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Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The objective of this study was to explore the lived experiences and perceptions of care of women treated for early pregnancy complications in the ED and early pregnancy clinic (EPC). Methods: We conducted an interpretive phenomenological qualitative study of women who presented to the ED or EPC of an urban tertiary care hospital with early pregnancy loss or threatened loss. We employed purposive sampling to recruit participants for in-depth, one-on-one telephone interviews conducted approximately 6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Our research team of two qualitative researchers, a clinician, a clinical researcher, and a research student performed a phenomenologically-informed thematic analysis including three phases of coding to identify essential patterns of lived experience and meaning across the sample. Results: Interviews were completed with 30 women between July and August 2018. Participants ranged in age from 22 to 45 years and reflected the diversity of the multicultural city where the study occurred. Four key themes of patient experience were identified: tensions between what is known and unknown by women and ED staff about early pregnancy complications and care in hospital, stigmatization of early pregnancy complications and ED use, normalization of a chaotic experience, and the overwhelm of unexpected outcomes during the ED visit. Conclusion: The perspectives of women attending the ED or EPC for early pregnancy complications highlights the ways in which the current health care system minimizes and medicalizes early pregnancy complications in this setting and fails to adequately support these women. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are traumatic for patients and families. However, the participants’ negative experiences occurring in the ED were often mitigated with their care in their follow-up with the EPC.
Introduction: Little is known about the variety of roles volunteers play in the emergency department (ED), and the potential impact they have on patient experience. The objective of this scoping review was to identify published and unpublished reports that described volunteer programs in EDs, and determine how these programs impacted patient experiences or outcomes. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. A grey literature search was also conducted (Web of Science, ProQuest, Canadian Business and Current Affairs Database ProQuest Dissertations and Theses Global). Two reviewers independently screened titles and abstracts, reviewed full text articles, and extracted data. Results: The search strategy yielded 4,589 potentially relevant citations. After eliminating duplicate citations and articles that did not meet eligibility criteria, 87 reports were included in the review. Of the included reports, 18 were peer-reviewed articles, 6 were conference proceedings, 59 were magazine or newspaper articles, and 4 were graduate dissertations or theses. Volunteer activities were categorized as non-clinical tasks (e.g., provision of meals/snacks, comfort items and mobility assistance), navigation, emotional support/communication, and administrative duties. 52 (59.8%) programs had general volunteers in the ED and 35 (40.2%) had volunteers targeting a specific patient population, including pediatrics, geriatrics, patients with mental health and addiction issues and other vulnerable populations. 20 (23.0%) programs included an evaluative component describing how ED volunteers affected patient experiences and outcomes. Patient satisfaction, follow-up and referral rates, ED and hospital costs and length of stay, subsequent ED visits, medical complications, and malnutrition in the hospital were all reported to be positively affected by volunteers in the ED. Conclusion: This scoping review demonstrates the important role volunteers play in enhancing patient and caregiver experience in the ED. Future volunteer engagement programs implemented in the ED should be formally described and evaluated to share their success and experience with others interested in implementing similar programs in the ED.
Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.
Introduction: Alcohol use disorder (AUD) is a chronic relapsing and highly comorbid disease. Patients suffering from AUD are frequently seen in the emergency department (ED) presenting intoxicated or in withdrawal. Brief interactions in the ED are often the only portal of entry to the healthcare system for many of these patients. Oral naltrexone and long acting injectable naltrexone are effective treatment options for AUD associated with decreased cravings, shorter length of hospital stay, and lower cost of healthcare utilization. This study's objective was to perform a systematic review of the literature evaluating initiation of naltrexone in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing initiation of naltrexone in patients (≥18 years) to standard care in the ED were included. Two reviewers independently screened titles and abstracts, reviewed full text articles for inclusion, assessed quality of the studies, and extracted data. Results: The search strategy yielded 183 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 10 articles were retrieved for full text review. There were no published RCTs that examined naltrexone initiation in the ED. There is one ongoing study being conducted in New York, which aims to assess naltrexone initiation in the ED and measure health outcomes and quality of life of study participants, as well as potential healthcare cost savings. Conclusion: The lack of published research in this area demonstrates a significant gap in knowledge. It is clear that well-designed RCTs are needed to evaluate the effectiveness of initiating naltrexone for those with AUD at the ED visit.
Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.
Introduction: Choosing Wisely Canada guidelines suggest that in the absence of red flags or clinical indicators suggestive of serious underlying conditions, physicians should not order radiological images for patients presenting with non-specific low back pain, and current recommendations do not endorse routine prescribing of opioids for this condition. The objective of this study was to determine how many patients presenting to the ED with non-traumatic low back pain have spinal imaging and how many are discharged home on opioids. Methods: We conducted a retrospective medical record review for adult (>17 years) patients presenting to an academic tertiary care ED with non-traumatic low back pain from April 1st 2014 to March 31st 2015 (pre-guideline) and April 1st 2017 to March 31st 2018 (post-guideline). Patients were excluded if they were >70 years old, were not discharged home, had a traumatic injury, features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, first episode of low back pain over 50 years of age, abnormal reflexes, loss of motor strength or loss of sensation in the legs. Results: 1060 (545 pre-guideline, 515 post-guideline) were included. Mean (SD) age was 39.6 (12.3) years and 549 (51.8%) were female. Pre-guideline, 45 (8.3%) patients had spinal imaging, compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% CI: −2.6% to 4.0%). Of the 84 (7.9%) patients who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline, compared to 10 (25.6%) patients post-guideline. The proportion of patients discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines (40.9% vs. 11.1%; Δ29.8%; 95% CI: 24.8% to 34.7%). Conclusion: Choosing Wisely Canada guidelines did not appear to alter the rate of imaging for patients presenting to the ED with non-traumatic low back pain. Overall the rate of spinal imaging was lower than expected. The proportion of patients who were discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines, however we don't know if this represents an overall trend in the reduction of opioid prescribing, or a specific change in practice related to the ED management of low back pain.
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
Despite extensive research on organizational virtue, our understanding about factors that promote virtue within organizations remains unclear. Drawing on upper echelon theory, we examine the relationship between five top management team (TMT) characteristics and organizational virtue orientation (OVO)—the integrated set of values and beliefs that support ethical traits and virtuous behaviors of an organization. Specifically, we utilize prospectuses of initial public offering (IPO) firms and 10-K post-IPO filings to explore how TMT composition with respect to member age, tenure, education, functional background, and gender influences OVO. Additionally, we examine the moderating effects of organizational size, and argue that the more expansive structures and processes associated with larger organizations diminish the main relationships. Our findings, using two sources of data, are consistent, but somewhat mixed in their support for our hypotheses. Overall, TMT characteristics do appear to influence OVO, but in more complex and counterintuitive ways than initially expected.
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.
Introduction: The optimal management of emergency department (ED) patients with alcohol withdrawal syndrome (AWS) includes a symptom driven approach with scheduled reassessments using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treatments according to symptom severity. The subjective nature of the CIWA-Ar, and lack of standardized competency-based education related to alcohol withdrawal results in widely variable treatment. The objective of this study was to perform a summative evaluation of clinical staff during the objective structured clinical examination (OSCE) of a simulated patient (SP) with AWS. Methods: The AWS education curriculum was completed by all staff nurses in our ED (mandatory for full-time, optional to part-time staff). It was based on a real clinical scenario depicting moderate alcohol withdrawal and portrayed by a single SP. Prior to the OSCE, participants attended a seminar orienting them to the simulation. Each participant was asked to do a complete assessment of the SP, and graded for completeness on 37 individual components of history/physical exam, including the 10 domains of the CIWA-Ar. Results: 74 participants completed the educational curriculum over 8 weeks. At least 9/10 domains of the CIWA-Ar assessment were completed by 65 (88%) of participants, and 28 (38%) correctly assessed at least 80% of all summative evaluation components. 63 (85%) participants correctly identified the need for treatment of withdrawal symptoms. Only 13 (18%) participant assessments exactly matched our exact target CIWA-Ar score of 15, however 61% were within 2 points on the CIWA-Ar scale. In only 4 (5%) instances would a participant have inappropriately rated AWS severity below the treatment threshold. 62/72 (86%) participants rated the SP tremor as 2-4 (intended tremor =3). Clinical features most often overlooked were history of other addictions (25 participants, 33%) and history of liver disease (15 participants, 20%). Conclusion: The majority of participants in this OSCE correctly assessed the important elements in the assessment of AWS, and diagnosed the SP as having moderate alcohol withdrawal. Thus our educational intervention resulted in 85% of participants properly identifying the severity of AWS, and developing an appropriate treatment strategy. The impact of this curriculum on actual patient treatment requires further evaluation.
Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.
In the Central Kenyan Highlands, dairy cattle ownership is a crucial element in poverty alleviation. For example, in Kiambu district just north of Nairobi, out of the population of 744010, 48% of 189709 households stall feed dairy cattle. Farm sizes average 1.1 to 2.0 ha per household. Producing sufficient forage for dairy cattle is difficult and low dry matter intake constrains dairy production and there is a positive correlation between stover intake and milk yield.. Napier grass comprised 40% of the total dry matter fed to cattle and maize forage 24% according to the project’s Rapid Rural Appraisal, maize thinnings and stover being routinely fed to livestock. In another survey, dry maize stover accounted for nearly 65% of dry matter intake of dairy cattle during October.
Introduction: In Canada, family physicians (FPs) provide the majority of early pregnancy care. To receive a same day US, most patients will be sent to the emergency department (ED). FPs are starting to use point of care ultrasound (POCUS) for a variety of indications. The FaMOUS course was modeled after the Canadian Emergency Ultrasound Society (CEUS) ED Echo (EDE) curriculum and adapted with permission for FPs. The objective of this study was to assess the indications for POCUS use in early pregnancy and determine the diagnostic accuracy of POCUS performed by FPs following FaMOUS certification to detect intrauterine pregnancy (IUP) and fetal cardiac activity (FCA). Methods: This was a prospective, observational study conducted in 3 FP clinics from November 2015 to June 2016. Pregnant women <20 weeks gestational age who underwent a focused, transabdominal POCUS by a FaMOUS-certified FP using a handheld GE VScan were enrolled. FPs documented the presence or absence of IUP and FCA. The reference standard was radiologist-interpreted US performed after the FP POCUS. FPs were surveyed to assess provider confidence using POCUS and perceived impact on clinical decision-making. Results: Of 253 eligible patients, 56 (22.1%) underwent POCUS. Of these, 50 (89.3%) had a radiologist-interpreted US following the office-based FP visit. POCUS was used for the following indications: 11 (19.6%) had vaginal bleeding, 5 (8.9%) had abdominal pain, 7 (12.5%) had both vaginal bleeding and abdominal pain, and the indication for 33 (58.9%) patients was unclear. All patients had a documented IUP, resulting in a sensitivity of 94.0% (95% CI: 83.5%, 98.5%) and 100% positive predictive value. FCA resulted in sensitivity of 82.9% (95% CI: 69.2, 92.4%) and specificity of 100% (95% CI: 29.2%, 100.0%). When surveyed, 100% of FPs were confident performing POCUS and reported POCUS had an overall positive impact on clinical practice. 75% agreed the use of POCUS decreased the need for urgent radiologist-interpreted US. Conclusion: Following a certification process modeled after the CEUS EDE curriculum, FPs used POCUS for both CEUS-defined indications and indications that were unclear. FPs trained in early pregnancy POCUS demonstrated excellent diagnostic accuracy identifying IUP and FCA. Future study should assess the clinical impact of office-based POCUS, including whether its use results in decreased ED visits for this patient population.
Background: Emergency department (ED) providers are frequently challenged with how best to treat acute pain in older patients, specifically when non-opioid analgesics are ineffective or contraindicated. Studies have documented older patients presenting to the ED with painful conditions are less likely to receive pain medications than younger patients, and this oligoanalgesia has been associated with increased risk of delirium and longer hospital stays. Given the concerns for drug interactions, side effects, over-sedation and addiction, emergency physicians often report uncertainty regarding the ideal choice of opioid analgesic in older adults. There are no guidelines informing best practice for the management of acute pain in this population. Objective: The primary objective is to compare the efficacy of codeine, oxycodone and hydromorphone for acute fracture pain in older patients discharged from the ED. Methods: This will be a blinded, randomized controlled trial of older adults (age>70) discharged home from the ED with acute pain secondary to an upper extremity, lower extremity, rib, pelvic or vertebral compression fracture. Patients will be randomized to receive a 3-day supply of codeine, oxycodone or hydromorphone. Patients will also be given acetaminophen. Patients will be contacted by phone or email 3 days following their ED visit. The primary outcome will be differences in pain scores at 3 days assessed using the validated Brief Pain Inventory (Short Form). Secondary outcomes will include side effects (ie: confusion, constipation), adverse events (ie: falls, healthcare visits) and pain interference with daily activity. Patients, physicians and all research staff will be blinded to group allocation. Data Analysis Plan: The study design assumed three arms (codeine, oxycodone and hydromorphone), therefore the 2-tailed alpha will be set to 0.025 to adjust for the increased risk of type-I error with 3 pairwise comparisons. To test for pairwise equality between groups, a 1-way ANOVA will be employed. Proportional differences will be assessed using Pearson chi-square statistic. Sample size calculation: Assuming a mean (SD) change in pain scores between groups of 2.2 (3.0), a minimum clinically important difference on the Brief Pain Inventory of 2.0, a 2-tailed alpha of 0.025 to adjust for 3 pairwise comparisons and a beta of 0.20, we estimate that 47 patients per group (N=141) will be required. To account for potential loss to follow-up, we will increase our sample size by 25% per group, resulting in a final sample size of 177 patients (59 per group). Importance: All analgesics (including opioids) prescribed to older adults are associated with risk of adverse events. This study seeks to inform ED providers of opioid efficacy, side effects and patient-important, functional outcomes in this growing patient population.
Introduction: Increased prescribing of high potency opioids has been associated with increasing opioid addiction and linked to serious adverse outcomes including misuse, diversion, overdose and death. Problems related to opioids are a major Canadian public health concern yet few data are available on prescribing in most Canadian provinces. The objective of this study was to describe opioid prescribing in Ontario EDs and patient harms associated with this practice. Methods: We conducted a population-based cohort study among Ontario residents aged 15-64 years who were eligible for public drug coverage between April 2008 and March 2012. Using administrative databases, we identified patients with no opioid use in the past 12 months who received a prescription opioid from an emergency or family physician. Patients were followed for 2 years following their index prescription. The primary outcome was hospital admission for opioid toxicity and secondary outcome was dose-escalation exceeding 200 mg morphine equivalents (MEQ). Results: Of the 77,270 unique patients included, 33,492 (43.3%) and 43,778 (56.7%) prescriptions were issued by emergency physician (EP) and family physicians (FP), respectively. FP patients were older (45.9 vs 41.2 yr, MSD 0.35), had fewer ED visits (0.9 vs 2.3, MSD 0.46), and more FP visits (11.5 vs 8.7 MSD 0.31) in the year prior to their index visit. For combination products, EPs were more likely to prescribe oxycodone compared to FPs (37.2% vs 16.7%, Δ 20.5, 95% CI: 19.9, 21.2). For single agent products, EPs were more likely to prescribe hydromorphone compared to FPs (44.5% vs 21.7%, Δ 22.8, 95% CI: 20.4, 25.2). FPs were more likely to prescribe codeine either as a combination or single agent formulation. EP prescriptions led to significantly more hospital admissions for opioid toxicity (0.5% vs 0.3%, Δ 0.2, 95% CI: 0.1, 0.3), while FP prescriptions more often resulted in dose escalation beyond 200 mg MEQs (0.1% vs 0.7%, Δ 0.6, 95% CI: 0.4, 0.7). Conclusion: A large percentage of opioid-naïve patients receive an initial opiate prescription in the ED, where the use of high potency opioids is much more common, with 1/200 of these patients subsequently hospitalized for opioid toxicity. Creation of a physician accessible provincial registry would be useful to monitor opioid prescribing and dispensing, inform clinical practice, and identify patients at high-risk who may benefit from early interventions.
Introduction: Abdominal pain is the most common complaint in the emergency department (ED), accounting for approximately 7% of all visits. Of the patients discharged from the ED with this complaint, 25% will carry a diagnosis of undifferentiated abdominal pain and many will subsequently have an outpatient ultrasound for further assessment. The objective of this study was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days. Methods: This was a retrospective chart review of non-pregnant patients aged 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound from November 2014 to November 2015. Data was abstracted by trained research personnel independently and in duplicate and inter-rater agreement was calculated for 25% of charts. Results: Of the 315 included patients, 261 (82.9%) were female and mean (SD) age was 28.5 (5.9) years. 28 (8.9%) patients had ultrasounds requiring intervention within 14 days. Of these, 8 (28.6%) had appendicitis, 6 (21.4%) had cholecystitis, 5 (17.9%) had gynecological, 5 (17.9%) had urological and 4 (14.3%) had gastrointestinal diagnoses. However, 15 (53.6%) patients requiring intervention within 14 days had symptoms which had improved or resolved at the time of the US. Of the 287 (91.1%) patients not requiring intervention, 92 (32.1%) had unchanged, 120 (41.8%) had improved, 52 (18.1%) had resolved and 5 (1.7%) had worsened symptoms at the time of follow-up. Of the non-intervention patients, 13 (4.5%) required alternative imaging (CT scan). Conclusion: The large majority of patients with abdominal pain discharged from the ED with planned next day US were found to have either no pathology or pathology that did not require further ED management. However, 8.9% of patients had pathological findings requiring intervention within 14 days and half of these had symptoms that had resolved or improved at the time of the US. Next day US imaging remains a viable option for identifying patients with serious pathology not appreciated at the time of their ED visit.
Introduction: The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian (and many international) emergency departments (EDs) for establishing the priority by which patients should be assessed. In addition to its clinical utility, CTAS has become an important administrative metric used by governments to estimate patient care requirements, ED funding and workload models. Despite its importance, the process by which CTAS scores are derived is highly variable. Emphasis on ED wait times has also drawn attention to the length of time the triage process takes. The primary objective of this study was to determine the interrater agreement of CTAS in current clinical practice. The secondary objective was to determine the time it takes to triage in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 738 consecutive patient CTAS assessments were audited over 21 seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients. Using the auditor’s CTAS score as the reference standard, on-duty triage nurses over-triaged 89 (12.1%) and under-triaged 95 (12.9%) patients. Interrater agreement was “good” with an unweighted kappa of 0.63 (95% CI: 0.58, 0.67) and quadratic-weighted kappa of 0.79 (95% CI: 0.67, 0.90). Research assistants captured triage time for 3808 patients over 69 shifts at 7 different EDs. Median (IQR) triage time was 5.2 (3.8, 7.3) minutes and ranged from 3.9 (3.1, 4.8) minutes to 7.5 (5.8, 10.8) minutes. Conclusion: Variability in the accuracy, and length of time taken to perform CTAS assessments suggest that a standardized approach to performing CTAS assessments would improve both clinical decision making, and administrative data accuracy.
Introduction: Emergency department (ED) visits for mental health and addiction related complaints are common and appear to be increasing. It is believed these patients come to the ED requiring urgent assessment either because they do not have a primary care or psychiatric healthcare provider or access to their provider is not available in a timely fashion. The objective of this study was to describe healthcare utilization in the previous 12 months by patients presenting to the ED with a mental health complaint. Methods: Between April-November 2016, a convenience sample of adult (≥18 years) patients presenting to an academic ED (annual census 65,000) with a mental health and/or addictions complaint were invited to complete a paper-based survey to determine their usage of ten different mental healthcare resources over the previous 12 months. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 134 patients who completed the survey, mean (SD) age was 37.9 (15.7) years and 64 (47.8%) were male. Only 7 (5.2%) patients did not access any mental health resource in the previous 12 months, and the most commonly accessed resource was hospital EDs (102, 76.1%), with 24 (23.5%) of these patients using the ED at least 6 times. Patients also accessed a variety of other mental health resources, with 28 (20.9%) seeing their family physician, 20 (14.9%) seeing their psychiatrist/psychologist, and 61 (45.5%) seeing both in the previous 12 months. Only 6 (5.9%) patients used the ED exclusively for a mental health related complaint. By comparison, respondents accessed other specific mental health resources such as crisis centres (19, 14.2%), helplines (34, 25.4%), and peer-support groups (24, 17.9%) less often. Conclusion: These findings suggest that the ED is the most commonly used mental health resource for this population. However, these patients also frequently access family physicians and psychiatrists/psychologists, with community resources such as crisis centres, helplines, and peer-support being used less often. This suggests that lack of timely access to other mental health resources may be the primary motivation for accessing the ED.
Introduction: Hip fractures affect over 35,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. The primary objective of this study was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture. Methods: This was a retrospective chart review of patients aged 65 years and older presenting to one of two academic EDs with a discharge diagnosis of hip fracture from January 1st 2014 to December 31st 2015. Multivariable logistic regression analysis was used to determine variables independently associated with the development of acute in-hospital delirium within 72 hours of ED arrival. Results: Of the 668 included patients, mean (SD) age was 84.1 (8.0) years and 501 (75%) were female. 521 (78.0%) patients received an opioid analgesic and/or femoral nerve block in the ED. The most common analgesics used in the ED were intravenous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED. 181 (27.1%) patients developed delirium within 72 hours of ED arrival. History of neurodegenerative disease or dementia (OR: 5.7, 95% CI: 3.9, 8.4), age >75 (OR: 2.8, 95% CI: 1.4, 5.6) and absence of analgesia in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with acute in-hospital delirium. Conclusion: The development of in-hospital delirium is common in patients diagnosed with a hip fracture. We have identified modifiable and non-modifiable risk factors independently associated with acute in-hospital delirium, which can be identified in the ED. Clinicians should be aware of these risk factors in order to implement strategies directed at reducing the development of acute delirium. Additionally, further research is needed in order to understand the relationship between analgesia delivered in the ED and the development of delirium for patients diagnosed with a hip fracture.