CJEM Articles: guidelines

Objective: We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes.

Methods: Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre-post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites.

Results: The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits.

Conclusion: Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Introduction: Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system.
Methods: Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a "practice point" was provided based on group opinion.
Results: The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisitionin the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation.
Conclusion: Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population.

Background: Procedural sedation guidelines were established for a tertiary care pediatric emergency department (ED). We developed a pediatric procedural sedation course to disseminate these guidelines.

Objective: Our objective was to evaluate the effectiveness of a sedation course in improving physicians' knowledge of pediatric procedural sedation practices and guidelines, relative to individual self-directed learning.

Methods: We recruited emergency staff physicians and fellows as well as fourth-year pediatric residents in a tertiary care pediatric ED to participate in a randomized, controlled, educational intervention. All consenting physicians received pediatric sedation educational material for individual study 2 weeks before a learning assessment. Participants were randomly assigned to one of 2 groups. The self-directed learning group (n = 24) completed a multiple-choice examination without receiving any formal teaching. The study group (n= 24) participated in a 4-hour formal multifaceted sedation course before writing the multiple-choice examination.

Results: The groups did not differ significantly in demographic characteristics or self-perceived knowledge of pediatric sedation. The formal teaching group's median examination score (83.3%; range 75.8%-96.5%) was significantly higher (p < 0.0001) than the median examination score of participants in the self-directed study group (73.3%, range 43.5%-86.6%).

Conclusion: The multifaceted sedation course was more effective in improving physician knowledge and understanding of sedation guidelines and practices than unstructured, self-directed learning.