CJEM Articles: Grant D. Innes
Displaying 1-6 of 6 results
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September
2005
7
5
Eric Grafstein, Grant D. Innes, James M. Christenson, Robert Stenstrom
Background: A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.
Methods: During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.
Results: The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) - 3.8 (triage level [1-5]) + 7.1 (ambulance arrival) - 1.1 (GCS [3-15]) + 0.1 (age in years) - 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p < 0.0001).
Conclusions: This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.
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September
2002
4
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Alan Drummond, Andrew Affleck, Anthony Taylor, Brian H. Rowe, Cheri L. Nijssen-Jordan, Douglas Sinclair, Eric Grafstein, Graham Dodd, Grant D. Innes, Howard Ovens, Marion Lyver, Michael J. Murray, W.B. Palatnick
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April
2001
3
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Cameron K. MacGougan, Grant D. Innes, James M. Christenson, Janet Raboud
Objectives: To determine Canadian emergency physicians' estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment.
Methods: 300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (~2 hour) assessment.
Results: Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease.
Conclusions: Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation. -
April
2000
2
2
Grant D. Innes, James M. Christenson, Mary Lesperance, R. Douglas McKnight, Victor M. Wood
Objectives: Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity.
Methods: This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18–65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25–50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes.
Results: Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%–75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%–83%) achieved successful pain relief at 60 minutes (p value for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p = 0.001).
Conclusions: In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment. -
April
1999
1
1
Grant D. Innes
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April
1999
1
1
Cathy Metcalfe, Edward C. Dillon, Grant D. Innes, Iain MacPhail, Min Gao
Objective: To determine whether the addition of intravenous dexamethasone to standard emergency department (ED) migraine therapy would decrease the incidence of severe recurrent headache 24 to 48 hours after initial treatment.
Methods: Patients aged 19 to 65 years whose headache was severe enough to require parenteral therapy and who met International Headache Society migraine criteria were eligible for this randomized, double- blind trial. The study was conducted in the ED of 2 community hospitals, 1 of which was a tertiary referral centre. Exclusion criteria included pregnancy, focal findings, fever, meningismus, allergy to the study drug, active peptic ulcer disease and diabetes mellitus. Demographic and clinical data, including headache severity, were recorded. After abortive therapy (antiemetics, intravenous nonsteroidal agents, dihydroergotamine or opioids), blinded nurses administered dexamethasone (24 mg intravenously) or placebo. Patients recorded headache severity on a Visual Analogue Scale (VAS) at time T = 0, T = 30 minutes and T = 60 minutes and at discharge. They were contacted 48 to 72 hours later and asked whether they had suffered a recurrence of their headache, categorized as class A (severe, provoking another physician visit), class B (severe, interfering with daily activity but not provoking a physician visit), class C (mild, requiring self-medication but not limiting activity) or class D (mild, requiring no treatment).
Results: Two of 100 patients were lost to follow-up, leaving 98 in the study sample. Placebo recipients were more likely to be female; other baseline characteristics were similar between groups. Median VAS pain score was 83 mm on ED arrival, 35 mm after initial treatment and 12 mm on discharge. At followup, 65 of 98 patients had suffered headache recurrence. In the placebo versus dexamethasone groups, respectively, the results were 11 versus 0 in class A, 11 versus 9 in class B, 7 versus 11 in class C and 4 versus 12 in class D. Regarding the primary outcome, 9 of 49 dexamethasone patients (18%) and 22 of 49 placebo patients (45%) had severe (classes A and B) recurrent headache (odds ratio 0.28; 95% CI, 0.11 to 0.69; p = 0 .005).
Conclusions: Migraine recurrence is common after “successful” ED treatment. Inflammation may be a critical factor in migraine genesis. Intravenous dexamethasone decreases the incidence of severe recurrent headache after ED treatment and should be offered to patients thought to be at risk of recurrent headache.
