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Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.
An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.
Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.
A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.
Introduction: Very low concentrations of high-sensitivity cardiac troponin can rule-out myocardial infarction (MI) at ED arrival in patients with chest pain. However, this single troponin rule-out strategy works poorly in patients with renal impairment and elevated baseline troponin levels. The objective of this study was to develop and validate a troponin adjustment strategy to accurately rule-out MI with a single hs-cTnTmeasurement in patients with kidney dysfunction. Methods: We used data from three cohorts of ED chest pain patients to develop an adjustment score for a high-sensitivity troponin T (hs-cTnT) assay in patients with kidney dysfunction. The derivation cohort (n = 8846) used administrative and registry data. Two validation cohorts (n = 1187 and 1092) were prospectively-collected. The score assigned points for increasing hs-cTnT levels and subtracted points for lower estimated glomerular filtration rate (eGFR). In the derivation cohort, hs-cTnT concentrations achieving 98.5% sensitivity in of patients with eGFR ≥60, 45-59, 30-44, 15-29 and <15 were assigned ascending positive integer values. Negative integer values were assigned to eGFR values 45-59, 30-44, 15-29 and <15. The scpres for troponin and eGFR were summed for each patient, with scores ranging from −4 to +5. The proportion of patients with 7-day MI ruled out by a score ≤0, sensitivity, NPV, negative likelihood ratio (LR-) and area under the curve (AUC) were quantified in each study cohort. Results: The derivation and validation cohorts had 7-day MI rates of 5.7, 8.6 and 9.1%. In the derivation cohort, a score ≤0 ruled out MI in 35% of patients, with a sensitivity for 7-day MI of 99.5% (95% CI 98-100), NPV of 99.9% (95% CI 98.4-99.9), LR- of 0.02 (95% CI 0.01-0.05) and AUC of 0.88. In the first validation cohort, a score ≤0 ruled out MI in 45% of patients, with a sensitivity for 7-day MI of 97% (95% CI 90-100%), NPV of 99% (95% CI 98-100%), LR- 0.06 (0.02-0.18) and AUC of 0.89. In the second validation cohort, a score ≤0 ruled out MI in 20% of patients, with a sensitivity for 7-day MI of 96% (95% CI 93-99%), NPV of 98% (95% CI 96-100%), LR- of 0.16 (95% CI 0.07-0.39) and AUC of 0.78. Conclusion: We developed and validated a simple scoring system to adjust hs-cTnT concentrations for a patient's kidney function that enables MI to be ruled out in a large proportion of chest pain patients using a single measurement on ED presentation.
Introduction: Acute aortic syndrome (AAS) is a time sensitive aortic catastrophe that is often misdiagnosed. There are currently no Canadian guidelines to aid in diagnosis. Our goal was to adapt the existing American Heart Association (AHA) and European Society of Cardiology (ESC) diagnostic algorithms for AAS into a Canadian evidence based best practices algorithm targeted for emergency medicine physicians. Methods: We chose to adapt existing high-quality clinical practice guidelines (CPG) previously developed by the AHA/ESC using the GRADE ADOLOPMENT approach. We created a National Advisory Committee consisting of 21 members from across Canada including academic, community and remote/rural emergency physicians/nurses, cardiothoracic and cardiovascular surgeons, cardiac anesthesiologists, critical care physicians, cardiologist, radiologists and patient representatives. The Advisory Committee communicated through multiple teleconference meetings, emails and a one-day in person meeting. The panel prioritized questions and outcomes, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations. The algorithm was prepared and revised through feedback and discussions and through an iterative process until consensus was achieved. Results: The diagnostic algorithm is comprised of an updated pre test probability assessment tool with further testing recommendations based on risk level. The updated tool incorporates likelihood of an alternative diagnosis and point of care ultrasound. The final best practice diagnostic algorithm defined risk levels as Low (0.5% no further testing), Moderate (0.6-5% further testing required) and High ( >5% computed tomography, magnetic resonance imaging, trans esophageal echocardiography). During the consensus and feedback processes, we addressed a number of issues and concerns. D-dimer can be used to reduce probability of AAS in an intermediate risk group, but should not be used in a low or high-risk group. Ultrasound was incorporated as a bedside clinical examination option in pre test probability assessment for aortic insufficiency, abdominal/thoracic aortic aneurysms. Conclusion: We have created the first Canadian best practice diagnostic algorithm for AAS. We hope this diagnostic algorithm will standardize and improve diagnosis of AAS in all emergency departments across Canada.
Introduction: Upper gastrointestinal bleeding (UGIB) is a common presentation to the emergency department (ED). Early endoscopy within 24 hours has been shown to reduce re-bleeding rates and lower mortality. However, low-risk patients can often be managed through outpatient follow-up. The aim of this study was to compare the timing and appropriateness of endoscopy and proton pump inhibitor (PPI) use in a tertiary care ED setting for low- and high-risk patients determined using the Glasgow Blatchford Score (GBS). Methods: Retrospective chart review was conducted to examine the management of patients presenting with an UGIB in 2016 to the University of Alberta Hospital ED. TANDEM and Emergency Department Information System (EDIS) databases were used to identify patients using specific ICD-10 codes and the CEDIS presenting complaints of vomiting blood or blood in stool/melena. Patients with GBS 0-3 were categorized as low-risk and those with GBS > 3 were considered high-risk with appropriateness of and time to endoscopy, disposition of patient at 24 hours, and use of PPIs determined for each group. Results: A total of 400 patients were included. A total of 319/400 patients (80%) underwent esophagogastroduodenoscopy (EGD). EGD was performed within 24 hours in 37% of patients (29/78) with GBS 0 to 3 and in 77% (248/322) with GBS greater than 3. Of the remaining high-risk patients, 11% (36/322) underwent EGD after 24 hours and 12% (38/322) did not undergo EGD. The endoscopic diagnoses were peptic ulcer disease (PUD) in 41% of patients (130/319), esophagitis in 18% (56/319), and varices in 14% (45/319). PPIs (data available 375/400) were administered (mainly intravenously) to 93% (279/300) of high-risk and 79% (59/75) of low-risk patients. Data on patient disposition showed 60/322 (19%) high-risk patients were discharged from the ED within 24 hours and only 31/60 (52%) of these underwent EGD before discharge. Of 29 low-risk patients undergoing EGD within 24 hours, 9 (31%) were admitted, 17 (59%) were discharged from ED, and 3 (10%) were kept for observation in the ED greater than 24 hours. Of low-risk patients, 76% (59/78) were discharged from the ED within 24 hours. Conclusion: A majority of patients presenting with UGIB appropriately received endoscopy within 24 hours. 19% of high-risk patients were discharged from the ED. Earlier discharge for low-risk patients can be improved as only 76% of low-risk patients were discharged from the ED within 24 hours. As expected, PPI use was high in these patients.
Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.
Introduction: Alberta has one of the highest rates of domestic violence (DV) in the country. Emergency departments (EDs) and urgent care centres (UCCs) are significant points of opportunity to screen for DV and intervene. In Alberta, the Calgary Zone began a universal education and direct inquiry program for DV in EDs and UCCs for patients > = 14 years in 2003. The Calgary model is unique in that (a) it provides universal education in addition to screening and (b) screening is truly universal as it includes all age groups and genders. While considering expanding this model provincially, we engaged in the GRADE Adolopment process, to achieve multi-stakeholder consensus on a provincial approach to DV screening, as herewith described. Methods: Using GRADE, we synthesized and rated the quality of evidence on DV screening and presented it to an expert panel of stakeholders from the community, EDs, and Alberta Health Services. There was moderate certainty evidence that screening improved DV identification in antenatal clinics, maternal health services and EDs. There was no evidence of harm and low certainty evidence of improvement in patient-important outcomes. As per Adolopment, the expert panel reviewed the evidence in the context of: a) values and preferences b) benefits and harms, and c) acceptability, feasibility, and resource implications. Results: The panel came to a unanimous decision to conditionally recommend universal screening, i.e., screening all adults above 14 years of age in EDs and UCCs. By conditional, the panel noted that EDs and UCCs must have support resources in place for patients who screen positive to realize the full benefit of screening and avoid harm. The panel deemed universal screening to be a logistically easier recommendation, compared to training healthcare professionals to screen certain subpopulations or assess for specific symptoms associated with DV. The panel noted that despite absence of evidence that screening would impact patient-important outcomes, there was evidence that effective interventions following a positive screen could positively impact these outcomes. The panel stressed the importance of evidence creation in the context of absence of evidence. Conclusion: A GRADE Adolopment process achieved consensus on provincial expansion of an ED-based DV screening program. Moving forward, we plan to gather evidence on patient-important outcomes and understudied subpopulations (i.e. men and the elderly).
Introduction: Iron Deficiency Anemia (IDA) is a common presentation to the emergency department (ED) and is often treated with red blood cell transfusions. Choosing Wisely and the American Association of Blood Banks released guidelines in 2016 outlining under what circumstances transfusions should be given for patients with IDA. Few well-powered studies have looked at the impact of these guidelines on transfusions in EDs. The goal of this study was to examine the number of RBC transfusions that were given in EDs in Calgary, Alberta from 2014-2018 and what proportion of these were potentially avoidable (PA). Methods: We analyzed 8651 IDA patient encounters from 2014–2018 at four centers in the Calgary Zone. A transfusion was considered PA if the patient's hemoglobin (hgb) was ≥70 g/L AND if the patient was hemodynamically stable. We performed descriptive statistics to assess the number of transfusions and the number of avoidable transfusions. We used chi-squared tests to determine if there were significant differences between site, time-period, hemoglobin level. Results: In total, 990 (11.4%) of the encounters received transfusions; 711 (71.8%) were indicated while 279 (28.1%) were PA. Out of the transfusions that were indicated, 230 (32.3%) were given to patients with a hgb <70 g/L and 481 (67.7%) were given to patients with a hgb >70 g/L but who were hemodynamically unstable. Out of the transfusions that were PA, the highest number were given to those in the 71-80 g/L hgb group (142) and the lowest number were given to those in the 110-130 g/L hgb group (9), a difference that was statistically significant (p < 0.001). The PA transfusion rates from 2014 to 2018 were 30.8%, 25.6%, 34.5%, 23.6%, 20.7% respectively, which was a statistically significant difference (p = 0.004). Conclusion: Our data suggest that the number of PA transfusions at the hospitals in the Calgary zone is comparable to the rates reported in the existing literature. In addition, the rate of PA transfusions has decreased since the release of the guidelines. A limitation of the present study was that it did not look at the number of units of red blood cells transfused and since many patients receive more than one unit, it is possible that the number of PA transfusions was underestimated. Nevertheless, we intend to use our results to create a safer and more cost-effective approach to managing IDA.
Introduction: Acute upper gastrointestinal bleeding (UGIB) is a common presentation to emergency departments (ED). Of these patients, 35-45% receive a blood transfusion. Guidelines for blood transfusion in UGIB have been well established, and recommend a hemoglobin (Hb) level below 70 g/L as the transfusion target in a stable patient. There is no consensus on a transfusion threshold for unstable UGIB. There is limited data regarding physician practices in the ED. The aim of our study is to determine the appropriateness, by expert consensus, of blood transfusions in UGIB in a tertiary care hospital ED. Methods: We retrospectively reviewed patients presenting with UGIB to the University of Alberta Hospital ED in 2016. These patients were then screened for blood transfusions. Data were obtained from the patient records. Chart derived data were verified with records obtained from the blood bank. For each patient, the history, vitals, Glasgow Blatchford Score (GBS), relevant labs, and record of blood transfusions were collected and organized into a case summary. Each patient summary was presented individually to a panel of three expert clinicians (2 Gastroenterology, 1 Emergency Medicine), who then decided on the appropriateness of each blood transfusion by consensus. Results: Blood transfusions (data available 395/400) were given to 51% (202/395) of patients presenting with UGIB. Of these, 86% (174/202) were judged to be appropriate. Of the 395 patients, 34% (135/395) had a Hb of <70 g/L. Of these, 93% (126/135) were transfused, and all of these were considered appropriate. 18% (70/395) had a Hb between 71-80. 74% (52/70) of these patients were given blood, and 79% (41/52) were considered appropriate. 13% (50/395) of the patients had a Hb between 81-90, with 28% (14/50) receiving a transfusion. Of these, 36% (5/14) were deemed to be appropriate. 35% (140/395) of patients had a Hb of >90. 7% (10/140) of these received blood. 20% (2/10) were considered appropriate. Conclusion: The panel of expert clinicians judged 86% of the blood transfusions to be appropriate. All transfusions under the recommended guideline of 70 g/L were considered appropriate. In addition, the majority of transfusions above a Hb of 70 g/L were considered appropriate, but 37% were not. Further studies evaluating the feasibility of current guideline recommendations in an ED setting are required. Educational interventions should be created to reduce inappropriate blood transfusions above a Hb 70 g/L.
The adaptation of high-frequency heating techniques to a vertical diffractometer will be discussed. The heating system functions as a. portion of an integrated system that provides a wide range of atmospheric and temperature control. Some of the design problems and their solutions and operating characteristics of the system will be described. The useful temperature range is from less than 200°C to greater than 1600°C, depending upon the fur-nace atmosphere and susceptors used. Gaseous pressures may be from vacuo of about 10−6 mm to about 30 psia; and, the sample may be heated in oxidizing, neutral, or reducing atmospheres.
Due to differences in the circulation of influenza viruses, distribution and antigenic drift of A subtypes and B lineages, and susceptibility to infection in the population, the incidence of symptomatic influenza infection can vary widely between seasons and age-groups. Our goal was to estimate the symptomatic infection incidence in the Netherlands for the six seasons 2011/2012 through 2016/2017, using Bayesian evidence synthesis methodology to combine season-specific sentinel surveillance data on influenza-like illness (ILI), virus detections in sampled ILI cases and data on healthcare-seeking behaviour. Estimated age-aggregated incidence was 6.5 per 1000 persons (95% uncertainty interval (UI): 4.7–9.0) for season 2011/2012, 36.7 (95% UI: 31.2–42.8) for 2012/2013, 9.1 (95% UI: 6.3–12.9) for 2013/2014, 41.1 (95% UI: 35.0–47.7) for 2014/2015, 39.4 (95% UI: 33.4–46.1) for 2015/2016 and 27.8 (95% UI: 22.7–33.7) for season 2016/2017. Incidence varied substantially between age-groups (highest for the age-group <5 years: 23 to 47/1000, but relatively low for 65+ years: 2 to 34/1000 over the six seasons). Integration of all relevant data sources within an evidence synthesis framework has allowed the estimation – with appropriately quantified uncertainty – of the incidence of symptomatic influenza virus infection. These estimates provide valuable insight into the variation in influenza epidemics across seasons, by virus subtype and lineage, and between age-groups.
D-dimer testing is an important component of the workup for pulmonary embolism (PE). However, age-related increases in D-dimer concentrations result in false positives in older adults, leading to potentially unnecessary imaging utilization. The objective of this study was to quantify the test characteristics of an age-adjusted D-dimer cut-off for ruling out PE in older patients investigated in actual clinical practice.
This observational study used administrative data from four emergency departments from July 2013 to January 2015. Eligible patients were ages 50 and older with symptoms of PE who underwent D-dimer testing. The primary outcome was 30-day diagnosis of PE, confirmed by imaging reports. Test characteristics of the D-dimer assay were calculated using the standard reference value (500 ng/ml), the local reference value (470 ng/ml), and an age-adjusted threshold (10 ng/ml × patient’s age).
This cohort includes 6,655 patients ages 50 and older undergoing D-dimer testing for a possible PE. Of these, 246 (3.7%) were diagnosed with PE. Age-adjusted D-dimer cut-offs were more specific than standard cut-offs (75.4% v. 63.8%) but less sensitive (90.3% v. 97.2%). The false-negative risk in this population was 0.49% using age-adjusted D-dimer cut-offs compared with 0.15% with traditional cut-offs.
Age-adjusted D-dimer cut-offs are substantially more specific than traditional cut-offs and may reduce CT utilization among older patients with suspected PE. We observed a loss of sensitivity, with an increased risk of false-negatives, using age-adjusted cut-offs. We encourage further evaluation of the safety and accuracy of age-adjusted D-dimer cut-offs in actual clinical practice.
As utilization of CT imaging has risen dramatically, evidence-based decision rules and clinical decision support (CDS) tools have been developed to avoid unnecessary CT use in low risk patients. However, their ability to change physician practice has been limited to date, with a number of barriers cited. The purpose of this study was to identify the barriers and facilitators to CDS adoption following a local CDS implementation. Methods: All emergency physicians at 4 urban EDs and 1 urgent care center were randomized to voluntary evidence-based CT imaging CDS for patients with either mild traumatic brain injury (MTBI) or suspected pulmonary embolism (PE). CDS was integrated into the computerized physician order entry (CPOE) software and triggered whenever a CT scan for an eligible patient was ordered. Physicians in both the MTBI and PE arms were ranked according to their CDS use, and a stratified sampling strategy was used to randomly select 5 physicians from each of the low, medium and high CDS use tertiles in each study arm. Each physician was invited to participate in a 30-minute semi-structured interview to assess the barriers and facilitators to CDS use. Physician responses were reported using a thematic analysis. Results: A total of 202 emergency physicians were randomized to receive CDS for either MTBI or PE, triggering CDS 4561 times, and interacting with the CDS software 1936 times (42.4%). Variation in CDS use ranged from 0% to 88.9% of eligible encounters by physician. Fourteen physicians have participated in interviews to date, and data collection is ongoing. Physicians reported that CDS use was facilitated by their confidence in the evidence supporting the CDS algorithms and that it provided documentation to reduce medico-legal risk. CDS use was not impeded by concerns over missed diagnoses or patient expectations. Reported barriers to CDS use included suboptimal integration into the CPOE such as the inability to auto-populate test results, it disrupted the ordering process and was time consuming. A common concern was that CDS was implemented too late in workflow as most decision making takes place at the bedside. Physicians did not view CDS as infringing on physician autonomy, however they advised that CDS should be a passive educational option and should not automatically trigger for all physicians and eligible encounters. Conclusion: Physicians were generally supportive of CDS integration into practice, and were confident that CDS is an evidence-based way to reduce unnecessary CT studies. However, concerns were raised about the optimal integration of CDS into CPOE and workflow. Physicians also stated a preference to a passive educational approach to CDS rather than an automatic triggering mechanism requiring clinical documentation.
Introduction: The effectiveness of intravenous alteplase is highly time dependent, and very short door-to-needle times (DNT) of 30 minutes or less have been reported in single centre hospitals, but never in an entire population. QuICR (Quality Improvement and Clinical Research) Alberta Stroke Program aimed to reduce DNT to a median of 30 minutes across the Canadian province of Alberta. Methods: We used the Improvement Collaborative Methodology from early 2015 to September 2016 with participation from all 17 Stroke Centres in Alberta. This methodology included 4 face-to-face workshops, site visits, webinars, data collection, data feedback, intensive process mapping, and process improvements. We compared data in the pre-intervention period from 2009-2014 (collected during the Alberta Provincial Stroke Strategy) to data in the post-intervention period from March 2016-February 2017 (collected during the QuICR DTN Collaborative). Data from January 2015-February 2016 were excluded, as improvements were being implemented during this time. Results: There were a total of 2,322 treated cases in the pre- and post-intervention periods. The results show that the median DNT dropped from 68 minutes (n=1846) in the pre-intervention period to 36 minutes (n=476) in the post-intervention period (p<0.001). There were reductions in DNT across all hospital types: median DNT dropped from 63 to 32 minutes in Urban Tertiary Centres (p<0.001), from 73 to 32 minutes in Community with 24/7 neurology (p<0.001), from 85 to 62 minutes in Community with limited/no neurology (p<0.001), and from 74 to 52.5 minutes in rural centres (p<0.001). Conclusion: There were 21.5 to 41 minute reductions in median DNT across all hospital types including smaller rural and community hospitals. A targeted multi-site improvement collaborative can be an effective intervention to reduce DNT across an entire population.
Clinical decision support (CDS) has been implemented in many clinical settings in order to improve decision-making. Their potential to improve diagnostic accuracy and reduce unnecessary testing is well documented; however, their effectiveness in impacting physician practice in real world implementations has been limited by poor physician adherence. The objective of this systematic review and meta-regression was to establish the effectiveness of CDS tools on adherence and identify which characteristics of CDS tools increase physician use of and adherence. Methods: A systematic review and meta-analysis was conducted. MEDLINE, EMBASE, PsychINFO, the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to June 2017. Included studies examined CDS in a hospital setting, reported on physician adherence to or use of CDS, utilized a comparative study design, and reported primary data. All tool type was classified based on the Cochrane Effective Practice and Organization of Care (EPOC) classifications. Studies were stratified based on study design (RCT vs. observational). Meta-regression was completed to assess the different effect of characteristics of the tool (e.g. whether the tool was mandatory or voluntary, EPOC classifications). Results: A total of 3,359 candidate articles were identified. Seventy-two met inclusion criteria, of which 46 reported outcomes appropriate for meta-regression (5 RCTs and 41 observational studies). Overall, a trend of increased CDS use was found (pooled RCT OR: 1.36 [95% CI: 0.97-1.89]; pooled observational OR: 2.12 [95% CI: 1.75-2.56]).When type of tool is considered, clinical practice guidelines were superior compared to other interventions (p=.150). Reminders (p=.473) and educational interventions (p=.489) were less successful than other interventions. Multi-modal tools were not more successful that single interventions (p=.810). Lastly, voluntary tools may be supperior to than mandatory tools (p=.148). None of these results are statistically significant. Conclusion: CDS tools accompanied by a planned intervention increases physician utilization and adherence to the tool. Meta-regression found that clinical practice guidelines had the biggest impact on physician adherence although not statistically significant. Further research is required to understand the most effective intervention to maximize physician utilization of CDS tools.
Introduction: Overuse of acute care services, particularly emergency department (ED) use, is an important topic for healthcare providers and policy makers within Canada and abroad. Prior work has shown that frail elderly patients with complex medical needs and limited personal and social resources are heavy users of ED services and are often admitted when they present to the ED. Updated information on the most effective strategies to avert ED presentation and hospital admission focused specifically on elderly patients is needed. Methods: This systematic review addressed the question: what interventions have demonstrated effectiveness in decreasing ED use and hospital admissions in elderly patients? Comprehensive literature searches were conducted in databases including Ovid Medline, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials with no language or date restrictions. Citations were limited to interventional studies. Grey literature and reference list searches, as well as communication with experts in the field were performed. Consensus or a third reviewer resolved any disagreements. Original research regarding interventions conducted in populations 65 years or older with acute illness, either living in community or facility-living were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included: mortality, cost, and patient-reported outcomes such as health-related quality of life and functional status. Results: Forty-three relevant studies were identified including 22 randomized controlled trials (RCT), 2 cluster-RCT, 2 trials with non-random allocation, 4 before-after studies, 6 quasi-experimental studies, and 7 cohort studies. Intervention settings included: home visits (22), long-term care (7), outpatient or primary care clinics (8), and ED (3) or inpatient (3). Data characterization revealed that home-based, outpatient and/or primary care-based strategies reduced ED visits and hospitalizations, particularly those which included comprehensive geriatric assessments, home visits or regular face-to-face contact and interdisciplinary teams. Hospital-based models generally showed no difference in ED or inpatient service utilization. There was, however, considerable variability across individual studies with respect to reporting of outcomes, statistical analyses performed, and overall risk of bias. Conclusion: Various interventional strategies have been studied to avert ED presentation and hospital admission for frail elderly patients. More rigorous methodology and standardization of outcome measures is needed to quantitatively assess the effects of these programs.
Introduction: Upper gastrointestinal bleeding (UGIB) is a common medical condition presenting to emergency departments (ED) and associated with substantial morbidity, mortality, and healthcare expenditures. Our aim was to evaluate the incidence of patients presenting to ED with UGIB in a large population-based surveillance cohort. Methods: The National Ambulatory Care Reporting System (NACRS) was used to identify all presentations to emergency departments for UGIB in Alberta from fiscal year 2010 to 2015 (n=56519) using the International Classification of Diseases Codes (ICD-10) in any diagnostic position. Baseline characteristics and UGIB incidence were calculated using descriptive statistics. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CI). Results: The median age of 56519 UGIB presentations was 56 years (interquartile range: 41 to 74 years), 56% were male, and 245% had at least one comorbidity. At time of disposition from the ED , 48.3% were admitted to or transferred to another hospital, 51.4% discharged, and 0.3% died in the emergency department. Further, 10.8% underwent upper endoscopy during their admission to the emergency department. The annual incidence of UGIB were 230.6 (2010), 232.8 (2011), 241.0 (2012), 242.2 (2013), 244.6 (2014), and 242.2 (2015) per 100,000 person-years. Between 2010 and 2015 the incidence of UGIB presenting to ED significantly increased overtime (AAPC=1.1; 95% CI: 0.3 to 2.0). Conclusion: UGIB is a common presentation to emergency departments and has been increasing overtime. Future studies are necessary to evaluate the underlying cause of UGIB and to determine its burden to Albertas healthcare system.
Introduction: Medical journals are an essential venue for knowledge translation. Skilled reviewers and editors are required to ensure quality standards in research publications and yet postgraduate programs rarely include this training in their curricula. Imparting appropriate skills and developing capacity in journalship has thus proved challenging. The Canadian Journal of Emergency Medicine (CJEM) is the national journal for Emergency Medicine (EM) in Canada. The CJEM editorial board recently decided to provide longitudinal mentorship for junior academic faculty members and trainees through an editorial internship. The internship had three goals for participants: (1) introduce and develop the responsibilities and skills of a good editor; (2) enhance a career in academic EM; and, (3) galvanize future participation as a reviewer or editor in scientific publications. Methods: The senior editorial board of CJEM and the inaugural intern developed a one-year Editorial Internship that was launched in June 2017. The curricular framework was designed by current and prior CJEM senior editors from four Canadian universities, and was informed by similar programs in the United States. The curriculum was refined iteratively based on feedback and discussion between the senior editors and intern. The internship was designed for a single individual in the Canadian EM community, including residents, pediatric fellows and practicing emergency physicians. Results: To develop the responsibilities and skills of being a good editor, the intern performed six mentored reviews of manuscripts either under current review at CJEM or previous submissions identified as difficult peer review decisions. In addition, the intern learned about CJEM values and norms by participating in monthly videoconference meetings and quarterly editorial board meetings. To enhance an academic career, the intern was assigned two writing projects under the guidance of senior editors for publication in CJEM, and completed an online critical appraisal course. Conclusion: The inaugural editorial intern gained experience as an editor and produced scholarly work. We feel the internship met its first two goals, and CJEM has committed to continue the internship annually. The ultimate determination of whether the internship achieved its third goal will only be known after longitudinal tracking of participants career involvement in academic publishing and editing.
Introduction: Safe and efficient handovers between emergency medical services (EMS) practitioners and emergency nurses are vital as poor transitions may lead to loss of information and place patients at risk for adverse events. We conducted a mixed methods systematic review to a) examine factors that disrupt or improve handovers from EMS practitioners to emergency department nurses, and b) investigate the effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. Methods: We searched electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); grey literature (grey literature databases, organization websites, querying experts in emergency medicine); and reference lists of the included studies. Citation tracking was conducted for the included studies. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the Joanna Briggs Institute Critic Appraisal Checklist for Qualitative Research. Narrative and thematic synthesis were conducted to integrate and explore relationships within the data. Results: Twenty-two studies were included in this review from the 6150 records initially retrieved. Our analysis suggests that qualitative, quantitative, and mixed methods research approaches have been utilized to explore handovers. Studies (n=11) have predominantly explored existing patterns of handovers focusing on barriers and facilitators. Interventions (e.g. multimedia transmission of pre-hospital information, tailored e-learning program) were investigated in five studies. Results suggest that lack of formal handover training, workflow interruptions, workload, and strained working relationships between EMS and nursing are perceived threats to optimal handovers. Conclusion: The findings from this review can inform the development of handover interventions and contribute to a more rigorous approach to researching handovers between EMS practitioners and emergency nurses. Furthermore, there is a need for studies in which specific interventions to optimize handovers are examined.
Introduction: Community Paramedics (CPs) require access to timely blood analysis in the field to guide treatment and transport decisions. Point of care testing (POCT), as opposed to traditional laboratory analysis, may offer a solution, but limited research exists on CP POCT. The objective of this study is to compare the validity of two POCT devices (Abbott i-STAT® and Alere epoc®) and their use by CPs in the community. Methods: In a CP programme responding to 6,000 annual patient care events, a split sample validation of POCT against traditional laboratory analysis for seven analytes (sodium, potassium, chloride, creatinine, hemoglobin, hematocrit, and glucose) was conducted on a consecutive sample of patients. The difference of proportion of discrepant results between POCT and laboratory was compared using a two sample proportion test. Usability was analysed by survey of CP experience, an expert heuristic evaluation of devices, a review of device-logged errors, coded observations of POCT use during quality control testing, and a linear mixed effects model of Systems Usability Scale (SUS) adjusted for CP clinical and POCT experience. Results: Of 1,649 CP calls for service screened for enrollment, 174 had a blood draw, with 108 patient care encounters (62.1%) enrolled from 73 participants. Participants had a mean age of 58.7 years (SD16.3); 49% were female. In 4 of 646 (0.6%) individual comparisons, POCT reported a critical value that the laboratory did not; with no statistically significant difference in the number of discrepant critical values reported with epoc® compared to i-STAT®. There were no instances of the laboratory reporting a critical value when POCT did not. In 88 of 1,046 (8.4%) individual comparisons, the a priori defined acceptable difference between POCT and the laboratory was exceeded; occurring more often in epoc® (10.7%;95%CI:8.1%,13.3%) compared to i-STAT® (6.1%;95%CI:4.1%,8.2%)(p=0.007). Eighteen of 19 CP surveys were returned, with 11/18 (61.1%) preferring i-STAT® over epoc®. The i-STAT® had a higher mean SUS score (higher usability) compared to the epoc® (84.0/100 vs. 59.6/100; p=0.011). Fewer field blood analysis device-logged errors occurred in i-STAT® (7.8%;95%CI:2.9%,12.7%) compared to epoc® (15.5%;95%CI:9.3%,21.7%) although not statistically significant (p=0.063). Conclusion: CP programs can expect valid results from POCT. Usability assessment suggests a preference for i-STAT.
Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.