1. The principle investigator would like to thank Ohio Valley Medical Center for their support in completing this study. Also, I’d like to thank Drs. Dougherty and Carney for their input and guidance. Thank you to Harriet Kelly for her research assistance. Lastly, I’d like to thank Lance Ridpath and West Virginia School of Osteopathic Medicine Research Center. Background Objectives Discussion References Acknowledgments Methods Klocek P., D.O. PGY-IV; D’Agostino S., D.O PGY-II; Carney M., D.O.;Dougherty J., D.O.; Ridpath L MS. Ohio Valley Medical Center, Wheeling, WV Results West Virginia and Rural Emergency Department Ultrasound – Do They Have it? 1. To determine if U/S is available in rural emergency departments in WV. 2. To determine what factors affect ultrasound availability in the ED. Is there a relationship to ED size, volume, proximity to transfer hospitals, CT scan availability or the presence of other ultrasound devices in the hospital? Using Google search and Google Maps, West Virginia was surveyed for all emergency departments. The physical locations of 56 EDs were recorded and saved on Google Maps Registry. This information was used to update the ED list maintained by WV ACEP and the WV Trauma Registry. The chief investigator personally contacted each facility in search of seven questions. Only forty-eight of the fifty-six hospitals were willing to give information. Each ED was assigned a number for anonymity. Number six from the questionnaire was discarded since the answer varied depending on several conditions, including weather. A data grid was created using Microsoft Excel. A statistician from the Mountain State Osteopathic Postdoctoral Training Institute (MSOPTI) Research Center at WVSOM analyzed the data using SAS version 9.2. From the data and analysis it becomes quite clear that smaller, lower volume emergency departments are far less likely to have access to ultrasound. This is a statistically significant correlation. Furthermore, trauma level designation significantly increases the likelihood that the facility will have bedside ultrasound. About seventy percent of level one, two, and three trauma centers have emergency department ultrasound. Interestingly, the distance to the preferred referral/transfer center did not correlate with the availability of bedside ultrasound. In future studies, including transfer rates may be a better way to evaluate the rural nature of some facilities. This was not factored into this study. At this point it is unclear what level of proficiency the providers at these sites might have. Physicians cannot cultivate sonography skills without access to the necessary tools. The purpose of this study was to demonstrate that many lower volume emergency departments that might benefit from the presence of ultrasound might not have access to it. Class size before expansion Photos. graphics, xrays, ???? 1 Tucker, J K et al. Traumatic intraperitoneal haemorrhage– Diagnosis by paracentesis. Annals RC of Surg of Eng. 1975 vol 56:33-37 2 Diercks DB. Clinical policy: critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med - 01-APR-2011; 57(4): 387-404 3 Brenner DJ, Hall EJ. Computed tomography – An Increasing Source of Radiation Exposure. N Engl J Med 2007 Nov;357(22):2277-2284. 4 Shackford SR, Rogers FB, Osler TM, et al: Focused abdominal sonogram for trauma: The learning curve of nonradiologist clinicians in detecting hemoperitoneum. J Trauma 1999; 46:553. 5. Blackbourne LH, Soffer D, McKinney MG, et al: Secondary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma 2004; 57:934. 6 Flynn, Candi MS et al. Emergency Medicine Ultrasonography in Rural Communities, Canadian Journal of Rural Medicine, 2012 ;17(3) 7 Gilman, Lawrence et al. Review – Clinician Performed Resuscitative Ultrasonography for the Initial Evaluation and Resuscitation of Trauma, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 6-August-2009 Evaluation of the relationship between other in-house ultrasound and emergency department bedside ultrasound showed that a raw value of 26 (59.1%) of the 44 hospitals with in house ultrasound in another department had ultrasound in the emergency department. No hospital had bedside ultrasound availability without other in house ultrasound (Tab2). CT scan availability did not appear to have any correlation. A Fischer’s Exact test was used and the p-value equal to 0.59 shows no suggestion of correlation between the two. Department volume, measured in visits per year, did show correlation with the likelihood of having ultrasound in the Emergency department. Logistic regression modeling was used to model that for every 1000 patient visits per year that the odds of having an emergency department ultrasound increased by 1.16. This showed statistical significance with a Wald Chi-Squared Test with a p-value equal to less than 0.01 (Tab2). Bed count, which logically increases with emergency department volume and would intuitively correlate with the likelihood of ED ultrasound was also tested. This actually showed a higher relative likelihood ratio than that demonstrated by ED volume. Logistic regression modeling was again used to show an odds ratio of 1.20 for each additional bed. All level 1,2 or 3 trauma centers in the State had ED ultrasound. There was variability between level 4 trauma center and non-designated EDs. Trauma centers had ED ultrasound in 71.4 percent of all cases. Those with no designator had ultrasound only 28.6 percent of the time (Fig3). Odds ratio was 5.83 in favor of having ED ultrasound with a trauma designation. The rural nature of the facility (miles by road to the preferred transfer center) did not show a definitive trend or correlation between the presence of ED ultrasound and the distance to the referral center. Figure 1. Physical Location of Emergency Departments in WV. Bedside ultrasound is rapidly gaining acceptance in the emergency department and playing an increasingly vital role in the trauma assessment. Historically, evaluation for intra-abdominal injuries has been performed by diagnostic peritoneal lavage (DPL). DPL requires an abdominal incision, which inherently has risks. Data show there is a 0.3-4% adverse event risk per incision. However, in recent decades the computed tomography (CT) has become faster, more reliable, specific and sensitive. As a result, DPL is not performed as frequently. The CT scan has enabled surgeons to identify specific injuries before taking patients to the operating theater. With new technology, there are also drawbacks. For example, many facilities do not have access to CT scans. Additionally, the patient may be unstable and the risk of a CT scan may outweigh its benefit. Radiation exposure is another risk inherent to CT scans. What can be done quickly, with adequate sensitivity, with low enough costs and minimal risk, to assess for those intra-abdominal injuries. Ultrasound (U/S) can be performed quickly at the bedside, with adequate sensitivity, is low risk and also has a relatively low cost. U/S can show evidence of abdominal free fluid with sensitivity that is comparable to DPL and CT. It can easily be repeated and there is no risk of ionizing radiation exposure nor a puncture/incision. U/S can also show pneumothorax, pleural effusions, and pericardial effusions and can evaluate specific organs such as the liver, spleen, kidneys and bladder. In the unstable trauma patient a FAST scan (focused assessment with sonography in trauma) can indicate the need for surgery and help identify the specific injury.. Bedside ultrasound can quickly and safely add invaluable information that is on par with DPL and CT scan. But, is it available? Table 2. Logistical Regression Predictors of Ultrasound in ED Figure 3. Likelihood of U/S in ED vs Trauma Designation Table 1. Questionnaire used for data collection