bluuebunny/crossref_metadata_2025 huggingface dataset:
Substance-related problems in patients visiting an urban Canadian emergency department
Authors: Brubacher Jeffrey R. , Mabie Amy , Ngo Michelle , Abu-Laban Riyad B. , Buchanan Jan , Shenton Tom , Purssell Roy
Published: July 2016

Objective:

For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use (length of ED stay and number of revisits) of patients with and without substance problems.

Methods:

Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003.

Results:

Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%–12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%–9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p< 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p< 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p< 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient,p< 0.001).

Conclusion:

Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.
Ruptured abdominal aortic aneurysm masquerading as isolated hip pain: an unusual presentation
Authors: Vaidyanathan Sriram , Wadhawan Himanshu , Welch Pedro , El-Salamani Murad
Published: July 2016

The rupture of an abdominal aortic aneurysm (AAA) is a catastrophic event. Misdiagnosis by first-contact emergency physicians remains a serious concern. Varied and frequently nonspecific presentations lead to erroneous diagnostic impressions and cause significant delays in definitive intervention. We report the case of a 73-year-old man with a ruptured AAA presenting with isolated acute right hip pain without any classical features such as truncal pain or hypotension. Despite major advances in imaging and definitive treatment, a heightened awareness among emergency physicians remains the only effective means of improving detection and thereby survival.
Introducing a nurse practitioner into an urban Canadian emergency department
Authors: Steiner Ivan P. , Blitz Sandra , Nichols Darren N. , Harley Dwight D. , Sharma Leneela , Stagg Andrew P.
Published: July 2016

Objective:

Our objective was to compare the emergency care provided by a nurse practitioner (NP) with that provided by emergency physicians (EPs), to identify emergency department (ED) patients appropriate for autonomous NP practice and to acquire data to facilitate the development of the clinical scope of practice recommendations for ED practice for NPs.

Methods:

Using a comprehensive 3-part process, we selected and hired the best NP from 12 applicants. The NP was oriented to the operations of our free-standing community ED and incorporated in the care team, working in real time with EP preceptors during a 6-month, prospective clinical assessment comparing NP care with EP care. ED preceptors reviewed every case in real time with the NP and completed an explicit evaluation form to determine whether NP assessment, investigation, treatment and disposition were “all equivalent to emergency physician care” (AEEPC) or whether they differed. The proportion of AEEPC interactions was determined for 23 patient presentation categories. Our a priori assumption was that a patient presentation category might be suitable for autonomous NP practice if 50% of NP encounters in that category were rated as AEEPC. Descriptive data were presented for patient case mix, teaching domains and time criteria.

Results:

Eighty-three NP shifts and 711 patient encounters were evaluated by 21 EP preceptors. The NP saw a median of 8 patients per shift. In 43% of encounters, NP care was AEEPC. Highest AEEPC rates were found in the patient follow-up categories general follow-up (55.4%), diagnostic imaging (91.7%) and microbiology laboratory results (87.6%). NP scores over 50% were also seen for lacerations (63.6%) and isolated sore throats (53%). With teaching, NP performance improved over time.

Conclusion:

With the exception of follow up–related complaints, simple lacerations and isolated sore throats, NP care differed substantially from EP care. Although NPs with extensive emergency experience and training might ultimately be able to function as autonomous ED care providers, Canadian EDs currently developing job descriptions for emergency NPs should focus on a model of collaborative practice with EPs.
Errors, near misses and adverse events in the emergency department: What can patients tell us?
Authors: Friedman Steven M. , Provan David , Moore Shannon , Hanneman Kate
Published: July 2016

Objective:

We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers.

Methods:

This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40 000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3–7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system.

Results:

Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3–7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%–8.96%), 8 near misses (4% incident rate; 95% CI 1.73%–7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; κ = 0.78, standard error [SE] 0.20; 95% CI 0.39–1.00;p= 0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system.

Conclusion:

ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety.
Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments
Authors: Green Robert S. , Djogovic Dennis , Gray Sara , Howes Daniel , Brindley Peter G. , Stenstrom Robert , Patterson Edward , Easton David , Davidow Jonathan S.
Published: July 2016

Introduction:

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.

Methods:

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.

Results:

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.

Conclusion:

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.
Left vertebral artery dissection causing bilateral internuclear ophthalmoplegia
Authors: Jickling Glen , Leung Kelvin , Gan Kenman , Shuaib Ashfaq , Lewis James , Mouradian Mikael S.
Published: July 2016

A 21-year-old woman presented to the emergency department 1 day after a fall. On the day of presentation, she awoke with horizontal diplopia and posterior neck pain. Based on clinical findings, she was diagnosed with bilateral internuclear ophthalmoplegia. A conventional angiogram identified a left vertebral artery dissection. She was started on anticoagulant therapy, with gradual improvement of her diplopia over several months. Diplopia is frequently seen in the emergency department. Internuclear ophthalmoplegia is a cause of binocular diplopia and is important to recognize because it indicates a brainstem lesion requiring neurologic evaluation.
Central diabetes insipidus misdiagnosed as acute gastroenteritis in a pediatric patient
Authors: Gharahbaghian Laleh , Lotfipour Shahram , McCoy Christopher E. , Hoonpongsimanont Wirachin , Langdorf Mark
Published: July 2016

This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl. The patient later returned to the emergency department (ED) with severe dehydration from idiopathic central diabetes insipidus (DI). At her first visit, this previously healthy patient presented with mild dehydration, signs of acute gastroenteritis and normal urine output. Her brother had experienced similar symptoms a few days earlier. She tolerated an oral fluid challenge and was discharged from the ED with stable vital signs. Two days later, the patient returned with severe dehydration, resolving diarrhea and persistent vomiting. She was admitted to the pediatric intensive care unit. Magnetic resonance imaging illustrated an absent posterior pituitary enhancing signal, which demonstrated a loss of function in that region. There were no other abnormalities. The patient subsequently received desmopressin with improving clinical status and was discharged on the eighth hospital day. DI is a rare disease, but can be fatal if left undiagnosed. It should, therefore, be considered in the differential diagnosis of a dehydrated patient with an unexpectedly low urine specific gravity.
Association of injury mechanism with the risk of cervical spine fractures
Authors: Thompson Wendy L. , Stiell Ian G. , Clement Catherine M. , Brison Robert J. ,   Canadian C-Spine Rule Study Group
Published: July 2016

Objective:

A full understanding of an injury event and the mechanical forces involved should be important for predicting specific anatomical patterns of injury. Yet, information on the mechanism of injury is often overlooked as a predictor for specific anatomical injury in clinical decision-making. We measured the relationship between mechanism of injury and risk for cervical spine fracture.

Methods:

Our case-control study is a secondary analysis of data collected from the Canadian C-Spine Rule (CCR) study. Data were collected from 1996 to 2002 and included patients presenting to the emergency departments of 9 tertiary care centres after sustaining acute blunt trauma to the head or neck. Cases are defined as patients who were categorized in the CCR study with a clinically important cervical spine fracture. Controls had no radiologic evidence of cervical spine injury. Bivariate and multivariate unconditional logistic regression models were used. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results:

Among the 17 208 patients in the CCR study, 320 (2%) received a diagnosis of a cervical spine fracture. Axial loads, falls, diving incidents and nontraffic motorized vehicle collisions (e.g., collisions involving snowmobiles or all-terrain vehicles) were injury mechanisms that were significantly related to a higher risk of fracture. For motor vehicle collisions, the risk of cervical spine injury increased with the posted speed, being involved in a head-on collision or a rollover, or not wearing a seat belt (p< 0.05). The occurrence of cervical spine fracture was negligible in simple rear-end collisions (1 in 3694 cases; OR 0.015, 95% CI 0.002–0.104]).

Conclusion:

Our study quantitatively demonstrates the relationship between specific mechanisms of injury and the risk of a cervical spine fracture. A full understanding of the injury mechanism would assist providers of emergency health care in assessing risk for injury in trauma patients.
Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital
Authors: Gravel Jocelyn , Manzano Sergio , Arsenault Michael
Published: July 2016

Objective:

We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (Paed-CTAS) for children visiting a pediatric emergency department (ED).

Methods:

This was a retrospective study evaluating all children who presented to a pediatric university-affiliated ED during a 1-year period. Data were retrieved from the ED database. Information regarding triage and disposition was registered in an ED database by a clerk following patient management. In the absence of a gold standard for triage, admission to hospital, admission to pediatric intensive care unit (PICU) and length of stay (LOS) in the ED were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from 1 to 5) and admission to hospital. The correlation between triage level and dichotomous outcomes was evaluated by aχ2test and an analysis of variance (ANOVA) was used to evaluate the association between triage level and ED LOS.

Results:

Over the 1-year period, 58 529 patients were triaged in the ED. The proportion admitted to hospital was 63% for resuscitation (level 1), 37% for emergent (level 2), 14% for urgent (level 3), 2% for semiurgent (level 4) and 1% for nonurgent (level 5) (p< 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (bothp< 0.001).

Conclusion:

This computerized version of PaedCTAS demonstrates a strong association with admission to hospital, admission to PICU and LOS in the ED. These results suggest that PaedCTAS is a valid tool for triage of children in a pediatric ED.
Refinement of the Quebec decision rule for radiography in shoulder dislocation
Authors: Émond Marcel , Le Sage Natalie , Lavoie André , Moore Lynne
Published: July 2016

Objective:

We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation.

Methods:

This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis.

Results:

A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%–100%), a specificity of 34.2% (95% CI 27.7%–41.2%), a negative predictive value of 99.2% (95% CI 92.8%–99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002–0.27). Patients younger than 40 years are at high risk for clinically important fracture-dislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%.

Conclusion:

The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation.
Use of personal protective equipment during infectious disease outbreak and nonoutbreak conditions: a survey of emergency medical technicians
Authors: Visentin Laura M. , Bondy Susan J. , Schwartz Brian , Morrison Laurie J.
Published: July 2016

Objective:

We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS).

Methods:

Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used.

Results:

The response rate was 67.3% (n= 230). During the SARS outbreak, an N95-type particulate respirator was reported to bealwaysused by 91.5% of respondents. Conversely, 72.9% of the respondents reported that theyneverused the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to bealwaysused (52.0%), while other items were used at an intermediate frequency. The most common reason for notalwaysdonning equipment was that paramedics deemed it unnecessary for the situation.

Conclusion:

Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance.
CAEP Position Statement on Gun Control
Authors: Snider Carolyn E. , Ovens Howard , Drummond Alan , Kapur Atul K.
Published: July 2016

EXECUTIVE SUMMARY

Firearm-related injury and death continue to be a significant problem in Canada. Since the 1990s Canadian emergency physicians (EPs) have played an active role in advocating for gun control. This paper updates the Canadian Association of Emergency Physician's (CAEP's) position on gun control. Despite a media focus on homicide, the majority of firearm-related deaths are a result of suicide. Less than 40% of firearm-related injuries are intentionally inflicted by another person. Since the implementation of Canada's gun registry in 1995, there has been a significant reduction in firearm-related suicides and intimate partner homicides. Proposed weakening of gun laws in Canada will have a significant impact on firearm-related mortality and injury. There must be instead an expansion of programs focused on prevention of suicide, intimate partner violence and gang-related violence.

The majority of intentional or unintentional firearm-related injuries involve a violation of safe storage or handling practice. The potential for future harm because of unsafe storage or handling or through gang conflict retribution supports our position that health care facilities report gunshot wounds (GSWs). Moreover, a nationwide surveillance system is necessary to support research and to guide future public policy development and legislation.

As EPs we must advocate for injury control. All firearm injuries and deaths are preventable, and we must advocate for a multifaceted approach in order to minimize this risk to our patients.
The appropriateness of referrals to a pediatric emergency department via a telephone health line
Authors: Al-Abdullah Tawfik , Plint Amy C. , Shaw Alyson , Correll Rhonda , Gaboury Isabelle , Pitters Carrol , Bottaglia Anna , Clifford Tammy
Published: July 2016

Objective:

We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line–referral, by self- or parent-referral, and by physician-referral.

Methods:

A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED.

Results:

Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line–referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line–referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p= 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%,p< 0.001) or by self- or parent-referral (63%,p= 0.002). There was no significant difference between these latter 2 referral routes (p= 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line–referred were similar to each other in these outcomes.

Conclusion:

There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.
Treatment of severe accidental hypothermia with intermittent hemodialysis
Authors: Sultan Nabil , Theakston Karl D. , Butler Ron , Suri Rita S.
Published: July 2016

The optimal management of moderate-to-severe hypothermia with hemodynamic instability remains unclear. Although cardiopulmonary bypass offers the most rapid rate of rewarming and has been suggested as the method of choice in the presence of circulatory arrest, there is no evidence to support the use of this highly invasive technique over other rewarming modalities in the absence of circulatory collapse. We report the successful treatment of hemodynamically unstable hypothermia with conventional hemodialysis in a patient with normal renal function, after initial efforts of rewarming using conventional strategies had failed. This case report and review of the literature highlights the advantages and the challenges of using hemodialysis in this setting, and suggests a potential role for hemodialysis in the routine management of moderate-to-severe hypothermia in the absence of circulatory arrest.
Emergency medicine as a career choice: a descriptive study of Canadian medical students
Authors: Scott Ian M. , Abu-Laban Riyad B. , Gowans Margot C. , Wright Bruce J. , Brenneis Fraser R.
Published: July 2016

Background:

Studies indicate that a student's career interest at medical school entry is related to his or her ultimate career. We sought to determine the level of interest in emergency medicine among students at the time of medical school entry, and to describe characteristics associated with students primarily interested in emergency medicine.

Methods:

We surveyed students in 18 medical school classes from 8 Canadian universities between 2001 and 2004 at the commencement of their studies. Participants listed their top career choice and the degree to which a series of variables influenced their choices. We also collected demographic data.

Results:

Of 2420 surveys distributed, 2168 (89.6%) were completed. A total of 6.1% (95% confidence interval 5.1%–7.1%) of respondents cited emergency medicine as their first career choice. When compared with students primarily interested in family medicine, those primarily interested in emergency medicine reported a greater influence of hospital orientation and a lesser influence of social orientation on their career choice. When compared with students primarily interested in the surgical specialties, those primarily interested in emergency medicine were more likely to report medical lifestyle and varied scope of practice as important influences. When compared with students primarily interested in the medical specialties, those who reported interest in emergency medicine were more likely to report that a hospital orientation and varied scope of practice were important influences, and less likely to report that social orientation was important.

Conclusion:

Students primarily interested in emergency medicine at medical school entry have attributes that differentiate them from students primarily interested in family medicine, the surgical specialties or the medical specialties. These findings may help guide future initiatives regarding emergency medicine education.
Impact of a nurse practitioner on patient care in a Canadian emergency department
Authors: Steiner Ivan P. , Nichols Darren N. , Blitz Sandra , Tapper Lloyd , Stagg Andrew P. , Sharma Leneela , Policicchio Carla
Published: July 2016

Objective:

Our objective was to determine whether the addition of a broad-scope nurse practitioner (NP) would improve emergency department (ED) wait times, ED lengths of stay (LOS) and left-without-treatment (LWOT) rates. We hypothesized that the addition of a broad-scope NP during weekday ED shifts would result in shorter patient wait times, reduced LOS and fewer patients leaving the ED without treatment.

Methods:

This prospective observational study was conducted in a busy urban free-standing community ED. Intervention shifts, with NP coverage, were compared with control shifts (similar shifts with emergency physicians [EPs] working independently). Primary outcomes included patient wait times, ED LOS and LWOT rates. Patient demographics, triage category, the provider seen, the time to provider and ED LOS were captured using an electronic database.

Results:

The addition of an NP was associated with a 12% increase in patient volume per shift and a 7-minute reduction in mean wait times for low-acuity patients. However, overall patient wait times and ED LOS did not differ between intervention and control shifts. During intervention shifts, EPs saw a smaller proportion of low-acuity patients and there was a trend toward a lower proportion of LWOT patients (11.9% v. 13.7%,p= 0.10).

Conclusion:

Adding a broad-scope NP to the ED staff may lower the proportion of patients who leave without treatment, reduce the proportion of low-acuity patients seen by EPs and expedite throughput for a subgroup of less urgent patients. However, it did not reduce overall wait times or ED LOS in this setting.
Multicentre evaluation of an emergency department asthma care pathway for adults
Authors: Lougheed M. Diane , Olajos-Clow Jennifer , Szpiro Kim , Moyse Patricia , Julien Brianna , Wang Miao , Day Andrew G. ,   Ontario Respiratory Outcomes Research Network
Published: July 2016

Objective:

We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes.

Methods:

Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre–post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites.

Results:

The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p< 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p= 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p= 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p= 0.002). There were no statistically significant differences in repeat ED visits.

Conclusion:

Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.
Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces
Authors: Schull Michael J. , Vaillancourt Samuel , Donovan Linda , Boothroyd Lucy J. , Andrusiek Dug , Trickett John , Sookram Sunil , Travers Andrew , Vermeulen Marian J. , Tu Jack V. ,   Canadian Cardiovascular Outcomes Research Team
Published: July 2016

Objective:

Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada.

Methods:

We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis.

Results:

Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%–77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%–41%) were trained in ECG interpretation. Only 18% (95% CI 10%–25%) of operators had prehospital bypass protocols; 45% (95% CI 35%–55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces.

Conclusion:

The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.
Opposites attract: a case of magnet ingestion
Authors: Wong Helen H.L. , Phillips Bruce A.
Published: July 2016

Foreign-body ingestion is relatively common in the pediatric population and most objects pass through the gastrointestinal tract with minimal complications. Popular toy magnetic construction sets have resulted in numerous reports in the literature of serious complications including death following ingestion of multiple magnets. We report a case of a 5-year-old girl who presented to our emergency department with nonbilious vomiting and mild abdominal pain after accidentally ingesting 2 magnets 10 hours apart. Abdominal radiography showed the presence of 2 magnets, and a laparoscopy revealed multiple areas of bowel wall necrosis and perforation requiring subsequent laparotomy for repair of the bowel wall and retrieval of the magnets. This report aims to alert emergency care physicians of the necessity for early surgical referral with any multiple magnet ingestion to prevent severe complications.
Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre–post intervention study
Authors: Abbass Allan , Campbell Samuel , Magee Kirk , Tarzwell Robert
Published: July 2016

Objective:

Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS.

Methods:

We implemented a service that included staff education, timely access to consultation and gathering of outcome data.

Results:

Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3–5.0,p< 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self-reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) (p< 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients.

Conclusion:

This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.
International partnerships to foster growth in emergency medicine in Romania
Authors: Krym Valerie F. , Retezar Rodica , Scott Steve
Published: July 2016

Emergency medicine (EM) is a growing specialty internationally, but has yet to be cultivated in countries with otherwise advanced health care systems. To promote the growth of EM, emergency physicians from countries where EM is a mature specialty can assist with knowledge transfer and development of emergency medical systems to make a lasting impact on the community served. We present our experience in assisting the development of emergency medicine in a university-affiliated regional hospital in Romania.

The International Emergency Medicine Fellowship program at the University of Toronto established links in Cluj-Napoca, Romania, in order to provide expertise and assist local leadership to stimulate growth in EM. In October 2005, a 3-member team travelled to Cluj-Napoca to provide input on how to best use a new physical plant, to deliver continuing education to physicians and nurses, and to help establish long-term development goals. The team identified the following priorities through a comprehensive needs assessment: physical plant organization and patient flow, staffing, staff education, equipment, medication and supplies, and infection control practices. In conjunction with local counterparts, a plan was developed addressing each priority.

Staff, hospital administration and university officials report positive growth in EM as a result of the collaboration. Further work is underway to implement the plan, including international exchange trips to promote mutual growth between partners.
Effect of online medical control on prehospital Code Stroke triage
Authors: Verma Aikta , Gladstone David J. , Fang Jiming , Chenkin Jordan , Black Sandra E. , Verbeek P. Richard
Published: July 2016

Objective:

Prehospital Code Stroke triage has the potential to overwhelm stroke centres by falsely identifying patients as eligible for fibrinolysis. We sought to determine whether online medical control (whereby paramedics contact the medical control physician before a Code Stroke triage is assigned) reduced the proportion of false-positive Code Stroke patients.

Methods:

Following the introduction of a protocol for prehospital Code Stroke triage in an urban centre, online medical control alternated with off-line medical control (whereby paramedics implement Code Stroke triage independently) over 4 discreet intervals. We reviewed data for patients triaged to 3 regional stroke centres to compare the proportion of false-positive Code Stroke patients during online versus off-line medical control. We predefined false positives as patients triaged as Code Stroke who had symptoms discovered on awakening, were last seen in their usual state of health greater than 2 hours before assessment or had a final diagnosis other than stroke.

Results:

The proportion of false positives was lower during online medical control (31% v. 42%, p = 0.003). This was explained by a lower proportion of patients whose symptoms were discovered on awakening (8% v. 14%, p < 0.001) and who were last seen in their usual state of health greater than 2 hours before assessment (22% v. 32%, p = 0.005). A final diagnosis of stroke was similar in the 2 groups (77% v. 79%, p = 0.39), as was the proportion of patients receiving fibrinolysis (35% v. 33%, p = 0.72). Eighteen percent of patients were denied Code Stroke triage during online control, most commonly because of the time of symptom onset.

Conclusion:

Online medical control is associated with a reduced proportion of false-positive Code Stroke triage.
Evaluation of the Prehospital Index, presence of high-velocity impact and judgment of emergency medical technicians as criteria for trauma triage
Authors: Lavoie Andre , Émond Marcel , Moore Lynne , Camden Stéphanie , Liberman Moishe
Published: July 2016

Objective:

We sought to evaluate the performance of the Prehospital Index (PHI), the high-velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.

Methods:

The study population included all prehospital trauma patients transported by an emergency medical service to 2 level-I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.

Results:

Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the lowest rate of overtriage.

Conclusion:

Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level-I trauma centre, overall sensitivity remains low and overtriage is high. More research is required to improve prehospital triage.
Mentoring in emergency medicine: the art and the evidence
Authors: Yeung Marianne , Nuth Janet , Stiell Ian G.
Published: July 2016

A mentor is a person who takes a special interest in the professional development of a junior colleague and provides guidance and support. Mentoring can be beneficial for students, residents, junior colleagues and researchers and can be very rewarding for the physician who provides this guidance. Although mentoring is a well-recognized topic in academic medicine, relatively little has been written about mentoring in emergency medicine (EM). Consequently, we conducted a literature review on mentoring in EM and present our findings in this paper. We discuss different models of mentoring, factors that foster the development of strong mentorship programs, the responsibilities of mentors and mentees, and issues specific to mentorship of female, minority and research physicians. We also present several case scenarios as a basis for recommendations for teachers and learners in EM.
Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
Authors: Stiell Ian G. , Clement Catherine M. , Perry Jeffrey J. , Vaillancourt Christian , Symington Cheryl , Dickinson Garth , Birnie David , Green Martin S.
Published: July 2016

Objective:

There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.

Methods:

This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.

Results:

A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procaïnamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procaïnamide and 6.5 hours for those requiring electrical conversion.

Conclusion:

This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.
The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients
Authors: Edmonds Marcia L. , Yan Justin W. , Sedran Robert J. , McLeod Shelley L. , Theakston Karl D.
Published: July 2016

Objective:

Computed tomography (CT) is an imaging modality used to detect renal stones. However, there is concern about the lifetime cumulative radiation exposure attributed to CT. Ultrasonography (US) has been used to diagnose urolithiasis, thereby avoiding radiation exposure. The objective of this study was to determine the ability of US to identify renal colic patients with a low risk of requiring urologic intervention within 90 days of their initial emergency department (ED) visit.

Methods:

We completed a retrospective medical record review for all adult patients who underwent ED-ordered renal US for suspected urolithiasis over a 1-year period. Independent, double data extraction was performed for all imaging reports and US results were categorized as “normal,” “suggestive of ureterolithiasis,” “ureteric stone seen” or “disease unrelated to urolithiasis.” Charts were reviewed to determine how many patients underwent subsequent CT and urologic intervention.

Results:

Of the 817 renal US procedures ordered for suspected urolithiasis during the study period, the results of 352 (43.2%) were classified as normal, and only 2 (0.6%) of these patients required urologic intervention. The results of 177 (21.7%) renal US procedures were suggestive of ureterolithiasis. Of these, 12 (6.8%) patients required urologic intervention. Of the 241 (29.5%) patients who had a ureteric stone seen on US, 15 (6.2%) required urologic intervention. The rate of urologic intervention was significantly lower in those with normal results on US (p< 0.001) than in those with abnormal results on US.

Conclusion:

A normal result on renal US predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected urolithiasis.