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Among patients with a history of ESBL infection, uncertainty remains regarding whether all of these patients require ESBL-targeted therapy when presenting with a subsequent infection. We sought to determine the risks associated with a subsequent ESBL infection to help inform empiric antibiotic decisions.
A retrospective cohort study of adult patients with positive index culture for Escherichia coli or Klebsiella pneumoniae (EC/KP) receiving medical care during 2017 was conducted. Risk assessments were performed to identify factors associated with subsequent infection caused by ESBL-producing EC/KP.
In total, 200 patients were included in the cohort, 100 with ESBL-producing EC/KP and 100 with ESBL-negative EC/KP. Of 100 patients (50%) who developed a subsequent infection, 22 infections were ESBL-producing EC/KP, 43 were other bacteria, and 35 had no or negative cultures. Subsequent infection caused by ESBL-producing EC/KP only occurred when the index culture was also ESBL-producing (22 vs 0). Among those with ESBL-producing index culture, the incidences of subsequent infection caused by ESBL-producing EC/KP versus other bacterial subsequent infection were similar (22 vs 18; P = .428). Factors associated with subsequent infection caused by ESBL-producing EC/KP include history of ESBL-producing index culture, time ≤180 days between index culture and subsequent infection, male sex, and Charlson comorbidity index score >3.
History of ESBL-producing EC/KP culture is associated with subsequent infection caused by ESBL-producing EC/KP, particularly within 180 days after the historical culture. Among patients presenting with infection and a history of ESBL-producing EC/KP, other factors should be considered in making empiric antibiotic decisions, and ESBL-targeted therapy may not always be warranted.
To evaluate the clinical impact of the BioFire FilmArray Pneumonia Panel (PNA panel) in critically ill patients.
Single-center, preintervention and postintervention retrospective cohort study.
Tertiary-care academic medical center.
Adult ICU patients.
Patients with quantitative bacterial cultures obtained by bronchoalveolar lavage or tracheal aspirate either before (January–March 2021, preintervention period) or after (January–March 2022, postintervention period) implementation of the PNA panel were randomly screened until 25 patients per study month (75 in each cohort) who met the study criteria were included. Antibiotic use from the day of culture collection through day 5 was compared.
The primary outcome of median time to first antibiotic change based on microbiologic data was 50 hours before the intervention versus 21 hours after the intervention (P = .0006). Also, 56 postintervention regimens (75%) were eligible for change based on PNA panel results; actual change occurred in 30 regimens (54%). Median antibiotic days of therapy (DOTs) were 8 before the intervention versus 6 after the intervention (P = .07). For the patients with antibiotic changes made based on PNA panel results, the median time to first antibiotic change was 10 hours. For patients who were initially on inadequate therapy, time to adequate therapy was 67 hours before the intervention versus 37 hours after the intervention (P = .27).
The PNA panel was associated with decreased time to first antibiotic change and fewer antibiotic DOTs. Its impact may have been larger if a higher percentage of potential antibiotic changes had been implemented. The PNA panel is a promising tool to enhance antibiotic stewardship.
To compare 2 methods of communicating polymerase chain reaction (PCR) blood-culture results: active approach utilizing on-call personnel versus passive approach utilizing notifications in the electronic health record (EHR).
Retrospective observational study.
A tertiary-care academic medical center.
Adult patients hospitalized with ≥1 positive blood culture containing a gram-positive organism identified by PCR between October 2014 and January 2018.
The standard protocol for reporting PCR results at baseline included a laboratory technician calling the patient’s nurse, who would report the critical result to the medical provider. The active intervention group consisted of an on-call pager system utilizing trained pharmacy residents, whereas the passive intervention group combined standard protocol with real-time in-basket notifications to pharmacists in the EHR.
Of 209 patients, 105, 61, and 43 patients were in the control, active, and passive groups, respectively. Median time to optimal therapy was shorter in the active group compared to the passive group and control (23.4 hours vs 42.2 hours vs 45.9 hours, respectively; P = .028). De-escalation occurred 12 hours sooner in the active group. In the contaminant group, empiric antibiotics were discontinued faster in the active group (0 hours) than in the control group and the passive group (17.7 vs 7.2 hours; P = .007). Time to active therapy and days of therapy were similar.
A passive, electronic method of reporting PCR results to pharmacists was not as effective in optimizing stewardship metrics as an active, real-time method utilizing pharmacy residents. Further studies are needed to determine the optimal method of communicating time-sensitive information.
To evaluate the frequency of antibiotic prescribing for common infections via telemedicine compared to face-to-face visits.
Systematic literature review and meta-analysis.
We searched PubMed, CINAHL, Embase (Elsevier platform) and Cochrane CENTRAL to identify studies comparing frequency of antibiotic prescribing via telemedicine and face-to-face visits without restrictions by publish dates or language used. We conducted meta-analyses of 5 infections: sinusitis, pharyngitis, otitis media, upper respiratory infection (URI) and urinary tract infection (UTI). Random-effect models were used to obtain pooled odds ratios (ORs). Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic test.
Among 3,106 studies screened, 23 studies (1 randomized control study, 22 observational studies) were included in the systematic literature review. Most of the studies (21 of 23) were conducted in the United States. Studies were substantially heterogenous, but stratified analyses revealed that providers prescribed antibiotics more frequently via telemedicine for otitis media (pooled odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.52; I2 = 31%) and pharyngitis (pooled OR, 1.16; 95% CI, 1.01–1.33; I2 = 0%). We detected no significant difference in the frequencies of antibiotic prescribing for sinusitis (pooled OR, 0.86; 95% CI, 0.70–1.06; I2 = 91%), URI (pooled OR, 1.18; 95% CI, 0.59–2.39; I2 = 100%), or UTI (pooled OR, 2.57; 95% CI, 0.88–7.46; I2 = 91%).
Telemedicine visits for otitis media and pharyngitis were associated with higher rates of antibiotic prescribing. The interpretation of these findings requires caution due to substantial heterogeneity among available studies. Large-scale, well-designed studies with comprehensive assessment of antibiotic prescribing for common outpatient infections comparing telemedicine and face-to-face visits are needed to validate our findings.
Introduction: Most emergency departments (ED) in Canada have a population of high frequency users that present to the ED on a regular basis. These patients are well described in the literature and typically defined by a frequency of 8-10 visits/year. In Thunder Bay, Ontario we have a significant population of patients that present more often that we have termed “super-users”. These patients often are typically from a vulnerable population with multiple co-morbidities and a high mortality rate. Although their risk for poor health outcomes is well recognized, both the chronicity and complexity of their symptoms often contributes to diagnostic dilemmas. The decision to order a computed tomography (CT) scan can be a difficult balance between ruling out life threatening diagnoses and exposing the patient to excessive radiation. Our objective was to describe how often these super-users of the ED received a CT scan and what types of imaging were completed. Methods: The Thunder Bay Regional Health Sciences Centre is a geographically isolated hospital in Northwestern Ontario with the next closest hospital based CT scanner greater than 300 km away. Based on previous literature and our preliminary scoping of the super-user group, we have identified a minimum of 25 visits as the threshold. A retrospective chart review was conducted for the year 2017 using our electronic medical record. Patient demographic data was collected along with the type and number of CT scans into a standardized collection tool. Results: Our preliminary results showed that our total population of super-users was 75 patients with an average of 32 visits to the ED per year. A total of 76% of the patients had a CT scan completed at least once. On average these patients have a CT during 10% of their visits with head CT comprising 50% of the imaging and abdominal/pelvis imaging comprising another 45%. For 20% of these super-users, they had CTs on 20% of their visits. From this population, only 10% of the patients had surgery in 2017 while 7% of visits required admission to hospital. The most common diagnoses for these patient visits relate to mental health/addictions, gastrointestinal complaints and infection. Conclusion: This study has shown that a significant number of our super-user population are receiving multiple CTs. Our next step is collect data on individual radiation doses and calculate exposure risks. We hope to inform policy and decision-makers who are developing programs to treat the underlying cause of their high resource use.
Introduction: Positive deviance recognizes that there are individuals and teams within our community of practice that succeed in spite of system constraints. Amazing and awesome rounds has been proposed as a forum to identify behaviours and processes that lead to exceptional results. The objective of this study was to determine the feasibility and acceptability of a structured amazing and awesome rounds model through an innovative educational intervention. Methods: The authors engaged a broad range of professional designations(physicians, surgeons, nurses, respiratory therapists, administrative staff) at a tertiary care institution. A&A rounds were open to all allied health professionals and administrative staff. The Northern A&A rounds model was developed, implemented, and then evaluated as a four-part intervention. This consisted of: 1) Allied health professional training on case selection and analysis, 2) Engaging inter professional members, 3) disseminating lessons learned, and 4) creating an administrative pathway for acting on issues identified through the A&A rounds. The measures of intervention feasibility included the proportion of sessions adherent to the new model and A&A rounds attendance. Post intervention surveys of presenters and attendees were used to determine intervention acceptability. A&A presentation content was reviewed to determine the most frequently adopted components of the model. Results: Nine out of 9(100%) of presented cases were adherent to the three components of the Northern A&A Model. A&A rounds were highest attended of all hospital wide grand rounds(N = 75 SD 2.4 P < 0.001). Nine case presentations were analyzed and 7 action items were identified for amplification across the hospital. Including 3 case reports published of a novel approach to a patient case,a rapid referral for trauma patients at risk for PTSD, AED placement in all community clinics and routine debrief after resuscitations. Presenters included a broad representation of hospital staff including surgeons, emergency physicians, radiologists, nurses, and administrators. Conclusion: The Northern A&A Model was a feasible intervention that was perceived to be effective by both presenters and attendees. The authors believe that this could be readily applied to any hospital seeking to enhance quality of care and patient safety.
Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.
Introduction: Wide variability exists in emergency department (ED) syncope management. The Canadian Syncope Risk Score (CSRS) was derived and validated to predict the probability of 30-day serious outcomes after ED disposition. The objective was to identify barriers and facilitators among physicians for CSRS use to stratify risk and guide disposition decisions Methods: We conducted semi-structured interviews with physicians involved in ED syncope care at 8 Canadian sites. We used purposive sampling, contacting ED physicians, cardiologists, internists, and hospitalists until theme saturation was reached. Interview questions were designed to understand whether the CSRS recommendations are consistent with current practice, barriers and facilitators for application into practice, and intention for future CSRS use. Interviews were conducted via telephone or videoconference. Two independent raters coded interviews using an inductive approach to identify themes, with discrepancies resolved through consensus. Our methods were consistent with the Knowledge to Action Framework, which highlights the need to assess barriers and facilitators for knowledge use and for adapting new interventions into local contexts. Results: We interviewed 14 ED physicians, 7 cardiologists, and 10 hospitalists/internists across 8 sites. All physicians reported the use of electrocardiograms for patients with syncope, a key component in the CSRS criteria. Almost all physicians reported that the low risk recommendation (discharge without specific follow-up) was consistent with current practice, while less consistency was seen for moderate (15 days outpatient monitoring) and high risk recommendations (outpatient monitoring and/or admission). Key barriers to following the CSRS included a lack of access to outpatient monitoring and uncertainty over timely follow-up care. Other barriers included patient/family concerns, social factors, and necessary bloodwork. Facilitators included assisting with patient education, reassurance of their clinical gestalt, and optimal patient factors (e.g. reliability to return, support at home, few comorbidities). Conclusion: Physicians are receptive to using the CSRS tool for risk stratification and decision support. Implementation should address identified barriers, and adaptation to local settings may involve modifying the recommended clinical actions based on local resources and feasibility.
Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.
Innovation Concept: Dizziness is an increasingly common presenting complaint in the emergency department (ED), accounting for >2% of visits annually or almost 30% of visits in patients aged over 65. Approximately half of all cases of dizziness in older adults are caused by benign paroxysmal positional vertigo (BPPV). The use of computerized tomography (CT) to rule out serious but rare underlying central nervous system (CNS) causes in patients with dizziness in the ED is increasing despite guidelines supporting the use of clinical exam maneuvers such as the Dix-Hallpike test and therapeutic canalith repositioning maneuvers. Evidence indicates that these clinical tools are underutilized due to clinician discomfort or lack of understanding in performing and interpreting the maneuvers, supporting brief and accessible clinical resources that incorporate video examples to address this. Methods: Through an iterative process the authors have developed a smartphone app that is designed to facilitate the clinical diagnosis of BPPV and provide treatment maneuvers where appropriate. The app is being tested by clinicians practicing emergency medicine or primary care in Northern Ontario. Curriculum, Tool, or Material: The BPPV Tool is designed as a step-wise guide to diagnose BPPV. Clinicians will be prompted to perform specific exam maneuvers based on clinical findings, and can follow short example videos or written directions. Potentially precipitated nystagmus is described along with example videos. Provocative tests include the Dix-Hallpike and Supine Roll. If appropriate, the clinician will be prompted to perform therapeutic repositioning maneuvers such as the Epley or Gufoni, with associated sample videos, descriptions, and billing information where available. If at any point a clinician's exam findings are not in keeping with a diagnosis of BPPV, they will be alerted to this and stop progressing through the app. Conclusion: The BPPV Tool is an accessible and easily disseminated smartphone app designed to improve clinician comfort in reliably diagnosing BPPV. Diagnosing this common condition clinically is supported in the literature and can reduce the number of unnecessary CT scans performed, which would reduce healthcare costs and ED length of stay for these visits, and could reduce the number of patient transfers from peripheral sites for imaging.
Introduction: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed in order to reduce the frequency of misdiagnoses and number of diagnostic tests. As part of the guidelines, a clinical decision aid was developed in order to facilitate clinician decision-making based on practice recommendations. The objective of this study was to identify barriers and facilitators among physicians to implementation of the decision aid. Methods: We conducted semi-structured interviews with emergency room physicians working at 5 sites distributed between urban academic and rural settings. We used purposive sampling, contacting ED physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators affecting the probability of decision aid uptake and accurate application of the tool. Two independent raters coded interview transcripts using an integrative approach to theme identification, combining an inductive approach to identification of themes within an organizing framework (Theoretical Domains Framework), discrepancies in coding were resolved through discussion until consensus was reached. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification while reducing resource use and missed diagnoses. Facilitators identified included validation and publication of the guidelines as well as adoption by peers. Barriers to implementation and application of the tool included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. Furthermore, scoring components were, at times, out of alignment with clinician practices and understanding of risk factors. The complexity of the decision aid was also identified as a potential barrier to accurate use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use, particularly within rural contexts. Key barriers identified included the complexity of scoring and inclusion criteria, and the variable acceptance of D-dimer among clinicians. These barriers should be addressed prior to implementation of the decision aid during validation studies of the clinical practice guidelines.
Introduction: Emergency department (ED) syncope management is extremely variable. We developed practice recommendations based on the validated Canadian Syncope Risk Score (CSRS) and outpatient cardiac monitoring strategy with physician input. Methods: We used a 2-step approach. Step-1: We pooled data from the derivation and validation prospective cohort studies (with adequate sample size) conducted at 11 Canadian sites (Sep 2010 to Apr 2018). Adults with syncope were enrolled excluding those with serious outcome identified during index ED evaluation. 30-day adjudicated serious outcomes were arrhythmic (arrhythmias, unknown cause of death) and non-arrhythmic (MI, structural heart disease, pulmonary embolism, hemorrhage)]. We compared the serious outcome proportion among risk categories using Cochran-Armitage test. Step-2: We conducted semi-structured interviews using observed risk to develop and refine the recommendations. We used purposive sampling of physicians involved in syncope care at 8 sites from Jun-Dec 2019 until theme saturation was reached. Two independent raters coded interviews using an inductive approach to identify themes; discrepancies were resolved by consensus. Results: Of the 8176 patients (mean age 54, 55% female), 293 (3.6%; 95%CI 3.2-4.0%) experienced 30-day serious outcomes; 0.4% deaths, 2.5% arrhythmic, 1.1% non-arrhythmic outcomes. The serious outcome proportion significantly increased from low to high-risk categories (p < 0.001; overall 0.6% to 27.7%; arrhythmic 0.2% to 17.3%; non-arrhythmic 0.4% to 5.9% respectively). C-statistic was 0.88 (95%CI0.86–0.90). Non-arrhythmia risk per day for the first 2 days was 0.5% for medium-risk, 2% for high-risk and very low thereafter. We recruited 31 physicians (14 ED, 7 cardiologists, 10 hospitalists/internists). 80% of physicians agreed that low risk patients can be discharged without specific follow-up with inconsistencies around length of ED observation. For cardiac monitoring of medium and high-risk, 64% indicated that they don't have access; 56% currently admit high-risk patients and an additional 20% agreed to this recommendation. A deeper exploration led to following refinement: discharge without specific follow-up for low-risk, a shared decision approach for medium-risk and short course of hospitalization for high-risk patients. Conclusion: The recommendations were developed (with online calculator) based on in-depth feedback from key stakeholders to improve uptake during implementation.
Innovation Concept: In Sudbury, ON 44% of out-of-hospital cardiac arrest (OHCA) patients receive bystander CPR (bCPR), and only 4.7% survive cardiac arrest. The Northern City of Heroes (NCH) community initiative was launched in April 2019 with a goal of improving survival from OHCA through hands-only bCPR in the municipality. One NCH initiative is an interactive exhibit at Science North, a science centre in Sudbury that hosts 250,000 visitors annually. The exhibit employs simulation trainers for CPR, accompanying signage and interactive elements. The goals of the exhibit are to activate bCPR, change and measure behaviours through exhibit interactions on how to deliver excellent CPR, and improve survival rates in OHCA patients. Methods: Data is being collected from 3000 visitors using self-reported surveying via SurveyGizmo to assess likelihood of performing bCPR, pre and post interacting with the exhibit. Visitor behaviour will be examined at the exhibit using video-recorded interactions and coding those behaviours using BORIS software. Behavioural data will be analyzed using the Visitor Engagement Framework (VEF) where initiation, transition and breakthrough learning-behaviours are coded and an exhibit Visitor Engagement Profile (VEP) is created. The VEF and VEP are tools used in informal learning settings to assess exhibit impacts on learning. Curriculum, Tool, or Material: The use of an easily-apprehendable, hands-on exhibit tool located in a public setting, such as a science centre, creates a platform for engaging large and diverse public audiences. This type of bCPR exhibitry has not been implemented in other similar environments. The informal learning setting allows the science centre staff to engage in personalized interactions that can solidify the quality of learning and confidence in employing the new skills developed. Conclusion: The NCH exhibit and new strategies for embedding informal curriculum are powerful tools to reach diverse audiences, build knowledge and skills, and have a measurable impact on bCPR and OHCA survival rates. Data is being captured and tracked by Health Sciences North around the City of Greater Sudbury's bCPR and OHCA survival rates to monitor long-term impacts of the NCH community initiatives. Limitations of the study may be found in the focused demographics as well as the nature of self-reported learning. Future research directions include broader geographical surveying to assess improvements in community response to OHCA as a direct result of an interactive bCPR exhibitry.
Introduction: The vast majority of patients presenting with dizziness to the emergency department (ED) are due to a benign self-limiting process. However, up to 5% have a serious central neurological cause. Our goal was to assess the sensitivity of clinical exam for a central cause in adult patients presenting to the emergency department with dizziness. Methods: At a tertiary care ED we performed a medical records review (Sep 2014- Mar 2018) including adult patients with dizziness (vertigo, unsteady, lightheaded), excluding those with symptoms >14days, recent trauma, GCS < 15, hypotensive, or syncope/loss of consciousness. 5 trained reviewers used a standardized data collection sheet to extract data. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database. Our outcome was a central cause defined as: ischemic stroke (IS), transient ischemic attack (TIA), brain tumour, intra cerebral haemorrhage (ICH), or multiple sclerosis (MS) diagnosed on either neurology assessment, computed tomography, magnetic resonance imaging, or diagnostic codes related to central causes found within ICES. A sample size of 1,906 was calculated based on an expected prevalence of 3% with an 80% power and 95% confidence interval to detect an odds ratio greater than 2. Univariate analysis and logistic regression were performed. Results: 3,109 were identified and 2,307 patients included (mean 57 years SD ± 20, Female 59.1%, Kappa 0.91). 62 central causes (IS 56.5%, TIA 14.5%, Tumour 11.3%, MS 9.7%, ICH 6.5%) of dizziness were identified. Imaging was performed in 945(42%) and neurology assessment in 42 (1.8%). ICES yielded no new diagnoses of a central cause for dizziness. Multivariate logistic regression found 11 high-risk findings associated with a central cause; history of IS/TIA (OR 3.8 95%CI 1.7-8.2), cancer (OR 3.2 95%CI 1.4-7.2), dyslipidemia (OR 2.3 95%CI 1.2-4.4), symptoms of visual changes (OR 2.1 95%CI 1.5-6.3), dysarthria (OR 9.1 95%CI 3-27.4), vomiting (OR 2 95%CI 1-3.7), motor deficit (OR 7.7 95%CI 2.9-20.2), sensory deficit (OR 28.9 95%CI 7.4-112.9), nystagmus (OR 3.3 95%CI 1.6-6.7), ataxia (OR 2.5 95%CI 1.3-4.9) and unable to walk 3 steps unaided (OR 3.4 95%CI 1.4-8.5). Absence of these findings had a sensitivity of 100% (95%CI 92.5-100%) for ICH, IS, Tumour and 95.2% (86.5-98.9) if including TIA and MS. Specificity was 51.5% (95%CI 49.4-53.6%). Conclusion: Clinical exam is highly sensitive for identifying patients without a central etiology for their dizziness.
Introduction: According to the International Evidence-Based Recommendations for Point-of-Care Lung Ultrasound published in 2012, the sonographic technique for evaluating a patient for a pneumothorax (PTX) “consists of exploration of the least gravitationally dependent areas progressing more laterally” in the supine patient. However, there is a wide variety of scanning protocols in the literature with varying accuracy and complexity. We sought to derive an efficient and accurate scanning protocol for diagnosing pneumothorax using point of care ultrasound in trauma. Methods: We performed a retrospective chart review of a tertiary care trauma registry from Nov 2006 to Aug 2016. We included patients with a PTX diagnosed on computed tomography (CT). Patients were excluded if they did not have an identifiable PTX on the CT scan or if they underwent a tube thoracostomy prior to the CT scan. Penetrating and blunt trauma were eligible. Data were extracted with a standardized data collection tool and 20% of charts reviewed by two reviewers. Pre defined zones were used to map area of PTXs on CT. Sensitivity, specificity and 95% CI are reported for presence of PTXs in each individual or combination of lung zones as identified on CT scan. Results: Data were collection yielded 170 traumatic PTX on chest CT with an average age of 44.2 and 77.8% male. The kappa for data extraction was 0.88. 19.4% of patients had bilateral PTX leading to a total sample size of 203. The average ISS score was 20.7 and 93% of patients survived to discharge. The length of ICU stay and hospital stay was 3.7 and 11.2 days respectively. The most accurate and efficient protocol would involve scanning the inferior border of the clavicle at the para-sternal border and again at the mid-clavicular line down to the cardiac (left hemithorax) and liver lung points (right hemithorax). The sensitivity of this scanning area in the detection of PTXs was 91.6% (95% CI 86.9-95%,). Limiting the area to the most anterior point of the chest wall increased the risk of missing a PTX (Sensitivity 89.7% (95%CI 84.6-93.5)). Conclusion: We have derived an evidence-based standardized accurate and efficient scanning protocol to rule out a pneumothorax on point of care ultrasound.
Innovation Concept: Residents bear an enormous burden of responsibility for patient care which can lead to stress and mental exhaustion, especially in the face-paced and acute environment of emergency medicine (EM). In addition to numerous demands faced by EM residents, being a member of a geographically distributive residency program presents many unique challenges from a support and wellness perspective. To address these issues we sought to implement a video conferenced peer support network in hopes to foster wellness in the NOSM Family Medicine/EM program, where learners are commonly separated for training. Methods: Participants completed a pre-pilot questionnaire that strongly showed interest for this type of novel network. Furthermore residents conveyed that they are reluctant to access formal services and commonly rely on co-residents for support. This pilot program intends to decrease barriers that geography and stigma create that negatively hinder seeking support throughout medical training. Keeping the network small, consisting of only co-residents maintains a collegial and confidential environment that enables colleagues to provide relevant help to one another. Offering this outlet allows the opportunity to debrief and share unique experiences, which can lead to improved knowledge and wellbeing. Curriculum, Tool or Material: Informal, co-resident run and easy to access sessions are held twice monthly and average one hour in length. Discussion topics commonly include residency issues, difficult patient encounters and challenging situations. These sessions are conducted via video conferencing making them easily accessible from a distance and also from a comfortable and convenient environment of the participants choosing. Residents have commented that this is a helpful platform to discuss important issues while providing and safe and confidential resource to help cope with residency challenges. Conclusion: Further data analysis is underway as we are in the initial stages of implementing the program. In the final stages (April 2018) a pending post-pilot questionnaire will be interpreted to explore barriers, limitations and to determine the role of the network going forward. If found to be effective it is something that can be implemented and adapted for future residents. Other programs can use this feasible model to increase wellness and foster the same supportive environment among residents, especially those separated geographically from peers who may benefit most.
Introduction: Dizziness is a common presentation in emergency departments (ED), accounting for 2-3% of all visits. The HINTS (Head impulse test, Nystagmus, Test of skew) exam has been proposed as a accurate test to help differentiate central from peripheral causes of vertigo. It is only applicable to patients presenting with acute vestibular syndrome (acute onset dizziness or vertigo, ataxia, nystagmus, nausea and/or vomiting, and head motion intolerance). We aimed to assess the diagnostic accuracy of HINTS in detecting central causes of dizziness and vertigo in adult patients presenting with AVS. Methods: We performed a medical records review of all patients with a presenting complaint of dizziness to a tertiary care ED between Sep 2014 and Mar 2018. We excluding those with symptoms >14days, recent trauma, GCS <15, hypotensive, or syncope/loss of consciousness. Data were extracted by 5 trained reviewers using a standardized data collection sheet. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database to assess for any patients with a missed central cause. The primary outcome measure was a central cause of dizziness; cardiovascular accident (CVA), transient ischemic attack (TIA), brain tumour (BT) or multiple sclerosis (MS) as diagnosed on either computed tomography, magnetic resonance imaging, neurology consult or diagnostic codes within ICES. Results: 3109 patients were identified and 2309 patients met the inclusion criteria, of those 450 patients (44% male) were assessed using HINTS exam. Of those examined with HINTS, 7 patients (1.6% - 4 CVA 2 TIA 1 MS) were determined to have a central cause for their dizziness. HINTS had a sensitivity of 28.6% (95%CI 3.7 – 71%), specificity 95% (95%CI 92.6-96.9%). Of the individuals assessed with HINTS, only 16 presented with AVS (3.6%), of which three patients were found to have a central cause (CVA 2, TIA 1). HINTS in AVS for all central causes is 66.7% (95%CI 9.4-99.2%)sensitive but is 100%(95%CI 15.8-100%) for CVA alone (excluding TIA). Only 38%(16/42) of patients presenting with AVS were assessed using the HINTS exam. Conclusion: The current use of HINTS is inaccurate and it is used inappropriately in a large number of patients. Future studies should focus on the correct implementation of HINTS in the ED only in patients presenting with AVS.
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: Dizziness is a common presentation in emergency departments (ED), accounting for 2-3% of all visits. The majority are due to benign causes the most common of which is benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is used to diagnose BPPV with an affected posterior semicircular canal. A positive Dix-Hallpike exam should lead physicians to exclude central causes for a patient's symptoms and confirm no need for further imaging. The purpose of our study was to verify the accuracy of the Dix-Hallpike maneuver for ruling out a central cause of dizziness. Methods: We performed a medical records review of adult patients with dizziness/vertigo presenting to a tertiary care ED (September 2014 and March 2018). We included those with a suspicion for BPPV and underwent a Dix-Hallpike maneuver. We excluded patients who presented with dizziness for longer than two weeks, syncope, systolic hypotension <90 or a GCS <15. Individual patient data were linked with the Institute of Clinical Evaluation Science (ICES) database. Our outcome was a central cause defined as: ischemic stroke (IS), brain tumour, intra cerebral haemorrhage (ICH), or multiple sclerosis (MS) diagnosed on either neurology assessment, computed tomography, magnetic resonance imaging, or diagnostic codes related to central causes found within ICES. Results: 3109 patients were identified of these 469 patients underwent a Dix-Hallpike manoeuvre. Central causes of dizziness accounted for 1.1% of all diagnoses. Probability of a central cause for dizziness in those with a positive Dix-Hallpike was 1.3%(3/229). Only 85(18.1%) patients were appropriate for the Dix-Hallpike(intermittent, position-evoked vertigo without any neurological deficits). In appropriate patients the prevalence of central cause of dizziness was 3%(1/31). This patient had > 3 risk factors for stroke (age > 65, hypertension, diabetes, ischemic heart disease). A positive Dix-Hallpike in appropriate patients with <3 risk factors for stroke was 100% (95%CI 88.8% -100%) sensitive in ruling out a central cause for dizziness. Conclusion: The Dix-Hallpike manoeuvre is performed on a large number of inappropriate patients. When performed on appropriate patients with <3 risk factors for stroke a positive Dix-Hallpike can rule out a central cause of vertigo. Educating physicians as to the appropriate patient population could reduce unnecessary imaging and improve diagnostic accuracy.
Introduction: Transportation of patients better served at an alternative destinations (diversion) is part of a proposed solution to emergency department (ED) overcrowding. We evaluated the pilot implementation of the “Mental Health and Addiction Triage and Transport Protocol”. This is the first Canadian diversion protocol that allows paramedics to transport intoxicated or mental health patients to an alternative facility, bypassing the ED. Our aim was to implement a safe diversion protocol to allow patients to access more appropriate service without transportation to the emergency department. Methods: A retrospective analysis was conducted on patients presenting to EMS with intoxication or psychiatric issues. Study outcomes were protocol compliance, determined through missed protocol opportunities, noncompliance, and protocol failure (presentation to ED within 48 hours of appropriate diversion); and protocol safety, determined through patient morbidity (hospital admission within 48 hours of diversion) and mortality. Data was abstracted from EMS reports, hospital records, and discharge forms from alternative facilities. Data was analyzed qualitatively and quantitatively. Results: From June 1st, 2015 to May 31st, 2016 Greater Sudbury Paramedic Services responded to 1376 calls for mental health or intoxicated patients. 241 (17.5%) met diversion criteria, 158 (12.9%) patients were diverted and 83 (4.6%) met diversion criteria but were transported to the ED. Of the diverted patients 9 (5.6%) represented to the ED <48rs later and were admitted. Of the 158 diversions, 113 (72%) were transported to Withdrawal Management Services (WMS) and 45 (28%) were taken to Crisis Intervention (CI). There was protocol noncompliance in 77 cases, 69 (89.6%) were due to incomplete recording of vital signs; 6 (10.3%) were direct protocol violations of being transferred with vital sings outside the acceptable range. Conclusion: The Mental Health and Addiction Triage and Transport Protocol has the potential to safely divert 1 in 6 mental health or addiction patients to an alternative facility.