CJEM Articles: Tammy Clifford
Displaying 1-3 of 3 results
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March
2009
11
2
Alyson Shaw, Amy C. Plint, Anna Bottaglia, Carrol Pitters, Isabelle Gaboury, Rhonda Correll, Tammy Clifford, Tawfik Al-Abdullah
Objective: We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral.
Methods: A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED.
Results: Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line-referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line-referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p = 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%, p < 0.001) or by self- or parent-referral (63%, p = 0.002). There was no significant difference between these latter 2 referral routes (p = 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line-referred were similar to each other in these outcomes.
Conclusion: There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.
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July
2005
7
4
Ken Farion, Shawn Dowling, Tammy Clifford
Objectives: Elbow injuries in children are a common presenting complaint to the emergency department. Although radiography is a valuable tool in the diagnosis of this injury, x-rays of the injured elbow are inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended to provide an anatomically "normal" radiograph. Recent studies have questioned the use of comparison views in the pediatric emergency department. The primary objective of this study was to determine current practices of non-pediatric emergency physicians in the use of comparison views for the diagnosis of elbow injuries in children.
Methods: A self-administered mail survey was sent to 300 randomly selected emergency physicians, using the Canadian Association of Emergency Physicians database.
Results: Two hundred and forty-two (81%) responses were received; 26 were excluded based on pre-determined criteria. Of eligible respondents, 95% ordered comparison views selectively and 64% of these physicians ordered comparison views infrequently. Eighty-eight percent found the comparison views to be "rarely" to "sometimes" useful. Forty-seven percent of respondents stated that they were only "somewhat" confident when interpreting x-rays of a child's elbow.
Conclusion: This survey demonstrates that non-pediatric emergency physicians are using comparison views selectively for elbow injuries in children, despite being only "somewhat" confident in interpreting the x-rays.
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March
2003
5
2
Amina Lalani, Amy Plint, Bich Hong Nguyen, Blake Bulloch, Gary Joubert, Jeff Perry, Kelly Millar, Martin Pusic, Samina Ali, Tammy Clifford
Objectives: Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons.
Methods: A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children's hospitals.
Results: Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combination (splint and cast) and 12% prefer backslabs. Sixty percent of ED physicians "usually or always" use casts and 31% "usually or always" use backslabs. Although there was variation among the orthopedic surgeons regarding the recommended length of immobilization, most (70%) recommended 2 to 4 weeks, although some (12%) treated only until pain free. ED physicians showed greater diversity regarding length of immobilization.
Conclusions: Although many physicians believe that wrist buckle fractures need to be immobilized, a significant number do not. There is substantial variability in the type and length of immobilization used. This variability suggests that the optimal management strategy for wrist buckle fractures is unclear and should be determined in future prospective studies.
