bluuebunny/crossref_metadata_2025 huggingface dataset:
Community-associated methicillin-resistant Staphylococcus aureus: prevalence in skin and soft tissue infections at emergency departments in the Greater Toronto Area and associated risk factors
Authors: Adam Heather J. , Allen Vanessa G. , Currie Andrea , McGeer Allison J. , Simor Andrew E. , Richardson Susan E. , Louie Lisa , Willey Barbara , Rutledge Tim , Lee Jacques , Goldman Ran D. , Somers Andrea , Ellis Paul , Sarabia Alicia , Rizos John , Borgundvaag Bjug , Katz Kevin C. ,   EMERGENT Working Group
Published: July 2016

Objective:

Community-associated methicillin-resistantStaphylococcus aureus(CA-MRSA), which is caused primarily by the Canadian methicillin-resistantStaphylococcus aureus-10 (CMRSA-10) strain (also known as the USA300 strain) has emerged rapidly in the United States and is now emerging in Canada. We assessed the prevalence, risk factors, microbiological characteristics and outcomes of CA-MRSA in patients with purulent skin and soft tissue infections (SSTIs) presenting to emergency departments (EDs) in the Greater Toronto Area.

Methods:

Patients withStaphylococcus aureusSSTIs who presented to 7 EDs between Mar. 1 and Jun. 30, 2007, were eligible for inclusion in this study. Antimicrobial susceptibilities and molecular characteristics of MRSA strains were identified. Demographic, risk factor and clinical data were collected through telephone interviews.

Results:

MRSA was isolated from 58 (19%) of 299 eligible patients. CMRSA-10 was identified at 6 of the 7 study sites and accounted for 29 (50%) of all cases of MRSA. Telephone interviews were completed for 161 of the eligible patients. Individuals with CMRSA-10 were younger (median 34 v. 63 yr,p= 0.002), less likely to report recent antibiotic use (22% v. 67%,p= 0.046) or health care–related risk factors (33% v. 72%,p= 0.097) and more likely to report community-related risk factors (56% v. 6%,p= 0.008) than patients with other MRSA strains. CMRSA-10 SSTIs were treated with incision and drainage (1 patient), antibiotic therapy (3 patients) or both (5 patients), and all resolved. CMRSA-10 isolates were susceptible to clindamycin, tetracycline and trimethoprimsulfamethoxazole.

Conclusion:

CA-MRSA is a significant cause of SSTIs in the Greater Toronto Area, and can affect patients without known community-related risk factors. The changing epidemiology of CA-MRSA necessitates further surveillance to inform prevention strategies and empiric treatment guidelines.
A 4-year review of pediatric mental health emergencies in Alberta
Authors: Newton Amanda S. , Ali Samina , Johnson David W. , Haines Christina , Rosychuk Rhonda J. , Keaschuk Rachel A. , Jacobs Philip , Klassen Terry P.
Published: July 2016

Objective:

We sought to determine and compare rates of pediatric mental health presentations and associated costs in emergency departments (EDs) in Alberta.

Methods:

We examined 16 154 presentations by 12 589 patients (patient age ≤ 17 yr) between April 2002 and March 2006 using the Ambulatory Care Classification System, a province-wide database for Alberta. The following variables of interest were extracted: patient demographics, discharge diagnoses, triage level, disposition, recorded costs for ED care, and institutional classification and location (i.e., rural v. urban, pediatric v. general EDs).

Results:

A 15% increase in pediatric mental health presentations was observed during the study period. Youth aged 13-17 years consistently represented the most common age group for first presentation to the ED (83.3%). Of the 16 154 recorded presentations, 21.4% were related to mood disorders and 32.5% to anxiety disorders. Presentations for substance misuse or abuse were the most prevalent reasons for a mental health-related visit (41.3%). Multiple visits accounted for more than one-third of all presentations. Presentations for mood disorders were more common in patients with multiple compared with single visits (29.3% v. 16.9%), and substance abuse or misuse presentations were more common in patients with single compared with multiple visits (47.4% v. 30.5%). The total direct ED costs for mental health presentations during the study period was Can$3.5 million.

Conclusion:

This study provides comprehensive data on trends of pediatric mental health presentation, and highlights the costs and return presentations in this population. Psychiatric and medical care provided in the ED for pediatric mental health emergencies should be evaluated to determine quality of care and its relationship with return visits and costs.
Important returns on investment: an evaluation of a national research grants competition in emergency medicine
Authors: Bawden Jaime , Manouchehri Namdar , Villa-Roel Cristina , Grafstein Eric , Rowe Brian H.
Published: July 2016

Objective:

We sought to examine scholarly outcomes of the projects receiving research grants from the Canadian Association of Emergency Physicians (CAEP) during the first 10 years of national funding (i.e., between 1996 and 2005).

Methods:

We sent email surveys to 62 emergency medicine (EM) researchers who received funding from CAEP. We focused our data collection on grant deliverables and opinions using a 1–7 Likert scale with regard to the value of the award.

Results:

Fifty-eight recipients responded to our survey. Grants were most commonly awarded to residents (21 [36%]), followed by senior (16 [28%]) and junior (13 [22%]) emergency staff. Twenty-six applicants from Ontario and 11 from Quebec received the majority of the grants. Overall, 51 projects were completed at the time of contact and, from these, 39 manuscripts were published or in press. Abstract presentations were more common, with a median of 2 abstracts presented per completed project. Abstract presentations for the completed projects were documented locally (23), nationally (39) and internationally (37). Overall, 19 projects received additional funding. The median amount funded was Can$4700 with an interquartile range of $3250–$5000. Respondents felt CAEP funding was critical to completing their projects and felt strongly that dedicated EM research funding should be continued to stimulate productivity.

Conclusion:

Overall, the CAEP Research Grants Competition has produced impressive results. Despite the small sums available, the grants have been important for ensuring study completion and for securing additional funding. CAEP and similar EM organizations need to develop a more robust funding approach so that larger grant awards and more researchers can be supported on an annual basis.
Interrater agreement of Canadian Emergency Department Triage and Acuity Scale scores assigned by base hospital and emergency department nurses
Authors: Dallaire Clémence , Poitras Julien , Aubin Karine , Lavoie André , Moore Lynne , Audet Geneviève
Published: July 2016

Objective:

We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores assigned during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival.

Methods:

We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted κ statistic to measure the agreement between the 2 CTAS scores.

Results:

Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate (κ = 0.50; 95% confidence interval 0.37–0.63).

Conclusion:

The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting.
Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome
Authors: Hess Erik P. , Perry Jeffrey J. , Ladouceur Pam , Wells George A. , Stiell Ian G.
Published: July 2016

Objective:

We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.

Methods:

We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as “normal,” “abnormal not requiring intervention” and “abnormal requiring intervention,” based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.

Results:

We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%–3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66–0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%–10.4%) and 36.1% specific (95% CI 32.0%–40.4%).

Conclusion:

This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.
Comparison of tracheal intubation and alternative airway techniques performed in the prehospital setting by paramedics: a systematic review
Authors: Jensen Jan L. , Cheung Ka Wai , Tallon John M. , Travers Andrew H.
Published: July 2016

This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag-mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups. Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.
Harmful effect of saline infusion in a patient with glycyrrhizic acid poisoning
Authors: Caubet-Kamar Natacha , Tubery Marie , Garrouste Cyril , Lauque Dominique , Kamar Nassim
Published: July 2016

Alcohol-free licorice beverages contain glycyrrhizic acid. Excess glycyrrhizic acid is a well-known cause of excess mineralocorticoid syndrome. We report a case of glycyrrhizic acid poisoning in an abstinent alcoholic complicated by severe pulmonary edema following excessive hydration with intravenous normal saline.
Defining normal jugular venous pressure with ultrasonography
Authors: Socransky Steven J. , Wiss Ray , Robins Ron , Anawati Alexandre , Roy Marc-Andre , Yeung I. Ching
Published: July 2016

Objective:

Determination of jugular venous pressure (JVP) by physical examination (E-JVP) is unreliable. Measurement of JVP with ultrasonography (U-JVP) is easy to perform, but the normal range is unknown. The objective of this study was to determine the normal range for U-JVP.

Methods:

We conducted a prospective anatomic study on a convenience sample of emergency department (ED) patients over 35 years of age. We excluded patients who had findings on history or physical examination suggesting an alteration of JVP. With the head of the bed at 45°, we determined the point at which the diameter of the internal jugular vein (IJV) began to decrease on ultrasonography (“the taper”). Research assistants used 2 techniques to measure U-JVP in all participants: by measuring the vertical height (in centimetres) of the taper above the sternal angle, and adding 5 cm; and by recording the quadrant in the IJV's path from the clavicle to the angle of the jaw in which the taper was located. To determine interrater reliability, separate examiners measured the U-JVP of 15 participants.

Results:

We successfully determined the U-JVP of all 77 participants (38 male and 39 female). The mean U-JVP was 6.35 (95% confidence interval 6.11–6.59) cm. In 76 participants (98.7%), the taper was located in the first quadrant. Determination of interrater reliability found κ values of 1.00 and 0.87 for techniques 1 and 2, respectively.

Conclusion:

The normal U-JVP is 6.35 cm, a value that is slightly lower than the published normal E-JVP. Interrater reliability for U-JVP is excellent. The top of the IJV column is located less than 25% of the distance from the clavicle to the angle of the jaw in the majority of healthy adults. Our findings suggest that U-JVP provides the potential to reincorporate reliable JVP measurement into clinical assessment in the ED. However, further research in this area is warranted.
A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air
Authors: Sivilotti Marco L.A. , Messenger David W. , Vlymen Janet van , Dungey Paul E. , Murray Heather E.
Published: July 2016

Objective:

Important questions remain regarding how best to monitor patients during procedural sedation and analgesia (PSA). Capnometry can detect hypoventilation and apnea, yet it is rarely used in emergency patients. Even the routine practice of performing preoxygenation in low-risk patients is controversial, as supplementary oxygen can delay the detection of respiratory depression by pulse oximetry. The purpose of this study was to determine whether the capnometer or the pulse oximeter would first detect respiratory events in adults breathing room air.

Methods:

During a randomized clinical trial comparing fentanyl with low-dose ketamine for PSA with titrated propofol, patients were monitored using pulse oximetry and continuous oral–nasal sampled capnography. Supplemental oxygen was administered only for oxygen desaturation. Sedating physicians identified prespecified respiratory events, including hypoventilation (end-tidal carbon dioxide > 50 mm Hg, rise of 10 mm Hg from baseline or loss of waveform) and oxygen desaturation (pulse oximetry < 92%). These events and their timing were corroborated by memory data retrieved from the monitors.

Results:

Of 63 patients enrolled, 57% (36) developed brief oxygen desaturation at some point during the sedation. All responded to oxygen, stimulation or interruption of propofol. Measurements of end-tidal carbon dioxide varied substantially between and within patients before study intervention. Hypoventilation (19 patients, 30%) was only weakly associated with oxygen desaturation (crude odds ratio 1.4 [95% confidence interval 0.47 to 4.3]), and preceded oxygen desaturation in none of the 12 patients in whom both events occurred (median lag 1:50 m:ss [interquartile range 0:01 to 3:24 m:ss]).

Conclusion:

During PSA in adults breathing room air, desaturation detectable by pulse oximeter usually occurs before overt changes in capnometry are identified.
Sex differences in clinical presentation, management and outcome in emergency department patients with chest pain
Authors: Hess Erik P. , Perry Jeffrey J. , Calder Lisa A. , Thiruganasambandamoorthy Venkatesh , Roger Veronique L. , Wells George A. , Stiell Ian G.
Published: July 2016

Objective:

We sought to assess sex differences in clinical presentation, management and outcome in emergency department (ED) patients with chest pain, and to measure the association between female sex and coronary angiography within 30 days.

Methods:

We conducted a prospective cohort study in an urban academic ED between Jul. 1, 2007, and Apr. 1, 2008. We enrolled patients over 24 years of age with chest pain and possible acute coronary syndrome (ACS).

Results:

Among the 970 included patients, 386 (39.8%) were female. Compared with men, women had a lower prevalence of known coronary artery disease (21.0% v. 34.2%, p < 0.001) and a lower frequency of typical pain (37.1% v. 45.7%, p = 0.01). Clinicians classified a greater proportion of women as having a low (< 10%) pretest probability for ACS (85.0% v. 76.4%, p = 0.001). Despite similar rates of electrocardiography, troponin T and stress testing between sexes, there was a lower rate of acute myocardial infarction (AMI) (4.7% v. 8.4%, p = 0.03) and positive stress test results (4.4% v. 7.9%, p = 0.03) in women. Women were less frequently referred for coronary angiography (9.3% v. 18.9%, p < 0.001). The adjusted association between female sex and coronary angiography was not significant (odds ratio 0.63, 95% confidence interval 0.37–1.10).

Conclusion:

Women had a lower rate of AMI and a lower rate of positive stress test results despite similar rates of testing between sexes. Although women were less frequently referred for coronary angiography, these data suggest that sex differences in management were likely appropriate for the probability of disease.
Acute compartment syndrome of the dorsal forearm following noncontact injury
Authors: Crawford Brent , Comstock Sean
Published: July 2016

Acute compartment syndrome is a limb-threatening condition in which early diagnosis and surgical consultation for fasciotomy are required to preserve functional outcome. The diagnosis is typically considered in patients with traumatic mechanisms of injury such as a direct blow and crush to the compartment, particularly when there is a fracture in the same compartment. We report the case of a patient with acute compartment syndrome of the dorsal forearm that occurred as a result of an atypical noncontact traumatic mechanism. Establishing the diagnosis of compartment syndrome was complicated in this patient, as some of the signs and symptoms of acute compartment syndrome could have been attributed to the presence of a coexisting rupture of the extensor digitorum muscle. This report serves to remind emergency physicians that, although rare, acute compartment syndrome can result from exertional and noncontact traumatic mechanisms.
Effect of inhaled hypertonic saline on hospital admission rate in children with viral bronchiolitis: a randomized trial
Authors: Kuzik Brian A. , Flavin Michael P. , Kent Steven , Zielinski David , Kwan Charisse W. , Adeleye Adetayo , Vegsund Bjorn C. , Rossi Carlo
Published: July 2016

Objective:

We sought to determine whether inhaled 3% hypertonic saline (HS) reduces admission to hospital in ambulatory children with moderately severe viral bronchiolitis. Secondary objectives compared changes in respiratory scores before and after treatment and assessed the need for unscheduled medical intervention within 7 days.

Methods:

Children under the age of 2 years presenting with moderately severe viral bronchiolitis to the emergency department of 4 general hospitals from November 2008 to March 2009 were randomly assigned to receive 3 consecutive 4-mL doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS; control group) in a double blind fashion, each coadministered with 1 mg salbutamol. Outcome measures included the difference in hospital admission rate and changes in respiratory distress scores.

Results:

A total of 81 children (mean age 8.9 mo, range 0.7–22 mo) were assessed over 88 visits on an intention-to-treat basis. No statistically significant differences were found between treatment groups. Children in the HS group had a nonsignificant trend toward greater improvement compared with NS controls with a same-day admission rate of 18% (95% confidence interval [CI] 9%–32%) versus 27% (95% CI 16%–42%), respectively. Respiratory Assessment Change Scores (RACS) favoured the HS group over NS controls (mean RACS 4.7 [95% CI 3.6–5.8] v. 3.7 [95% CI 2.5–4.9], respectively), although the CIs overlap and these differences were not statistically significant.

Conclusion:

The short-term use of nebulized 3% HS did not result in any statistically significant benefits, although a nonsignificant trend toward a decrease in admission rate and improvement in respiratory distress was found. A larger study would be required to determine whether these trends arise from a clinically relevant treatment effect.
Abdominal pain: a survey of clinically important outcomes for future research
Authors: Mills Angela M. , Dean Anthony J. , Hollander Judd E. , Chen Esther H.
Published: July 2016

Objective:

We aimed to use the consensus opinion of a group of expert emergency physicians to derive a set of emergency diagnoses for acute abdominal pain that might be used as clinically significant outcomes for future research.

Methods:

We conducted a cross-sectional survey of a convenience sample of emergency physicians with expertise in abdominal pain. These experts were authors of textbook chapters, peer-reviewed original research with a focus on abdominal pain or widely published clinical guidelines. Respondents were asked to categorize 50 possible diagnoses of acute abdominal pain into 1 of 3 categories: 1) unacceptable not to diagnose on the first emergency department (ED) visit; 2) although optimal to diagnose on first visit, failure to diagnose would not be expected to have serious adverse consequences provided the patient had follow-up within the next 2–7 days; 3) if not diagnosed during the first visit, unlikely to cause long-term risk to the patient provided the patient had follow-up within the next 1–2 months. Standard descriptive statistical analysis was used to summarize survey data.

Results:

Thirty emergency physicians completed the survey. Of 50 total diagnoses, 16 were categorized as “unacceptable not to diagnose in the ED” with greater than 85% agreement, and 12 were categorized as “acceptable not to diagnose in the ED” with greater than 85% agreement.

Conclusion:

Our study identifies a set of abdominal pain conditions considered by expert emergency physicians to be clinically important to diagnose during the initial ED visit. These diseases may be used as “clinically significant” outcomes for future research on abdominal pain.
Variations in the management of pneumonia in pediatric emergency departments: compliance with the guidelines
Authors: Alak Aiman , Seabrook Jamie A. , Rieder Michael J.
Published: July 2016

Objective:

We sought to assess compliance with evidence-based guidelines for the management of pediatric pneumonia, including the variations in tests ordered and antimicrobials prescribed. Our primary hypothesis was that compliance with the treatment recommendations from the most current guidelines would be low for antimicrobial prescriptions.

Methods:

We conducted a chart review at the Children's Hospital in London, Ont., to assess variation in the management of pediatric pneumonia. All patients aged 3 months to 18 years seen at the pediatric emergency department between Apr. 1, 2006, and Mar. 31, 2007, with a diagnosis of pneumonia were eligible for inclusion in the study.

Results:

Compliance with management guidelines was 59.7% (95% confidence interval [CI] 53%–66%,n= 211) in children 5–18 years old and 83.0% (95% CI 80%–86%,n= 605) in children 3 months to 5 years old. Significant variation existed in the choice of antimicrobial agent for children with pneumonia, with nonrecommended agents frequently prescribed.

Conclusion:

Significant variation existed in the management of pediatric pneumonia, and adherence to guidelines was low for the group of patients aged 5–18 years. Future studies should attempt to provide guidance to distinguish between viral and bacterial etiology to allow judicious use of antimicrobials.
Patient expectations of emergency department care: phase I – a focus group study
Authors: Watt Denise , Wertzler William , Brannan Gordon
Published: July 2016

Objectives:

To explore the public's expectations of emergency department care and to compare these with emergency department staff perceptions of patient expectations.

Methods:

Focus groups were conducted with the residents of Calgary, Alta., and with emergency department staff in the Calgary Health Region. Both recent users of the emergency department and people who had not used the emergency department in the past 3 years were included in this study. An experienced moderator conducted the focus groups, which were taped and then transcribed. A well established method of qualitative analysis identified common themes.

Results:

The focus groups identified common expectations of emergency department care. Public expectations were categorized into 6 thematic areas: staff communication with patients, appropriate waiting times, the triage process, information management, quality of care, and improvements to existing services. Those who had recently used the emergency department had similar expectations to those who had not. Emergency department care providers understand some, but not all, of the public's expectations.

Conclusions:

Public expectations of emergency department care were identified by this study. The findings are important for quality improvement initiatives and were used to develop a quantitative questionnaire.
Influenza vaccination rate among emergency department personnel: a survey of four teaching hospitals
Authors: Saluja Inderpal , Theakston Karl D. , Kaczorowski Janusz
Published: July 2016

Objectives:

To determine influenza vaccination rates and attitudes toward vaccination among emergency department health care workers at 4 Ontario teaching hospitals.

Methods:

During the influenza season of 1999–2000 a confidential 28-item survey was distributed to emergency physicians and residents, nurses, respiratory therapists, and other allied health care workers at the emergency departments of 4 London, Ontario teaching hospitals.

Results:

Of 426 surveys distributed, 343 were returned, for an overall response rate of 80.5%. The mean age of respondents was 38.5 years (standard deviation = 8.3), 74.3% were female, and 86.6% were non-smokers. The overall vaccination rate was 37.0% (95% confidence interval, 31.9%–42.4%). Vaccination rates were 45.9% for respiratory therapists, 35.3% for emergency physicians and residents, 34.5% for nurses and 27.1% for other allied health care workers (p = 0.083). Multivariate logistic regression analysis revealed that age ≥41 and a chronic medical condition were positively associated with influenza vaccination (p < 0.05). Close to one-third of respondents (28.3%) believed that adverse affects were common, 51.6% believed vaccination was effective, 52% would support a program to improve vaccination rates among emergency department staff, and 24.4% would support mandatory vaccination for this population. Only 26.8% believed that patients were at increased risk of contracting influenza from emergency department staff, but 58.3% perceived that emergency department staff were at increased risk of contracting influenza through exposure to patients.

Conclusions:

In this study, only 37% of emergency department health care workers were immunized against influenza, with chronic illness and older age being the only 2 significant correlates. Strategies to improve emergency department health care worker attitudes toward influenza vaccination for themselves and to increase vaccination rates for this population should be developed.
Révision de L’échelle canadienne de triage et de gravité pour les départements d’urgence : Guide d’implantation
Authors: Murray Michael , Bullard Michael , Grafstein Eric ,   pour les Groupes de travail nationaux sur l’ÉTG et le SIDUC
Published: July 2016

Depuis sa création en 1999,L’échelle canadienne de triage et de gravité pour les départements d’urgence(ÉTG) a été largement implantée à travers le Canada. Ce document de consensus, créé par le Groupe de travail national sur l’éTG composé d’infirmières et de médecins experts dans le domaine du triage au département d’urgence, est considéré comme un document évolutif qui doit être modifié régulièrement pour refléter l’expérience acquise. Le présent article expose les premières modifications importantes apportées à l’ÉTG.
Predicting intervention in renal colic patients after emergency department evaluation
Authors: Papa Linda , Stiell Ian G. , Wells George A. , Ball Ian , Battram Erica , Mahoney John E.
Published: July 2016

Objectives:

There is no set of prospectively validated criteria to identify the emergency department (ED) patients with renal colic who are most likely to eventually have to undergo an intervention. This study prospectively assessed predictors of intervention in this patient population.

Methods:

This prospective cohort study included adult patients with renal colic who presented to 2 tertiary care hospital EDs. Patients had an 18-variable data form completed by an emergency physician and a radiological study to confirm urolithiasis. After discharge, patients were followed at 1 and 4 weeks to assess for intervention. The outcome criteria included the patient having had at least 1 of the following procedures performed: extracorporeal shockwave lithotripsy (ESWL), ureteroscopy, percutaneous nephrostomy or open surgery. Data were analyzed using appropriate univariate techniques, and those variables associated with intervention were combined using logistic regression analysis.

Results:

Over an 8-month period, 245 patients with confirmed urolithiasis were followed; 20% (95% confidence interval [CI] 15%–25%) eventually had a procedure to remove their calculi. Three variables were significantly correlated with having a procedure: i) size of calculus ≥ 6 mm (odds ratio [OR] 10.7, 95% CI 4.6–24.8), ii) location of calculus above mid-ureter (OR 6.9, 95% CI 3.0–15.9), and iii) Visual Analogue Scale score for pain at discharge from the ED ≥ 2 cm (OR 2.6, 95% CI 1.0–6.8). The area under receiver operating characteristic curve was 0.77 (95% C I 0.70–0.84) (p< 0.001). If all variables were present there was a 90% probability of the patient having an intervention performed within 4 weeks of discharge from the ED. Conversely, if none of the variables were present there was only a 4% probability of an intervention. Overall, the model had a sensitivity of 92% (95% CI 89%–96%) and a specificity of 63% (95% CI 57%–69%).

Conclusions:

This study has identified variables that could potentially be used to identify those renal colic patients who require an intervention after ED evaluation. Future studies will prospectively validate this model.
Ontario's alternate funding arrangements for emergency departments: the impact on the emergency physician workforce
Authors: Schull Michael J. , Vermeulen Marian
Published: July 2016

Background:

Difficulty maintaining physician staffing in emergency departments (EDs) prompted the government of Ontario to offer alternate funding arrangements (AFAs) to replace fee-for-service remuneration for physicians working in EDs.

Objective:

To analyze the effect of AFAs on physician staffing and practice patterns.

Methods:

We obtained Ontario Health Insurance Program fee-for-service and shadow-billing records for all physician services provided in EDs one year before and one year after implementation of an ED AFA. Only sites with reliable billing data were retained. Physicians were assigned to small/rural, community or teaching hospital groups based on their billing claims. For each hospital type, and all hospitals combined, we compared the pre- and post-AFA periods in terms of the number of physicians working regularly in the ED and their workload. As a possible unintended consequence of AFAs, we also compared physicians' involvement in primary care.

Results:

Overall, 76.2% of eligible hospitals adopted an ED AFA, of which 49 (42.6%) were included in our study (16 small/rural, 27 community and 6 teaching hospitals). In the post-AFA period, the number of physicians working in EDs increased by 7, from 674 to 681, representing a 1.0% increase overall in the workforce (p = 0.84). The change varied by hospital type, from a 5.8% increase in teaching hospitals to a 2.2% decrease in community hospitals, though none was significant. In the post-AFA period, the number of physicians working a moderate number of days per month increased from 190 to 214, representing a 3.2% absolute increase (p = 0.39), and the number working few (<5) or many (>10) days per month decreased. Post-AFA, the number of physicians working in EDs who also provided primary care services decreased by 1.7%, from 544 to 535 (p = 0.10).

Conclusion:

Emergency department AFAs have been widely adopted in Ontario, but have not been associated with substantial changes in the overall physician workforce in EDs. However, trends toward increased physician numbers were seen in small/rural and teaching hospitals. There was little evidence of any adverse effects on the provision of primary care services by physicians.
Coronary artery occlusion following blunt chest trauma: a case report and review of the literature
Authors: Guldner Gregory T. , Schilling Thomas D.
Published: July 2016

Blunt chest trauma causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a healthy 29-year-old man who developed a myocardial infarction due to complete occlusion of the proximal right coronary artery following blunt chest trauma. A review of the literature found 63 cases of previously healthy patients under 40 years of age who developed coronary artery occlusion following blunt chest trauma; diagnosis in all cases had been proven by angiography or during autopsy. The presentation, results of electrocardiography and echocardiography and laboratory findings of these patients are described.
Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions
Authors: Kelly Anne-Maree , Brumby Catherine , Barnes Caroline
Published: July 2016

Objectives:

Traditionally, patients have to wait until assessed by a physician for opioid analgesia to be administered, which contributes to delays to analgesia. Western Hospital developed a protocol enabling nurses to initiate opioid analgesia prior to medical assessment for selected conditions. The aim of this study was to determine the impact of this protocol on time to first opioid dose in patients presenting to the emergency department (ED) with renal or biliary colic.

Methods:

This was an explicit medical record review of all adult patients with an ED discharge diagnosis of renal or biliary colic presenting to a metropolitan teaching hospital ED. Patients were identified via the ED data management system. Data collected included demographics, condition, triage category, time of presentation, whether analgesia was nurse-initiated or not, and interval from arrival to first opioid analgesic dose. The narcotic drug register for the relevant period was also searched to cross-check whether opiates were doctor- or nurse-initiated.

Results:

There were 58 presentations in the nurse-initiated opioid analgesia group and 99 in the non-nurse-initiated analgesia group. Groups were reasonably well matched for gender, triage category and time of presentation, but there was a higher proportion of biliary colic in the non-nurse-initiated analgesia group. Median time to first analgesic dose was 31 minutes in the nurse-initiated group and 57 minutes in the non-nurse-initiated analgesia group (effect size, 26 minutes; 95% confidence interval 16-36 min;p< 0.0001]. There were no major adverse events in either group.

Conclusion:

A nurse-initiated opioid analgesia protocol reduces delays to opioid analgesia for patients with renal and biliary colic.
Maintaining continuity of care: a look at the quality of communication between Ontario emergency departments and community physicians
Authors: Stiell Andrew P. , Forster Alan J. , Stiell Ian G. , van Walraven Carl
Published: July 2016

Background:

To maintain continuity of care when a patient's care is transferred between physicians, continuity of patient information is required. This survey determined how, and how well, Ontario emergency departments (EDs) communicate patient information to physicians in the community.

Methods:

We surveyed Ontario ED chiefs to determine the most common media and methods used for disseminating information. We measured the perceived quality of their system, which was regressed against the hospital teaching status and community size using generalized logits modelling. Finally, we elicited the components of an ideal communication system for the ED.

Results:

One hundred and forty-three (85.6%) Ontario ED chiefs participated. The ED record of treatment was the most commonly used medium (95%). Postal service was the most common (55%) method of disseminating information. Thirty-three chiefs (23%) perceived the quality of communicating patient information from their ED as unsatisfactory or inadequate. This perception was significantly more prevalent in larger communities (excellent v. unsatisfactory [odds ratio (OR) 44.9, 95% confidence interval (CI) 13.9-140] and satisfactory v. unsatisfactory [OR 2.9, 95% CI 1.6-5.1]) and in teaching hospitals (satisfactory v. unsatisfactory [OR 9.7, 95% CI 4.7-20.3]). Seventy-eight percent of responding chiefs felt that patient information should be disseminated using electronic means, either through email or server access.

Conclusions:

To communicate patient information to community physicians, Ontario ED chiefs report that a copy of the ED record of treatment is sent by postal service. More than one-fifth of ED chiefs perceived communication from their department as unsatisfactory or inadequate. Studies that assess the completeness and accuracy of the record of treatment are required as a first step for measuring the quality of patient information communication in the Ontario ED system.
SARS assessment clinic: a rapid response to an infectious outbreak
Authors: Rutledge Tim , Penciner Rick , Popovich Karyn
Published: July 2016

The Toronto SARS outbreak began in February 2003 and lasted more than 16 weeks. The city and its health care system faced enormous challenges in responding to this new infectious disease, learning about its transmission, diagnosis and treatment, in containing its spread and in coping with its socioeconomic impact. As the site of a significant cluster of cases in the second wave of the outbreak, North York General Hospital (NYGH) quickly adapted many components of its operations, focusing on the fight against SARS. In order to assess potential SARS cases in a safe, efficient and effective manner, NYGH established a SARS assessment clinic. We describe the design features, construction, layout and operation of this clinic. This type of clinic can be rapidly deployed and may be of great value during future infectious outbreaks, including pandemic influenza.
Emergency department procedural sedation and analgesia: A Canadian Community Effectiveness and Safety Study (ACCESS)
Authors: Mensour Mark , Pineau Robert , Sahai Vic , Michaud Jennifer
Published: July 2016

Objectives:

To determine the effectiveness and safety of procedural sedation and analgesia (PSA) in a Canadian community emergency department (ED) staffed primarily by family physicians and to assess the role of capnometry monitoring in PSA.

Methods:

One hundred and sixty (160) consecutive procedural sedation cases were reviewed from the ED of a rural hospital in Huntsville, Ont. The ED is mainly staffed by family physicians who have received in-house training in PSA. Safety and effectiveness measures were extrapolated from a standardized PSA form by a blinded research assistant.

Results:

The mean age of the patient population was 33.6 years (standard deviation = 23.6). Fifty-four percent of the patients were male, and 33% of the cases were pediatric. PSA medications included propofol (84%), fentanyl (51%) and midazolam (15%), and the procedural success rate was 95.6%. The adverse event (AE) rate was 18% and included apnea (10%), inadequate sedation (3%), bradycardia (2%), desaturation (1%), hypotension (1%) and bag-valve-mask use (1%). In those aged ≥65 years there was a greater incidence of apnea. There were no episodes of emesis and there were no intubations. A modified jaw thrust manoeuvre was used in 23% of the cases. In the 64% of cases where capnometry was used, there was no association between its use and any AE measures.

Conclusion:

Procedural sedation was safe and effective in our environment. Capnometry recording did not appear to alter outcomes, although the data are incomplete.
Capacity-related interfacility patient transports: patients affected, wait times involved and associated morbidity
Authors: Stolte Esther , Iwanow Rod , Hall Christine
Published: July 2016

Objectives:

The trend toward operating Canadian hospitals at full capacity necessitates in some settings the transfer of patients from one hospital's emergency department (ED) to another hospital for admission, due to lack of bed availability at the first hospital. Our objectives were to determine how many and which patients are transported, to measure how much time is spent in the peri-transport process and to document any morbidity or mortality associated with these periods of transitional care.

Methods:

In this retrospective, observational health records review, we obtained health records during February, June and October 2002 for patients evaluated in any 1 of 3 adult EDs from a single Canadian city and subsequently transferred for admission to 1 of the other 2 hospitals. Data included the reason for transport, admitting service, transport process times and administration of key medications (asthma, cardiac, diabetes, analgesic or antibiotics).

Results:

Five hundred and thirteen records of transported patients were reviewed, and 507 were evaluated. Of those, 372 (73.4%) transfers were capacity-related and 135 (26.6%) were transferred for specialty services. Of the capacity transports, 219 (58.9%) were admissions for psychiatry and 123 (33.1%) for medicine. Median wait time at the first hospital was 6.7 hours, being longest for psychiatric patients. Thirty patients (8.1%) missed 1 or more doses of a key medication in the peri-transport process, and 8 (2.2%) missed 2 or more.

Conclusions:

Overcrowding of hospitals is a significant problem in many Canadian EDs, resulting in measurable increases in lengths of stay. Transfers arranged to other facilities for admission further prolong lengths of stay. Increased boarding times can result in missed medications, which may increase patient morbidity. Further study is needed to assess the need for capacity transfers and the possible risk to patients associated with periods of transitional care.
Demography of pediatric emergency care in Halifax, Canada
Authors: Taylor B.W.
Published: July 2016

Objectives:

Demography affects emergency department (ED) utilization and influences the health care needs of patients, yet the demographics of the caregivers who accompany children to pediatric EDs are not well described. The objective of this study was to provide a demographic description of this population. The hypothesis was that single parent status, annual income less than $20 000, and education no greater than high school constitute a social triad that might reduce the ability to provide health care for a sick child.

Methods:

Over a 1-month period, a convenience survey of caregivers who brought children to a pediatric ED was conducted. Twelve hundred surveys were distributed to 1733 eligible subjects. Social and economic determinants were captured, including age, gender, visible minority status, income group, employment, single parent status and education level.

Results:

In total, 1018 (85%) of 1200 surveys were returned — a population response rate of 59%. Single parent status, income less than $20 000/yr, and education no greater than high school were found to be risk factors for altered delivery of health care. Overall, 40.9% of caregivers had at least one risk factor, including 43.2% of women, 63.4% of those under 30 years of age, 65.1% of those with visible minority status, and 71.6% of women who were from a visible minority. In addition, 41.7% of single parents had no more than a high school education, and 75.7% of single parent families had incomes of less than $40 000 per year.

Conclusions:

It was found that a high level of educational, social and financial disadvantage in our population. These factors may adversely affect parental capability to provide health care at home for their child. The extent of this problem in other regions is not well defined and should be a focus of future research. It is recommended that inquiry into parental income, education and single parent status be a routine part of the history in pediatric emergency populations.
Perinephric abscess secondary to a staghorn calculus presenting as a subcutaneous abscess
Authors: Tsukagoshi Dylan , Dinkovski Bozanka , Dasan Sunil , Jethwa Jalpesh
Published: July 2016

Perinephric abscesses often present with flank pain and signs of sepsis, and are known to discharge to the skin. We report a case of a young patient presenting with a 48-hour history of painful swelling in her right renal angle following a urinary tract infection and no overt signs or symptoms of sepsis. Plain abdominal films showed a perinephric abscess secondary to a staghorn calculus in the upper pole of the right kidney. On incision and drainage, 700 mL of pus was drained freely. The patient recovered well but required partial nephrectomy.

Subcutaneous abscess as a result of intra-abdominal pathology is a recognized but rare complication. This case illustrates that subcutaneous abscesses may have underlying intra-abdominal pathology without overt signs of sepsis.
Primary amebic meningoencephalitis: a silent killer
Authors: Grate Isaac
Published: July 2016

One week after swimming in a man-made lake, a 9-year-old boy presented to the emergency department with headache, vomiting and lethargy. He had neck pain upon flexion and was unable to stand or walk. Cerebrospinal fluid examination revealed trophozoite and diflagellate forms consistent withNaegleria fowleri, an ameba species known to cause primary amebic meningoencephalitis. Despite aggressive management with amphotericin B and rifampin, he died 2 days later. This case report describes the clinical presentation, diagnostic findings and management of this uncommon but lethal entity.