Results: Three hundred thirty-seven (96%) of 352 patients surveyed voiced

a boarding location preference. Two hundred twenty-three (66.2%) patients

preferred boarding in the inpatient ward hallway versus 114 (33.8%) in the ED.

Two hundred sixty-four (75.9%) patients were surveyed on the ward and 88 (25%)

in the ED. Boarding location preference was not affected by interview site. Less

than a 1.8% absolute difference existed across sites for ward and ED hallway

preferences. A rationale for hallway preference was supplied by 146 (65.5%) who

favored boarding in the ward and 80 (70.2%) who favored the ED. Of those

preferring the ward, 74 (50.7%) patients desired to avoid the ED’s high level of

traffic, noise, commotion, or low level of privacy. Forty-three (29.5%) patients

cited physical proximity to their room, to ‘‘get in faster,’’ or ‘‘see your room.’’

Seventeen (11.6%) pro-ward hallway patients’ justification could be grouped under

a common category characterized by feeling uncomfortable in the ED because it

was ‘‘too dangerous’’ or ‘‘rough,’’ made them nervous, had more germs or weird

people, and had less cosmetic appeal. Of the patients opting for boarding in the

ED, 46 (57.5%) patients justified their decision by reporting that health care and

treatment would be quicker or better or involve physicians. Fourteen (17.5%)

patients thought that the ED was more comfortable, safer, private, and spacious,

with less traffic and fewer people to ‘‘look at me funny.’’ The next most common

justification was by 5 (6.3%) patients who believed they would reach their room in

less time. When asked to choose their degree of objection, those desiring boarding

in the ward and ED chose ‘‘no problem’’ (27.4 versus 21.9%), ‘‘minor

inconvenience’’ (30.9% versus 31.6%), ‘‘dissatisfied’’ (23.4% versus 26.3%), ‘‘very

dissatisfied but understand’’ (7.2% versus 7.9%), ‘‘very dissatisfied and angry’’

(10.8% versus 9.6%), or had no answer (0.4% versus 2.7%).

Conclusion: Nearly twice as many patients would prefer to be boarded in an

inpatient hallway in contrast to the ED hallway. In suboptimal situations when there

is no other care location than the hallway, administrators and the JCAHO should

also consider the admitted patient’s preference. Patients in our hospital were

surprisingly forgiving of the potential of being placed in the hallway.

374 Effect of Interhospital Transfer Patterns on Hospitals’ QualityPerformance Measurement Results

Graff LG, Foody J, Galusha D, Tuozzo K, Meehan T, Radford M/Qualidigm,

Middletown, CT

Study objectives: National measures for quality of care (QOC) for acute

myocardial infarction (AMI) are emerging, and results of these measures are used

to communicate and compare hospitals’ QOC. Although the AMI QOC measures

use the ‘‘ideal candidate’’ methodology (theoretically immune to differences in

patient cohort characteristics), underuse among ‘‘ideal candidates’’ is not

independent of patient characteristics. Interhospital transfer patterns are likely to

accentuate differences in cohort characteristics at different hospitals, and these

cohort differences may lead to loss of comparability of QOC measures across

hospitals. We study the difference in cohort characteristics and QOC results

between ‘‘transfer-out’’ (T) hospitals and ‘‘receiving’’ (R) hospitals in Connecticut

(CT).

Methods: Our analysis cohort (n=1,356) was assembled from AMI QOC

assessments by the CT Quality Improvement Organization in 1998 and 2001. We

excluded patients younger than 65 years. Hospitals were divided into those that

transferred out less than 10% (R) and those that transferred out 10% or more of their

AMI patients. We compared AMI cohort characteristics and AMI QOC for

administration to ‘‘ideal candidates’’ of aspirin and b-blocker within the first day

after hospital admission and at hospital discharge, according to transfer pattern of

the hospitals and transfer status of the cases.

Results: Twenty-two T hospitals cared for 683 AMI cases, whereas 7 R hospitals

cared for 673 AMI cases. T hospitals transferred out 221 (32.4%) of their AMI cases,

and 271 (40.3%) were received in transfer to R hospitals. Cases transferred out of T

hospitals or into R hospitals were younger, less often female patients, with fewer

comorbidities than cases not transferred (Table). QOC measures were higher for

cases transferred (Table), particularly for T hospitals, which outperformed R

hospitals on early QOC (P\.05, T versus R hospitals). All differences between

transferred and nontransferred cases were significant to P\.05, except where noted

by an asterisk.

Conclusion: Current QOC measures disadvantage hospitals that transfer out

a substantial portion of AMI cases to tertiary care centers.

375 Does the Evidence Support the Joint Commission onAccreditation of Healthcare Organizations’s Requirement forSpiritual Assessment?

Jang TB, Kryder GD, Tan D, Char DM/Washington University School of Medicine,

St. Louis, MO

Study objectives: Our hospital was recently cited for not obtaining adequate

spiritual assessments on patients presenting to the emergency department (ED), and

obtaining spiritual assessments is required for accreditation by the Joint Commission

on Accreditation of Healthcare Organizations. We assess whether patients presenting

to the ED by ambulance have religious or spiritual needs or want such interactions

with clinicians.

Methods: Fifty consecutive ambulance patients on each of 4 shifts—weekday day,

weekday night, weekend day, and weekend night—were asked to complete and

return questionnaires.

Results: Eighty-six patients consented to participate. Ninety-four women (51%)

and 92 men (49%) participated, with a median age range of 46 to 55 years. Fifty-five

percent thought that their religious or spiritual beliefs affected their health care

choices and decisions, whereas 43% had religious or spiritual needs at presentation

to the ED. Eighty-four percent thought providers should address the spiritual

concerns of patients in the ED, but only 56% actually wanted their providers to ask

about such needs during their current presentation, whereas 52% wanted someone

to pray or meditate with them while in the ED. However, 81% of patients reported

never having a provider ask about their beliefs or needs in the ED.

Conclusion: Most of the ambulance patients in our sample thought that

providers should address the spiritual beliefs and concerns of patients in the ED,

whereas a large portion presented to the ED with concomitant religious or

spiritual needs.

Table, abstract 374.

TransferHospitals (683 Cases)

ReceivingHospitals (673 Cases)

NotTransferred

TransferredOut

TransferredIn

NotTransferred

Mean age, y (SD) 82 (8) 76 (6) 75 (7) 78 (8)Female sex, % 60 42 45 54Frail, % 33 6 7 19Previous stroke, % 22 12 11 15Diabetes, % 36 25 26 33Creatinine >2.5

mg/dL, %25 8 11 18

Heart failureon admission, %

44 32 21 44

QOCAspirin on

admission, %88 94 NA 87

b-blocker onadmission, %

70 82 NA 66

Aspirin atdischarge, %

85 NA 87* 88*

b-blocker atdischarge, %

73 NA 92* 80*

R E S E A R C H F O R U M A B S T R A C T S

S 1 1 6

376 Emergency Medicine Workforce Study in Israel: 2003

Drescher MJ, Peleg J, Aharonson-Daniel L, Liebman Y/Sheba Medical Center and

University of Connecticut, Tel Hashomer, Israel; Gertner Institute for Epidemiology and

Health Policy Research, Tel Hashomer, Israel

Study objectives: Emergency medicine was officially recognized as a specialty in

Israel in 1999. In November 2003, the first class of 9 Israeli trained and examined

A N N A L S O F E M E R G E N C Y M E D I C I N E 4 4 : 4 O C T O B E R 2 0 0 4

EMF-7 EMTALA: Two Decades Later

Ballard DW, Derlet RW, Rich BA, Lowe RA/University of California–Davis, Sacramento,

CA; Oregon Health Science University, Portland, OR

Study objectives: We determine whether emergency departments (EDs) continue

to willfully deny screening and stabilization in violation of the Emergency Medical

Treatment and Active Labor Act (EMTALA) and to examine the evidence used to

justify EMTALA violations.

Methods: Under the Freedom of Information Act, the Centers for Medicare and

Medicaid was petitioned for the 200 most recent EMTALA citations requiring

a corrective plan of action. Each violation was classified into 1 of 3 primary

categories: (1) refusal to perform a screening examination or to stabilize; (2)

possible refusal to screen or stabilize; and (3) no evidence of refusal to screen or

stabilize. Citations were also classified into 10 additional subcategories, including

actual or risk of harm to patient(s), screening or treatment decisions based on

financial or insurance status, clinical judgment errors, procedural deficiencies, and

documentation failures. Violations occurring in inpatient locations and not

involving the ED were excluded. Three investigators independently reviewed

a subset of data, and interrater reliability was computed (k).

Results: We received 206 records from the period from November 1999 to

September 2001. Of these 206, 174 (84%) violations met inclusion criteria and 57

(33%) were category 1 (clear instances of EDs refusing to screen or stabilize), 43

(25%) were category 2 (possible refusal), and 74 (43%) were category 3 (no refusal).

Subcategory classifications included harm to patient(s) (17 [10%] of 174), financial

(7 [4%] of 174), clinical judgment (26 [15%] of 174), procedural (93 [53%] of 174),

and documentation (137 [79%] of 174). The interrater reliability k statistics for the

‘‘refusal to screen/treat’’ classifications (category 1 to 3) were 0.29 and 0.56 (fair to

moderate agreement).

Conclusion: Willful ED refusal to screen or stabilize still occurs despite EMTALA

regulation and enforcement. However, a substantial number of violations reviewed

contained no evidence of deliberate denial of care.

R E S E A R C H F O R U M A B S T R A C T S

emergency physicians were certified as specialists. We undertake this survey to

assess current staffing of emergency departments (EDs) in Israel and attempt to

estimate the need for emergency physicians in the future.

Methods: A survey instrument was sent to all ED directors in general hospitals

having EDs in Israel. The ED directors were informed that the information would be

kept anonymous and only used in the aggregate. We asked questions relating to ED

staffing by number of physicians, type of specialty, resident or specialist, and

differential staffing by time of the day and week. In addition, we inquired as to the

census, structure, hospital resources available, and size of the ED.

Results: We had a response rate of 96% (23 of 24 hospitals). There are 59 certified

emergency medicine specialists working in EDs in Israel, caring for a total of

1,872,500 visitors annually. A minority are residency trained. There are currently 37

emergency medicine residents enrolled in 19 programs in Israel. Emergency care is

otherwise given by specialists and residents in other fields and by nonspecialist

physicians. Presence of emergency medicine specialists is not evenly distributed by

hospital type or time of day. During the day shift at large hospitals, there is an

average of 2.25 emergency medicine specialists and another 4 specialists of other

types on duty. From midnight to 8 AM in large hospitals, there is an average of less

than 1 specialist of any kind (typically not emergency medicine) on duty in the ED.

Evenings and nights in most EDs, care is given by nonspecialists (residents in

various specialties and others nonspecialists) working 16-hour shifts. The shortage

of emergency physicians is greatest in medium-sized hospitals (average ED census

88,000 visits per year) where there is an average of only 5.3 full-time physicians (of

all types) employed, which is in contrast to large hospitals (average ED census

104,000) where there is an average of 9.3 full-time ED physicians (of all specialties).

Nineteen of 23 responding hospitals have been recognized as potential training sites

for emergency medicine residents.

Conclusion: The recognition of the need for emergency medicine as a specialty in

Israel by the medicopolitical establishment has not as yet translated into care of

emergencies by emergency physicians for most patients. It is apparent that to

adequately staff the existing EDs in Israel around the clock full time, there is a need

for a large increase in the number of emergency specialists. This increase will require

a policy emphasis on funding positions for emergency medicine staff and

a concentrated effort directed at emergency medicine resident education.

377 Factors Contributing to Increased Emergency Department UseAmong Patients With Chronic Conditions

Sorondo B, Zickgraf T, Fisher J, Minczak B/Philadelphia College of Osteopathic

Medicine, Philadelphia, PA; Albert Einstein Medical Center, Philadelphia, PA;

Thomas Jefferson University, Philadelphia, PA

Study objectives: The purpose of the study is to identify risk factors for emergency

department (ED) utilization among patients with chronic conditions.

Methods: This is a descriptive, population-based study using data from the

Medical Expenditure Panel Survey 2000. Individuals aged 18 years or older and with

diagnoses of chronic obstructive pulmonary disease, congestive heart failure,

diabetes mellitus, or hypertension were included as having chronic conditions.

Those patients were classified as ED users and non-ED users. Variables representing

characteristics such as demographics, socioeconomic status, health care utilization,

and number of chronic conditions were used in the analysis. STATA software was

used for Taylor-series approach to estimate SE for weighted survey estimates.

Multivariable analysis (stratification) and regression model were used to compare

the 2 groups and to assess the factors associated with visits to the ED. Confidence

intervals were calculated in each analysis.

Results: Of 25,095 cases reviewed, 3,997 (16%) were identified as having at least 1

of the 4 chronic conditions, and 18% of those were ED users. There were no

statistically significant differences between ED users and non-ED users in variables

such as age and insurance status. When the regression model was analyzed,

statistically significant factors associated with ED users were being female, nonwhite,

or unmarried; lacking prescription medical insurance; having a higher incidence of

outpatient physician visits; and having a higher incidence of prescriptions drug

refills (P\.01).

Conclusion: Individuals who have chronic conditions and are poor, lack

prescription insurance, are female, are nonwhite, have less than a college education,

or have a poor perception of their mental and physical health status are more likely

to use the ED for care.

378 A Prospective Study Comparing Standard Laryngoscopy to theTrachview Videoscope System for Orotracheal Intubation byEmergency Medicine Residents and Medical Students

Roppolo LP, Brockman CR, Hattan B, Hynan LS/University of Texas Southwestern,

Dallas, TX

Study objectives: Flexible fiberoptic bronchoscopy is a skill that can be difficult

for emergency physicians to use in the setting of an emergency intubation. The

TrachView Videoscope (TV) consists of a narrow high-resolution fiberoptic cable

whose tip is positioned at the distal end of the endotracheal tube. The image is

displayed on a small portable bedside monitor. In this way, the TV does not alter the

standard method of intubation but adds a second, possibly improved, view of the

vocal cords. The TV has never been formally studied. We determine the ease of use

and improvement in the percentage of glottic opening (POGO) score using the TV

by individuals with various levels of intubation experience.

Methods: The study was conducted in 2 phases on a mannequin model during an

airway laboratory for emergency medicine residents and medical students in

a university setting. Phase 1 consisted of a nonrandomized group sequential study

design in which, after a 10-minute demonstration of the TV, emergency medicine

residents assessed the POGO score using direct laryngoscopy (DL) and compared it

with their observed POGO score using the TV. Part 2 consisted of a crossover study

with first- and second-year medical students with no intubation experience. The

students were randomized into 2 groups that differed by the method of intubation

instruction given first: DL or TV. The students were given a 10-minute

demonstration of each technique and had 2 attempts to return the demonstration.

The POGO score noted by the student was recorded for each technique. The groups

were then crossed and the process was repeated. Additional information collected

from study subjects included ease of use of the TV and improvement in intubation

using the TV.

Results: In phase 1, the residents consisted of 4 postgraduate year (PGY)-1, 10

PGY-2, and 11 PGY-3 residents, and 3 participants whose level was not recorded, for

a total of 28. Overall, the median POGO score for DL was 50%, and the median

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