CJEM Articles: Ian G. Stiell

Objective: There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.

Methods: This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.

Results: A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.

Conclusion: This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.

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 con gestive 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%-40.4%) 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.

A mentor is a person who takes a special interest in the professional development of a junior colleague and provides guidance and support. Mentoring can be beneficial for students, residents, junior colleagues and researchers and can be very rewarding for the physician who provides this guidance. Although mentoring is a well recognized topic in academic medicine, relatively little has been written about mentoring in emergency medicine (EM). Consequently, we conducted a literature review on mentoring in EM and present our findings in this paper. We discuss different models of mentoring, factors that foster the development of strong mentor ship programs, the responsibilities of mentors and mentees, and issues specific to mentorship of female, minority and research physicians. We also present several case scenarios as a basis for recommendations for teachers and learners in EM.

Objective: Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form.
Methods: During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community.
Results: We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%-88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p < 0.001). descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]).
Conclusion: Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form.