CJEM Articles: emergency department
Displaying 1-10 of 81 results
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November
2011
13
6
Gulnaz Jiwa, J. Douglas Matheson, Paul T. Engels, Sheila C. Caddy
Cardiac arrest in pregnancy is a rare occurrence, particularly in the emergency department setting. The resuscitation of a pregnant patient in cardiac arrest is unique in a number of ways. Early identification and treatment of possible etiologies, appropriate response to the physiologic changes present in pregnancy, relief of potential vena cava obstruction by the gravid uterus, and expeditious preparation for possible cesarean delivery are important considerations for a successful resuscitation. We report and discuss the case of a pregnant patient with pulmonary edema and cardiac dysfunction who presented with severe hypoxemia and subsequent cardiac arrest and underwent a perimortem cesarean delivery and simultaneous fetal and maternal resuscitation in the emergency department.
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November
2011
13
6
Heather Hames, Shelley McLeod, Wanda Millard
Objective: The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications.
Methods: This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications.
Results: Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ – 25 minutes; 95% CI – 32, 70; p = 0.46). There was a significantly lower rate (p < 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p < 0.05). There were no reported complications in either group at time of reduction or follow-up.
Conclusions: There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.
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September
2011
13
5
Astrid Guttmann, Brian H. Rowe, Caroline M. Hatcher, Chad A. Leaver, Geoffrey M. Anderson, Marian Vermeulen, Merrick Zwarenstein, Michael J. Schull
Background:
The evaluation of emergency department (ED) quality of care is hampered by the absence of consensus on appropriate measures. We sought to develop a consensus on a prioritized and parsimonious set of evidence-based quality of care indicators for EDs.
Methods:
The process was led by a nationally representative steering committee and expert panel (representatives from hospital administration, emergency medicine, health information, government, and provincial quality councils). A comprehensive review of the scientific literature was conducted to identify candidate indicators. The expert panel reviewed candidate indicators in a modified Delphi panel process using electronic surveys; final decisions on inclusion of indicators were made by the steering committee in a guided nominal group process with facilitated discussion. Indicators in the final set were ranked based on their priority for measurement. A gap analysis identified areas where future indicator development is needed. A feasibility study of measuring the final set of indicators using current Canadian administrative databases was conducted.
Results:
A total of 170 candidate indicators were generated from the literature; these were assessed based on scientific soundness and their relevance or importance. Using predefined scoring criteria in two rounds of surveys, indicators were coded as “retained” (53), “discarded” (78), or “borderline” (39). A final set of 48 retained indicators was selected and grouped in nine categories (patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection). Gap analysis suggested the need for new indicators in patient satisfaction, a healthy workplace, mental health and addiction, elder care, and community-hospital integration. Feasibility analysis found that 13 of 48 indicators (27%) can be measured using existing national administrative databases.
Discussion:
A broadly representative modified Delphi panel process resulted in a consensus on a set of 48 evidence-based quality of care indicators for EDs. Future work is required to generate technical definitions to enable the uptake of these indicators to support benchmarking, quality improvement, and accountability efforts.
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July
2011
13
4
Andrew Worster, Cheryl L. Main, Jocelyn A. Srigley, Patrick H.P. Tang
Introduction: The objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).
Methods: We conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members' stethoscopes at three EDs. Study participants were asked to complete a questionnaire.
Results: Fifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.
Conclusions: This study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low. -
May
2011
13
3
David Johnson, Josephine Ho, Renee Jackson
We describe the course of a toddler who ingested a massive amount of levothyroxine and review treatment options for such overdoses. A 2½-year-old boy presented shortly after an ingestion of up to 7.6 mg of levothyroxine (potentially as much as 700 μg/kg). He was initially asymptomatic, treated with oral charcoal 1 g/kg, and discharged home from the emergency department after a few hours. He returned approximately 24 hours later with a temperature of 38.5°C, heart rate of 163 beats per minute, respiratory rate of 30 breaths per minute, and blood pressure of 136/70 mm Hg. He had a slightly decreased appetite and no signs or symptoms of infection. He was admitted to hospital and treated with oral acetaminophen. The initial free thyroxine (T4) was > 100 pmol/L and free triiodothyronine (T3) was 35.3 pmol/L. The patient had desquamation of the palms and soles, hair loss, and irritability during the month following the ingestion. Resolution of the elevated free T4 occurred by 12 days post-ingestion and normalization of the thyroid-stimulating hormone by 7 weeks post-ingestion. There were no long-term sequelae. Levothyroxine overdose can result in significant complications, including seizures and arrhythmias, both of which should be monitored for. However, as our case illustrates, massive ingestion of levothyroxine in children typically follows a benign course.
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March
2011
13
2
Clare L. Atzema, Jack V. Tu, Michael J. Schull, Peter C. Austin
Objective:The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time.
Methods:This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time.
Results:In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%.
Conclusions:Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less. -
November
2010
12
6
Angela M. Mills, Anthony J. Dean, Esther H. Chen, Judd E. Hollander
Objective: We aimed to use the consensus opinion of a group of expert emergency physicians to derive a set of emergency diagnoses for acute abdominal pain that might be used as clinically significant outcomes for future research.
Methods: We conducted a cross-sectional survey of a convenience sample of emergency physicians with expertise in abdominal pain. These experts were authors of textbook chapters, peer-reviewed original research with a focus on abdominal pain or widely published clinical guidelines. Respondents were asked to categorize 50 possible diagnoses of acute abdominal pain into 1 of 3 categories: 1) unacceptable not to diagnose on the first emergency department (ED) visit; 2) although optimal to diagnose on first visit, failure to diagnose would not be expected to have serious adverse consequences provided the patient had follow-up within the next 2–7 days; 3) if not diagnosed during the first visit, unlikely to cause long-term risk to the patient provided the patient had follow-up within the next 1–2 months. Standard descriptive statistical analysis was used to summarize survey data.
Results: Thirty emergency physicians completed the survey. Of 50 total diagnoses, 16 were categorized as “unacceptable not to diagnose in the ED” with greater than 85% agreement, and 12 were categorized as “acceptable not to diagnose in the ED” with greater than 85% agreement.
Conclusion: Our study identifies a set of abdominal pain conditions considered by expert emergency physicians to be clinically important to diagnose during the initial ED visit. These diseases may be used as “clinically significant” outcomes for future research on abdominal pain.
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September
2010
12
5
David D. Sweet, MD, MD; Dean Chittock, MD; Dharmvir Jaswal, MD; Jen Rachel, MD; Matt Bouchard, MD; Praveena Sivapalan, MD; Winnie Fu, MSc
Objective: We sought to determine whether the implementation of a sepsis protocol in a Canadian emergency department (ED) improves care for the subset of patients admitted to the intensive care unit (ICU).
Methods: After implementing a sepsis protocol in our ED we used an ICU database and chart review to compare various time-dependent end points and outcomes between a historical control year and the first year after implementation. We re-viewed the charts of all patients admitted to the ICU within 24 hours of ED admission with a primary or other diagnosis of sepsis, severe sepsis or septic shock, who met criteria for early goal-directed therapy within the first 6 hours of their ED stay.
Results: We compared 29 patients from the control year with 30 patients from the year after implementation of our sepsis protocol. We found that patients treated during the postintervention year had improvements in time to antibiotics (4.2 v. 1.0 h, difference = –3.2 h, 95% CI –4.8 to –2.0), time to central line placement (above the diaphragm) (11.6 v. 3.2 h, difference = –8.4 h, 95% CI –12.1 to –4.7), time to arterial line placement (7.5 v. 2.3 h, difference = –5.2 h, 95% CI –7.4 to –3.0), and achievement of central venous pressure and central venous oxygen saturation goals (11.1 v. 5.1 h, difference = –6.0 h, 95% CI –11.03 to –1.71, and 13.1 v. 5.5 h, difference = –7.6 h, 95% CI –11.97 to –3.16, respectively). There were no statistically significant differences in ICU length of stay, hospital length of stay or mortality (31.0% v. 20.0%, difference = –11.0%, 95% CI–33.1% to 11.1%).
Conclusion: Implementation of an ED sepsis protocol im-proves care for patients with severe sepsis and septic shock. -
July
2010
12
4
Daniel Peterson, Marc Francis, Tom Rich, Tyler Williamson
Objective: We sought to evaluate the time to antibiotics for emergency department (ED) patients meeting criteria for severe sepsis before and after the implementation of an ED sepsis protocol. Compliance with published guidelines for time to antibiotics and initial empiric therapy in sepsis was also assessed.
Methods: A retrospective chart review was conducted. Emergency department patient encounters with International Classification of Diseases codes related to severe infections were screened during a 3-month period before and after the implementation of a sepsis protocol. Encounters meeting criteria for severe sepsis were further assessed. The time to initiation of antibiotics was determined as well as the initial choice of antimicrobial therapy based on the presumed source of infection.
Results: We reviewed 213 unique ED patient encounters meeting criteria for severe sepsis. Analysis of the period before implementation showed a median time from the time criteria for severe sepsis were met to delivery of antibiotics of 163 minutes (95% confidence interval [CI] 124 to 210 min). Analysis of the period after implementation of the protocol revealed a median time of 79 minutes (95% CI 64 to 94 min), representing an overall reduction of 84 minutes (95% CI 42 to 126 min). Before the implementation of the protocol, 47% of patients received correct antibiotic coverage for the presumed source of infection in compliance with locally published guidelines. After the initiation of the protocol, 73% received appropriate initial antibiotics, for an overall improvement of 26%.
Conclusion: A guideline-based ED sepsis protocol for the evaluation and treatment of the septic patient appears to improve the time to administration of antibiotics as well as the appropriateness of initial antibiotic therapy in patients with severe sepsis.
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July
2010
12
4
Antoinette Colacone, Bernard Unger, Eddy Lang, Eli Segal, Eric Grafstein, Jean François Boivin, Marc Afilalo, Michael Bullard, Michael Schull, Nathalie Soucy, Xiaoqing Xue
Objective: Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).
Methods: Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the EDspecific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.
Results: Of the 83 reviewers, 76% were emergency medicine (EM)–trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n = 292), followed by gastrointestinal (n = 59), musculoskeletal (n = 55) and infectious disease (n = 42). Chapters with the lowest number retained were neoplasm (n = 18) and pregnancy (n = 12).
Conclusion: We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.
