reported having no problems with their vision. Sixty percent (605/1004) reportedthat they drive. Driving patterns are described in Table 1.

Conclusion: In this single site study, approximately half of our elderly EDpatients were visually impaired. A significant percentage of elderly patients whoadmitted to driving may not be fully aware of their vision impairment. Future studiesshould investigate whether ED vision screening can identify drivers at-risk for injury.

162 Serum Lipase and Amylase in the Diagnosis of AcutePancreatitis in Elderly Patients

Reilly R, Wu M, Chan SB/Resurrection Medical Center, Chicago, IL

Study Objectives: The diagnosis of acute pancreatitis in the emergencydepartment (ED) is challenging and increased morbidity and mortality have beenseen with age and co-morbidities. Amylase and lipase levels 3 times normal has beenestablished to have sensitivity and specificity of 100% and 95% when diagnosingacute pancreatitis. However, age-related structural and enzymatic changes arecommonly seen with advanced age. This study investigates the sensitivity andspecificity of serum amylase and lipase in the elderly population.

Methods: Twenty-two month retrospective chart review of patients 65 years andolder from a single community teaching hospital ED. Patients had amylase and lipasedrawn within 24 hours of ED visit and CT abdominal scans of the pancreas within48 hours of visit. Data collected included demographics, amylase and lipase levels,CT abdominal scan results, and final discharge diagnosis. Data collection wasperformed by all investigators. All abnormal CT reports were reviewed by allinvestigators and a patient was considered to have acute pancreatitis if the CT scanshowed evidence of acute inflammation of the pancreas. Sensitivity and specificitywere calculated with 95% confidence intervals.

Results: There were 1266 patients 65 years or older seen in the ED with serumamylase/lipase levels and CT abdominal scan. 47 patients (3.7%) had evidence ofacute inflammation of the pancreas. Using a lipase value of 3 times normal, asensitivity of 59.6% (95% CI: .455, .736) and specificity of 96.0% (95% CI: .949,.971) were calculated. Of note, 10/47 (21.3%) of the elderly patients with acutepancreatitis had normal lipase levels. Using an amylase value of 3 times normal, thesensitivity was 50.0% (95% CI: .337, .663) the specificity was 97.2% (95% CI: .962,.982).

Conclusion: The previously reported high sensitivity for lipase/amylase indiagnosis of acute pancreatitis does not hold true in patients 65 and older. Althoughthe specificity remains high (96-97%), the sensitivity (50-60%) is so poor as to makethe tests useless for ruling out the disease in the elderly.

163 Emergency Department Procedural Sedation inGeriatric Patients: A High Risk Patient Population

Mace SE, Ulintz A/Cleveland Clinic Foundation, Cleveland, OH; University ofDayton, Dayton, OH

Study Objectives: Geriatric patients have been found to be a high risk group ofpatients in various settings. For example, geriatric trauma patients have a significantlyhigher morbidity and mortality than non-geriatric adult patients. This is also true forelderly patients presenting to the emergency department (ED) with undifferentiatedabdominal pain and those with cardiac disease. Procedural sedation is commonlyperformed in the ED for various procedures including fracture reduction,cardioversion, reduction of dislocated joints, foreign body removal, and wound care.Whether geriatric patients are at a higher risk for ED procedural sedation isunknown. The objective of this study was to evaluate ED procedural sedationincluding adverse events with comparisons based on age, focusing on the geriatricpatient.

Methods: This was a prospective data collection on a standardized hospital-widequality improvement (QI) form of all patients (pediatric and adult) undergoingprocedural sedation in the ED over 10 years. Pediatric patients were age � 21 years,adults were � 22 years of age and geriatric patients were � 65 years of age. Geriatricpatients were further subdivided into “younger” geriatric (65 to 79 years of age) and“older” geriatric patients (age 80 years and above). The setting was the ED of aacademic, urban, tertiary-care hospital.

Results: There were 2460 procedural sedations done over ten years in ED patientsfrom 2 weeks of age to 102 years with 45% female, 55% male. There were 857chidren and infants and 1603 adults, with 940 non-geriatric adults, and 663 geriatricadults. There were 476 “younger” geriatric (65 to 79 years) and 187 “older” geriatricpatients (age 80 years and above). The most common adverse events werehypotension, oxygen saturation � 90%, bradynpea/apnea, dysrhythmia,

hypertension, and allergic reactions. The incidence of adverse events were pediatricpatients 4.6%, nongeriatric adults 18.2%, geriatric adults 24.0%, younger geriatricpatients 21.6% vs. older geriatric patients 31%. The results between the 3 age groupsand between the younger and older geriatric patients were all highly significant(p�0.01). Older patients tended to have higher American Society of Anesthesia(ASA) classes but these age differences remained irrespective of other parametersincluding the ASA class, procedure being done, and sedative used. Multivariateanalysis confirmed that the significant differences based on age (pediatric vs.nongeriatric adult vs. geriatric) and within the elderly (eg, younger vs. older geriatricpatients) remained irrespective of other variables.

Conclusion: The elderly represent a high-risk group of patients undergoingprocedural sedation in the ED even when other factors such as ASA class, sedativeused and procedure being done are considered. Furthermore, there are also importantdifferencs within the geriatric population with a significantly greater incidence ofadverse events occurring in the “older” geriatric patient (age � 80 years) compared tothe “younger” geriatric patient (age � 80 years).

164EMFShould Miss Daisy Be Driving? Factors AssociatedWith Adverse Driving Events Among Older Drivers

Betz ME, Schwartz R, Valley M, Lowenstein SR/University of Colorado School ofMedicine, Aurora, CO

Study Objectives: By 2025, 25% of United States drivers will be over age 65.Some of these older drivers are at higher risk of motor vehicle crashes (MVCs), butthere is no brief screening tool to predict crash risk accurately. As the first step in thedevelopment of such a tool, we sought to identify demographic, health and driving-related characteristics associated with adverse driving experiences (ADEs: MVCs andpolice stops) among older drivers.

Methods: Older (65� years) patients visiting the emergency department andgeriatric clinic at a university hospital completed a confidential, pilot-tested surveyand 3-month telephone follow-up. Non-English speaking patients, those with criticalillness or significant cognitive impairment and those who had not driven in the past30 days were excluded. We used logistic regression to identify demographic, healthand driving-related factors associated with an ADE in the past year and at 3 months.Variables with statistically significant or strong (OR�2) relationships in bivariateanalysis were included simultaneously in the final model.

Results: The response rate was 50% (N�230) and 77% (n�178) completed the3-month telephone follow-up. The median age was 76 (range: 65-93). Almost all(97%) lived in a private residence. Most drove daily or almost daily but reportedrestricting their driving in certain conditions (Table), and 16% (95CI 11-20)reported an ADE in the past year. Of those with an ADE, 39% (95%CI 23-57) had aMVC, 44% (95%CI 28-62) a police stop, and 17% (95%CI 6-33) both. Inmultivariate logistic regression, 5 factors were associated with an ADE in the pastyear: avoiding driving alone (OR 34.17; 95%CI 1.81-646.71); driving daily oralmost everyday (OR 14.33; 95%CI 01.76-116.37); having someone else recommenddriving cessation (OR 7.13; 95%CI 0.86-59.09); ever experiencing vision problemswhile driving (OR 3.22; 95%CI 0.79-13.21); and ever being confused while driving(OR 2.29; 95%CI 1.06-4.96). After 3 months, 5% (95%CI 2-9) of contacted drivershad stopped driving and 5% (95%CI 2-9) had experienced an ADE. Only 1 drivercharacteristic (avoiding driving alone) was associated with an ADE at 3-months (OR20.13; 95%CI 1.15-351.87).

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Conclusion: Adverse driving events among older drivers are somewhat common.Certain reported driving behaviors and experiences--notably, avoiding driving alone--are associated with a recent ADE and possibly with a future ADE. Driving-relatedquestions appear to have stronger associations than demographic characteristics andmight be used to develop a brief screening tool to identify older drivers at risk forfuture ADEs.

165 Driving Patterns Among Older EmergencyDepartment Patients

Betz ME, Schwartz R, Valley M, Lowenstein SR/University of Colorado School ofMedicine, Aurora, CO

Study Objectives: Many older adults who visit emergency departments (EDs) areactive drivers, and some are at elevated risk of traffic crash involvement and injury.However, the driving patterns and crash experiences of older emergency department(ED) patients are unknown. We sought to describe older ED patients’ drivingprevalence, patterns and experiences, including medical conditions associated withcrash risk, self-imposed driving restrictions and motor vehicle crashes (MVC).

Methods: Consecutive older adult (65� years) patients visiting an urban EDfrom 7am to 7pm were invited to complete a pilot-tested, confidential 2-part surveyregarding their driving patterns and crash experiences. Non-English speaking patientsand those with cognitive impairment or a critical illness were excluded. We calculatedproportions and 95% confidence intervals to describe the characteristics andexperiences of older drivers, and we used logistic regression to examine factorsassociated with self-imposed driving restrictions.

Results: Of 276 eligible ED patients, 90% (N�249) participated; 9% weremissed because study staff were busy, and 2% declined participation. Among allparticipants, 140 (56%; 95CI 50-62) were current drivers; most (91%) currentdrivers completed the full survey. Drivers had a lower mean age than non-drivers (73vs. 77 years; p�0.001) but similar proportions of women (49%; 95% ConfidenceInterval [CI] 40-57) and men (51%; 95%CI 43-60) reported driving (p�0.2).Among current drivers, all but 1 lived in an independent home or apartment, and36% (95%CI 28-45) described their health as excellent or very good. However, 82%(95%CI 75-89) had at least 1 medical condition previously identified as possiblyincreasing crash risk, including hypertension (67%; 95%CI 58-75), diabetes (25%;95%CI 17-32), and heart disease (23%; 95%CI 16-30), and drivers were taking amedian of 6 daily medications (range: 0-23). Many reported needing a cane or otherequipment (33%; 95%CI 25-42) or assistance (15%; 95%CI 9-21) in their dailyactivities. Most drivers reported driving daily or almost daily (80%; 95CI 73-87) andrestricting their driving (65%; 95%CI 57-74) in at least 1 traffic situation, usually atnight (46%; 95%CI 37-55), in bad weather (43%; 95%CI 34-51), in heavy traffic(27%; 95%CI 19-34), on highways (25%; 95%CI 18-33), or in unfamiliar places(24%; 95%CI 16-31). A third of drivers (33%; 95%CI 26-42) said they had feltconfused, nervous or uncomfortable while driving. In a multivariate logisticregression, the following factors were associated with self-restriction of driving: femalesex (Odds Ratio [OR] 5.88; 95%CI 2.41-14.35); ever feeling confused while driving(OR 4.45; 95%CI 1.64-12.05); and age 70 or older (OR 2.84; 95%CI 1.19-6.70).Eight percent of drivers (95%CI 3-13) reported being involved in an MVC in thepast year; self-restricted driving was not associated with crash involvement. (OR 1.26;95%CI 3.0-5.13).

Conclusion: Many older ED patients are current drivers and have medicalproblems that could increase their crash risk. Among these drivers, women, driversover 70 and those who have felt confused while driving are more likely to self-restricttheir time on the road.

166 Assessing the Costs and Clinical CharacteristicsAssociated With Frequent Emergency DepartmentUsers in a Suburban Emergency Department

Ascher J, Swor R/William Beaumont Hospital, Royal Oak, MI

Introduction: Patients who present frequently to emergency departments forevaluation (“frequent ED users”) have been shown to represent a significant challengeto urban hospitals with large indigent populations. The impact of frequent ED userson suburban hospitals is not well understood.

Study Objective: Our objective in this study is to compare hospital costs andclinical characteristics of frequent ED users versus controls in a high volume suburbanemergency department.

Methods: We performed this study in a single, large, community-based academicemergency center (115,000 visits annually). We utilized a retrospective review of

emergency department records for the calendar year of 2009, selecting frequent EDusers, defined as adults (age � 18) with 12 or more clinical encounters during theyear. Control patients were selected as age and sex matched controls, with � 12 visitsduring the study period. We analyzed hospital costs (as determined by hospitalaccounting), types of insurance (none, public, or private), and admission rates in the2 groups, on a per visit basis. Secondarily, we evaluated the nature of the visits withrespect to emergency department discharge diagnoses. Descriptive statistics were usedfor presentation. Chi-square and Fisher’s exact test were used for associations.

Results: We identified frequent ED users (N�65 pts, 1335 visits), and controls(N�259 pt, 328 visits) matched for age and sex. Frequent users accounted for 1.1%of total ED visits, and 3.7% of total ED costs. Frequent users had a median of 17visits (range 12 to 40), and controls a median of 1 visit. Both frequent users andcontrol patients had relatively low rates of admissions (11.0% vs 11.6%, p�0.77).Hospital costs per visit did not differ between the study and control groups ($1049 vs$1256, p�0.34). Frequent users were significantly more likely to be uninsured thanour controls (16.5% vs 9.5%, p�0.001), and were more likely to hold publicinsurance (37.5% vs 21%, p�0.001). Comparison of ED discharge diagnosesbetween groups revealed that frequent users presented most often with chest andabdominal pain (17.3% vs 12.8%, p� 0.05). A small percentage had neurologic(6.6% vs 1.2%, p�0.001) or psychiatric/alcohol-related (8.6% vs 4.0%, p�0.001)complaints.

Conclusion: In this suburban ED population, we identified that there was nodifference in costs per visit between frequent user and control populations. FrequentED users more often had public insurance, or no insurance at all, decreasingreimbursement to the institution. These data demonstrate that frequent users have amodest negative impact on ED financial performance. Still, the majority of frequentED users are insured. Finally, frequent ED users more often had psychiatric oralcohol-related visits, but this category of diagnoses represented a small proportion ofED frequent visits.

167 Physician in Triage Improves Patient SatisfactionImperato J, Morris DS, Sanchez L, Setnik G/Mount Auburn

Hospital, Cambridge, MA; Beth Israel Deaconess Medical Center, Boston, MA

Background: Placing a physician in triage has been suggested as 1 intervention tohelp alleviate crowding, but little is known about its effect on patient satisfaction.

Study Objectives: To determine if a physician in triage (PIT) improves patientsatisfaction as measured by patient responses to Press Ganey surveys.

Methods: An interventional study compared patient satisfaction scores for the6-month period before (January 1 - June 30, 2008) and after (July 1 - December 31,2008) implementation of a PIT model in a 23-bed emergency department (ED) in acommunity teaching hospital with an annual volume of 36,000 patients. During theinterventional time period an additional attending physician was assigned to triagefrom 1 PM to 9 PM daily, and a nurse and ED technician were reassigned to thetriage area. This physician conducted brief histories and exams and placed initialorders for diagnostic tests and interventions. Outcome measures were mean scoresobtained from respondents to Press Ganey surveys for selected questions most likelyto be impacted by PIT implementation and those included in the physician section ofthe survey. Responses were in the form of ratings between 1 (very poor) and 5 (verygood).

Results: 508 respondents seen in the 6 months before the initiation of the PITteam and 458 respondents in the 6 months while the PIT team was in place wereincluded in the study. Respondents’ overall rating of ED care improved from 4.22(SD � 1.02) in the 6 months before adding the PIT to 4.38 (SD � 0.93) in thesubsequent 6 months (p � 0.013), which represents an improvement from the 6thpercentile to the 68th percentile among similar hospitals. Scores on the specificquestion of satisfaction with the waiting time to a physician increased from 3.73(1.21) to 3.91 (1.16) (p�0.019), or from the 3rd to 51st percentile. There wasimprovement in the scores in the intervention time period across all questionsanalyzed with statistically significant differences (p�0.05) noted for 8 of the 10questions studied.

Conclusion: Patient satisfaction scores as measured by responses to Press Ganeysurveys had small but statistically significant improvements in the absolute scores.Small gains in absolute scores can have large effects on the percentile rank of an ED.Costs of adding a PIT should be weighed again institutional importance of improvingthese scores.

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