2003 CAEP/ACMU Scientific Abstracts: 21-40
CAEP Abstracts
CJEM 2003;5(3):179-209
Disclaimer: The large number of abstracts submitted and the short time interval between submission and publication did not permit communication with authors, abstract revision of CJEM editorial review. The following abstracts are presented, unedited, as they were submitted to the CAEP Research Committee. Abstract authors are from the department or division of emergency medicine of their respective universities unless otherwise specified.
abstracts : 001-020 : 021-040 : 041-060 : 061-080 : 081-100
021 Family Physicians' Perceptions of a Standardized Communication System (SCS) that Delivers Computer-Based Emergency Department (ED) Patient Information to their Offices.
Lang E, Afilalo M, Boivin JF, Leger R, Colacone A, Giguere C, Xue X, Vandal AC, Rosenthal S, Unger B. SMBD Jewish General Hospital, McGill University, Montréal, Quebec.
INTRODUCTION: The lack of communication between EDs and family physicians (FPs) is often cited as a problem in the health care system. The SCS is an Internet and e-mail-based application that enables FPs to access detailed reports regarding their patients who have received ED care. This study measures the perceptions of family physicians with regards to the utility of the SCS in comparison with snail-mailed copies of the ED physician's hand-written note. METHODS: Prior to and subsequent to the completion of a randomized triple-crossover trial of 23 FP practices examining the impact of the SCS on measures of health care delivery, these same physicians were asked to complete surveys focused on issues of communication between the ED and their offices. The non-parametric McNemar test was applied to compare responses prior to and following exposure to the SCS. RESULTS: Completion rates for both the pre and post surveys were 91% (22/23). Of responding FPs, the majority were males (85%) with an average of 24 years in practice (range 6 to 33 years). The FP practice profile was reported to consist of 32% of patients older than 70 years of age and 36% of patients suffering from at least one chronic disease. While exposed to the SCS intervention 90% of FPs reported that the information received was useful compared with 15% who felt the same way regarding the mailed copy of the ED chart (p< 0.0001). SCS information was deemed to be more complete (95% vs. 10%, p<0.001) and more precise (86% vs. 40%, p=0.04). SCS was also perceived by the FPs to reduce the time required to obtain lab and imaging results (72% vs. 14%, p< 0.01). Furthermore, while having access to SCS, more FPs were satisfied with their ability to care for their patients than during control periods (90% vs. 43% p< 0.01). CONCLUSIONS: Rapid electronic transmission of detailed information from the ED to FPs regarding their patients who sought ED care was perceived by FPs to be highly useful to the provision of patient care. Key words: Information systems, quality
022 The Use of Electronic Clinical Practice Guideline Resources in Two Canadian Emergency Departments.
Rowe BH, Bullard MJ, Meurer DM, Colman I, Holroyd BR. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Access to valid clinical practice guideline (CPG) information in the emergency department (ED) has the potential to improve practice efficiency and patient care. This study examined the use of electronic CPG applications by emergency physicians. METHODS: Desktop computers containing an ED tracking system were widely available to all staff in two linked EDs. In addition, EM-specific desktop CPG materials including decision tools, order sets, full care maps, and discharge instructions were accessible using an intranet website (eCPG). Access was provided to 38 full-time EM staff over a 20 month study. Staff use was documented using a web counter, database (n = 2267) and end of session questionnaires (n =840) using a 7-point Likert scale. Descriptive and comparative analyses are reported (p < 0.05). RESULTS: All physicians accessed the tools at least once over the study, with over 5500 "hits" recorded to the site. Most (88%) physicians used 1 application per site visit of which many (64%) preferred the defaulted templates. Overall, the most common resource accessed was the outpatient information in 1138 cases (50%), followed by decision tools in 603 cases (27%), and order sets in 526 (23%) cases; over seven 3-month periods, use of all applications increased (p<0.0001). The respondents reported that they found the resources easy to find (6/7; IQR = 5,7) and helpful (6/7; IQR = 5,7). Physicians felt more confident with the care they delivered (6/7; IQR: 4,6) and felt that the application improved the quality of care they provided (6/7; IQR: 4, 6). Finally, most physicians felt satisfied both with the information contained in the document (6/7; IQR: 5, 7). CONCLUSIONS: An intranet based EM-specific eCPG site was used widely by pediatric and adult physicians in busy EDs. Overall, physicians felt the eCPG information was valid and helped them practice better medicine in the ED. Further research is required to determine if access to eCPGs improves patient outcomes. Key words: clinical practice guideline
023 Does Physician Order Entry Reduce ED Length of Stay (LOS) in an Overcrowded ED?
Innes G, Grafstein E, Christenson J, Purssel R, Stenstrom R. St. Paul's Hospital and The University of British Columbia, Vancouver, BC.
INTRODUCTION: The practice of holding admitted patients in the ED reduces stretcher availability and limits access to emergency care. When ED stretcher occupancy is above 100% and sick patients are treated in waiting rooms (WR), reducing ED LOS improves throughput and care access for waiting patients. In November 2000, we instituted ED physician order entry (POE), which reduces process times and expedites testing for WR patients. Our hypothesis was that the change to POE would reduce ED LOS, especially for patients treated in the WR. METHODS: A controlled before-after study conducted at St. Paul's Hospital (SPH), an inner city Vancouver teaching centre. The before cohort included all patients discharged from the SPH ED from June 10-Nov 10, 2000. The POE (after) cohort included all patients discharged from June 10-Nov 10, 2001. Concurrent control data was gathered from a nearby teaching hospital with similar volume and triage mix that did not implement POE. The primary outcome was ED LOS for discharged patients. RESULTS: The POE and before cohorts included 19,225 and 22,191 patients respectively. Age (42.8 vs. 41.9), gender (62.5% vs. 61.3% male) and disease spectrum were similar in the two groups. During the study period, ED overcrowding and gridlock increased: The mean daily n of admitted patients held in the (22-bed) ED rose from 17.6 to 20.7 and ED LOS (wait time) for admitted patients rose from 11.6 to 31.5 hrs. ED LOS for discharged patients rose by 36 minutes (17%) at the control hospital and 12 minutes (8%) at the POE hospital (p<.001). ED LOS fell by 18 minutes for WR patients treated at the POE site. We are unaware of confounding variables to explain these findings.
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CONCLUSIONS: We believe POE expedites patient care, particularly in non-traditional locations, and mitigates the negative impact of overcrowding on ED LOS. Key words: physician order entry, quality, outcomes
024 Do Electronic Linkages Between the ED and Primary Care Physicians Reduce Resource Utilization in the ED? Results of a Randomized Controlled Trial.
Afilalo M, Lang E, Boivin JF, Leger R, Colacone A, Giguere C, Xue X, Vandal AC, Rosenthal S, Unger B. Emergency Department, SMBD Jewish General Hospital, McGill University, Montréal, Quebec.
INTRODUCTION: The lack of communication between emergency departments (EDs) and primary care physicians (PCPs) is often cited as a cause of inefficiency in ED-based care. Despite this, few EDs consistently transmit clinical information about the patients they care for to PCPs. We hypothesized that an electronic communication tool would reduce resource utilization in the ED. METHODS: The Standardized Communication System (SCS) is a secure, e-mail and internet -based application that enables PCPs to receive detailed reports including laboratory and imaging data as well as consultation reports and disposition and follow-up information regarding their patients who have received ED care. We conducted a non-blinded, prospective, triple-crossover, randomized controlled trial of PCPs' practices, stratified by age and load of ED-using patients. While allocated to intervention, PCPs received reports via the SCS and while in control, mailed copies of the hand-written ED note. Outcomes of interest were 14-day revisit rates, admission rates upon revisit and ED length of stay (LOS) as well as consult requests and test ordering in the ED. The study was designed with 0.80 power to detect a 25% reduction (alpha = .05) in revisit rates. Mixed models analysis was employed for all comparisons. RESULTS: 2022 ED visits (974 SCS vs. 1048 control) were entered into the trial. The clinical and demographic characteristics of the patients in each arm were comparable. The SCS intervention did not reduce 14-day revisit rates (adjusted OR 1.10, 95% CI 0.80-1.51). There was also no difference in admission rates upon revisit (23% with SCS vs. 26% in controls; p=ns) nor ED LOS (10.3 hrs. with SCS vs. 10.4 with controls; p=ns). Consult requests (16% SCS vs. 15% controls; p=ns) and test ordering (84% SCS vs. 85% control; p=ns) were also unaffected by the intervention. CONCLUSIONS: In comparison with mailed copies of the ED chart, electronic communication between EDs and PCPs does not reduce resource utilization in the ED. Key words: information systems, utilization
025 Supporting Clinical Practice at the Bedside Using Wireless Technology.
Bullard MJ, Meurer D, Colman I, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
OBJECTIVES: Despite studies that show improvements in both standards of care and outcomes with the judicious application of clinical practice guidelines (CPG), clinical utilization remains low. This randomized trial examines the use of a wirelessly networked mobile computer (MC) by physicians at the bedside with access to an ED information system, decision support tolls and other software options. METHODS: Each of 10 volunteer Emergency Physicians were randomized using a matched pair design to work 5 shifts in their standard fashion and 5 shifts with a wireless networked laptop computer. Work pattern issues and electronic template use were compared using end-of-shift satisfaction questionnaires and reviewing the database for electronic template usage. Repeated measures ANOVA was used to examine between shift differences. RESULTS: 99% compliance with post-shift questionnaires was achieved. Using a 7 point Likert scale (MC values first) MC shifts were rated as being as fast (5.04 vs 4.54; p = 0.128) and convenient (5.08 vs 4.14; p = 0.071) as desk top computers. Overall, physicians rated MC to be less efficient (3.18 vs 4.30; p= 0.015) but resulted in more frequent use of CPG forms (4.10 vs 3.47; p = 0.034) without impacting on doctor-patient communication (2.78 vs 2.96; p = 0.512). During the study period, physicians demonstrated more frequent use of CPGs during shifts assigned to the mobile computer compared to the desktop (3.6 vs 2.0; p=0.033). The major concerns of the study physicians were the size of the computer and cart and the limited number of CPGs available on-line. CONCLUSIONS: The MC technology permitted physicians to rapidly access information at the bedside and use the CPG tools more frequently. Patients appeared to accept physician's use of information technology to assist in decision making. The major limitations remain MC size and portability, requiring ongoing development of new computer technology. Key words: information systems
026 The Prevalence and Effect of Information Gaps in the Emergency Department.
Stiell A, Forster A, Stiell IG, van Walraven C. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Information gaps (IG) occur when previously collected information is unavailable to a physician who is currently treating a patient. This study measured the prevalence and impact of IG for patients presenting to the ED. METHODS: This prospective cross-sectional survey was conducted in a teaching hospital ED on a stratified sample of adult patients. A trained research assistant interviewed ED attending and housestaff physicians immediately after patient assessment to determine if there was previously collected information that was not available in the ED. The physicians identified what data was missing, why it was required, and its importance to the patient's care on a 5-point Likert scale. We reviewed patient charts to measure severity of illness and determine if the patient was referred to the ED by a community physician. Multiple linear regression was used to determine if IG were associated with ED length of stay. RESULTS: Information was collected for 1002 visits (983 patients) over an 8-week period. At least one information gap was identified in 323 (32.2%, 95% CI 29.4%-35.2%) of ED visits. IG most commonly comprised hospital record (36.9%), laboratory (23.3%), medication (13.4%), and physician record (9.2%) data were felt to be essential to patient care 47.8% of the time. Patients with IG were more likely to: be older (60 vs 48 yrs), have arrived by ambulance (34.1% vs 20.9%), have triage level 'emergent' (15.5% vs 7.5%), be in a monitored bed (26.6% vs 12.4%), have a cardiovascular diagnosis (23.8% vs 9.7%), and be admitted (24.8% vs 11.3%); all p-values <.0001. After adjusting for important confounders, ED length of stay was 1.2 hours longer for patients with IG (p <.0001). CONCLUSIONS: IG were present in one-third of ED patients, most common in the sickest patients, and independently associated with prolonged stay in the ED. IG could have huge implications to the patient and the health care system and future research should identify strategies to decrease IG. Key words: quality
027 Impact of Medical Trainees on Clinician Efficiency and Diagnostic Utilization.
Innes G, Marsden J, Christenson J, Grafstein E, Stenstrom R. St. Paul's Hospital and the University of British Columbia, Vancouver, BC.
INTRODUCTION: Trainees may enhance emergency physician (EP) efficiency by reducing the time they spend with each patient, but trainees may also increase diagnostic utilization. Our hypothesis was that trainee care would reduce EP time with patients, increase hospital admission rates and prolong ED length of stay (LOS) for discharged patients. METHODS: During a representative sample of ED shifts, research assistants shadowed attending EPs and tracked patients seen by trainees, patient characteristics and EP time spent on patient care and teaching. Patient disposition, LOS and test utilization were captured from hospital databases. The number of shifts covered was based on project funding and the size of the study groups was based on the number of patients seen by trainees. RESULTS: During 32 shifts, 22 EPs treated 446 patients alone and 139 in conjunction with trainees. Patients treated by EPs alone were more likely to have comorbid conditions (34.8% vs. 28.8%), to arrive by ambulance (30.1% vs. 25.7%), to require procedures (23.1% vs. 19.4%) and to have GCS <15 (6.4% vs. 4.8%). For each patient seen by a trainee, EPs provided more teaching and less clinical care (table). Patients seen by trainees had higher admission rates, longer LOS and more diagnostic tests.
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CONCLUSION: Bedside teaching is "time-neutral" but trainees may increase admission rates, ED LOS and test utilization. Close supervision of trainee care is required. Key words: medical education, utilization
028 A Standardized Communication System (SCS) Linking the Emergency Department with Primary Care Physicians: Impact on Continuity of Care.
Lang E, Afilalo M, Boivin JF, Leger R, Colacone A, Giguere C, Xue X, Vandal AC, Rosenthal S, Unger B. Emergency Department, SMBD Jewish General Hospital, McGill University, Montréal, Quebec.
INTRODUCTION: The seamless integration i.e. continuity of care (CC) between the emergency department (ED) and primary care physicians (PCPs) depends on accurate and timely sharing of information. However, for various reasons, EDs inconsistently transmit information about the patients they care for to PCPs. The objective of this study was to determine the impact of an electronic communication tool on measures of CC. METHODS: The SCS is an internet and e-mail-based application that enables PCPs to receive detailed reports regarding their patients who have received ED care. We conducted a non-blinded prospective, triple-crossover, randomized controlled trial of PCP practices, stratified by age and load of ED-using patients. While allocated to intervention, PCPs received reports via the SCS and while in control, mailed copies of the hand-written ED note. Outcomes were measured with a patient-specific questionnaire that was completed by PCPs 3 weeks following the ED visit of interest. Mixed model analysis was employed for all comparisons. RESULTS: From June 2001 to May 2002, 2022 ED visits (974 SCS vs. 1048 control) were entered into the trial. The clinical and demographic characteristics of the patients in each arm were comparable. The questionnaire response rate was 77% overall and differed little between intervention and control periods. SCS resulted in an increase in PCP follow-up directly related to the ED visit (adjusted OR 0.56, 95% CI 0.38-0.82). PCPs in the intervention arm also reported having better knowledge of their patients' ED visits than controls (adjusted OR 0.16, 95% CI 0.12-0.22). SCS did not reduce duplication of test ordering at the time of PCP follow-up (hematological exams 22% vs. 16%, microbiologic exams 12.6% vs. 7%, EKGs 10% vs. 5% p=ns for all). CONCLUSIONS: Enhanced transfer of clinical information between the ED and PCPs improves CC primarily through improved PCP follow-up of ED visits and better knowledge of the care provided to their patients in the ED. Key words: information systems
029 The Inter-Rater Reliability of Triage in an Acute Care ED Setting.
Grafstein EJ, Innes GD, Westman J, Christenson JM, Thorne A. Department of Emergency Medicine, Providence Health Care, Vancouver, BC.
Background: Triage reliability studies typically use hypothetical scenarios and weighted kappa scores where agreement within 1 level is considered satisfactory. If triage category is used to define comparative ED case-mix groups, agreement on exact triage level and major system involved is important. We have previously developed a computerized presenting complaint list linked to the 5-level Canadian Triage and Acuity Scale (CTAS). Our hypothesis was that a computerized menu that links presenting complaints to preferred triage levels (PC-linked triage) would provide high triage reliability. Objectives: To assess inter-rater reliability of PC-linked triage using the CTAS in a real-time clinical setting, considering agreement on exact triage level and the presenting complaint system involved. Methods: This prospective study was conducted at St. Paul's Hospital, a Canadian inner-city academic centre. The on duty triage nurses assessed a convenience sample of ED patients and entered a presenting complaint and a PC-linked triage level. A second nurse, blinded to the triage assignment, concurrently observed the patient interview and independently entered the same information on a dummy terminal. Each nurse also assigned a subjective triage level without PC-linking. Results: Between August and November 2002, 15 pairs of nurses triaged 265 patients. Study patients matched actual ED case mix closely, with 1%, 13%, 36%, 33% and 18% in levels 1-5 respectively. Kappa statistics were 0.66 (95% CI 0.59 - 0.73) for PC-linked triage (exact level) agreement and 0.80 (95% CI 0.69 - 0.91) for agreement on major system involved. Raw agreement between the subjectively assigned acuity levels and PC-linked triage levels was 0.55 (95% CI 0.51 - 0.59). Using subjective triage, nurses assigned fewer patients to levels 1, 2 and 5. Conclusion: PC-linked triage reliability is high in a real-time clinical setting. Nurses triaging subjectively are more likely to cluster patients in triage levels 3 and 4. Key words: triage
030 A Randomized Controlled Trial of a Novel Anti-Arrhythmic Agent RSD1235 in the Treatment of Acute Atrial Fibrillation.
Rowe BH, Roy D, Stiell IG, Dickinson G, Lee J, Vidaillet H, Phaneuf D, Grant S, Beatch GN, Ezrin AM for the CRAFT Investigators. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
INTRODUCTION: Acute atrial fibrillation (AF) is a common arrhythmia, and cardioversion agents are often ineffective. This study determined the efficacy and safety of a novel anti-arrhythmic (RSD1235) for the termination of AF. METHODS: This phase II, multi-centered, randomized, double-blind, placebo-controlled, parallel group study enrolled patients with uncomplicated AF (3hr < AF < 72hr). Patients were randomized LOW (0.5 and 1 mg/kg) or HIGH (2 and 3 mg/kg) dose RSD1235 compared to placebo (PLAC) given by infusion over 10 min. Safety was assessed by: incidence of adverse events (AEs); vital signs; ECG monitoring, and laboratory data. The primary endpoint was termination of AF during infusion or the following 30-min. Secondary endpoints included number of patients in normal sinus rhythm (NSR) post-infusion and time to NSR conversion. RESULTS: 20 US and Canadian sites enrolled 56 patients during 2002; demographics were similar between groups (61% males; age = 61 years). HIGH dose showed significant improvements over PLAC in: termination of AF within 30-min (61% vs. 5%; p =0.0003), patients in NSR 30 min post-dose (56% vs. 5%; p = 0.0008), patients in NSR 1 hour post-dose (53% vs. 5%; p = 0.0014), and median time to achieve NSR (14 vs. 162 minutes; p = 0.016). Five patients had SAEs: 4 PLAC patients and one LOW patient. All SAEs resolved and none were deemed related to drug. Clinically significant abnormal ECG results were seen in PLAC (7), LOW (4) and HIGH (3) dose patients. CONCLUSION: RSD1235, a new atrial-specific, mixed Na/K channel blocking agent, appears to be efficacious and safe for patients with acute AF. Further Phase III studies using wider inclusion criteria and larger populations are required before this promising drug can be approved in this setting. Key words: atrial fibrillation
031 Multicenter Prospective Validation of the Canadian CT Head Rule.
Stiell IG, Clement C, Wells GA, Brison R, McKnight RD, Schull M, Rowe B, Dreyer J, Bandiera G, Lee J, MacPhail I, Lesiuk H, for the CCC Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: The Canadian CT Head Rule (CCHR) for use of CT was previously derived in a cohort of 3,121 patients and stratifies minor head injury patients into High-, Medium-, and Low-Risk categories, based upon 7 clinical criteria. This study prospectively and explicitly evaluated the accuracy, reliability, and acceptability of the CCHR. METHODS: This prospective cohort study was conducted in 9 tertiary care EDs and enrolled adult minor head injury patients with witnessed loss of consciousness, amnesia, or confusion and a GCS score of 13-15. More than 350 physicians completed 15-item data forms and interpreted the CCHR status for patients prior to diagnostic imaging. In some cases 2nd physicians performed interobserver assessments. The outcome standards were 'need for neurological intervention' and 'clinically important brain injury'. Analyses included kappa coefficient, sensitivity, and specificity with 95% CIs. RESULTS: The 2,588 patients enrolled over 30 months had these characteristics: mean age 38.4 (range 18-99), male 69.3%, ambulance arrival 76.9%, clinically important brain injury on CT 8.2%, unimportant injury 3.6%, neurological intervention 1.6%, death 0.2%. The five CCHR High-Risk Criteria classified patients for neurological intervention (N = 41) with sensitivity 100% (95% CI 91-100), specificity 65.4% (63-67), and would have required CT for 35.7%. The seven CCHR High- and Medium-Risk Criteria classified patients for 212 important brain injuries with sensitivity 100% (95% CI 98-100), specificity 41.0% (39-43), and would have required CT for 62.4%. The kappa value for MD interpretation of the CCHR was 0.80 (0.76-0.92). MDs under-estimated the risk in 7.1% and were uncomfortable applying the rule in 7.7%. CONCLUSIONS: The CCHR has proven to be an accurate, reliable, and acceptable decision rule for the use of CT in minor head injury. Widespread implementation would stabilize or decrease use of CT, decrease health care costs and ensure optimal patient outcomes. Key words: clinical prediction rule, computed tomography
032 Oral Prednisone for the Prevention of Relapse in Outpatients Discharged from the Emergency Department with Exacerbations of Chronic Obstructive Pulmonary Disease.
Aaron SD, Vandemheen KL, Hebert P, Dales R, Stiell IG, Ahuja J, Dickinson G, Brison R, Rowe BH, Dreyer J, Yetisir E, Cass D, Wells GA. Division of Respiratory Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: This multi-center randomized, double-blind, placebo-controlled clinical trial studied the effectiveness of prednisone in reducing relapse after the treatment of acute outpatient COPD exacerbation. METHODS: We enrolled 147 patients who were being discharged from the emergency department (ED) after treatment for acute exacerbations of COPD and randomly assigned them to outpatient treatment with oral prednisone 40 mg once daily, or identical placebo given for 10 days. All patients received oral antibiotics for 10 days, plus inhaled short-acting bronchodilators given four times daily throughout the 30-day follow-up period. The primary endpoint was relapse within 30 days of entry into the trial, defined as an unscheduled visit to a physician's office, or a return to the ED, because of worsening dyspnea. RESULTS: The overall rate of 30-day relapse was significantly lower in the prednisone-treated group compared to the placebo group (27% vs. 43%, P=0.05), and the time to relapse was significantly prolonged in those taking prednisone (P = 0.04). After 10 days of therapy, patients allocated to prednisone showed greater improvements in FEV1 (34 ± 42% from baseline versus a 15 ± 31% improvement in the placebo-treated patients; P = 0.006). Patients randomized to prednisone experienced greater improvements in dyspnea as measured by the transitional dyspnea index (3.95 ± 4.62 vs. 2.07 ± 5.53, P = 0.04) and by the change in the chronic respiratory questionnaire dyspnea index (1.69 ± 1.55 vs. 0.97 ± 1.83, P = 0.02). Improvements in health-related quality of life were not significantly greater for those treated with prednisone compared to placebo (P = 0.14), and patients treated with prednisone reported more adverse effects including insomnia (p=0.0009) and hyperphagia (p=0.003). CONCLUSION: Outpatient treatment with oral prednisone for 10 days reduces relapse within 30 days, improves lung function and decreases dyspnea following an acute COPD exacerbation. Key words: chronic obstructive lung disease, corticosteroids
033 Pediatric Wrist Buckle Fractures: Management and Outcomes.
Plint A, Perry JJ, Tsang JLY. Department of Emergency Medicine, University of Ottawa, Ottawa, ON.
INTRODUCTION: Wrist buckle fractures are common in children yet there is little literature regarding their management and outcome. This study described the management and outcomes of wrist buckle fractures in children presenting to a children's hospital. METHODS: All charts at a tertiary care children's hospital over a 1 year period with a diagnosis of wrist, forearm, radial or ulnar fracture were reviewed. Charts with a diagnosis of distal radius or ulna buckle fracture, confirmed by pediatric radiologist report, were further reviewed. A standardized data form was used to extract demographic information, presentation, initial and subsequent management, refracture, and fracture displacement. RESULTS: 324 patients were eligible for inclusion. 51.4% were male and mean age was 8.6 years (SD 3.9). 78%, 1%, and 21% had radial, ulnar, and both radial and ulnar fractures. All but 1(0.3%) patient presented to the ED for initial management and 89% of these were managed by the ED physician. 86% were casted and 14% were splinted. 30(11%) of casted patients revisited the ED for a cast complication, while only 1(2%) splinted patient had a repeat ED visit. 93% had follow-up with an orthopedic clinic: 35% had 1 visit and 65% had 2 follow-up visits. 58% had only an initial x-ray, 28% had 2 and 14% had 3 x-rays. 4(1%) patients had a refracture of the same bone within 6 months. 2(0.6%) were reported to have displacement on follow-up x-ray. Both of these patients were initially casted. Neither patient required a reduction and final outcomes were acceptable. CONCLUSIONS: In our population, the majority of patients have 2 follow-up orthopedic visits and many have multiple x-rays, yet <1% had subsequent fracture displacement. Patients treated with casts appeared to have more complications than those patients treated with a splint. Given the low risk of displacement and complications of these fractures it appears that routine orthopedic follow-up and x-rays may be unnecessary health care expenses. Key words: buckle fracture
034 Diagnostic Accuracy of Ultrasound and Computed Tomography for Emergency Department Diagnosis of Appendicitis: A systematic review
Turner TWS, Wiebe N, Cramer K, Hartling L, Klassen TP. Department of Pediatrics, University of Alberta, Edmonton, AB
INTRODUCTION Appendicitis is common, representing 5% of Emergency Department (ED) visits for abdominal pain, and can be difficult to diagnose clinically. Many adjunctive studies are used to confirm the diagnosis in the ED setting, including diagnostic imaging studies such as ultrasound (US) and computed tomography (CT). However, the diagnostic accuracy of US and CT in the ED setting has not been systematically examined. This study systematically reviews studies that examine the diagnostic accuracy of US and CT in acute appendicitis presenting to the ED, and describes the outcomes associated with the use of these tools. METHODS A systematic review of diagnostic studies was conducted, examining the sensitivity and specificity of US and CT for appendicitis. Secondary outcomes included cost and time spent in imaging. A comprehensive search strategy was employed, and inclusion criteria were applied independantly by two reviewers. Study quality was assessed using empirically evaluated measures. Data were extracted independently by two reviewers, and contingency tables were recreated where possible. RESULTS Thirteen studies were included. Twelve were U.S. based and 1 was Australian. All were cohort studies. Nine were prospective and 4 were retrospective chart reviews. All studies used differential verification: surgery and clinical follow-up. Prevalence of appendicitis in cohorts ranged from 19 to 79%. Fixed effects pooled sensitivities for US and CT were 62% (95% CI 58,65) and 89% (86,92) respectively. US sensitivity was heterogeneous (IQ 40,83%); specificities and CT sensitivity were not. US random effect estimates of positive and negative likelihood ratios (LR) were 4.9 (2.6,9.1) and 0.35 (0.22,0.57). CT estimates are 9.1 (4.5,18.3) and 0.10 (0.05,0.21). LR chi-square tests for heterogeneity are significant. When outliers are removed from CT estimates, the results are homogeneous. Outcomes of cost and time associated with testing are described. CONCLUSIONS Prevalence of appendicitis varies widely between studies, implying that referral patterns to diagnostic imaging vary. Quality of studies was variable. CT is homogeneous and accurate for both sensitivity and specificity; US shows significant heterogeneity for sensitivity. Further research is required regarding variable apparent disease prevalence, and to identify reasons for heterogeneity of US measurements. Standardized methods for quality assessment of studies of diagnostic tests require further development. Key words: appendicitis, diagnostic imaging, computed tomography
035 Practice Variation Among Pediatric Emergency Physicians in the Treatment of Bronchiolitis.
Plint AC, Johnson DW, Wiebe N, Bulloch B, Pusic M, Joubert G, Pianosi P, Turner T, Thompson G, Klassen TP. Department of Pediatrics, University of Ottawa, Ottawa, ON.
INTRODUCTION: Bronchiolitis is the most common disease of the lower respiratory tract in the 1st year of life. Treatment is controversial; RCTs give conflicting views on the benefits of bronchodilators and steroids. The objectives of this study were to describe: (1) management of bronchiolitis in pediatric emergency departments (EDs) in Canada, (2)patient outcomes, (3)bronchiolitis symptoms, medical history, previous treatment. METHOD: A prospective consecutive cohort of children with bronchiolitis presenting to 7 Canadian pediatric EDs was enrolled during a 1-3 week period in 2002. Standardized interviews of parents provided data regarding symptoms, previous treatment, and past history. Charts were reviewed for treatment, investigations, and disposition. Telephone follow-up at 2-3 weeks collected information regarding length of symptoms and return visits. RESULTS: 238/261 eligible patients were enrolled. 191 had interview and chart reviews; 48 only chart reviews. Follow-up completed for 167. Median age 5 months and 59% were male. On ED presentation, 11% had been prescribed bronchodilators, 2% steroids, and 24% antibiotics. 74% (ED range 59-100%) were treated in the ED with bronchodilators (usually salbutamol or epinephrine) and 5% (0-14%) with oral steroids. 25% were discharged on bronchodilators and 2% on oral steroids. Chi-square tests indicated significant practice variation in ED bronchodilator use (p<0.001) and bronchodilator use at discharge (p=0.001). Admission rate was 31% (23-43%). Viral studies were obtained in 52%; 76% were RSV+. 17% revisited the ED and 1% were admitted after 1st visit. Median length of cough was 7 days, wheeze 5 days, and difficulty breathing 3 days. CONCLUSIONS: Our findings are consistent with the literature for bronchodilator use but much lower for steroid use. Bronchodilator use in the ED and at discharge varied significantly by site. Our results capture variation in treatment practices in Canadian EDs which may be the result of discordant RCT evidence. Key words: bronchiolitis
036 Dexamethasone for the Treatment of Sore Throat in Children with Suspected Infectious Mononucleosis: A Double Blind, Randomized, Placebo Controlled Clinical Trial.
Roy M, Bailey B, Amre DK, Girodias JB, Bussieres JF, Gaudreault P. Division of Emergency Medicine, Department of Pediatrics, Hopital Ste-Justine, Montréal, Quebec.
INTRODUCTION: Steroids are used to treat upper airway obstruction (UAO) caused by infectious mononucleosis (IM). The efficacy of steroids to relieve pain associated with IM-induced sore throat in the absence of UAO is not known. METHODS: We conducted a randomized, double-blind, placebo-controlled, pediatric emergency department-based, outpatient clinical trial. Patients aged 8 to 18 years with sore throat from clinically suspected IM were eligible. Patients were randomized to receive either an oral dose of 0.3 mg/kg (max 15 mg) of dexamethasone (D) or placebo (P). Patients completed a diary of symptoms and rated their pain on a visual analog scale (0 to 100 mm) at time 0h, 12h, 24h, 48h, 72h and on day 7. An improvement of 20 mm from baseline in the VAS was used as the primary endpoint. RESULTS: Twenty patients were recruited in each group; mean age was 13.5 +/- 2.8 years. There were no differences between the study groups (D vs P) with respect to the duration of sore throat prior to presentation (median 4.5 vs 4.0 days, p=0.74), initial intensity of the sore throat (71.3 +/- 21.0 vs 69.0 +/- 16.0 mm, p=0.70), proportion of patients with a confirmed diagnosis of IM (16/20 vs 17/20, p=1.0) and proportion of patients with streptoccocus co-infection (13% vs 6%, p=0.60). In comparison with P, a significantly greater proportion of patients given D achieved pain relief within the first 12 hours (60% vs 26%, p=0.03). On further follow-up, the proportions achieving pain relief were similar among the groups: 55% vs 30% at 24h (p=0.10), 55% vs 55% at 48h (p=1.0), 75% vs 79% at 72h (p=0.93) and 95% vs 95% at day 7 (p = 1.0). There was no difference in the use of acetaminophen between the D and P groups (median 12.4 vs 35.6 mg/kg/day, p=0.24). CONCLUSION: The short-lived relief in pain of the acute exudative pharyngitis in children with suspected IM may suggest that a single oral dose of dexamethasone may not be sufficient and that additional doses may be necessary for insuring lasting relief. Key words: mononucleosis, corticosteroids
037 Parenteral Metoclopramide For Acute Migraine: A Systematic Review Of The Literature
Colman I, Brown MD, Innes G, Roberts T, Grafstein E, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB
INTRODUCTION: In addition to its anti-emetic properties when used to treat acute migraine headache, metoclopramide also appears to reduce headache pain. This systematic review was designed to determine the effectiveness of parenteral metoclopramide for episodes of acute migraine. METHODS: Randomized controlled trials were identified using MEDLINE, EMBASE, other computerized databases, hand searching, bibliographies, and contacts with industry and authors. Studies in which metoclopramide (alone or in combination with other agents) was compared to placebo or any other standard migraine therapy were considered. Relevance, inclusion, and study quality were assessed independently by two reviewers. RESULTS: From 479 potentially relevant abstracts, 14 trials met the inclusion criteria. Metoclopramide alone was compared to placebo in 5 studies; metoclopramide was more effective for significant pain reduction (odds ratio(OR) = 0.40, 95% confidence interval (95% CI): 0.22, 0.72). Metoclopramide alone was compared to other therapies in 5 studies; significant heterogeneity was present as metoclopramide was more effective than some therapies and less effective than others in reducing pain. In 7 combination treatment studies, metoclopramide administered in conjunction with other therapies was shown to be more effective than therapies without metoclopramide over several different outcomes, including complete resolution of migraine (OR=0.15, 95% CI: 0.04, 0.53), significant pain reduction (OR=0.31, 95% CI: 0.06, 1.51), and relapse of migraine (OR=0.25, 95% CI: 0.07, 0.94). CONCLUSIONS: Current evidence supports the use of metoclopramide as an effective treatment for migraine headache, particularly in combination with other therapies. Given its non-narcotic and anti-emetic properties, metoclopramide should be considered as a first-line agent in the treatment of acute migraines in the Emergency Department. Key words: migraine, metoclopramide
038 A Cellulitis Guideline at a Community Hospital ED: a 12 Month Prospective Study.
Burton-MacLeod R, Campbell SG, Howlett T. Department of Emergency Medicine, Dalhousie University, Halifax NS.
INTRODUCTION: Cellulitis is a common emergency department (ED) presentation, yet treatment remains unstandardized. The Nova Scotia Cellulitis Guidelines were piloted at a teaching hospital previously. We wanted to assess the safety and cost-effectiveness of the guideline in a community hospital setting. METHODS: A prospective study covering the period from November 2001-2002 was undertaken at the Dartmouth General Hospital. Physicians were asked to follow the guideline in the management of their cellulitis patients. Patients were contacted by telephone 5 days after their ED visit. Patients who did not report an improved condition at that point, were re-contacted at 10 days after presentation, in order to ascertain their outcome. Physician 'compliance' with the guideline was defined as following > 3/5 recommendations for antibiotic choice, dose, mode of administration, duration, and follow-up. RESULTS: Of the 272 patients, 147 (54.1%) were classified according to the guideline as Grade 1, 53 (19.5%) as Grade II, 33(12.1%) as Grade 3, and 6 (2.2%) as Grade IV. In 12.1% there was insufficient information on the patient chart to assign a Grade. 43.5% were treated in a manner that was considered 'compliant'. Of these 'compliance' cases, 83.3% reported an improved condition at 5 day follow-up, while 87.7% of the patients treated in a non-compliant manner reported an improved condition. At10 days, 98.8% of the 'compliance' patients and 94.7% of 'non-compliance' reported an improvement. 41 patients (20 and 21 in each group respectively) were lost to follow-up. Regarding antibiotic costs for Grades I-III, in 'compliance' patients average costs/patient were: Grade 1 $8.48, Grade II $16.65, Grade II $96.53. For 'non-compliance' patients the costs were $35.68, $51.28, and $150.18 respectively. CONCLUSIONS: Patients treated in accordance with the cellulitis algorithm had similar outcomes to those treated otherwise, at significantly lower cost. Further efforts to improve compliance are warranted. Key words: cellulitis, clinical practice guideline
039 Glucose-Insulin-Potassium for the Treatment of Acute Myocardial Infarction? A Systematic Review.
Diner BM, Blitz M, Knopp J, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB.
OBJECTIVE: The concept of metabolic protection in acute myocardial infarction (AMI) is not new and the use of glucose, insulin and potassium (GIK) for the treatment of AMI has been proposed. This systematic review evaluated the randomized controlled trial evidence for GIK in AMI. METHODS: A comprehensive search for trials was conducted using MEDLINE, EMBASE, bibliographies and author contacts. Studies were included if they involved treatment of AMI with intravenous (IV) GIK. Two reviewers performed selection, methodological quality, and data extraction independently. Sensitivity, sub-group and overall analyses were performed; for dichotomous variables, odds ratio (OR) with 95% confidence intervals (CI) were calculated and for continuous variables, weighted mean difference or standardized mean difference and 95% CI were calculated. RESULTS: The search yielded over 300 original publications from which 22 trials (4787 patients) were included. Overall, GIK does not appear to reduce mortality compared to placebo. GIK was not superior in preventing death compared to placebo when analyzed with random effects model but does show statistical significance when a fixed effects model is used (OR 0.78; 95% CI: 0.66, 0.93). High dose GIK appeared to decrease mortality (OR 0.57; 95% CI: 0.32, 0.99). The rate of arrhythmia or re-infarction was not reduced using GIK compared to placebo. Patients underwent re-vascularization procedures at similar rates in both groups. The NNT for GIK in AMI is 25 patients to prevent 1 death or 1 arrhythmia and 83 patients to prevent 1 re-infarction. CONCLUSION: GIK failed to demonstrate a clear statistical benefit in AMI; however, a favorable trend does exist. There is no difference in the rate of arrhythmia or re-infraction and at high doses; GIK in the treatment of AMI may decrease mortality. Large-scale studies are warranted to determine if GIK has value in addition to current therapy. Key words: myocardial infarction
040 Parenteral Dihydroergotamine (DHE) For Acute Migraine: A Systematic Review of the Literature
Colman I, Brown MD, Innes G, Grafstein E, Roberts T, Rowe BH. Division of Emergency Medicine, University of Alberta, Edmonton, AB
INTRODUCTION: Many therapies are used in the treatment of acute migraine headache with little agreement on which are most effective. This systematic review was designed to determine the effectiveness of parenteral DHE for episodes of acute migraine. METHODS: Randomized controlled trials were identified using MEDLINE, EMBASE, other computerized databases, hand searching, bibliographies, and contacts with industry and authors. Studies in which DHE (alone or in combination with an anti-emetic) was compared to placebo or any other standard migraine therapy were considered. Relevance, inclusion, and study quality were assessed independently by two reviewers. Studies were pooled using odds ratios (OR) or standardized mean differences (SMD) with 95% confidence intervals (CI). RESULTS: From 281 potentially relevant abstracts, 11 studies met the inclusion criteria. Solitary DHE use was compared to standard therapies in 3 studies; results failed to demonstrate a significant benefit of DHE over other therapies. In 8 combination treatment studies, DHE administered with an anti-emetic was more effective than other therapies in complete resolution of migraine (OR = 0.15; 95% CI: 0.04, 0.53), significant pain reduction (OR = 0.22; 95% CI: 0.03, 1.62), pain reduction on 10cm VAS scale (SMD = -0.30; 95% CI: -0.85, 0.25), improvement in functional ability (OR = 0.27; 95% CI: 0.13, 0.56), and relapse of migraine (OR = 0.46; 95% CI: 0.22, 0.97). There was significant heterogeneity among studies, likely due to the variation in comparison therapies used in trials. Overall, DHE was well tolerated and safe. CONCLUSIONS: This evidence suggests that DHE is not as effective as standard care as a single agent for treatment of acute migraine headache; however, when administered with an anti-emetic, DHE is more effective than comparison treatments. Given its low cost and non-narcotic properties, parenteral DHE should be considered as first-line therapy in clinical practice. Key words: migraine, dihydroergotamine
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