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An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation.
This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death.
ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar.
The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.
Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice.
This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 – 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes.
In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone.
There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.
Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy.
A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives.
Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0–3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1–21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement.
VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.
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.
The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner.
Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010.
Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED.
Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.
Les directives de l'Association canadienne des médecins d'urgence (ACMU) relatives à la sepsie, créées par le Critical Care Practice Committee de l'ACMU (C4) et publiées dans le Canadian Journal of Emergency Medicine (CJEM), constituent la plus importante publication consacrée à la prise en charge de la sepsie au sein des services des urgences (SU) canadiens. Notre intention consistait à identifier lesquels, parmi les éléments de prise en charge proposés dans ce document, sont spécifiquement nécessaires au sein du SU et de présenter ensuite ces éléments sous la forme d'une liste de contrôle à plusieurs niveaux pouvant être utilisée par n'importe quel praticien d'un SU canadien.
Les points pratiques de la publication du CJEM consacrée à la sepsie ont été identifiés afin de générer une liste pratique en plusieurs points. Les membres du C4 ont ensuite eu recours, de mai à octobre 2009, à une procédure de consensus selon la technique Delphi, par courriel, en vue de créer une liste de contrôle à plusieurs niveaux relatives aux eléménts de la prise en charge de la sepsie pouvant ou non être assurés au sein d'un SU canadien lors de la prise en charge d'un patient victime d'un choc septique. Cette liste de contrôle a ensuite été évaluée en vue de son utilisation par le biais d'un questionnaire adressé à des praticiens de SU travaillant dans divers contextes (SU rural, SU communautaire, SU tertiaire), cela de juillet à octobre 2010.
Vingt éléments de la prise en charge de la sepsie ont été identifiés dans les directives de l'ACMU relatives à la sepsie. Quinze eléménts ont été jugés nécessaires pour la prise en charge dans le cadre d'un SU. On a ensuite crée deux niveaux de liste de contrôle pouvant être utilisés dans un SU canadien. La plupart des médecins urgentistes travaillant dans des centres de soins communautaires et tertiaires ont pu réaliser toutes les parties de la liste de contrôle de niveau I pour le sepsis. Les centres ruraux rencontrent souvent des difficultés en ce qui concerne la possibilité d'obtention d'un dosage du lactate valeurs et d'un accès veineux central. Un grand nombre d'éléments de la liste de contrôle de niveau II pour le sepsis n'ont pas pu être réalisés en dehors des SU de centres de soins tertiaires.
La prise en charge de la sepsie fait toujours partie intégrante et constitue un élément majeur du domaine des SU. Les points pratiques pour la prise en charge de la sepsie qui requièrent un monitorage spécialisé et des techniques invasives sont souvent limités aux SU de soins tertiaires plus importants et, bien que bon nombre de corps médicaux soulignent leur importance, ne peuvent pas raisonnablement être attendus dans tous les centres. Lorsque les ressources d'un centre limitent la prise en charge du patient, un transfert peut s'avérer nécessaire.
Our primary objective was to determine the effectiveness of 3 immobilization methods (circumferential casting [CC], volar–dorsal splinting [VDS] and modified sugar-tong [MST] splinting) in maintaining the position of displaced distal radius fractures after successful closed reduction. Our secondary objective was to assess long-term functional outcomes associated with immobilization with fibreglass splinting versus standard CC in patients maintaining initial nonoperative reductions.
We conducted a prospective randomized single-blind controlled trial in patients over 18 years of age who presented to the emergency department with a displaced fracture of the distal radius requiring closed reduction. The primary outcome was loss of reduction (defined as radiologic slippage or the need for surgical fixation during the 3–4 week primary immobilization period after initial successful reduction). Secondary outcomes included DASH (disabilities of the arm, shoulder and hand) score, return to work, activities of daily living, wrist pain, range of motion and grip strength assessed at 8 weeks and 6 months.
Thirty participants were randomly assigned to receive MST splinting, 31 to receive VDS and 40 to receive CC. Baseline characteristics were similar among groups. Radiographic loss of reduction occurred in 16% (95% confidence interval [CI] 3.1%–28.9%) of participants in the VDS group, 20% (95% CI 7.6%–32.4%) in the CC group and 30% (95% CI 13.6°%–46.4°%) in the MST splinting group (p = 0.17). Based on multivariate analysis of variance, functional outcomes at 8 weeks were similar among groups (p = 0.89). DASH scores at 8 weeks and 6 months were similar among groups, based on 1-way analysis of variance (p > 0.25).
Rates of loss in anatomic position were not statistically significant among the 3 types of dressings used. However, there was a clinically important trend of increased loss of reduction with the use of MST splinting. Functional outcomes at 8 weeks and 6 months were not significantly different between CC, VDS and MDS splinting. Ease of application and familiarity with use should guide clinical decisions when choosing a dressing type for displaced Colles fractures.
We sought to estimate the period prevalence of methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) and evaluate risk factors for MRSA SSTI in an emergency department (ED) population.
We carried out a cohort study with a nested case–control design. Patients presenting to our ED with a wound culture and a discharge diagnosis of SSTI between January 2003 and September 2004 were dichotomized as MRSA positive or negative. Fifty patients with MRSA SSTI matched by calendar time to 100 controls with MRSA-negative SSTI had risk factors assessed using multivariate conditional logistic regression.
Period prevalence of MRSA SSTI was 54.8% (95% confidence interval [CI] 50.2%–59.4%). The monthly period prevalence increased from 21% in January 2003 to 68% in September 2004 (p < 0.01). Risk factors for MRSA SSTI were injection drug use (IDU) (odds ratio [OR] 4.6, 95% CI 1.4–16.1), previous MRSA infection and colonization (OR 6.4, 95% CI 2.1–19.8), antibiotics in 8 weeks preceding index visit (OR 2.6, 95% CI 1.2–8.1), diabetes mellitus (OR 4.1, 95% CI 1.4–12.1), abscess (OR 5.6, 95% CI 1.8–17.1) and admission to hospital in previous 12 months (OR 2.6, 95% CI 1.1–11.2).
The period prevalence of MRSA SSTI between January 2003 and September 2004 was 54.8% at our institution. There was a marked increase in the monthly period prevalence from the beginning to the end of the study. Risk factors are IDU, previous MRSA infection and colonization, prescriptions for antibiotics in previous 8 weeks and admission to hospital in the preceding 12 months. On the basis of local prevalence and risk factor patterns, emergency physicians should consider MRSA as a causative agent for SSTI.
La prise en charge optimale du sepsis grave dans les départements d'urgence a connu une évolution rapide. Le but des présentes lignes directrices est de revoir pour le bénéfice des médecins d'urgence canadiens les principes clés qui régissent la prise en charge du sepsis grave en se fondant sur un système de classification fondé sur des preuves.
Ce sont les membres du comité de l'ACMU pour les soins critiques, ou comité C4 (pour CAEP Critical Care Interest Group) qui ont déterminé les secteurs clés de la prise en charge des patients atteints de sepsis. Chaque membre du C4 avait pour tâche de répondre à une question qui lui avait été assignée après avoir fait un survol de la littérature établie selon le système de classification Oxford, après quoi, chaque secteur faisait l'objet d'une seconde révision par un autre membre du C4. D'autres experts de l'extérieur ont procédé à un troisième examen et les modifications ont été déterminées par voie de consensus. La classification reposait sur des publications révisées par des pairs uniquement, et là où les preuves étaient insuffisantes pour répondre à une question importante, le groupe a proposé un «point pratique».
Le projet a débuté en 2005 et a pris fin en décembre 2007. Les secteurs clés qui ont été passés en revue incluent la définition du terme sepsis, l'utilisation des interventions effractives, la réanimation liquidienne, l'utilisation d'agents vasopresseurs/inotropes, l'importance des prélèvements pour culture aux départements d'urgence, l'antibiothérapie et le contrôle des sources. Parmi les autres secteurs examinés, mentionnons l'utilisation des corticostéroïdes, la protéine C activée, les transfusions et la ventilation mécanique.
La prise en charge précoce du sepsis dans les départements d'urgence est extrêmement importante pour améliorer le pronostic des patients. L'énoncé de position du C4 sur le sepsis fournit un cadre de travail afin d'améliorer les soins prodigués à cette population de patients dans les départements d'urgence.
Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system.
Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a “practice point” was provided based on group opinion.
The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisition in the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation.
Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population.
Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.
An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.
Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%–53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%–47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3–20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.
Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.
A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.
During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.
The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) – 3.8 (triage level [1–5]) + 7.1 (ambulance arrival) – 1.1 (GCS [3–15]) + 0.1 (age in years) – 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p < 0.0001).
This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.
To assess the association of diagnostic predictors available in the emergency department (ED) with the outcome diagnosis of severe acute respiratory syndrome (SARS).
This retrospective cohort study describes all patients from the Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical and diagnostic predictors were recorded, along with ED diagnoses. Final diagnoses were established independently based on diagnostic tests performed after the ED visit. Associations of key predictors with the final diagnosis of SARS were described.
Of 821 patients, 205 had confirmed SARS, 35 undetermined SARS and 581 non-SARS. Multivariable logistic regression showed that the strongest predictors of SARS were abnormal chest x-ray (odds ratio [OR] = 17.4), subjective fever (OR = 9.7), temperature >38°C (OR = 6.4), myalgias (OR = 5.5), chills and rigors (OR = 4.0) and contact exposure (OR = 2.6). In a subset of 176 patients who had a complete blood cell count performed, the strongest predictors were temperature ≥38ºC (OR = 15.5), lymphocyte count <1000 (OR = 9.3) and abnormal chest x-ray (OR = 5.7). Diarrhea was a powerful negative predictor (OR = 0.03) of SARS.
Two components of the World Health Organization case definition — fever and contact exposure — are helpful for ED decision-making, but respiratory symptoms do not discriminate well between SARS and non-SARS. Emergency physicians should consider the presence of diarrhea, chest x-ray findings, the absolute lymphocyte count and the platelet count as significant modifiers of disease likelihood. Prospective validation of these findings in other clinical settings is desirable.
To compare the diagnostic accuracy of emergency department (ED) physicians with the World Health Organization (WHO) case definition in a large community-based SARS (severe acute respiratory syndrome) cohort.
This was a cohort study of all patients from Hong Kong’s Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical findings and WHO case definition criteria were recorded, along with ED diagnoses. Final diagnoses were established independently based on relevant diagnostic tests performed after the ED visit. Emergency physician diagnostic accuracy was compared with that of the WHO SARS case definition. Sensitivity, specificity, predictive values and likelihood ratios were calculated using standard formulae.
During the study period, 818 patients presented with SARS-like symptoms, including 205 confirmed SARS, 35 undetermined SARS and 578 non-SARS. Sensitivity, specificity and accuracy were 91%, 96% and 94% for ED clinical diagnosis, versus 42%, 86% and 75% for the WHO case definition. Positive likelihood ratios (LR+) were 21.1 for physician judgement and 3.1 for the WHO criteria. Negative likelihood ratios (LR–) were 0.10 for physician judgement and 0.67 for the WHO criteria, indicating that clinician judgement was a much more powerful predictor than the WHO criteria.
Physician clinical judgement was more accurate than the WHO case definition. Reliance on the WHO case definition as a SARS screening tool may lead to an unacceptable rate of misdiagnosis. The SARS case definition must be revised if it is to be used as a screening tool in emergency departments and primary care settings.
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