 3.3Level 5 38,334 (6.5%) $2,494 $867 $432 $396 $73 4.9

413 Patient Perceptions of Resident Physician WhiteCoat Attire in the Emergency Department

Loo T, Brooks K, Cook I, Newbold S, Amin M, Aguilar V, Heffner J/Kern MedicalCenter, Bakersfield, CA

Study Objectives: To determine if wearing white coat attire changes patients’perceptions and confidence in their resident physician in the emergency department.

Methods: A convenience sample of 104 adult patients was enrolled in the study basedon the work schedule of 4 resident physicians and research assistants between October2010 and February 2011. Four resident physicians (2 males, 2 females) alternated attirebased on odd/even days of the week. On even days, residents wore a white coat over scrubattire. On odd days, residents wore scrub attire only. After evaluating the patient, theresearch assistant handed out and collected a 3-page survey from the patient. The studywas completed when each resident enrolled a total of 26 patients - 13 with white coatattire, and 13 with scrub attire. Prisoners, trauma, pediatric patients, and patients whowere signed out during shift change were excluded from the study.

Results: Fifty-seven patients (55%) preferred their physician to wear a white coat.Eighty-seven (84%) patients had no preference in regards to sex of physician. Femalepatients with female-related chief complaints preferred to see a female physician. A scalefrom 1-10 was used to rate patient confidence levels in their physician and professionalappearance ratings. A 2-tailed T-test was used to evaluate the data. Professional appearanceratings were higher when physicians were wearing a white coat versus scrub attire (p�0.04). There was no difference in patient confidence in their physician with a white coatas compared to scrub attire (p �0.4).

Conclusion: Over half of the patients surveyed preferred their physician to wear awhite coat in the emergency department. Physicians were also ranked higher onprofessional appearance when wearing a white coat. However, patient confidence intheir physician was not affected by white coat attire.

414 Development and Implementation of ResuscitationRoom Protocol for Cardiac Arrest in EmergencyDepartment

Choi M, Choi H, Lee J, Shin S, Shin S, Kim D/Seoul National UniversityHospital, Seoul, Republic of Korea

Study Objectives: The resuscitation room in emergency department (ED) is acritical space for cardiopulmonary resuscitation (CPR). The purpose of our studywas to develop a resuscitation room protocol for patients with cardiac arrest andto examine the impact of the protocol on the improvement of clinicalperformances and outcomes.

Methods: Using the Delphi technique and consensus meetings, a panel of 6 expertemergency physicians made consensus for critical interventions and times that they shouldbe completed. A systemic protocol for CPR were developed and this protocol wereimplemented during a 6-month study period. Using a checklist based on the intervention/time-limit list, we analysed the video-recorded clinical performance in resuscitation roomfor phase 1 (pre-protocol period) and phase 2 (post-protocol period).

Results: A total of 79 cases (29 in phase 1 and 50 in phase 2) were analysed.Demographic data were not different between 2 groups. The performance rates ofall 11 intervention within specified time intervals were significantly improved inpatients of phase 2 (phase 1, 62.1% vs. phase 2, 68.7%, p�0.047). Especially,the timely rates of vascular access and endotracheal intubation were significantlyhigher in patients of phase 2 (phase 1, 34.4% vs. phase 2, 44.0%, p�0.04).There was no differences in return of spontaneous circulation rate and survival tohospital discharge rate between 2 groups.

Conclusion: Standard resuscitation room protocol for respiratory failure may bebeneficial in timely performance of critical intervention in crowded ED.

415 Too Sick for Hospice? Acuity and Outcomes ofPatients Admitted to a New Inpatient Hospice CareUnit

Zalenski R, Waselewsky D, Bonani M/Wayne State University, Detroit, MI

Background: Each year, thousands of patients die in acute care hospitals withpoorly controlled pain and suffering because they are too acutely ill to be dischargedto hospice in the home or nursing home. We opened a dedicated inpatient hospiceunit in an acute care hospital to provide palliative care services for this group, usuallyconsidered “too sick” for hospice. Such patients typically do not have access tohospice because of the limited time window of their rapid dying trajectories and

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S318 Annals of Emergency Medicine Volume , . : October

because the intensity of services needed, such as intravenous infusions or ventilatorsupport.

Methods: Retrospective review of the unit’s first 8 months of service (May 3 -Dec 31, 2010), using both clinical chart abstraction and data extraction from anadministrative database. We examined demographics, admitting diagnoses, length ofstays pre and post hospice, and mortality data. IRB review for exemption is pending.

Results: During 2010, 243 patients comprised a total of 270 admissions to theunit. Age: Mean�71 years (Min�22, Max�98); Male�112; Female�131. Theaverage length of stay in hospice was 5.5 days (min �1; max� 23; median�4). Atotal of 187 patients were admitted from the hospital, with 79% (148/187) admittedfrom medical floors, 15% (28/187) from ICU, and 4% (8/187) directly from the ED.The patients spent a mean of 9.8 days and a median of 7 (range 1-59) days in thehospital prior to discharge to hospice. A total of 59% (n�159) of admissions diedthere. 10 patients died the same day of admittance and 32 patients died the day afteradmittance, so that 17% died within their first 2 days of stay. Although the diagnosisof most patients admitted was for non-malignant conditions (58%; n�141), cancerwas the most common diagnosis (42.4%; n�103), followed by dementia (14.4%;n�35) and stroke (7.8%; n�19). Acute diagnoses accounted for 25% of all patients,which included heart failure (6.5%; n�16), respiratory failure (6.2%; n�15),septicemia (5.3%; n�13), liver failure (4.1%; n�10), kidney failure (2.9%; n�7).COPD (4.1%; n�10); miscellaneous diagnoses (6.5%; n�16) accounted for theremainder. Most patients had “Do Not Resuscitate” status (n�237), but 6 were fullcode. Fifteen patients were admitted with mechanical ventilation (6%; n�15) forventilator withdrawal.

Conclusion: An inpatient hospice unit permits the enrollment of patients dyingof acute illness with severe symptoms, with nearly 20% dying within 2 days. Thesepatients have typically eluded hospice enrollment because of their acuity of illness.This unit not only provides aggressive symptom relief and psychosocial support, butfrees up inpatient beds for cases more likely to respond to acute care interventions.

EMF-1 Use of Observation Care after ED Visits inMassachusetts, 2005-2009

Venkatesh AK/Brigham and Women’s Hospital, Boston, MA

Background: Observation care is an important alternative to inpatient admissionfollowing an emergency department (ED) visit, yet little is known about the use ofobservation care across health systems.

Study Objective: To describe the clinical conditions most frequently receivingobservation care after ED visits.

Methods: Retrospective, observational analysis of Massachusetts hospitaldischarge data sets. We included all adult ED, observation and inpatient discharges in2005, 2008 and 2009. The primary outcome was the proportion of ED patients thatsubsequently received observation care relative to inpatient admission for short stays(�2days) (OBS/SS Proportion) based on Clinical Classification System (CCS)condition. We report statewide disposition proportions with 95% ConfidenceIntervals (CI). Chi-square test was used to test differences in disposition by ClinicalClassification System between 2005 and 2009, * �P�.05.

Results: In 2005, across 74 Massachusetts EDs, there were a total 2,298,222 EDvisits, resulting in 102,123 observation discharges (4.4% of total ED visits, 95% CI:4.37%-4.5%) and 379,925 inpatient discharges (16.5%, 95% CI: 16.4%-16.6%). In2008, these figures were 2,969,929 with 149, 412 (5.0%, 95% CI: 4.9%-5.1%) and409,417 (13.8%, 95% CI: 13.7%-13.9%), respectively. In 2009, these figures were3,017,685 with 158,199 (5.2%, 95% CI: 5.1%-5.3%) and 422,432 (14.0%, 95%CI: 13.9%-14.1%), respectively. There was a significant increase in the statewideOBS/SS Proportion between 2005 and 2009 (P�0.001). The table shows theconditions most frequently observed with OBS/SS Proportion. In 2005, 2008 and2009 the most frequently observed condition was non-specific chest pain. From 2005to 2009 the OBS/SS Proportion increased for 8 of the most frequently observedconditions including: non-specific chest pain, syncope, cardiac dysrhythmias,abdominal pain, congestive heart failure, coronary artery disease, pneumonia andasthma.

Conclusion: Observation care is used for a wide range of clinical conditions afteran ED visit in Massachusetts. Further research is necessary to understand if changesin clinical condition distribution were due to changes in clinical care, codingpractices, or policy initiatives.

Table 1.

ClinicalCondition (CCS)

Observationdischarges,

2005

Observationdischarges,

2008

Observationdischarges,

2009

OBS/SSProportion,

2005

OBS/SSProportion,

2008

OBS/SSProportion,

2009

Non-specificChest Pain*

24,102 30,686 33,330 .66 0.79 0.81

Syncope* 4,356 5,728 6,382 .47 0.64 0.62Cardiac

Dysrhythmias*3,398 4,375 4,393 .30 0.43 0.41

Abdominal Pain* 3,057 4,362 4,524 .57 0.73 0.72Fluid &

ElectrolyteDisorders

2,586 753 807 .30 0.35 0.33

CHF, non-hypertensive*

2,370 779 537 .13 0.21 0.21

CAD and heartdisease*

2,369 2,122 2,354 .22 0.40 0.45

Pneumonia* 2,346 1,401 1,334 .13 0.22 0.20COPD 1,985 1,034 1,071 .21 0.26 0.24Asthma* 1,732 2,130 1,897 .29 0.37 0.33

416 How Do Emergency Physicians Interpret PrescriptionNarcotic History When Assessing PatientsPresenting to the Emergency Department With Pain?

Grover CA, Garmel GM/Stanford/Kaiser Emergency Medicine Residency,Stanford, CA

Study Objective: Narcotics are frequently prescribed in the emergencydepartment (ED), and their abuse is increasing. Prescription monitoring programshave been shown to change emergency physician prescribing practices, yet little isknown on how emergency physicians interpret prescription records. The goal of thisstudy was to assess how emergency physicians interpret prescription narcotic historywhen evaluating patients presenting with pain.

Methods: This study consisted of an anonymous survey of attending and residentemergency physicians at 1 academic medical center. We created 6 fictitious cases ofpatients presenting to the ED with low back pain and a request for narcotics. Foreach case, a prescription history for the previous 2 months, including medicationname, prescription date(s), provider name(s), medication dose and quantity wereprovided, with prescription history revealed after the case presentation. Each casevaried in the number of prescriptions, providers, and narcotic strength. One case wasselected as the index case against which all other cases were compared. For each case,respondents were asked to rank how likely they thought the patient was drug seekingon a 4-point scale: 1 � very unlikely, 2 � unlikely, 3 � likely, 4 � very likely.Respondents ranked, using the same scale, how likely they thought the informationobtained from the prescription record in each case would change their prescribingbehavior.

Results: We collected 59 responses (30 attendings, 29 residents), with anoverall response rate of 78.7%. Respondents rated the index case 3.09 out of 4 (1provider, 3 prescriptions/month, low-strength narcotic) as to how likely thepatient was drug seeking. Respondents rated the second case 2.42 (1 provider, 1.5prescriptions/month, low-strength narcotic), the third case 3.46 (1 provider, 6prescriptions/month, low-strength narcotic), the fourth case 3.33 (3 providers,3 prescriptions/month, low-strength narcotic), the fifth case 3.67 (6 providers, 3prescriptions/month, low-strength narcotic), and the sixth case 2.87 (1 provider,3 prescriptions/month, high-strength narcotic). When each case was compared tothe index case to isolate each of the 3 variables, all differences were statisticallysignificant (p�0.05). For the index case, respondents rated the information fromthe prescription record 3.44 as to how likely the information would change theirprescribing practice. Respondents rated the second case 2.98 and the fifth case3.68, both of which were statistically significant (p�0.05) when compared to theindex case. The remaining cases were not statistically different from the indexcase as to the likelihood of changing prescribing practice.

Conclusion: A higher number of prescriptions per month and a greater numberof prescribing providers in the patient’s prescription record increased emergencyphysicians’ suspicion for drug-seeking behavior in our survey. Patients regularlytaking high-potency narcotics were less suspected of drug seeking than patients onlow-potency narcotics. In all cases except the case with 1 provider, low-potencynarcotic, and 1.5 prescriptions/month, emergency physician respondents reportedthat the information obtained from a prescription record would likely changeprescribing patterns. A greater number of prescribing providers listed on the record

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Volume , . : October Annals of Emergency Medicine S319