CJEM Articles: emergency
Displaying 1-10 of 18 results
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July
2012
14
4
Isser Dubinsky
Background:
A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.
Objective:
In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload modelConclusion:
None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested. -
March
2011
13
2
F. Jonathan Guilfoyle, Niranjan Kissoon, Ruth Milner
Objective:To describe the frequency and proportion of successful resuscitation interventions in a pediatric emergency department (PED).
Methods and Material:This was a retrospective chart review of children at the BC Children's Hospital (BCCH) PED who were admitted to the BCCH pediatric intensive care unit (PICU) in 2004 and 2005. Demographic data, diagnosis, and resuscitation interventions in the PED and within the first 24 hours of PICU admission were recorded. The training of the operator and the number of attempts needed were also recorded.
Results:There were 75,133 PED visits; 304 of 329 (92.4%) who met inclusion criteria were reviewed. Diagnoses included respiratory distress (n = 115, 35%), trauma (n = 50, 15%), sepsis (n = 36, 11%), seizures (n = 37, 11%), and cardiac disease (n = 22, 7%). Ninety-nine patients required intubation. Intubations in the PED were performed by residents (20%), pediatric emergency medicine (PEM) fellows (15%), PEM attending staff (29%), and PICU fellows (12%); 81% of these were successful on the first attempt. In the PED, seven central lines were placed, seven intraosseous needles were inserted, 15 patients required inotropes, and 9 patients required chest compressions.
Conclusion:Critical illness in our emergency department is a rare event; hence, opportunities to resuscitate, secure airways, and place central venous catheters are limited. Additional training, close working relationships between the PED and the PICU teams, and resuscitation protocols for early PICU involvement may be needed. -
March
2011
13
2
Anne-Maree Kelly, Lim Beng Leong
Objectives:Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED.
Data source:We searched the Cochrane, Medline, Embase, and CINAHL databases.
Study selection:Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included.
Data extraction:Primary outcomes were subjective or objective headache relief (> 50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents.
Data synthesis:Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54–42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33–6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36–6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45%; akathesia and sedation were the most common.
Conclusions:Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems. -
November
2010
12
6
Glen Bandiera, Ray Guo, Robert J. Sowerby, Steven Marc Friedman
Objective: We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors.
Methods: A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec.
Results: Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 respondents (30.5% [95% confidence interval (CI) 19.9%–41.1%]) agreed with the statement, “I sometimes feel unsafe or unqualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician” and 32 of 81 (39.5% [95% CI 28.2%–50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%–52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%–59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%–51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%–49.3%]), admission decisions (13/79, 16.5% [7.6%–25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%–25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%–61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%–50.2%]).
Conclusion: Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.
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November
2009
11
6
Jeffrey Freeman
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September
2009
11
5
Amanda S. Newton, Christina Haines, David W. Johnson, Philip Jacobs, Rachel A. Keaschuk, Rhonda J. Rosychuk, Samina Ali, Terry P. Klassen
Objective: We sought to determine and compare rates of pediatric mental health presentations and associated costs in emergency departments (EDs) in Alberta.
Methods: We examined 16 154 presentations by 12 589 patients (patient age ≤ 17 yr) between April 2002 and March 2006 using the Ambulatory Care Classification System, a province-wide database for Alberta. The following variables of interest were extracted: patient demographics, discharge diagnoses, triage level, disposition, recorded costs for ED care, and institutional classification and location (i.e., rural v. urban, pediatric v. general EDs).
Results: A 15% increase in pediatric mental health presentations was observed during the study period. Youth aged 13-17 years consistently represented the most common age group for first presentation to the ED (83.3%). Of the 16 154 recorded presentations, 21.4% were related to mood disorders and 32.5% to anxiety disorders. Presentations for substance misuse or abuse were the most prevalent reasons for a mental health-related visit (41.3%). Multiple visits accounted for more than one-third of all presentations. Presentations for mood disorders were more common in patients with multiple compared with single visits (29.3% v. 16.9%), and substance abuse or misuse presentations were more common in patients with single compared with multiple visits (47.4% v. 30.5%). The total direct ED costs for mental health presentations during the study period was Can$3.5 million.
Conclusion: This study provides comprehensive data on trends of pediatric mental health presentation, and highlights the costs and return presentations in this population. Psychiatric and medical care provided in the ED for pediatric mental health emergencies should be evaluated to determine quality of care and its relationship with return visits and costs. -
September
2009
11
5
Jeffrey Freeman
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July
2009
11
4
Shane Neilson
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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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September
2008
10
5
David Provan, Kate Hanneman, Shannon Moore, Steven M. Friedman
Objective: We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers.
Methods: This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40 000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3-7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system.
Results: Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3-7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%-8.96%), 8 near misses (4% incident rate; 95% CI 1.73%-7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; κ = 0.78, standard error [SE] 0.20; 95% CI 0.39-1.00; p = 0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system.
Conclusion: ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety.
