CJEM Articles: George Wells
Displaying 1-3 of 3 results
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September
2010
12
5
A. Adam Cwinn, Alan Forster, Christian Vaillancourt, George Wells, Guy Hebert, Ian Stiell, Jason Leclair, Jeffrey Perry, Lisa Anne Calder, Melanie Nelson
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.
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July
2005
7
4
George Wells, Heather Murray, Ian Stiell
Objective: To identify the rate of treatment failure in emergency department patients with cellulitis.
Methods: This prospective observational convenience study enrolled adult patients with uncomplicated cellulitis. Physicians performed a standardized assessment prior to treatment. To calculate the interrater reliability of the assessment, duplicate data collection forms were completed on a small subsample of patients. Treatment failure was defined as the occurrence of any one of the following events after the initial emergency department visit: incision and drainage of abscess; change in antibiotics (not due to allergy/intolerance); specialist consultation; or, hospital admission. Comparison of means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate.
Results: Seventy-five patients were enrolled; 57% were male, the mean age was 48 (standard deviation 19), 71 (95%) patients had extremity cellulitis and 10 (13%) had abscess with cellulitis. Fourteen episodes (18.7%, 95% confidence interval [CI] 11%-28%) were classified as treatment failures, with an oral antibiotic failure rate of 6.8% (95% CI 2%-22%) and an emergency department-based intravenous antibiotic failure rate of 26.1% (95% CI 16%-40%). Patients with treatment failure were older (mean age 59 yr v. 46 yr, p = 0.02) and more likely to have been taking oral antibiotics at enrolment (50% v. 16.4%, p = 0.01). Patients with a larger surface area of infection were also more likely to fail treatment (465.1 cm2 v. 101.5 cm2, p < 0.01). Interrater agreement was high for the presence of fever (kappa 1.0) and the size of surface area of infection (intraclass correlation coefficient 0.98), but low for assessments of both severity (kappa 0.35) and need for admission (kappa 0.46).
Conclusions: The treatment of cellulitis with daily emergency department-based intravenous antibiotics has a failure rate of more than 25% in our centre. Cellulitis patients with a larger surface area of infection and previous (failed) oral therapy are more likely to fail treatment. Further research should focus on defining eligibility for treatment with emergency department-based intravenous antibiotics.
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September
2002
4
5
Alena Spacek, George Wells, Ian Stiell, Jeffrey J. Perry
Objectives: This study evaluated the incidence of subarachnoid hemorrhage (SAH) and the use of computed tomography (CT) and lumbar puncture (LP) in a cohort of emergency department (ED) patients with acute headache.
Methods: Health records from a tertiary care ED were used to identify all patients over 15 years of age who presented with headache over a 10-month period. Patients were excluded if they had been referred with confirmed SAH or if they had recurrent headache, head trauma, decreased level of consciousness or new neurologic deficits. Outcome measures included ED diagnosis, use of CT or LP, and ED length of stay. Analysis included descriptive statistics, 95% confidence intervals (CIs) and analysis of variance for length of stay.
Results: The mean age of the 891 patients was 41.9 years. Ten (1.1%) of the patients had SAH, 313 (35.1%) underwent CT, and 85 (9.5%) underwent LP. Only 9 (2.9%) of the CT scans and 2 (2.4%) of the LPs were positive for SAH. Of the 296 patients with normal CT results, 232 (78.4%) did not undergo subsequent LP. The mean length of stay was 4.0 hours (95% CI, 3.8-4.1) if no diagnostic testing was performed, 5.0 hours (95% CI, 4.7-5.4) if CT was performed and 7.1 hours (95% CI, 6.3-7.9) if LP was performed (p = 0.001).
Conclusions: Diagnostic testing was associated with substantially prolonged lengths of stay. CT and LP had low diagnostic yields, which suggests the need for a clinical decision rule to rule out SAH in ED patients with acute headache.
