bluuebunny/crossref_metadata_2025 huggingface dataset:
An Exploratory Analysis of the Geographical Distribution of Trauma Incidents in Shenzhen, China
Authors: Zhang Gui Xi , Fan Joe King Man , Chan Fion Siu Yin , Leung Gilberto Ka Kit , Lo Chung Mao , Yu Yi Min , Zhang Hong , Brundage Susan I. , Jansen Jan O.
Published: May 2017

Background

The city of Shenzhen, China, is planning to establish a trauma system. At present, there are few data on the geographical distribution of incidents, which is key to deciding on the location of trauma centres. The aim of this study was to perform a geographical analysis in order to inform the development of a trauma system in Shenzhen.

Methods

Retrospective analysis of trauma incidents attended by Shenzhen Emergency Medical Services (EMS) in 2014. Data were obtained from Shenzhen EMS. Incident distribution was explored using dot and kernel density estimate maps. Clustering was determined using the nearest neighbour index. The type of healthcare facilities which patients were taken to was compared against patients’ needs, as assessed using the Field Triage Decision Scheme.

Results

There were 49,082 recorded incidents. A total of 3513 were classed as major trauma. Mapping demonstrates that incidents predominantly occurred in the western part of Shenzhen, with identifiable clusters. Nearest neighbour index was 0.048. Of patients deemed to have suffered major trauma, 8.5% were taken to a teaching hospital, 13.6% to a regional hospital, 42.6% to a community hospital, and 35.3% to a private hospital. The proportions of Step 1 or 2 negative patients were almost identical.

Conclusion

The majority of trauma patients, including trauma patients who are at greater likelihood of severe injury, are taken to regional and community hospitals. There are areas with identifiable concentrations of volume, which should be considered for the siting of high‐level trauma centres, although further modelling is required to make firm recommendations.
Surgical Treatment of Extraesophageal Manifestations of Gastroesophageal Reflux Disease
Authors: Sidwa Feroze , Moore Alessandra L. , Alligood Elaine , Fisichella P. Marco
Published: May 2017

Objective

To review the current literature on the role of antireflux surgery (ARS) for the treatment of extraesophageal manifestations of GERD.

Summary background data

The extraesophageal manifestations of gastroesophageal reflux disease (GERD) include chronic cough, laryngopharyngeal reflux, and asthma. They are responsible for significant morbidity in affected patients and a high economic burden on healthcare resources. We recently published a larger review on the symptoms, diagnosis, medical, and surgical treatment of the extraesophageal manifestations of GERD. Through our investigation, we found that the role of ARS for respiratory symptoms was unclear. Hence, we resorted through the data of our previous meta‐analysis to compile a comprehensive and focused review on the role of ARS for respiratory symptoms.

Methods

Using the archive of our previous meta‐analysis, we selected studies extracted from the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases pertaining to the surgical treatment of extraesophageal manifestations of reflux (cough laryngopharyngeal reflux, and asthma). We applied a similar reporting methodology as was used in our previous manuscript and then hand searched the bibliographies of included studies yielding a total of 27 articles for review. We graded the level of evidence and classified recommendations by size of treatment effect per the American Heart Association Task Force on Practice Guidelines.

Results

Observational data indicated that syndromes of chronic cough, laryngopharyngeal reflux and asthma might improve after antireflux surgery only in highly selected patients—likely those with non‐acid reflux—while those patients with objective markers of asthma severity do not. Because of the varied methods of diagnosis and surgical technique, non‐comparative observational data may be unreliable. Additionally, our search found no randomized controlled trials (RCTs) comparing antireflux surgery to medical therapy in the treatment of cough or laryngopharyngeal reflux. One RCT compared medical treatment to antireflux surgery in patients with asthma, but medical treatment included high‐dose H2 blockers instead of PPIs.

Conclusions

Extraesophageal manifestations of GERD are common, costly, and difficult to treat. ARS might be effective in highly selected patients, especially in those whose extraesophageal manifestations are caused by non‐acid reflux. The available data to date are generally of poor quality or outdated. Well‐designed randomized controlled trials or large‐scale observational cohort studies are urgently needed.
Doubly labelled water assessment of energy expenditure: principle, practice, and promise
Authors: Westerterp Klaas R.
Published: May 2017

The doubly labelled water method for the assessment of energy expenditure was first published in 1955, application in humans started in 1982, and it has become the gold standard for human energy requirement under daily living conditions. The method involves enriching the body water of a subject with heavy hydrogen (2H) and heavy oxygen (18O), and then determining the difference in washout kinetics between both isotopes, being a function of carbon dioxide production. In practice, subjects get a measured amount of doubly labelled water (2H
2
18
O) to increase background enrichment of body water for 18O of 2000 ppm with at least 180 ppm and background enrichment of body water for 2H of 150 ppm with 120 ppm. Subsequently, the difference between the apparent turnover rates of the hydrogen and oxygen of body water is assessed from blood-, saliva-, or urine samples, collected at the start and end of the observation interval of 1–3 weeks. Samples are analyzed for 18O and 2H with isotope ratio mass spectrometry. The doubly labelled water method is the indicated method to measure energy expenditure in any environment, especially with regard to activity energy expenditure, without interference with the behavior of the subjects. Applications include the assessment of energy requirement from total energy expenditure, validation of dietary assessment methods and validation of physical activity assessment methods with doubly labelled water measured energy expenditure as reference, and studies on body mass regulation with energy expenditure as a determinant of energy balance.
Effects of aeration on metabolic profiles ofMortierella alpinaduring the production of arachidonic acid
Authors: Zhang Xin , Jiang Ling , Zhu Li-Ying , Shen Qin-Ke , Ji Xiao-Jun , Huang He , Zhang Hong-Man
Published: May 2017

To investigate the metabolic regulation against oxygen supply, comparative metabolomics was performed to explore the metabolic responses of Mortierella alpina in the process of arachidonic acid (ARA) production. More than 110 metabolites involved in Embden–Meyerhof–Parnas pathway, pentose phosphate pathway, tricarboxylic acid cycle, inositol phosphate metabolism, fatty acid biosynthesis, and amino acid metabolism were identified by gas chromatography–mass spectrometry. Samples at different aeration rates were clearly distinguished by principal components analysis and partial least squares analysis, indicating that oxygen supply had a profound effect on the metabolism of M. alpina. Eleven major metabolites were identified as potential biomarkers to be primarily responsible for the difference of metabolism. Further study of metabolic changes with the relevant pathways demonstrated that the levels of several intermediate metabolites in relation to central carbon metabolism changed remarkably via both processes and citrate and malate was supposed to play vital roles in polyunsaturated acid (PUFA) synthesis. Increase of myo-inositol and sorbitol were probably for osmo-regulation and redox balance, while enhanced phosphoric acid and pyroglutamic acid were supposed to have function in the activation of signal transduction pathway for stress resistance. The present study provides a novel insight into the metabolic responses of M. alpina to aeration rates and the metabolic characteristics during the ARA fermentation.
Microstructures and Grain Refinement of Additive-Manufactured Ti-xW Alloys
Authors: Mendoza Michael Y. , Samimi Peyman , Brice David A. , Martin Brian W. , Rolchigo Matt R. , LeSar Richard , Collins Peter C.
Published: May 2017

It is necessary to better understand the composition–processing–microstructure relationships that exist for materials produced by additive manufacturing. To this end, Laser Engineered Net Shaping (LENS™), a type of additive manufacturing, was used to produce a compositionally graded titanium binary model alloy system (Ti-xW specimen (0 ≤ x ≤ 30 wt pct), so that relationships could be made between composition, processing, and the prior beta grain size. Importantly, the thermophysical properties of the Ti-xW, specifically its supercooling parameter (P) and growth restriction factor (Q), are such that grain refinement is expected and was observed. The systematic, combinatorial study of this binary system provides an opportunity to assess the mechanisms by which grain refinement occurs in Ti-based alloys in general, and for additive manufacturing in particular. The operating mechanisms that govern the relationship between composition and grain size are interpreted using a model originally developed for aluminum and magnesium alloys and subsequently applied for titanium alloys. The prior beta grain factor observed and the interpretations of their correlations indicate that tungsten is a good grain refiner and such models are valid to explain the grain-refinement process. By extension, other binary elements or higher order alloy systems with similar thermophysical properties should exhibit similar grain refinement.
Surface mass balance, ice velocity and near-surface ice temperature on Qaanaaq Ice Cap, northwestern Greenland, from 2012 to 2016
Authors: Tsutaki Shun , Sugiyama Shin , Sakakibara Daiki , Aoki Teruo , Niwano Masashi
Published: May 2017

To better understand the processes controlling recent mass loss of peripheral glaciers and ice caps in northwestern Greenland, we measured surface mass balance (SMB), ice velocity and near-surface ice temperature on Qaanaaq Ice Cap in the summers of 2012–16. The measurements were performed along a survey route spanning the terminus of an outlet glacier to the upper reaches (243–968 m a.s.l.). The ice-cap-wide SMB ranged from −1.10 ± 0.29 to −0.13 ± 0.26 m w.e. a−1for the years from 2012/13 to 2015/16. Mass balance showed substantially large fluctuations over the study period under the influence of summer temperature and snow accumulation. Ice velocity showed seasonal speedup only in the summer of 2012, suggesting an extraordinary amount of meltwater penetrated to the bed and enhanced basal ice motion. Ice temperature at a depth of 13 m was −8.0°C at 944 m a.s.l., which was 2.5°C warmer than that at 243 m a.s.l., suggesting that ice temperature in the upper reaches was elevated by refreezing and percolation of meltwater. Our study provided in situ data from a relatively unstudied region in Greenland, and demonstrated the importance of continued monitoring of these processes for longer timespans in the future.
LO38: Hypoglycemia is a rare peri-seizure finding in pre-hospital patients
Authors: Eby D. , Woods J.
Published: May 2017

Introduction: Conventional wisdom states that hypoglycemia is a frequent peri-seizure phenomenon and must be tested for. Conventional wisdom also lists hypoglycemia as a cause of seizures. Recent literature disputes this. Paramedic medical directives continue to direct paramedics to determine the blood sugar level on all seizure patients. The purpose of this study was to determine the frequency of hypoglycemia in patients identified as having “seizure” as the primary or final problem code in Ambulance Call Reports (ACRs) from a large regional paramedic base hospital program. Methods: We conducted a retrospective analysis of iMedic platform, electronic ACRs, for a 2 year period (Jan 01, 2014 to Dec 31, 2015), from 8 Paramedic Services serving a rural and urban population of 1.4 million. 5854 calls, had “seizure” listed as a primary or final problem code. A 10% sample was generated using a random number table. ACRs were manually searched, data abstracted onto spread sheets, and the results analyzed using descriptive statistics (Wizard ver 1.8.16 for Mac). Results: 582 calls were analyzed. 430 (73.9%) were adults and 152 (26.1%) were paediatric (age <18). A blood sugar was determined in 501/582 (86.1%) of all calls; adults 388/430 (90.2%), peadiatric 113/152 (74.3%). The Glasgow Coma Score, when measured, was 15 in 280/575 (48.7%) cases. Seizures were witnessed by paramedics in 47/582 (8.1%) calls; adults 33/430 (7.7%), paediatric 14/152 (9.2%). In calls were paramedics witnessed a seizure a blood sugar was determined 36/47 (76.6%) of the time; adults 25/33 (75.8%), paediatric 11/14 (78.6%). Hypoglycemia (BS<4.0 mmol/L in an adult and 3.0 mmol/L in child<age 2 ) was found in 1 case when BS was checked-overall 1/501 (0.2%); adults 1/388 (0.3%), paedatric 0/113 (0.0%). Case 1-age 70 yr, GCS 12, BS 3.8 mmol/L. Conclusion: Hypoglycemia was rarely found in patients who had a pre-hospital seizure. It did not require treatment. When it was found, hypoglycemia was unlikely to be the cause of the seizure. The results are similar to the findings from other recent, retrospective, reviews. The routine determination of blood sugars in all patients who have had a seizure prior to paramedic arrival should be reconsidered.
LO41: Disrupting quality improvement: integrating design thinking in the emergency department
Authors: Gupta S. , von Hauff P.M.
Published: May 2017

Introduction/Innovation Concept: Quality Improvement (QI) remains a challenge and has been identified as a key competency by the Royal College of Physicians and Surgeons. Hospitals can be dehumanized environments, both for patients and the staff working there. The distant understandings of each other’s expectations during their health care encounter often create a sense of futility, frustration, and moral distress in therapeutic relationships. The transient nature of interactions and workplace culture in emergency departments (ED) enhances this distress. Methods: Working in a cross-disciplinary fashion, we explored how residents could develop quality improvement initiatives as a way to engage personal interests for QI measures. Key goals for developing these tools were 1) Learn cross-disciplinary tools for observation, inquiry, and improvement, 2) Develop reflective practice for residents, and 3) create ownership for the work and ongoing areas for improvement in local EDs for learners. Curriculum, Tool, or Material: We developed a process that would connect designers, residents, and content experts to an area of QI. Residents will be asked to identify an area in the ED that they field would benefit from a QI project (examples include: trauma team activation, waiting room anxiety, and referral delays from the ED). Working with designers and stakeholders (including patient representatives), learners would map the experience of a particular project. Strengths and opportunities for improvements would be identified at each step of the project. The team would then prototype solutions which will be presented to site chiefs for implementation and evaluation. Conclusion: Working with designers offers a practical and powerful approach to undertaking QI projects in the ED. We hope that this process allows residents to undertake projects that they are personally invested in and helps build longitudinal relationships beyond direct clinical work with the local ED they are working in
LO43: Does point of care ultrasound improve resuscitation markers in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 1) Study; an international randomized controlled trial
Authors: Taylor L. , Milne J. , Lewis D. , Diegelmann L. , Lamprecht H. , Stander M. , Lussier D. , Pham C. , Henneberry R. , Fraser J. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , van Hoving D.J. , Fredericks D. , Peach M. , Dahn T. , Hurley S.T. , MacSween K. , Cox C. , Richardson L. , Loubani O. , Stoica G. , Hunter S. , Olszynski P. , Atkinson P.R.
Published: May 2017

Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.
LO44: Initial validation of the core components in the SHoC-Hypotension Protocol. What rates of ultrasound findings are reported in emergency department patients with undifferentiated hypotension? Results from the first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial
Authors: Lussier D. , Pham C. , Milne J. , Lewis D. , Diegelmann L. , Lamprecht H. , Henneberry R. , Fraser J. , Stander M. , van Hoving D.J. , Fredericks D. , Howlett M. , Mekwan J. , Ramrattan B. , Middleton J. , Olszynski P. , Peach M. , Taylor L. , Dahn T. , Hurley S.T. , MacSween K. , Cox C. , Hunter S. , Bowra J. , Lambert M. , Jarman R. , Harris T. , Noble V. , Connolly J. , Atkinson P.R.
Published: May 2017

Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.
LO47: Use of C-reactive protein can safely decrease the number of emergency department patients with sepsis who require blood cultures
Authors: Stenstrom R. , Choi J. , Grafstein E. , Kawano T. , Sweet D. , Bischoff T. , Leung V. , Halim S.
Published: May 2017

Introduction: Sepsis protocols call for the acquisition of blood cultures in septic emergency department (ED) patients.However, the criteria for blood cultures are vague, they are costly, only positive 8-12% of the time, with up to half of these being false positives. The objective of this study was to establish if positive blood cultures could be excluded in low-risk sepsis patients with levels of CRP below 20 ml/L. Methods: This was a multicenter prospective cohort study of 765 ED patients at St Paul’s and Mount St Joseph’s hospitals in Vancouver with sepsis (2 or more SIRS criteria and infection) and none of: immuncompromised, injection drug use, indwelling vascular device or septic shock (SBP<90 mmhg). Consecutive patients with sepsis had CRP and blood cultures obtained at the same time.OUTCOMES. True positive blood cultures, false positive blood cultures, positive blood cultures that changed patient management. True and false positive blood cultures were based on Infectious Disease Society of America Guidelines, and change in management was defined as change in type or length of antibiotic therapy and was blindly adjudicated by a medical microbiologist. Results: 765 ED patients with sepsis met inclusion criteria. Mean age was 48.3 years and 57% were male. Blood cultures were positive in 99/765 (12.9%) subjects, of which 19 were false positive (19.2%). CRP was >20 mg/L in 595/765 (77.8%) of patients. Of 170 subjects with a CRP<20 mg/L, 3 had a positive blood culture (1.8%; 95% CI 0.1%- 5%). Management was not changed in any patient with a positive blood culture and CRP level<20 mg/L. Of 19 subjects with a false positive blood culture, CRP was <20 mg/L for 6 (31.6%). Conclusion: In this cohort of low-risk sepsis patients, based on a CRP of <20 mg/L, acquisition of blood cultures could be safely avoided in 22.2% of patients, at significant savings to the health care system.
LO48: Evaluation of the effect of nightshifts on patient outcomes: a multi-center study
Authors: Pedersen E.M. , Lang E.
Published: May 2017

Introduction: Nightshifts may represent a more challenging work environment due to staff fatigue. Our objective was to determine if an association exists between health outcomes for patients seen in Calgary Zone Emergency Department (ED) during nightshifts as compared to other time periods. Methods: Administrative data from a city-wide electronic health record was collected from four urban EDs on all discharged patients during a 2-year period: January 2015-December 2016. A total of 454,125 patient visits were included and patients with a scheduled return to the ED were excluded. Three primary outcomes were selected to assess the effects of night shifts on the quality of care received by patients in the ED at night; (i) unscheduled returns to the ED within 7 days resulting in admission, (ii) mortality within 48 hrs and, (iii) mortality within 7 days of being seen by a physician. Non-night shifts were defined as patients seen on day and evening or 700-2300. The data was analyzed using descriptive statistics and precision reported via 95% confidence intervals. Results: For the outcome of returns resulting in admission, a 2.6% rate was noted for patients seen at night compared to 2.3% during non-night; OR 1.15 (95% CI 1.09-1.21). Furthermore, patients seen at night had a 0.033% rate of death, while non-night patients had a 0.022% chance of death within 48 hrs of discharge; OR 1.53 (95% CI 0.98-2.38). For mortality within 7 days, the rate of death observed was 0.10% and 0.078% respectively; OR 1.24 (95% CI 0.97-1.60). Conclusion: Our study identified presenting to the ED at night as a potential risk factor for adverse patient outcomes using 3 primary quality of care indicators. An adjusted analysis is needed to account for potential confounding variables and effect modifiers and is underway.
LO50: Headache presentations to emergency departments in Alberta: understanding investigative approaches
Authors: Alexiu C. , Krebs L. , Villa-Roel C. , Kirkland S.W. , Holroyd B.R. , Ospina M. , Pryce C. , Bakal J. , Jelinski S.E. , Lang E. , Innes G. , Rowe B.H.
Published: May 2017

Introduction: Headaches are a common emergency department (ED) presentation. The objective of this study was to characterize headache presentations in Alberta over a five-year period and explore the proportion of patients with potentially severe pathology. Methods: Administrative health data for Alberta (years 2011-2015) were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) headache presentations (ICD-10-CA: G43, G44, R51). Patients with a primary or secondary diagnosis code of headache were eligible for inclusion in the study. Exclusions were made using the following criteria: 1) sites without computed tomography (CT) scanners; 2) presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1; 3) patients with trauma or external mechanism of injury (e.g., ICD-10-CA codes S,T,V,W,X,Y); and 4) presentations receiving an enhanced/contrast CT (head). NACRS data were linked with a provincial diagnostic imaging data. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, 98,333 presentations were made by 66,970 patients (~0.3 presentations per patient per year; equivalent to one presentation every 3.4 years). Headache presentations increased from 15,643 in 2011 to 21,636 in 2015. The median age was 38 years (IQR: 29, 51 years); more patients were female (69.3%), had a CTAS score of 3 (55%) and arrived at the ED without ambulance (90.3%). The majority of patients had a primary ED diagnosis of headache (88%) and the most common co-diagnosis was benign hypertension (2.8%). Additional diagnoses indicating severe or pathological headaches, included: stroke (0.63%), subarachnoid hemorrhage (0.43%), infection (i.e., meningitis) (0.11%), and other brain hemorrhages (0.08%). Overall, the ED management of approximately 25% of presentations involved a head CT. Most patients were discharged from the ED (89.4%) after a median length of stay of 3.5 hours (IQR: 2.1, 5.2 hours). Conclusion: Headache-related ED presentations are increasing in Alberta, yet few severe/pathological diagnoses are being identified. Efforts to ensure appropriateness of head CT ordering could reduce exposure to ionizing radiation, improve patient flow and reduce health care costs; this imaging represents a target for future interventions.
LO53: Resuscitation status documentation availability among emergency patients with advanced disease
Authors: Russell E. , Hall A.K. , McKaigney C. , Goldie C. , Harle I. , Sivilotti M.
Published: May 2017

Introduction: Patients with advanced malignant and non-malignant disease (advanced disease—AD) who do not want or benefit from aggressive resuscitation may unfortunately receive such treatments if unable to communicate in an emergency. Timely access to patients’ resuscitation wishes is imperative for treating physicians and for medical information systems. Our aim was to determine what proportion of emergency department (ED) patients with AD have accurate, readily accessible resuscitation status documentation. Methods: This cross-sectional, prospective study was conducted at a tertiary care ED during purposefully sampled random accrual times in summer 2016. We enrolled all patients with: 1) palliative care consultation, 2) metastatic malignancy, 3) COPD or CHF on home oxygen, 4) hemodialysis, or 5) advanced neurodegenerative disease/dementia. The primary outcome was the retrieval of any existing resuscitation status documents. Documentation was obtained from a standardized review of forms accompanying the patient (“arrival documents”) and electronic medical record (“EMR”). We measured the time to retrieve this documentation, and interviewed consenting patients to corroborate documentation with their current wishes. Results: Of 85 enrolled patients, only 33 (39%) had any documentation of resuscitation status: 28 (33%) had goals of care retrieved from the hospital EMR, and 11 (15%) from arrival documents (some had both). Patients from long-term care facilities were more likely to have documentation available (odds ratio 13 [95% CI 2.5-65] vs community-living). Of 32 patients who were able to be interviewed, 20 (63%) expressed “do not resuscitate” wishes. Ten of these 20 lacked any documents to support their expressed resuscitation wishes. Previously expressed resuscitation wishes took more than 5 minutes to be retrieved in 3 cases when not filed “one click deep” in our EMR. Conclusion: The majority of patients with AD, including half of those who would not wish resuscitation from cardiorespiratory arrest, did not have goals of care documents readily available upon arrival to the ED. Patients living in the community with AD appear to be at high risk for unwanted resuscitative treatments should they present to hospital in extremis. Having documentation of their goals of care that is easily retrievable from the EMR shows promise, though issues of retrieval, accuracy, and validity remain important considerations.
LO61: Geographic variation in Transient Ischemic Attack (TIA)/minor stroke care in Alberta emergency departments (EDs)
Authors: Leong M. , Lang E. , Coutts S.D. , Stang J. , Wang D. , Patocka C.
Published: May 2017

Introduction: The risk of recurrent stroke following a transient ischemic attack (TIA) has been estimated to be as much as 5 percent in the first 48 hours and ten percent in the first week following initial TIA symptoms, but can be modified as a result of intensive risk factor management. Care pathways for these patients vary between different regions within Alberta with Edmonton admitting more TIA patients and Calgary using computed tomography angiography (CTA) based triage. To examine regional differences in the quality of care, the rate of admission for stroke within 90 days of an index ED visit for TIA/minor stroke was investigated. Methods: Data analysts from the Data Integration, Measurement and Reporting (DIMR) branch of Alberta Health Services (AHS) used the National Ambulatory Care Reporting System (NACRS) to identify patients in Alberta who were admitted for stroke within 90-days of an index emergency department (ED) visit for TIA/minor stroke from April 2010 to March 2016. Information extracted included patient demographics, region of residence (Edmonton, Calgary or non-major urban [NMU]), return diagnosis and timing of return ED visit. Analysis included descriptive summaries and proportions were compared using a χ2 test. Results: During the study period, there were 26,232 index visits to Alberta EDs for TIA/minor stroke. 5426 (26.1%) of patients were admitted on their index visit. Calgary (22.5%) had lower rates of admission on index visit followed by Edmonton (31.4%) and the NMU (46%). 20,806 (79.3%) were discharged home following their index visit. Of the patients discharged on their index visit 729 (3.5%) had an admission for stroke within 90-days of their index ED visit with rates in Edmonton (3.8%) and the NMU regions (3.8%) being significantly higher than Calgary (2.8%, p<0.01). Conclusion: Our study demonstrates significantly lower rates of admission for stroke within 90-days of ED visit for minor stroke/TIA in Calgary compared to Edmonton and the NMU. Further work should focus on validating this result and consideration of standardized care pathways that promote effective resource utilization and quality of care.
LO64: Emergency department directed multifaceted interventions to improve outcomes after asthma exacerbations: a 3-armed randomized controlled trial
Authors: Villa-Roel C. , Majumdar S.R. , Leigh R. , Senthilselvan A. , Bhutani M. , Borgundvaag B. , Lang E. , Rosychuk R.J. , Rowe B.H.
Published: May 2017

Introduction: Approximately 20% of Canadians who present to emergency departments (EDs) with acute asthma relapse within 4 weeks of discharge. The reasons are likely multi-factorial; however, the lack of timely primary care provider (PCP) follow-up and inadequate patient self-management are thought to be important variables. Therefore, we tested the effectiveness of ED-directed multifaceted interventions that targeted PCPs and enhanced patient self-management to reduce asthma relapse following ED discharge. Methods: Adults with acute asthma discharged from 6 Alberta EDs were randomly allocated, in a centralized and concealed manner, to receive usual care (UC), opinion leader [OL] guidance to their PCPs, or OL guidance + nurse case-management [OL+CM] for patients (NCT01079000). The main outcome was asthma relapse within 90-days of ED discharge. Secondary outcomes included PCP visits, time to relapse, hospitalizations and asthma-related quality of life (QoL). Outcomes were collected independently and assessors were masked to intervention assignment. Results: From 943 screened patients, 367 patients were allocated to the study arms (UC=146; OL=110; OL+CM=111). Median age was 28 years, 64% were women, median peak flow at discharge was 350 L/min; 77% were discharged home on prednisone and 85% on either inhaled corticosteroids (ICS) or ICS/long-acting β2-agonists. Compared with UC, both interventions significantly
increased
rates of relapse at 90-days: UC=12%, OL=28%, OL+CM=19%; p=0.006. Based on an absolute increased risk of 0.16 (95% CI: 0.05, 0.25), the number needed to treat for harm was 6 (95% CI: 3.9, 19.0) for the OL arm. Across study differences in PCP follow-up visits, time to relapse, hospitalizations or asthma-related QoL were not identified. Conclusion: Two different theory-informed and evidenced-based interventions intended to decrease asthma relapse robustly and significantly increased rates of relapse compared with UC. While the reasons for these unintended consequences require further study, we caution against the adoption of similar interventions by other EDs.
LO65: Outpatient care gaps in subjects presenting to emergency departments with acute asthma
Authors: Villa-Roel C. , Bhutani M. , Majumdar S.R. , Leigh R. , Borgundvaag B. , Lang E. , Senthilselvan A. , Rosychuk R.J. , Rowe B.H.
Published: May 2017

Introduction: Many patients presenting to Emergency Departments (EDs) with acute asthma have limited or no access to health care providers, medications and preventive resources. This study explored outpatient care gaps among subjects presenting to the ED for acute asthma, before being discharged. Methods: Cross-sectional analysis of data obtained in a comparative effectiveness trial conducted in six EDs in Alberta (NCT01079000). Data were collected through patient interviews and chart reviews at ED presentation. Two clinician-investigators independently reviewed and adjudicated the following preventive actions: use of spacer devices, written asthma action plans (AAPs) and asthma medication; influenza immunization, cigarette smoking, and referral to asthma education. Agreement between adjudicators was calculated based on kappa (k) statistics. Results: The median age of the study population (n=367) was 28 years and 64% were women. Overall, 26% of patients reported not having a regular family physician. Agreement between reviewers was excellent (k=0.96). More than half (59%) reported not using spacer devices despite being indicated and 3% reported having a written AAP. Following the recommendations of the current asthma guidelines, 38% of the patients required the initiation of inhaled corticosteroids (ICS), 11% required the addition of ICS/long-acting β-agonists combination agents and 39% required reinforcement of adherence with preventer medications. Finally, 37% reported receiving influenza vaccination in the past year, 7% had been referred to asthma education in the last 10 years, and 31% were still smoking, suggesting that cessation counselling was indicated. Conclusion: The ED encounter for patients with acute asthma represents a unique opportunity to establish important partnerships across the continuum of asthma care (e.g., link them with a family doctor). This study provided a robust assessment of the outpatient care gaps in this patient population, which identified many areas for targeted interventions. The method of delivery and type of messaging needs further study.
LO67: The impact of CPR quality during entire resuscitation episode on survival from cardiac arrest
Authors: Drennan I. , Taher A.K. , Cheskes S. , Zhan C. , Byers A. , Feldman M. , Dorian P. , Morrison L.J. , Lin S.
Published: May 2017

Introduction: High-quality cardiopulmonary resuscitation (CPR) is essential for patient survival. Typically, CPR quality is only measured during the first 10 minutes of resuscitation. There is limited research examining the quality of CPR over the entire duration of resuscitation.Objective: To examine the quality of CPR over the entire duration of resuscitation and correlate the quality of CPR to patient survival. Methods: This was a retrospective observational study using data from the Toronto RescuNET Epistry-Cardiac Arrest database. We included consecutive, adult (>18) OHCA treated by EMS between January 1, 2014 and September 30, 2015. High-quality CPR was defined, in accordance with 2015 AHA Guidelines, as a chest compression rate of 100-120/min, depth of 5.0-6.0 cm and chest compression fraction (ccf) of >0.80. We further categorized high-quality resuscitation as meeting benchmarks >80% of the time, moderate-quality between 50-80% and low-quality meeting benchmarks <50% of the resuscitation. We used multivariable logistic regression to determine association between variables of interest, including CPR quality metrics, and survival to hospital discharge. Results: A total of 5,208 OHCA met our inclusion criteria with a survival rate of 8%. The median (IQR) duration of resuscitation was 23.0 min (15.0,32.7). Overall CPR quality was considered high-quality for ccf in 81% of resuscitation episodes, 41% for rate, and 7% for depth. The percentage of resuscitations meeting the quality benchmarks differed between survivors and non-survivors for both depth (15% vs 6%) and ccf (61% vs 83%) (P value <0.001). After controlling for Utstein variables maintaining a chest compression depth within recommendations for >80% showed a trend towards improved survival (OR 1.68, 95% CI 0.96, 2.92). Other variables associated with survival were public location, initial CPR by EMS providers or bystanders, witnessed cardiac arrest (EMS or bystander), and initial shockable rhythm. Increasing age and longer duration of resuscitation were associated with decreased survival. Conclusion: Overall, EMS providers were not able to maintain rate or depth within guideline recommendations for the majority of the duration of resuscitation. Maintaining chest compression depth for greater than 80% of the resuscitation showed a trend towards increased survival from OHCA.
LO72: Implementation of an educational program to improve the cardiac arrest diagnostic accuracy of ambulance communication officers: a concurrent control before-after study
Authors: Vaillancourt C. , Kasaboski A. , Charette M. , Calder L. , Boyle L. , Nakao S. , Crete D. , Kline M. , Souchuk R. , Kristensen N. , Wells G.A. , Stiell I.G.
Published: May 2017

Introduction: Most ambulance communication officers receive minimal education on agonal breathing, often leading to unrecognized out-of-hospital cardiac arrest (OHCA). We sought to evaluate the impact of an educational program on cardiac arrest recognition, and on bystander CPR and survival rates. Methods: Ambulance communication officers in Ottawa, Canada received additional training on agonal breathing, while the control site (Windsor, Canada) did not. Sites were compared to their pre-study performance (before-after design), and to each other (concurrent control). Trained investigators used a piloted-standardized data collection tool when reviewing the recordings for all potential OHCA cases submitted. OHCA was confirmed using our local OHCA registry, and we requested 9-1-1 recordings for OHCA cases not initially suspected. Two independent investigators reviewed medical records for non-OHCA cases receiving telephone-assisted CPR in Ottawa. We present descriptive and chi-square statistics. Results: There were 988 confirmed and suspected OHCA in the “before” (540 Ottawa; 448 Windsor), and 1,076 in the “after” group (689 Ottawa; 387 Windsor). Characteristics of “after” group OHCA patients were: mean age (68.1 Ottawa, 68.2 Windsor); Male (68.5% Ottawa, 64.8% Windsor); witnessed (45.0% Ottawa, 41.9% Windsor); and initial rhythm VF/VT (Ottawa 28.9, Windsor 22.5%). Before-after comparisons were: for cardiac arrest recognition (from 65.4% to 71.9% in Ottawa p=0.03; from 70.9% to 74.1% in Windsor p=0.37); for bystander CPR rates (from 23.0% to 35.9% in Ottawa p=0.0001; from 28.2% to 39.4% in Windsor p=0.001); and for survival to hospital discharge (from 4.1% to 12.5% in Ottawa p=0.001; from 3.9% to 6.9% in Windsor p=0.03). “After” group comparisons between Ottawa and Windsor (control) were not statistically different, except survival (p=0.02). Agonal breathing was common (25.6% Ottawa, 22.4% Windsor) and present in 18.5% of missed cases (15.8% Ottawa, 22.2% Windsor p=0.27). In Ottawa, 31 patients not in OHCA received chest compressions resulting from telephone-assisted CPR instructions. None suffered injury or adverse effects. Conclusion: While all OHCA outcomes improved over time, the educational intervention significantly improved OHCA recognition in Ottawa, and appeared to mitigate the impact of agonal breathing.
LO75: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score in 7 emergency departments
Authors: McLeod S.L. , McCarron J. , Stein K. , Scott S. , Ovens H.J. , Mittman N. , Borgundvaag B.
Published: May 2017

Introduction: The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian (and many international) emergency departments (EDs) for establishing the priority by which patients should be assessed. In addition to its clinical utility, CTAS has become an important administrative metric used by governments to estimate patient care requirements, ED funding and workload models. Despite its importance, the process by which CTAS scores are derived is highly variable. Emphasis on ED wait times has also drawn attention to the length of time the triage process takes. The primary objective of this study was to determine the interrater agreement of CTAS in current clinical practice. The secondary objective was to determine the time it takes to triage in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 738 consecutive patient CTAS assessments were audited over 21 seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients. Using the auditor’s CTAS score as the reference standard, on-duty triage nurses over-triaged 89 (12.1%) and under-triaged 95 (12.9%) patients. Interrater agreement was “good” with an unweighted kappa of 0.63 (95% CI: 0.58, 0.67) and quadratic-weighted kappa of 0.79 (95% CI: 0.67, 0.90). Research assistants captured triage time for 3808 patients over 69 shifts at 7 different EDs. Median (IQR) triage time was 5.2 (3.8, 7.3) minutes and ranged from 3.9 (3.1, 4.8) minutes to 7.5 (5.8, 10.8) minutes. Conclusion: Variability in the accuracy, and length of time taken to perform CTAS assessments suggest that a standardized approach to performing CTAS assessments would improve both clinical decision making, and administrative data accuracy.
LO77: Compliance of older emergency department patients to community-based specialized geriatric services
Authors: MacDonald Z. , Eagles D. , Stiell I.G.
Published: May 2017

Introduction: The Geriatric Emergency Management (GEM) model has been developed to facilitate identification of older patients that are at higher risk of functional decline, repeat Emergency Department (ED) visits and future hospitalization. Those identified at risk, are referred for more in-depth evaluation and management in community-based specialized geriatric services. Our objective was to: 1) determine the compliance rate to outpatient evaluation following ED recommendation; and 2) identify barriers and facilitators to attendance. Methods: We conducted a prospective cohort study at two sites of an academic, tertiary level hospital ED between July and December 2016. We enrolled a convenience sample of ED patients, 65 years and older who were seen by a GEM nurse, referred to outpatient specialized geriatric services and consented to study participation. The GEM nurses conducted targeted geriatric assessments, identifying those who would benefit from further community management. We conducted a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used. Results: A total of 101 patients were prospectively enrolled, with 30.4% of eligible participants declining outpatient referral. Enrolled subjects had a mean age of 83.3 years, 58.4% female and 62.0% cognitively impaired. Reasons for referral to specialized geriatric services included: mobility (86.1%), cognition (57.4%), pain (38.6%), mood (34.7%), medication management (33.6%) and nutrition (30.7%). Outpatient referrals were to: geriatric day hospital (51.5%), geriatric outreach (22.7%), falls clinic (11.8%) and geriatric psychiatry (9.9%). Compliance with follow-up within 6 weeks was 64.4%. Barriers to attendance included: patient did not feel specialized geriatric services was needed (52.6%); admitted to hospital (10.5%); reported not called for appointment (15.8%); forgot appointment (5.3%) and transportation (5.3%). Family support with scheduling and transportation to appointments, reported by 68.6%, was the most common enabler to compliance. Conclusion: Over one third of older ED patients referred by GEM for further specialized geriatric services are non-compliant with their community-based evaluation, while one in four older ED patients decline referral to these evaluations while in the ED. Future work should focus on interventions that promote increased referral acceptance and address barriers to attendance.