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Introduction: eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods: This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results: There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion: A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.
Introduction: The Maximizing Aging Using Volunteer Engagement in the ED (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program and the activities performed with older patients by its volunteers. Methods: The MAUVE + ED program was implemented in the ED (annual census 65,000) of a large academic tertiary hospital in Toronto, Ontario. Volunteers were trained to identify and approach older patients and others at greater risk for adverse outcomes, including poor patient experience, in the ED and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form. Results: Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median (IQR) time a MAUVE volunteer spent with a patient was 10 (5, 20) minutes, with a range of 1 to 130 minutes. The median (IQR) number of patients seen per shift was 7 (6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%). Conclusion: Preliminary data suggest the MAUVE + ED volunteers were able to enrich the experience of older adults and their families/carers in the ED.
Introduction: Participant interviews are often considered the ‘gold standard’ for measuring outcomes in diagnostic and prognostic studies. Participant exposure data are frequently collected during study interviews, but the reliability of this information often remains unknown. The objective of this study was to compare patient-reported medication exposures and outcomes to data extracted from electronic medical records (EMRs) to determine reliability. Methods: This was a secondary data analysis from a prospective observational cohort study enrolling older (≥ 65 years) patients who presented to one of three emergency departments after a fall. After patients had consented to participate in the study, they were asked about their use of antiplatelet and anticoagulation medications (exposures of interest). During follow up, participants were asked if a physician had told them they had bleeding in their head (diagnosis of intracranial hemorrhage). Patient-reported responses were compared to data extracted from a structured EMR review. Trained research assistants extracted medication exposure and outcome data from the hospital EMRs in duplicate for all visits to any hospital within 42 days. Inter-rater agreement was estimated using Cohen's kappa (K) statistics with 95% confidence intervals (CIs). Results: 1275 patients completed study interviews. 1163 (91%) responded to questioning about antiplatelet use and 1159 (91%) to anticoagulant use. Exact agreement between patient reported antiplatelet use compared to EMR review was 77%, with K = 0.50 (95% CI: 0.44 to 0.55). For anticoagulation use, exact agreement was 87%, with K = 0.68 (95% CI: 0.63 to 0.72). 986 (78%) patients had a follow up interview after 42 days. Exact agreement between patient reported intracranial bleeding and EMR review was 95%, with K = 0.30 (95% CI: 0.15 to 0.45). Using the EMR review as the reference standard, the sensitivity and specificity of patient reported intracranial bleeding was 34% (95% CI: 20 to 52%) and 97% (95% CI: 96 to 98%), respectively. Conclusion: In this population of older adults who presented to the ED after a fall, patient reported use of antiplatelet and anticoagulant medications was not a reliable method to identify medication use. Patients who were diagnosed with intracranial bleeding were particularly poor at reporting this diagnosis.
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: The Canadian population is aging and an increasing proportion of emergency department (ED) patients are seniors. ED visits among seniors are frequently instigated by a fall at home. Some of these patients develop intracranial hemorrhage (ICH) because of falling. There has been little research on the frequency of ICH in elderly patients who fall, and on which clinical factors are associated with ICH in these patients. The aim of this study was to identify the incidence of ICH, and the clinical features which are associated with ICH, in seniors who present to the ED having fallen. Methods: This was a prospective cohort study conducted in three EDs. Patients were included if they were age >65 years, and presented to the ED within 48 hours of a fall on level ground, off a bed/chair/toilet or down one step. Patients were excluded if they fell from a height, were knocked over by a vehicle or were assaulted. ED physicians recorded predefined clinical findings (yes/no) before any head imaging was done. Head imaging was done at the ED physician's discretion. All patients were followed for 6 weeks (both by telephone call and chart review at 6 weeks) for evidence of ICH. Associations between baseline clinical findings and the presence of ICH were assessed with multivariable logistic regression. Results: In total, 1753 patients were enrolled. The prevalence of ICH was 5.0% (88 patients), of whom 74 patients had ICH on the ED CT scan and 14 had ICH diagnosed during follow-up. 61% were female and the median age was 82 (interquartile range 75-88). History included hypertension in 76%, diabetes in 29%, dementia in 27%, stroke/TIA in 19%, major bleeding in 11% and chronic kidney disease in 11%. 35% were on antiplatelet therapy and 25% were on an anticoagulant. Only 4 clinical variables were independently associated with ICH: bruise/laceration on the head (odds ratio (OR): 4.3; 95% CI 2.7-7.0), new abnormalities on neurological examination (OR: 4.4; 2.4-8.1), chronic kidney disease (OR: 2.4; 1.3-4.6) and reduced GCS from baseline (OR: 1.9; 1.0-3.4). Neither anticoagulation (OR: 0.9; 0.5-1.6) nor antiplatelet use (OR: 1.1; 0.6-1.8) appeared to be associated with ICH. Conclusion: This prospective study found a prevalence of ICH of 5.0% in seniors after a fall, and that bruising on the head, abnormal neurological examination, abnormal GCS and chronic kidney disease were predictive of ICH.
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.
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: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.
Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.
To make pragmatic recommendations on best practices for the engagement of patients in emergency medicine (EM) research.
We created a panel of expert Canadian EM researchers, physicians, and a patient partner to develop our recommendations. We used mixed methods consisting of 1) a literature review; 2) a survey of Canadian EM researchers; 3) qualitative interviews with key informants; and 4) feedback during the 2017 Canadian Association of Emergency Physicians (CAEP) Academic Symposium.
We synthesized our literature review into categories including identification and engagement, patients’ roles, perceived benefits, harms, and barriers to patient engagement; 40/75 (53% response rate) invited researchers completed our survey. Among respondents, 58% had engaged patients in research, and 83% intended to engage patients in future research. However, 95% stated that they need further guidance to engage patients. Our qualitative interviews revealed barriers to patient engagement, including the need for training and patient partner recruitment.
Our panel recommends 1) an overarching positive recommendation to support patient engagement in EM research; 2) seven policy-level recommendations for CAEP to support the creation of a national patient council, to develop, adopt and adapt training material, guidelines, and tools for patient engagement, and to support increased patient engagement in EM research; and 3) nine pragmatic recommendations about engaging patients in the preparatory, execution, and translational phases of EM research.
Patient engagement can improve EM research by helping researchers select meaningful outcomes, increase social acceptability of studies, and design knowledge translation strategies that target patients’ needs.
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: 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. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity, however, the ability of clinicians to reliably quantify tremor is highly dependent on experience. The objective of this study was to prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application. Methods: A prospective observational study of patients ≥18 years presenting to an academic emergency department in alcohol withdrawal was conducted from Oct 2014 to Aug 2015. Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Accelerometer derived results were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 76 patients with 78 tremor recordings were included. Accelerometer derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by ≥ 2 points in 5 (6.4%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘very good’ 0.92 (95% CI: 0.86, 0.99). Conclusion: iOS accelerometer based assessment of the tremor component of the CIWA-Ar score is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will impact and improve the care of patients with alcohol withdrawal.
Introduction: It is estimated 15-50% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop post-concussive syndrome (PCS). Although expert consensus recommends cognitive rest and graduated return to usual activities, these interventions are not based on prospective clinical evidence. The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions. Methods: This was a pragmatic, randomized trial of adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit. Patients were contacted by text message or phone 2 weeks post ED discharge and again at 4 weeks and asked to complete a validated, 22 item questionnaire to determine if there was a change in their PCSS. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school. Results: 118 patients were enrolled in the study (58 in the control group and 60 in the intervention). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs 12.8; Δ 2.3, 95% CI: 7.0, 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; Δ 2.8, 95% CI: 6.9, 12.7) for the intervention and control groups, respectively. The number follow-up physician visits and time off work/school was similar when the groups were compared. Conclusion: Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given patients continue to experience low to moderate symptoms 2 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with post-concussive symptoms.
Introduction: Of the domains assessed by the CIWA-Ar, tremor is the most objective, and reliable clinical symptom of alcohol withdrawal syndrome. Even so, anecdotal evidence suggests that the ability of health care workers to reliably rate tremor severity is highly variable, and there is no high quality, readily available training to teach this competency. Improper evaluation and interpretation of tremor may result in under or over treatment, posing serious risks to patient safety, prolonging emergency department (ED) length of stay, and increasing the likelihood of complications/hospital admission. The objective of this study was to prospectively compare tremor assessment scores assigned by nurses and clinical experts for patients with alcohol withdrawal syndrome in the ED. Methods: A prospective observational study was conducted for patients ≥18 years presenting to an academic ED in alcohol withdrawal from Oct 2014 to Aug 2015. Individual tremor assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts, blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA scale (0=no tremor, 7=severe tremor). Tremor severity scores assigned in real-time by the nurses were compared to expert assessments of each video. Inter-rater agreement was estimated using Cohen’s kappa (k) statistic. Results: 31 patients with 62 tremor recordings were included. Nurse-derived tremor scores matched exactly with expert assessor scores in 11 (17.7%) cases, within 1 point for 29 (46.8%) cases and differed by ≥ 2 points in 33 (53.3%) cases. The overall kappa for agreement within 1 point for tremor severity was ‘fair’ 0.39 (95% CI: 0.25, 0.53). Conclusion: These results confirm the high variability in the assessment of alcohol withdrawal tremor by health care workers. Future research should focus on ways to improve the accuracy of tremor in alcohol withdrawal patients, and the development and implementation of an educational program to improve the individual competencies of clinical staff in the recognition and treatment of alcohol withdrawal in the ED.
Introduction: Collecting patient-reported follow-up data for prospective studies in the emergency department (ED) is challenging in this acute care, minimal continuity setting. Follow-up is frequently attempted using telephone contact and in some instances mail correspondence. The objective of this study was to determine if text messaging study participants involved in an ongoing randomized trial resulted in a lower rate of attrition as compared to conventional telephone follow-up. Methods: This was a secondary analysis of research participants enrolled in a randomized controlled trial assessing head injury discharge instructions. Adult (18-64 years) patients presenting to an academic ED (annual census 65,000) with chief complaint ‘head injury’ occurring within 24 hours of ED visit were contacted by telephone 2 and 4 weeks post ED visit to complete a symptom questionnaire. During the first 4 months of study follow-up, participants were contacted by a conventional telephone call. Attrition was higher than anticipated, thus we received subsequent ethics approval for the final 3 months of follow-up duration to contact participants by text message on the day of the first telephone attempt as a reminder of the telephone interview scheduled later that day. The proportion of patients lost to follow-up at 2 and 4 weeks post ED visit was compared between participants not receiving and receiving reminder text messages. Results: 118 patients were enrolled in the study (78 underwent conventional follow-up and 40 received text messages). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) were male. During the period of conventional follow-up, 3 participants withdrew from the study. Of the remaining 75 participants, 24 (32.0%) at 2 weeks and 32 (42.7%) at 4 weeks were unable to be contacted. Of the 40 participants receiving a reminder text message, 4 (10.0%) at 2 weeks and 10 (25.0%) at 4 weeks were unable to be contacted. Overall, text messaging study participants decreased attrition by 22% (95% CI: 5.9%, 34.7%) and 17.7% (95% CI: -0.8%, 33.3%) at 2 and 4 week follow-up, respectively. Conclusion: In this young ED cohort participating in a randomized trial, text message reminders of upcoming telephone follow-up interviews decreased the rate of attrition. Text messaging is a viable, low-cost communication strategy that can improve follow-up participation in prospective research studies.
In the wide-field Panoramic Imaging Survey of Centaurus and Sculptor (PISCeS), we investigate the resolved stellar halos of two nearby galaxies (the elliptical Centaurus A and the spiral Sculptor, D ~ 3.7 Mpc) out to a projected galactocentric radius of 150 kpc with Magellan/Megacam. The survey has led to the discovery of ~20 faint satellites to date, plus prominent streams and substructures in two environments that are substantially different from the Local Group, i.e. the Centaurus A group dominated by an elliptical and the loose Sculptor group of galaxies. These discoveries clearly attest to the importance of past and ongoing accretion processes in shaping the halos of these nearby galaxies, and provide the first census of their satellite systems down to an unprecedented MV < −8. The detailed characterization of the stellar content, shape and gradients in the extended halos of Sculptor, Centaurus A, and their dwarf satellites provides key constraints on theoretical models of galaxy formation and evolution.
Previous research has found that mental health is strongly associated with life satisfaction. In this study we examine associations between mental health problems and life satisfaction in a birth cohort studied from 18 to 35 years.
Data were gathered during the Christchurch Health and Development Study, which is a longitudinal study of a birth cohort of 1265 children, born in Christchurch, New Zealand, in 1977. Assessments of psychiatric disorder (major depression, anxiety disorder, suicidality, alcohol dependence and illicit substance dependence) using DSM diagnostic criteria and life satisfaction were obtained at 18, 21, 25, 30 and 35 years.
Significant associations (p < 0.01) were found between repeated measures of life satisfaction and the psychiatric disorders major depression, anxiety disorder, suicidality, alcohol dependence and substance dependence. After adjustment for non-observed sources of confounding by fixed effects, statistically significant associations (p < 0.05) remained between life satisfaction and major depression, anxiety disorder, suicidality and substance dependence. Overall, those reporting three or more mental health disorders had mean life satisfaction scores that were nearly 0.60 standard deviations below those without mental health problems. A structural equation model examined the direction of causation between life satisfaction and mental health problems. Statistically significant (p < 0.05) reciprocal associations were found between life satisfaction and mental health problems.
After adjustment for confounding, robust and reciprocal associations were found between mental health problems and life satisfaction. Overall, this study showed evidence that life satisfaction influences mental disorder, and that mental disorder influences life satisfaction.