To determine the percentage of injured impaired drivers brought to the only trauma centre in Nova Scotia who were charged with impaired driving.

This retrospective observational study identified alcohol impaired drivers involved in a motor vehicle crash (MVC) brought to the emergency department (ED). Patients were selected based on blood alcohol concentrations (BACs) found to be above the legal limit. Medical records were examined to determine if the patient was the driver in an MVC. Patient records were then cross-referenced with a police database to determine the percentage of injured impaired drivers who were charged with impaired driving.

Between April 1, 2006, and April 1, 2008, 1,102 patients brought to the QEII Health Sciences Centre (QEII HSC) ED were found to have BACs over the legal limit. Of these patients, only 57 (5.2%) were found to have been the driver in an MVC. The majority of patients were male (49; 86%), with an average age of 32 years. Most injuries (51; 89.5%) were the result of a single-vehicle crash. The mean Glasgow Coma Scale score was 12.6, and the mean Injury Severity Score was 14.4. Cross-referencing with police records showed that only 22.8% (13 of 57) of injured drivers were charged with impaired driving. Those drivers not charged with impaired driving had a significantly lower median BAC and median age.

During the study, the majority of alcoholimpaired drivers injured in an MVC who were brought to the QEII HSC ED for assessment of their injuries were not charged with impaired driving.

Little information exists regarding how accurately emergency physicians (EPs) predict the probability of acute coronary syndrome (ACS). Our objective was to determine if EPs can accurately predict ACS in a prospectively identified cohort of emergency department (ED) patients who met enrolment criteria for a study of coronary computed tomographic angiography (CCTA) and were admitted for a “rule out ACS” protocol.

A prospective observational pilot study in an academic medical centre was carried out. EPs caring for patients with chest pain provided whole-number estimates of the probability of ACS after clinical review. This substudy was part of the now published Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) study, a study of CCTA and admission of patients for a rule out ACS protocol after a nondiagnostic evaluation. Predictions were grouped into probability groups based on the validated Goldman criteria. ACS was determined by an adjudication committee using American Heart Association/American College of Cardiology/European Society of Cardiology guidelines.

A total of 334 predictions were obtained for a study population with a mean age of 54 (SD 12) years, 63% of whom were male. There were 35 ACS events. EPs predicted ACS better than by chance, and increasingly higher estimates were associated with a higher incidence of ACS (p = 0.0004). The percentage of patients with ACS was 0%, 6%, 7%, and 17%, respectively, for very low, low, intermediate, and high probability groups. EPs' estimates had a sensitivity of 63% using a > 20% probability of ACS to define a positive test. Lowering this threshold to > 7% to define a test as positive increased the sensitivity of physician estimates to 89% but lowered specificity from 65% to 24%

Our data suggest that for a selected ED cohort meeting eligibility criteria for a study of CCTA, EPs predict ACS better than by chance, with an increasing proportion of patients proving to have ACS with increasing probability estimates. Lowering the estimate threshold does not result in an overall sensitivity level that is sufficient to send patients home from the ED and is associated with a poor specificity.

Prehospital vital signs are an important and required component of patient assessment. We compared the temporal artery thermometer (TAT) to the digital thermometer currently used in our emergency medical service (EMS) system and then to the digital thermometer used in the emergency department. The primary objective of this study was to assess the usefulness of the TAT in the prehospital setting. Other outcomes of interest included whether extraneous factors or cold ambient temperatures affected the TAT readings and paramedic satisfaction with the TAT.

This was a prospective, observational study. Patient temperature was taken by EMS personnel with both the digital thermometer and the TAT, and a chart review was conducted on a sample of these patients to compare the TAT to the emergency department digital thermometer.

A total of 818 patients had their temperatures taken with both thermometers in the prehospital setting. The relationship between the TAT and digital thermometer measurement was positive and moderate; however, there was poor agreement between the two devices. Sixty-nine charts were reviewed, and a positive correlation was found between the TAT and the emergency department digital thermometer, with good agreement between the two devices. No extraneous factors were found to have a noticeable effect on the temperature measurements; the TAT performed well in cold weather, and the EMS personnel reported it to be easy to use.

The TAT appears to be a suitable alternative to digital thermometers currently used in many EMS systems. The paramedics involved in this study liked the TAT better than the in-ambulance digital thermometer and believed it to be more accurate. Further research on this topic is required.

Methanol or ethylene glycol ingestion may result in significant morbidity or death without prompt treatment. Despite traditional and widespread use of intravenous ethanol as an antidote, its safety is not well described. An evaluation of the safety and ease of titrating ethanol infusions is necessary given the availability of an alternative antidote.

To evaluate the safety and ease of titrating ethanol infusions for the treatment of methanol or ethylene glycol ingestion.

We reviewed the hospital records of adults treated with ethanol at The Ottawa Hospital for methanol or ethylene glycol ingestion over a 9-year period. Using a standardized case report form, a single reviewer identified prespecified adverse events that developed after the start of ethanol therapy and classified dose adjustments during ethanol therapy as appropriate or inappropriate based on a priori criteria.

Forty-nine cases of methanol or ethylene glycol ingestion treated with ethanol were included in the analysis, of which 45 underwent hemodialysis, 38 were admitted to the intensive care unit, and 4 died. At least one adverse event was identified in 45 (92%) cases, including 35 (71%) with agitation requiring chemical or physical restraints and 10 (20%) with a depressed level of consciousness treated with intubation. The median number of ethanol concentration measurements per treatment course was 6 (range 0–24), of which only 27% were within the target range of 22 to 30 mmol/L and 47% were below. When measured concentrations were outside the target, the adjustment in ethanol dosing (or lack thereof) was deemed inappropriate 59% of the time, including 69% of the time during hemodialysis.

Based on actual practice in a large academic centre, adverse events occur frequently with intravenous ethanol infusions, and ethanol titration is inefficient. The safety profile and therapeutic drug monitoring considerations for ethanol should be considered when choosing an antidote for methanol or ethylene glycol ingestion.

To date, there has been minimal research on advance directives (ADs) among elderly patients in Canadian emergency departments (EDs). The purpose of this study was to determine the prevalence of ADs among elderly patients visiting an urban ED. We also explored whether there were factors associated with the existence of an AD and possible barriers to having one.

This prospective study ran between October and December 2008. Individuals over the age of 70 who presented to the ED between 7 am and 7 pm, 7 days a week, were considered for enrolment. Exclusion criteria included previous enrolment and inability to provide informed consent. A team of nurses who specialize in assessment of geriatric patients administered a study instrument consisting of 28 questions. Topics included demographics, level of education, medical information, and knowledge of and attitudes toward ADs.

The results from 280 participants, with an average age of 80.6 years, were analyzed. Thirty-five percent of participants reported that they knew what an AD was; 19.3% of participants said they had an AD, but only 5.6% brought it to the hospital; 50.7% were interested in further information regarding ADs; and 67.9% of participants felt that it was important for physicians to know their wishes about life support.

Knowledge of ADs among elderly patients visiting an urban Canadian ED is limited and is likely a significant factor precluding wider prevalence of ADs. There is interest in further discussion about ADs in this population group.

Endotracheal intubation (ETI) is considered the gold standard for protecting the airway. Alternative devices for airway protection have been developed that can be used by untrained personnel, by those with less experience, and for when ETI is not possible. The main goals of our study were to evaluate the success rate and speed of insertion of different supraglottic airway devices and to determine whether the devices could be properly inserted under simulated critical conditions.

Fifty medical students used an airway simulation trainer (Laerdal SimMan 3G) to assess the success rate and time used to insert seven different supraglottic airway devices under simulated physiologic and pathologic conditions in two different runs.

Although all airway devices could be inserted without problems, only the Combitube and the EasyTube could be successfully inserted in simulations of trismus, limited mobility of the cervical spine, or a combination of pathologic conditions such as trismus plus limited mobility of the spine and trismus plus tongue edema. The insertion time was significantly longer with LMA Unique, Fastrach, and I-Gel devices in both the first and second runs.

The Combitube and the EasyTube were most easily inserted under simulated conditions such as trismus, limited mobility of the cervical spine, and combined pathologic conditions. Although all devices are useful for establishing an airway by nontrained medical students in standard simulations, we suggest that the Combitube and the EasyTube may offer advantages in difficult airway situations.

To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres.

An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada.

Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%).

Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.

Africa's first postgraduate training program in emergency medicine (EM) was established at the University of Cape Town/Stellenbosch University (UCT/SUN) in 2004. This study of the UCT/SUN EM program investigated the backgrounds, perceptions, and experiences of its graduates.

This was a cross-sectional descriptive study. The study population was the 30 graduates from the first four classes in the UCT/SUN EM program (2007–2010). We employed a scripted interview with a combination of closed and open-ended questions. Data were analyzed using the thematic method of qualitative analysis.

Twenty-seven (90%) graduates were interviewed. Initial career goals were primarily (78%) to practice EM in a nonacademic clinical capacity. At the time of the interview, 52% held academic positions, 15% had nonacademic clinical positions, and 33% had temporary positions and were looking for other posts. The three most commonly cited strengths of their program were diversity of clinical rotations (85%), autonomy and procedural experience (63%), and importance of being pioneers within Africa (52%). The three most commonly cited weaknesses were lack of bedside teaching in the ED (96%), lack of career options after graduation (74%), and lack of preparation for academic careers (70%).

The lessons identified from structured interviews with graduates from Africa’s first EM training include the importance of strong clinical training, difficulty of ensuring bedside teaching in a new program, the necessity of ensuring postgraduation positions, and the need for academic training. These findings may be useful for other developing countries looking to start EM training programs.

We sought to determine the antibiotic susceptibility of organisms causing community-acquired urinary tract infections (UTIs) in adult females attending an urban emergency department (ED) and to identify risk factors for antibiotic resistance.

We reviewed the ED charts of all nonpregnant, nonlactating adult females with positive urine cultures for 2008 and recorded demographics, diagnosis, complicating factors, organism susceptibility, and risk factors for antibiotic resistance. Odds ratios (ORs) and 95% confidence intervals (CIs) for potential risk factors were calculated.

Our final sample comprised 327 UTIs: 218 were cystitis, of which 22 were complicated cases and 109 were pyelonephritis, including 22 complicated cases. Escherichia coli accounted for 82.3% of all UTIs, whereas Staphylococcus saprophyticus accounted for 5.2%. In uncomplicated cystitis, 9.5% of all isolates were resistant to ciprofloxacin and 24.0% to trimethoprim-sulfamethoxazole (TMP-SMX). In uncomplicated pyelonephritis, 19.5% of isolates were resistant to ciprofloxacin and 36.8% to TMP-SMX. In UTI (all types combined), any antibiotic use within the previous 3 months was a significant risk factor for resistance to both ciprofloxacin (OR 3.34, 95% CI 1.16–9.62) and TMP-SMX (OR 4.02, 95% CI 1.48–10.92). Being 65 years of age or older and having had a history of UTI in the previous year were risk factors only for ciprofloxacin resistance.

E. coli was the predominant urinary pathogen in this series. Resistance to ciprofloxacin and TMP-SMX was high, highlighting the importance of relevant, local antibiograms. Any recent antibiotic use was a risk factor for both ciprofloxacin and TMP-SMX resistance in UTI. Our findings should be confirmed with a larger prospective study.

A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program.

Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP.

Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001).

Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.

Within the emergency department (ED) patient population there is a subset of patients who make frequent visits. This chart review sought to characterize this population and identify strategies to reduce frequent ED visits.

Frequent use at an urban tertiary care centre was defined as 15 or more visits over 1 year. The details of each visit—demographics, entrance complaint, discharge diagnosis, arrival method, Canadian Triage and Acuity Scale (CTAS) score, and length of stay—were analyzed and compared to data from the entire ED population for the same period.

Ninety-two patients generated 2,390 ED visits (of 25,523 patients and 44,204 visits). This population was predominantly male (66%) and middle-aged (median 42 years), with no fixed address (27.2%). Patients arrived by ambulance in 59.3% of visits with less acute CTAS scores than the general population. Substance use accounted for 26.9% of entrance complaints. Increased lengths of stay were associated with female gender and abnormal vital signs, whereas shorter stays were associated with no fixed address and substance use (p < 0.05). Admissions were lower than the general population, and women were twice as likely as men to be admitted (p < 0.05). Patients left without being seen in 15.8% of visits.

High-frequency ED users are more likely to be male, younger, and marginally housed and to present secondary to substance use. Although admissions among this population are low, the costs associated with these presentations are high. Interventions designed to decrease visits and improve the health of this population appear warranted.

Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA.

We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded.

A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%.

This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.

A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.

In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload model.

None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested.

The objective of this study was to determine whether skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) in patients presenting to The Ottawa Hospital emergency departments (TOHEDs) differed from SSTIs caused by methicillin-susceptible Staphylococcus aureus (MSSA) with regard to risk factors, management, and outcomes.

All patients seen at TOHEDs in 2006 and 2007 with SSTIs who yielded MRSA or MSSA in cultures from the site of infection were eligible for inclusion. We excluded patients with decubitus ulcers and infections related to diabetes or peripheral vascular disease. We used an unmatched case-control design. Cases were defined as patients with MRSA isolated from the infection site, and controls were defined as patients with MSSA isolated from the infection site. Data were collected retrospectively from health records and laboratory and hospital information systems.

A total of 153 patients were included in the study (81 cases and 72 controls). The mean age of cases was 37 years, compared to 47 years for the controls (p < 0.001). Cases were more likely to have transient residence (31% v. 3% [OR 15.6, 95% CI 3.9–61.8, p < 0.001]), present with abscesses (64% v. 15% [OR 9.9, 95% CI 4.3–23.7, p < .001]), have a documented history of hepatitis C infection (28% v. 3% [OR 13.9, 95% CI 3.9–55.0, p < 0.001]), and have a history of substance abuse (53% v. 10% [OR 10.5, 95% CI 4.4–25.1, p < 0.001]). Cases most commonly used crack cocaine and injection drugs.

SSTIs caused by MRSA at TOHEDs mainly occur in a population that is young and transient with comorbidities such as hepatitis C and substance abuse.

It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.

This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion.

A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2 score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74).

We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.

Providing patients with instructions and equipment regarding self-removal of nonabsorbable sutures could represent a new efficiency in emergency department (ED) practice. The primary outcome was to compare the proportion of patients successfully removing their own sutures when provided with suture removal instructions and equipment versus the standard advice and follow-up care. Secondary outcomes included complication rates, number of physician visits, and patient comfort level.

This prospective, controlled, single-blinded, pseudorandomized trial enrolled consecutive ED patients who met the eligibility criteria (age > 19 years, simple lacerations, nonabsorbable sutures, immunocompetent). The study group was provided with wound care instructions, a suture removal kit, and instructions regarding suture self-removal. The control group received wound care instructions alone. Outcomes were assessed by telephone contact at least 14 days after suturing using a standardized questionnaire.

Overall, 183 patients were enrolled (93 in the intervention group; 90 in the control group). Significantly more patients performed suture self-removal in the intervention group (91.5%; 95% CI 85.4–97.5) compared to the control group (62.8%; 95% CI 52.1–73.6) (p < 0.001). Patients visited their physician less often in the intervention group (9.8%; 95% CI 3.3–16.2) compared to the control group (34.6%; 95% CI 24.1–45.2%) (p < 0.001). Complication rates were similar in both groups.

Most patients are willing to remove, and capable of removing, their own sutures. Providing appropriate suture removal instructions and equipment to patients with simple lacerations in the ED appears to be both safe and acceptable.