CJEM Articles: Christian Vaillancourt

Objective: To enhance patient safety, it is important to understand the frequency and causes of adverse events (defined as unintended injuries related to health care management). We performed this study to describe the types and risk of adverse events in high-acuity areas of the emergency department (ED).

Methods: This prospective cohort study examined the outcomes of consecutive patients who received treatment at 2 tertiary care EDs. For discharged patients, we  conducted a structured telephone interview 14 days after their initial visit; for admitted patients, we reviewed the inpatient charts. Three emergency physicians independently adjudicated flagged outcomes (e.g., death, return visits to the ED) to determine whether an adverse event had occurred.

Results: We enrolled 503 patients; one-half (n = 254) were female and the median age was 57 (range 18–98) years. The majority of patients (n = 369, 73.3%) were discharged home. The most common presenting complaints were chest pain, generalized weakness and abdominal pain. Of the 107 patients with flagged outcomes, 43 (8.5%, 95% confidence interval 8.1%–8.9%) were considered to have had an adverse event through our peer review process, and over half of these (24, 55.8%) were considered preventable. The most common types of adverse events were as follows: management issues (n = 18, 41.9%), procedural complications (n = 13, 30.2%)  and diagnostic issues (n = 10, 23.3%). The clinical consequences of these adverse events ranged from minor (urinary tract infection) to serious (delayed diagnosis of aortic dissection).

Conclusion: We detected a higher proportion of preventable adverse events compared with previous inpatient studies and suggest confirmation of these results is warranted among a wider selection of EDs.

Objective: The general objective of this study was to explore the challenges of establishing an out of hospital cardiac arrest (OOHCA) surveillance program in Canada. More specifically, we attempted to determine the organizational structure of the delivery of emergency medical services (EMS) in Canada, describe the cardiac arrest data collection infrastructure in each province and determine which OOHCA variables are being collected.

Methods: We conducted a national survey of 82 independent EMS health authorities in Canada. Methodology experts devel oped the survey and distribution using a modified Dillman tech nique. We distributed 67 surveys electronically (84%) and the rest by regular mail. We weighted each survey response by the popu lation of the catchment area represented by the responding health authority (2004 census). Descriptive statistics are reported.

Results: We received 60 completed surveys, representing a 73% response rate. The responding health authorities' catchment areas represented 80% of the Canadian population (territories excluded). Our survey results highlight a lack of common OOHCA data definitions used among health authorities, sporadic use of data quality assurance procedures, rare linkages to in hospital survival outcomes and potential confidentiality issues. Other chal lenges raised by respondents included determining warehousing location and finding financial resources for a national OOHCA registry.

Conclusion: Results from this survey demonstrate that, although it is challenging, it is possible to collect OOHCA data and access in hospital survival outcomes. Collaborative efforts with the Resuscitation Outcomes Consortium and other potential provin cial partners should be explored.

Objectives: Acute compartment syndrome (ACS) is a limb-threatening condition often first diagnosed by emergency physicians. Little is known about the rapidity with which permanent damage may occur. Our objective was to estimate the time to muscle necrosis in patients with ACS.

Methods: This historical cohort analysis of all patients who had a fasciotomy for ACS was conducted in 4 large teaching hospitals. Diagnosis was confirmed clinically or by needle measurement of compartment pressure. Muscle necrosis was determined using pathology reports and surgeons' operative protocols. We used descriptive statistics and estimated tissue survival probability using the Vertex exchange method for interval-censored data.

Results: Between 1989 and 1997 there were 76 cases of ACS. Most cases occurred in young men (median age 32) as a result of a traumatic incident (82%). Forty-nine percent (37/76) of all patients suffered some level of muscle necrosis, and 30% (11/37) of those with necrosis lost more than 25% of the muscle belly. Necrosis occurred in 2 of 4 cases in which the patient had been operated on within 3 hours of the injury, and our exploratory survival analysis estimates that 37% (95% confidence interval, 13%-51%) of all cases of ACS may develop muscle necrosis within 3 hours of the injury.

Conclusions: This is the largest cohort of ACS and the first clinical estimation of time to muscle necrosis ever published. Ischemia from ACS can cause muscle necrosis before the 3-hour period post-trauma that is traditionally considered safe. Further research to identify risk factors associated with the development of early necrosis is necessary.