8 MHz convex (endocavity) transducer was used to observe the path of the resident’sneedle without interference with the placement procedure. Unknown to studyparticipants, researchers tracked the frequency of posterior wall penetration, and finalneedle location when the resident felt optimal needle placement was achieved in thelumen of the internal jugular. Residents were also asked about their confidenceregarding appropriate final needle position on a ten point Likert scale. Statisticalanalysis consisted of descriptive statistics and regression analysis. /b�

Results: A total of 25 residents participated. All had placed at least one US guidedcentral lines previously. The mean number of previous US guided cannulations was9.7. Sixteen residents accidentally penetrated the posterior wall of the IJ duringcannulation. Mean number of posterior wall penetrations was 2.4. In 5 cases the finallocation of the needle was actually through the posterior wall and deep to the venouslumen. In 3 cases the carotid artery was mistakenly cannulated. Mean confidence byresidents regarding appropriate needle placement was 8.7. There was no correlationbetween previous experience, level of residency training and number of posterior wallpenetrations.

Conclusion: In this study residents accidentally penetrated the posterior vessel wall ofthe internal jugular in a life like vascular access mannequin in the majority of cases. Theseresults suggest that care must be taken even with ultrasound guided central line placementand alternative ultrasound guidance techniques such as longitudinal imaging of the targetvessel and cannulating needle may need to be considered.

218 The Utility of Bedside Ultrasound in the Detectionof a Ruptured Globe in a Porcine Model

Chandra A, Mastrovitch T, Samudre S, Ladner H, Ting V/New York HospitalQueens, Flushing, NY; Eastern Virginia Medical School, Norfolk, VA

Background: Ocular trauma is associated with pain and surrounding soft tissueedema that may impede direct visualization of the eye in an emergency setting.Ultrasound examination by a trained emergency (EM) physician may expedite thediagnosis and treatment of traumatic pathology. However, the potential of a rupturedglobe is a relative contraindication to the use of ultrasound due to the inherent risk ofintraocular content extrusion.

Study Objectives: This study investigated the ability of emergency physicians to detectsonographic changes in ruptured globes in an ex vivo porcine model. Additionally, changesin intraocular pressure (IOP) during probe applanation with and without a clear plasticbarrier were measured in order to evaluate the safety of this technique.

Methods: Following a 15 minute lecture on the use of ultrasound in emergencyeye conditions, 15 EM residents and 4 EM attendings performed ocular sonography(10-MHz linear-array transducer) on 9 consecutive porcine heads (18 eyes). The eyeswere pretreated as normal, ruptured globes with abnormal anatomy and moderatevitreous loss (MVL), and complete vitreous loss (CVL) conditions. A subset of eyeswas cannulated and attached to a pressure sensor to evaluate IOP changes during theprocedure. The utility of a clear plastic barrier (1mm thick) to alleviate this pressuredifferential was also assessed.

Results: The sensitivity of this technique to identify globe rupture was 71%, witha specificity of 60%. In the current experimental group, a 63% positive predictivevalue (PPV) was established for MVL, with a 79 % PPV for CVL. Based on traininglevel, attending ER physicians were consistently more accurate than residents inidentifying ocular conditions, although second year residents as a group had thehighest scores. When maximal pressure was applied with the probe on normal eyes,IOP increased by 17%. IOP increased by only 5% when using the minimal amountof pressure to obtain a clear image. With a plastic shield, the probe did not cause ameasurable increase in IOP nor did it alter the quality of the ultrasound image.

Conclusions: Ultrasound can be used by trained emergency physicians to identifyglobe rupture. The use of a clear plastic barrier prevents an increase in IOP withoutaffecting image quality. The advanced training of second year residents and attendingphysicians was reflected in the data. The sensitivity and specificity could likely beimproved with further training.

219 The Use of an Express Admit Unit to Alleviate EDCrowding

Hong R, Cleary Lake A, O’Connor RE, Laskowski Jones L, Farley H, Heath S,Michalke J, Bollinger M/Christiana Care Health System, Newark, DE

Study Objectives: To evaluate the effectiveness of an Express Admit Unit (EAU)in reducing emergency department (ED) length of stay (LOS) and in increasing EDrevenues.

Methods: This prospective randomized, controlled study included 930 patients

over 16 years of age admitted through the ED to general floor status during the studyperiod. The EAU uses dedicated staff to complete admission orders prior to sendingthe patient to an inpatient bed. Patients admitted to a higher level of care thangeneral floor status, patients requiring a specialty unit, patients with a fractured hip,or admitted patients that require a change in level of care were excluded. Patientsadmitted to intensive care or to a specialty unit, or those showing clinicaldeterioration while in the ED were excluded. Data were collected using a passiveelectronic patient tracking system, an automated hospital database, and chart review.Patients were randomized to either the study group (admitted through EAU) or thecontrol group (admitted directly to floor bed) per protocol. Comparison of the meanbetween EAU and non-EAU patients will utilize the independent group t-test fornormally distributed data and the Mann-Whitney U test data for non-normaldistributions. Data comparison between the APR-DRG groups will incorporate theANOVA and Kruskal-Wallis tests. A cost analysis was performed to determinerevenues potentially gained from an hour of decreased ED boarding time for eachEAU-qualified patient. The hospital Institutional Review Board has approved thestudy.

Results: The following data were obtained:

Based on the results, EAU patients had a mean statistically significant decrease inED length of stay of 62 minutes. The cost analysis based on Year 2006 ED census of97,206 with this study’s admission rate of EAU-qualified patients of 15.61% showeda potential revenue increase of $2,693,824 as a result of an average decreased EDLOS of 1 hour. This revenue is generated by increasing ED capacity to see 3,236more patients.

Conclusion: An EAU can help alleviate ED crowding by reducing ED LOS.Decreased ED boarding time can also significantly increase ED revenues by treatingmore patients in areas no longer boarded by admitted patients.

220 Productivity: Do 8-9 Hour Shifts Make aDifference?

Hart A, Krall S/Christus Spohn Memorial, Corpus Christi, TX

Study Objectives: Compare average physician hourly productivity when theywork 8 or 9 hour shifts versus 12 hour shifts in the main emergency department.

Methods: Data was collected at an urban emergency department that sees 47,000patients annually is staffed by 60 hours of attending physician coverage, 48 hours inthe main department, with an admission rate of 27%. The facility was the level 2trauma center for the area, with a trauma team and infrequent internal medicineresidents rotating through the department. Data was collected from an internaltracking system in an excel database format. Data analysis was done on all maindepartment shifts except the overnight 23:00 to 07:00 and 11:00-23:00 urgent careshift. “Busy period” was defined as 09:00-13:00 for the day shift and 18:00-21:00 forthe evening shift. Results were analyzed using Student T Test and summary statistics.

Results: Average patients seen per hour for the 8-9 hour shifts was 1.89 patientsversus 1.66 for the 12 hour shift. The day shift comparison showed a greaterproductivity for the 07:00 to 15:00 compared to 06:00 to 18:00, with animprovement of 0.52 patients per hour for the 8 hour shift, see Table 1.

Research Forum Abstracts

Volume , . : September Annals of Emergency Medicine S69