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Patients may present to Emergency Departments (ED) in shock for various reasons. Emergency medicine physicians may require the use of vasopressors or inotropes to manage these patients. The Critical Care Practice Committee of the Canadian Association of Emergency Physicians (C4) conducted an intensive literature search and guideline development process to help create an evidence based approach for use of these agents in the stabilization of shock.
Objectives: 1) To assess temporal patterns in historical patient arrival rates in an emergency department (ED) to determine the appropriate number of shift schedules in an acute care area and a fast-track clinic and 2) to determine whether physician scheduling can be improved by aligning physician productivity with patient arrivals using an optimization planning model.
Methods: Historical data were statistically analyzed to determine whether the number of patients arriving at the ED varied by weekday, weekend, or holiday weekend. Poisson-based generalized additive models were used to develop models of patient arrival rate throughout the day. A mathematical programming model was used to produce an optimal ED shift schedule for the estimated patient arrival rates. We compared the current physician schedule to three other scheduling scenarios: 1) a revised schedule produced by the planning model, 2) the revised schedule with an additional acute care physician, and 3) the revised schedule with an additional fast-track clinic physician.
Results: Statistical modelling found that patient arrival rates were different for acute care versus fast-track clinics; the patterns in arrivals followed essentially the same daily pattern in the acute care area; and arrival patterns differed on weekdays versus weekends in the fast-track clinic. The planning model reduced the unmet patient demand (i.e., the average number of patients arriving at the ED beyond the average physician productivity) by 19%, 39%, and 69% for the three scenarios examined.
Conclusions: The planning model improved the shift schedules by aligning physician productivity with patient arrivals at the ED.
To determine whether a nursing intervention delivered at emergency department (ED) discharge would reduce ED revisits.
A randomized study was conducted in the ED of a tertiary cardiac hospital in Montreal, Quebec. Between November 2006 and March 2010, 3,795 patients were assessed for eligibility based on two risk factors for ED revisits (≥1 ED visit in the past year and ≥6 medications); 132 were randomized to the experimental group (EG) and 133 to the control group (CG). The intervention included one nurse-patient meeting before leaving the ED, with two additional telephone contacts over the next 2 weeks. The primary outcome was time to ED revisits within 30 days after discharge. Secondary outcomes included time to ED revisits over 90, 180, and 365 days and hospitalizations over 30, 90, 180, and 365 days.
A planned interim analysis that stopped the study with half of the planned sample showed that the time to ED revisits was similar in both groups at 30 days (p=0.81; revisits: 18.2% in EG, 19.6% in CG), 90 days (p=0.44), 180 days (p=0.98), and 365 days (p=0.75). The only difference identified was a lower hospitalization proportion at 180 days in the EG group (13.6% v. 24.1%; p=0.038).
These findings are consistent with previous research showing that few ED-based interventions are successful in reducing ED returns. Factors other than those targeted by the intervention, including an improvement in usual care, may explain the findings.
One of the many challenges facing emergency departments (EDs) across North America is timely access to emergency radiology services. Academic institutions, which are typically also regional referral centres, frequently require cross-sectional studies to be performed 24 hours a day with expedited final reports to accelerate patient care and ED flow.
The purpose of this study was to determine if the presence of an in-house radiologist, in addition to a radiology resident dedicated to the ED, had a significant impact on report turnaround time.
Preliminary and final report turnaround times, provided by the radiology resident and staff, respectively, for patients undergoing computed tomography or ultrasonography of their abdomen/pelvis in 2008 (before the implementation of emergency radiology in-house staff service) were compared to those performed during the same time frame in 2009 and 2010 (after staffing protocols were changed).
A total of 1,624 reports were reviewed. Overall, there was no statistically significant decrease in the preliminary report turnaround times between 2008 and 2009 (p = 0.1102), 2009 and 2010 (p = 0.6232), or 2008 and 2010 (p = 0.0890), although times consistently decreased from a median of 2.40 hours to 2.08 hours to 2.05 hours (2008 to 2009 to 2010). There was a statistically significant decrease in final report turnaround times between 2008 and 2009 (p < 0.0001), 2009 and 2010 (p < 0.0011), and 2008 and 2010 (p < 0.0001). Median final report times decreased from 5.00 hours to 3.08 hours to 2.75 hours in 2008, 2009, and 2010, respectively. There was also a significant decrease in the time interval between preliminary and final reports between 2008 and 2009 (p < 0.0001) and 2008 and 2010 (p < 0.0001) but no significant change between 2009 and 2010 (p = 0.4144).
Our results indicate that the presence of a dedicated ED radiologist significantly reduces final report turnaround time and thus may positively impact the time to ED patient disposition. Patient care is improved when attending radiologists are immediately available to read complex films, both in terms of health care outcomes and regarding the need for repeat testing. Providing emergency physicians with accurate imaging findings as rapidly as possible facilitates effective and timely management and thus optimizes patient care.
To determine the outcomes of patients discharged from the emergency department (ED) with a bloodstream infection (BSI) and how these outcomes are influenced by antibiotic treatment.
We identified every BSI in adult patients discharged from our ED to the community between July 1, 2002, and March 31, 2011. The medical records of all cases were reviewed to determine antibiotic treatment in the ED and at discharge. Microorganism sensitivities were used to determine whether antibiotics were appropriate. These data were linked to population-based administrative data to determine specific patient outcomes within the subsequent 2-week period: death, urgent hospitalization, or an unplanned return to the ED.
A total of 480 adults with BSI were identified (1.49 cases per 1,000 adults discharged from the department). Compared to controls (321,048 patients), BSI patients had a significantly higher risk of urgent hospitalization (adjusted OR 2.1 [95% CI 1.6–2.8]) and unplanned return to the ED (adjusted OR 4.1 [95% CI 3.3–4.9]). Outcome risk was significantly lowered in BSI patients who received appropriate antibiotics in the ED and at discharge. In elderly patients, the risk of urgent hospitalization increased significantly as the time to appropriate antibiotics was delayed.
BSI patients discharged from the ED have a significantly increased risk of urgent hospitalization and unplanned return to the ED in the subsequent 2 weeks. These risks decrease significantly with the timely provision of appropriate antibiotics. Our results support the aggressive use of measures ensuring that such patients receive appropriate antibiotics as soon as possible.
Determining which patients with ureterolithiasis are likely to require urologic intervention is a common challenge in the emergency department (ED). The objective was to determine if normal renal sonogram could identify low-risk renal colic patients, who were defined as not requiring urologic intervention within 90 days of their initial ED visit and can be managed conservatively.
This was a prospective cohort study involving adult patients presenting to the EDs of a tertiary care centre with suspected renal colic over a 20-month period. Renal ultrasonography (US) was performed in the diagnostic imaging department by trained ultrasonographers, and the results were categorized into four mutually exclusive groups: normal, suggestive of ureterolithiasis, visualized ureteric stone, or findings unrelated to urolithiasis. Electronic medical records were reviewed to determine if patients received urologic intervention within 90 days of their ED visit.
Of 610 patients enrolled, 341 (55.9%) had US for suspected renal colic. Of those, 105 (30.8%) were classified as normal; none of these patients underwent urologic intervention within 90 days of their ED visit. Ninety (26.4%) US results were classified as suggestive, and nine (10%) patients received urologic intervention. A total of 139 (40.8%) US results were classified as visualized ureteric stone, and 34 (24.5%) patients had urologic intervention. Seven (2.1%) US results were classified as findings unrelated to urolithiasis, and none of these patients required urologic intervention. The rate of urologic intervention was significantly lower in those with normal US results (p<0.001) than in those with abnormal findings.
A normal renal sonogram predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected renal colic.
Given the recent publication of several large trials and systematic reviews, we undertook a study of the current management of bronchiolitis in Canadian pediatric emergency departments (EDs) and explored physicians’ rationale for their treatment decisions. The overarching purpose of this study was to assist in planning a future trial of combined epinephrine and dexamethasone for bronchiolitis.
Physicians in the Pediatric Emergency Research Canada (PERC) database received an 18-item electronic survey. A modified Dillman method was used.
Of the 271 physicians surveyed, 191 (70.1%) responded. The majority (120 of 271; 66.5%) reported ‘‘typically’’ giving a bronchodilator trial in the ED, with respondents almost evenly divided between treatment with salbutamol (n=62) and treatment with epinephrine (n=61). Of those who use salbutamol, 77.4% indicated that they prefer it because it can be prescribed for home use. Of those who use epinephrine, 80.3% indicated that they believe the medical literature supports its benefit over salbutamol. Few participants (2.6%) reported ‘‘always’’ using steroids, whereas the majority (62.8%) reported ‘‘sometimes’’ using them. The most common factor reported to influence steroid use was illness severity (73.3%). The majority (60.5%) reported that if corticosteroids were beneficial in bronchiolitis, they prefered treatment with a single dose in the ED as opposed to a multiday course.
Our results indicate that physicians practicing in Canadian pediatric EDs commonly use bronchodilators to manage bronchiolitis but use corticosteroids less commonly. They appear to be uncomfortable using corticosteroids, particularly longer courses, and have a stated preference for a single dose. Any future trial examining the role of corticosteroids in bronchiolitis should carefully consider the issue of steroid dosage.
To determine the influence of early pain relief for patients with suspected appendicitis on the diagnostic performance of surgical residents.
A prospective randomized, double-blind, placebo-controlled trial was conducted for patients with suspected appendicitis. The patients were randomized to receive placebo (normal saline intravenous [IV]) infusions over 5 minutes or the study drug (morphine 5 mg IV). All of the clinical evaluations by surgical residents were performed 30 minutes after administration of the study drug or placebo. After obtaining the clinical probability of appendicitis, as determined by the surgical residents, abdominal computed tomography was performed. The primary objective was to compare the influence of IV morphine on the ability of surgical residents to diagnose appendicitis.
A total of 213 patients with suspected appendicitis were enrolled. Of these patients, 107 patients received morphine, and 106 patients received placebo saline. The negative appendectomy percentages in each group were similar (3.8% in the placebo group and 3.2% in the pain control group, p=0.62). The perforation rates in each group were also similar (18.9% in the placebo group and 14.3% in the pain control group, p=0.75). Receiver operating characteristic analysis revealed that the overall diagnostic accuracy in each group was similar (the area under the curve of the placebo group and the pain control group was 0.63 v. 0.61, respectively, p=0.81).
Early pain control in patients with suspected appendicitis does not affect the diagnostic performance of surgical residents.
Not all patients with suspected acute coronary syndrome (ACS) receiving cardiac troponin (cTn) testing present to the emergency department (ED) with cardiac chest pain. Since elderly patients (age ≥70) have increased morbidity and mortality associated with ACS, complaints other than cardiac chest pain may justify cTn testing. Our primary objective was to characterize the population of ED patients who receive cTn testing. The secondary objective was to determine if elderly patients underwent cTn testing for different presenting complaints than their younger counterparts.
We created an electronic database including Canadian Emergency Department Information Systems (CEDIS) presenting complaints, age, sex, disposition, and Canadian Triage Acuity Scale (CTAS) score, for patients who received cTn testing in three Canadian EDs during 2011. We analyzed the data for patient characteristics and sorted by age (<70 and ≥70) for further analysis.
In the 15,824 included patients, the average age was 66 (51%<70; 51% female). The most common presenting complaints were cardiac chest pain (n=3,267) and shortness of breath (n=2,266). The elderly underwent cTn testing for significantly (p<0.0001) different complaints than their younger counterparts. They more commonly presented with generalized weakness (n=898), whereas younger patients more frequently had abdominal pain (n=576).
Cardiac chest pain and shortness of breath are presenting complaints in one-third of patients undergoing ED cTn testing. The majority of patients undergoing cTn testing did not have typical ACS symptoms. Half of all cTn testing in the ED is on the elderly, who present with different complaints than their younger counterparts.
Unenhanced computed tomography (CT) has become a standard imaging technique for uncomplicated renal colic in many countries. The appropriate timing of CT imaging has not been established, and guidelines recommend that this imaging be performed between 1 and 7 days of presentation. The primary objective of this study was to determine the prevalence of alternative diagnosis identified with low-dose unenhanced CT in the emergency department (ED) in patients with suspected uncomplicated renal colic.
This prospective single-centre study was carried out in a large university hospital ED. Over a 6-month period, all patients with clinically diagnosed renal colic and a plan to be discharged underwent low-dose unenhanced CT in the ED. Pregnant women, women of childbearing age not willing to have a pregnancy test, and patients who had already undergone diagnostic imaging were excluded. The primary outcome was the number and nature of the alternative diagnosis. Univariate analyses were performed to assess factors associated with the primary outcome.
A total of 178 patients were screened, and 155 underwent CT in the ED. The mean age was 42.2 years; 69% were male. The diagnosis of uncomplicated renal colic was confirmed in 118 participants (76%); 27 (17%) had an inconclusive CT scan. Overall, 10 patients (6%; 95% confidence interval [CI] 3–10) had an alternative diagnosis, 5 of whom were subsequently hospitalized.
Low-dose unenhanced CT in the ED detects alternative diagnoses in 6% (95% CI 3–10) of patients with suspected uncomplicated renal colic, half of whom are subsequently hospitalized. Our prospective findings, which were similar to those reported in retrospective studies, are a potential argument for a systematic approach to ED imaging in suspected renal colic. Future research involving intervention and control groups would be helpful.
Emergency medicine point-of-care ultrasonography (EM-PoCUS) is a core competency for residents in the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada emergency medicine (EM) training programs. Although EM-PoCUS fellowships are currently offered in Canada, there is little consensus regarding what training should be included in a Canadian EM-PoCUS fellowship curriculum or how this contrasts with the training received in an EM residency.
To conduct a systematic needs assessment of major stakeholders to define the essential elements necessary for a Canadian EM-PoCUS fellowship training curriculum.
We carried out a national survey of experts in EM-PoCUS, EM residency program directors, and EM residents. Respondents were asked to identify competencies deemed either nonessential to EM practice, essential for general EM practice, essential for advanced EM practice, or essential for EM-PoCUS fellowship trained (‘‘expert’’) practice.
The response rate was 81% (351 of 435). PoCUS was deemed essential to general EM practice for basic cardiac, aortic, trauma, and procedural imaging. PoCUS was deemed essential to advanced EM practice in undifferentiated symptomatology, advanced chest pathologies, and advanced procedural applications. Expert-level PoCUS competencies were identified for administrative, pediatric, and advanced gynecologic applications. Eighty-seven percent of respondents indicated that there was a need for EM-PoCUS fellowships, with an ideal length of 6 months.
This is the first needs assessment of major stakeholders in Canada to identify competencies for expert training in EM-PoCUS. The competencies should form the basis for EM-PoCUS fellowship programs in Canada.
Although penetrating neck injuries (PNIs) represent a small subset of patients presenting to the emergency department (ED), they can result in significant morbidity and mortality. The approach to airway management in PNI varies widely according to clinical presentation and local practice, such that global management statements are lacking. Although rapid sequence intubation (RSI) may be safe in most patients with PNI, the high-risk subset (10%) of patients with laryngotracheal injury require particularly judicious airway management. It is not known if RSI is safe in such patients, nor has there been reported use of videolaryngoscopy in patients with open PNI. Established principles of airway management in patients with an open airway injury include the avoidance of both positive pressure bag-mask ventilation and blind tube passage and the early consideration of a surgical airway. Because this high-risk subset may not be clinically apparent on initial presentation in the ED, such guiding principles apply to all patients with PNI until the nature of the injury is more accurately defined. In this report, we present the case of a patient who presented to the ED with a zone II open PNI, which occurred as a result of a stab wound.
Although bedside ultrasonography can accurately distinguish esophageal from tracheal intubation, it is not used to establish the correct depth of endotracheal tube insertion. As indirect sonographic markers of endotracheal tube insertion depth have proven unreliable, a method for visual verification of correct tube depth would be ideal. We describe the use of saline to inflate the endotracheal cuff to confirm correct endotracheal tube depth (at the level of the suprasternal notch) by bedside ultrasonography during resuscitation. This rapid technique holds promise during emergency intubation.