2005 CAEP / ACMU Scientific Abstracts - Poster Presentations: 100-116
2005 Scientific Abstracts
May 29 - June 1, 2005
Disclaimer: The large number of abstracts submitted and the short time interval between submission and publication does not permit communication with authors, abstract revision, or 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.
Avertissement : Le grand nombre de résumé soumis et le court délai entre leur réception et la date de publication on empêché la communication avec les auteurs, la révision des résumés, ou l'évaluation par le comité de réduction du JCMU. Les résumés qui suivent sont présentés non édités, tel qu'ils ont été soumis au Comité de Recherche de l'ACMU. Les auteurs des résumés sont rattachés au département de médecine d'urgence de leur université respective, sauf indication contraire.
indices: author index | keyword index
Temporal changes in vaccine uptake of an ED-based pneumococcal and influenza vaccination program for unprotected high-risk patients.
Lang E, Leger R, Colacone A, Xue X, Guttman A, Pearson E, Afilalo M. Sir Mortimer B Davis Jewish General Hospital-McGill University, Montreal, QC
INTRODUCTION: Uncertainty exists regarding the utility of an ED-based vaccination program. This study examines temporal changes (2001-2003) of vaccine uptake in an ED-based pneumococcal (PVX) and influenza vaccination (FLUVX) program. METHODS: Design: Multi-phased cross-sectional study. Setting: Tertiary-care academic center. Participants: Patients presenting to the ED, eligible to receive either FLUVX or PVX and who did not plan on being vaccinated elsewhere. Study phases: Weekdays from 10:00 to 18:00. Phase #1: Nov. 1 to Nov. 30, 2001. Phase #2: Nov. 3, 2003 to Jan. 31, 2004. Participants answered a questionnaire that examined vaccination history and attitudes towards vaccination. Consenting patients were then vaccinated by a dedicated vaccination nurse. RESULTS: The study periods differed in length (4 vs. 12 weeks). The average weekly number of patients screened was comparable during the two phases (2092 vs. 2246). The 2001 phase identified a weekly average of 140 patients eligible for either the PVX or FLUVX; this number fell to 58 in 2003. During the 2001 phase, the program vaccinated 46 pts/wk corresponding to a 33% uptake rate. In 2003, 13 pts/week received the FLUVX representing 22% uptake (p < 0.001 for both). As for PVX, the 2001 phase vaccinated 41 pts/week representing a 29% uptake. This fell to 10 pts/wk in 2003 or 18% uptake (p < 0.001 for both). In both phases, the main reason for vaccination refusal was the patients' perception that the vaccines were not required (37% vs. 33%). CONCLUSIONS: We observed a multifactorial decline in vaccine uptake between 2001 and 2003 related to expanded community-based outreach and a perceived lack of efficacy associated with the 2003 FLUVX. Despite lower uptake in 2003, there remain high-risk unvaccinated patients who would benefit from these interventions. Future research evaluating the cost-benefit of an ED-based vaccination protocol is warranted. Key words: emergency medicine; vaccination; influenza; pneumonia
SAVETIME: 24/7 Emergency Telehealth consult service at Calgary's tertiary care emergency departments.
Jordan VL, Curry G, McCarthy M, Keenan C, Cleary M. Department of Emergency Medicine, Calgary Health Region, Calgary, AB
INTRODUCTION: The "Southern Alberta Access to Vital E-Services Telehealth Initiative for Medical Emergencies" (SAVETIME) was developed as an innovative new service designed to link rural physicians by videoconference to emergency physicians in an urban tertiary center. Real time 24/7 remote assessment by consultant physicians, located in urban adult and pediatric emergency departments, has facilitated decision making for rural emergency patients. METHODS: A successful government grant application supported the project team. In November 2003, a needs assessment was performed with rural physicians and a multi-disciplinary working group was created. A process was developed where rural physicians were connected with Calgary emergency physicians for Telehealth consultation using a preexistent urgent referral line as first point of contact. Telehealth equipment and cameras were purchased and installed in both an urban adult and pediatric emergency department. At the rural sites, Telehealth equipment also included a document camera for the transmission of X-rays, ECGs and other documents. Staff in eight rural EDs and two urban EDs were trained to use the system. Formal midterm and final evaluations were conducted using questionnaires or telephone follow up. RESULTS: From February 2004 to January 2005, 46 consults have been completed. The top four types of consults were adult orthopedic (16), followed by pediatric orthopedic (10), general pediatric (7) and plastic surgery (6) cases. Use of the service by rural physicians has increased over time. Transport into Calgary for further assessment was avoided in the majority of cases. The average consult took 10 minutes. CONCLUSIONS: Emergency Telehealth consults are possible, useful and improve patient access to Tertiary care. The service has been well accepted and appreciated by the rural physicians. Key words: telehealth; emergency medicine; rural medicine
Injury / Trauma
Visits by youth to Toronto emergency departments due to injuries caused by violence.
Snider CS. Division of Emergency Medicine, University of Toronto, Toronto, ON
INTRODUCTION: Youth violence is of significant public concern. Youth are increasingly visiting Toronto emergency departments with injuries due to violence. To date, we do not have a clear understanding of the specific causes or nature of these injuries, or of how many injured youth leave hospitals directly from the emergency department. Previous studies have shown that victims of violence are more likely to become repeat victims of violence and are often perpetrators of future violence. Health care workers often discharge youths who have been injured due to violence from the emergency department with little to no violence prevention intervention. METHODS: An observational study was designed to determine the cause of injury, nature and demographics of the injured, and disposition of the patients aged 19 and under who presented to emergency departments with injuries that resulted from violence during a period of two years (April 2002-March 2004). Data was collected and analyzed from the National Ambulatory Care Reporting System (NACRS) database. RESULTS: A total of 4622 patients aged 19 and under who incurred injuries due to violence visited Toronto emergency departments during the period of this study. Assault or homicide due to bodily force (vs. sharp objects, guns or other) was the most common cause of injury due to violence (62%) [95% CI 60-64%]. Patients aged 15-19 accounted for 76% of the injuries [95% CI 75-77%]. Males accounted for the majority (72% [95% CI 71-73%]) of victims. Most patients (90% [95% CI 89-91%]) were discharged directly from the emergency department. CONCLUSIONS: Males aged 15-19 who have been assaulted by bodily force form the most common group of youth incurring injuries due to violence who visit Toronto Emergency Departments. A large proportion (90%) of these youth are discharged directly from emergency departments. Given victims often become repeat victims or future perpetrators, an opportunity exists for the development of youth violence prevention initiatives in emergency departments. Key words: trauma; adolescents; epidemiology
Documentation of substance problems in Canadian trauma patients.
Cowie SE, Brubacher JR, Lee D, Lee SK, Simons R. Resident, Department of Surgery, Vancouver General Hospital and University of British Columbia, Vancouver, BC
INTRODUCTION: Substance abuse is an important risk factor for preventable injury. Substance problems in Canadian trauma patients are not well documented. We investigated rates of documented substance abuse in a Canadian trauma population. METHODS: Trained evaluators using explicit criteria reviewed sequential charts of patients admitted to a Canadian tertiary care trauma service from 01/04/2002 to 31/03/2003. Documentation of substance problems was linked with trauma registry data (ethanol levels (BAL), age, ISS, and length of stay [LOS]). RESULTS: 289 patients met inclusion criteria and 274 (95%) charts were reviewed. Of these, 95 (34.7%: 95% CI = 29.0%-40.6%) "positive" patients had at least one of BAL > 0, CAGE >1, or substance abuse recorded in the chart and 179 (65.3%: 95% CI = 59.4%-71.0%) "negative" patients did not. The (mean/SD/median) ISS was 24.6/15.1/22 for negative patients vs. 19.4/11.7/17 for positive patients (p = 0.004). There were 4/95 (4.2%: 95% CI = 1.2%-10.4%) deaths in positive patients and 12/179 (6.7%: 95% CI = 3.5%-11.4%) in negative patients (p = 0.40). The mean/SD/median LOS (days) was 11.0/9.6/7 for surviving positive patients versus 18.7/21.2/10 for surviving negative patients (p = 0.001). The mean/SD/median age was 39.4/15.9/35 for positive patients vs. 43.7/20.7/40 for negative patients (p = .079). CONCLUSIONS: Substance problems are common in Canadian trauma patients. Substance positive patients were less severely injured, had a shorter length of stay and tended to be younger. Our data supports the need for programs designed to recognize and treat substance problems in trauma victims. Key words: substance abuse; trauma; ethanol
Feasibility of ED screening for trauma risk factors: Do major trauma patients visit the ED prior to sustaining major trauma?
Brubacher JR, Lee D, Purssell RA. Department of Emergency Medicine, Vancouver General Hospital and University of British Columbia, Vancouver, BC
INTRODUCTION: Risk factors for trauma might be identified and modified by ED based screening programs. We sought to determine how often major trauma victims visit the ED in the years preceding their injury. METHODS: The provincial trauma registry identified major trauma patients admitted to our hospital from 01/04/2002 till 31/03/2004. We searched our ED database visits between 01/01/1999 and 31/03/2004 and selected as cases patients who lived in Vancouver and could be linked to both databases. We selected as controls Vancouver patients visiting the ED on the first of each month from 01/04/2002 till 31/03/2004. We determined how many pts visited the ED prior to their index ED visit or trauma admission. RESULTS: During the study period there were 3012 trauma admissions for 2982 pts. 2543 pts could be linked to the ED database and 1473 cases lived in Vancouver. Most injuries (1311/1473) were accidental but 154 were intentional (29 self-inflicted, 125 assaults). Falls caused 891 injuries and MVCs caused 360. The mean ISS was 12.73, 107 pts died. Ages ranged from 14-102 years, 744 pts were female and 729 were male. BAC was measured in 505 pts and was positive in 150. Of the 1473 trauma pts, 619 (42.0% 95% CI = 39.5%-44.6%) visited the ED prior to their index event. This included 436/891 (48.9% 95% CI = 45.6%-52.3%) fall victims, 106/360 (29.4% 95% CI = 24.8%-34.5%) pts involved in MVCs, 65/198 (32.8% 95% CI = 26.3%-39.8%) drivers, 30/75 (40% 95% CI = 28.9%-52.0%) assault victims, and 41/122 (33.6% 95% CI = 25.1%-42.7%) pts with BAC > 17.5. There were 2619 controls: 1310 female and 1309 male. Age ranged from 12 to 101 years. Controls had a higher previsit rate than trauma pts (1361/2619 = 52.0% 95% CI = 50.0%-53.9%), p < 0.001. CONCLUSIONS: We found that 40% of major trauma pts had a prior ED visit. ED programs screening for trauma risk factors could have captured these patients. Trauma pts at our referral centre were less likely to previsit the ED than controls. Key words: trauma; self-injury; risk factors
Mechanisms of injury associated with vertebral column fractures and spinal cord injury in agricultural trauma.
Innes M, Brison R. Division of Emergency Medicine, University of Toronto, Toronto, ON
INTRODUCTION: The agricultural sector is considered to be one of the most dangerous industries in Canada. It is not uncommon for agriculture-related trauma to involve vertebral injuries, yet the mechanisms of these injuries have not been well described. Recognizing the mechanisms most commonly associated with vertebral injuries may assist in the development of interventions that will decrease the frequency of these injuries. The objectives of this study were to examine the most frequent mechanisms of injury for agriculture-related vertebral fractures and vertebral fractures accompanied by spinal cord injury, and to determine whether specific injury mechanisms are more commonly associated with either of these anatomic injury patterns. METHODS: We conducted a retrospective review of the Canadian Agricultural Injury Surveillance Program's hospitalization and fatality databases. We examined all cases of agricultural injuries from April 1990 to March 2000 in which the primary diagnosis or most serious injury was vertebral fracture. We compared the mechanisms of injury associated with cases of vertebral fracture alone to those associated with cases of vertebral fracture accompanied by spinal cord injury (SCI). RESULTS: 565 cases were identified. 108 (19.1%) involved spinal cord injury. Common mechanisms of injury were falls (from heights, machines, and animals) (49.9%) and being struck by objects (15.8%). Three mechanisms were more likely to be associated with spinal cord injury: being involved in a machine rollover, being run over by a machine, and becoming entangled in a machine. In general, machine-related mechanisms of injury were more likely to be associated with spinal cord injury. CONCLUSION: A focus on fall prevention may reduce the risk of vertebral fractures. A focus on the prevention of machine rollovers and entanglements may reduce the incidence of spinal cord injuries in the agricultural population. Key words: vertebral fractures; spinal cord injuries; prevention; etiology
What are the key features of minor head injury patients who present with GCS score 15 but go on to require neurological intervention?
Clement CM, Stiell IG, Schull M, Rowe BH, Brison R, Lee J, Wells GA, for the CCC Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON
INTRODUCTION: Emergency Physicians fear the rare minor head injury patients who present with a Glasgow Coma Scale score (GCS) 15, yet eventually require emergency craniotomy or other intervention. This study evaluated the unique features of these patients. METHODS: This prospective cohort study was conducted in 10 tertiary care EDs and involved adults who had suffered minor head injury and had initial ED GCS of 15. MDs conducted standardized assessments and completed data forms prior to imaging. Need for neurological intervention was defined as craniotomy, skull fracture elevation, intubation or ICP monitoring. Analyses included univariate association, kappa, odds ratio and 95% CIs. RESULTS: The 4,556 patients enrolled over 72 months had: mean age 38.1, important brain injury 5.2%, neurological intervention 0.7%. Table 1 (of Abstract 106) shows % of intervention (N = 31) and non-intervention (N = 4,525) patients. Patients requiring neurological intervention also had confusion (77%), amnesia (94%), and focal blow to head (45%). Those who deteriorated (55%) did so within 6 hours. CONCLUSIONS: Patients who deteriorate and require intervention after presenting with GCS 15 have findings that should alert physicians to their high risk, including suspected open skull fracture, basal skull fracture signs, drop in GCS, age 65, vomiting, and increasing confusion. Key words: clinical guidelines; head injury; minor head injury
|Findings||Interv / No int, %*||Kappa / O.R.||95% CI|
|Canadian CT Head Rule|
|GCS < 15 @ 2 hr||22.6 / 29.0||N/A / 0.7||0.3-1.6|
|Age 65 or older||38.7 / 10.3||0.62 / 5.5||2.6-11.4|
|Vomited 2 or more||35.5 / 9.7||0.94 / 5.1||2.4-10.8|
|Suspected open skull #||41.9 / 2.9||0.90 / 24.0||11.5-50.0|
|Signs of basal skull #||38.7 / 4.8||0.81 / 12.5||6.0-26.1|
|Amnesia before > 30 min||25.8 / 16.9||0.47 / 1.7||0.8-3.8|
|Dangerous mechanism||25.8 / 22.3||0.47 / 1.2||0.5-2.7|
|Witnessed LOC||64.5 / 48.2||0.79 / 1.8||0.9-3.7|
|Object recall < 3/3||52.2 / 34.5||0.68 / 2.1||0.9-4.6|
|Any drop in GCS||54.9 / 11.3||NA / 9.9||4.9-19.8|
|Mean age in years||54.4 / 37.9||N/A / -||-|
|*Unless otherwise indicated.|
Delivery of analgesics in the pre-hospital sporting environment.
Chahal AM, McLaren A, Brink B, Crickmer S, Mohr B, Oldring B, Rowe BH. Division of Emergency Medicine, University of British Columbia, Vancouver, BC
OBJECTIVES: Analgesia has long been an issue in the pre-hospital care of injured patients. Parenteral narcotics are fast acting and efficacious in relieving pain, but not without side effects (respiratory depression, hypotension, anaphylaxis, nausea). Our goal was to determine the use of analgesics for transported injured skiers assessed on Blackcomb Mountain (Whistler, BC). METHODS: This was a prospective observational study combined with a retrospective chart review. Our population included patients treated by the ski patrol during 01-04/04 who received treatment for acute pain. Subjects used a standardized 100 point visual-analog scale (VAS) to rate pain at start and end of transport as well as at the patient transfer center. The main outcome measured was change in pain scores (pre and post-treatment VAS). Diagnosis and additional treatment were collected retrospectively from the patient's emergency record. RESULTS: 2387 callouts were recorded of which 166 (7%) received analgesics. Overall, 98 winter sport enthusiasts were enrolled in the study; the mean age was 29.7, 58% were male. More boarders (53%) than skiers sustained injuries; 45% of enthusiasts had advanced level skills. The mean initial VAS was 61.7, mean final VAS was 38.8and mean VAS change was -22.9. Injuries included fractures (48%), sprains/contusions (22%), and dislocations (13%). Analgesics were administered in 62 patients, of whom 51 received IV narcotics. Patients who did not receive analgesics had less improvement in pain compared those who received analgesics (15.6 vs 57.6%; p < 0.01). There was a clear association between severity at the initial VAS score and the administration of analgesics. CONCLUSIONS: On-hill oligo-analgesia and sub-optimal pain relief for orthopedic injuries were observed. Pain scores predict use of intravenous narcotics; however, more data are required before other factors can be evaluated. This study will continue in 2005 and collect additional injury data. Key words: sports medicine; analgesia; prehospital; pain assessment; injuries
Reflective clothing use among cyclists and pedestrians.
Rizkallah JW, Lamy A, Belton K, Jhangri G, Willis V, Sevcik W, Rowe BH, Cherry N, Hagel B. Alberta Centre for Injury Control & Research, Department of Public Health Sciences, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB
INTRODUCTION: Cyclist and pedestrian injuries are a leading cause of injury-related morbidity and mortality. The purpose of this study was to determine the reliability of clothing visibility and other risk factor data collected on uninjured cyclists-pedestrians in Edmonton, AB. METHODS: This study was conducted from 06-08/04. Reflective clothing of uninjured cyclists-pedestrians was assessed at randomly selected locations by two independent observers. Observers noted cyclist-pedestrian characteristics such as age, sex, clothing color, use of reflectors, flags, helmets, and a subjective impression of overall visibility. Environmental conditions and a third visibility assessment were also recorded. RESULTS: Data were collected for 836 uninjured individuals; most were either walking/jogging (approximately 63%) or cycling (approximately 33%). For the entire sample, inter-rater agreement (Kappa) ranged from 0.61 (major leg colour) to 0.98 (sex) - substantial to almost perfect agreement. In addition, the prevalence of bright coloured clothing on the trunk ranged from 13.4%-15.1%, but fell to under 4% for the legs. Few people used any kind of reflective strips. Restricting the sample to cyclists, inter-rater agreement ranged from 0.35 (speed) to 0.95 (headgear) - fair to almost perfect agreement. The prevalence of helmet use was approximately 53%; 13-14% of headgear was brightly coloured, and 51-52% was white. Approximately one-fourth of the cyclists had a front light while half had a rear reflector. Few cyclists used a flag and 57% used spoke reflectors. CONCLUSIONS: There seems to be acceptable inter-observer reliability for data collection regarding cyclist visibility and reflective clothing. The results also indicate that the prevalence of visibility aid use among cyclists-pedestrians is far below optimal. Future research should determine the role of visibility in cyclist-pedestrian injury prevention. Key words: prevention; injuries; cycling
Triage tool inter-rater reliability using live cases vs. paper case scenarios.
Worster A, Sardo A, Fernandes CMB, Eva K, Upadhye S. Division of Emergency Medicine, McMaster University, Hamilton, ON
INTRODUCTION: Published studies of triage scale inter-rater reliability assessment have been conducted mostly using paper case scenarios. Our objective was to determine if this method of inter-rater reliability assessment generated significantly different measures from those generated from live triage cases. METHODS: This is a multi-center, prospective, observational cohort study of population-based random sample of patients triaged at 2 EDs during a 2-month period. All patients presenting to the ED within the study periods were simultaneously and independently triaged using a five-level triage acuity scale by two to three research triage nurses all blind to each other's assessment and to the study objective. Six months later, the same nurses were asked to assign triage scores to paper case scenarios of the same patients that they had each previously triaged. RESULTS: Each of the nine research nurses triaged approximately 90 cases. The inter-rater reliability as measured by an intra-class correlation coefficient was 0.9 (95% CI = 0.88, 91) for the live triage assessments and 0.76 (95% CI = 0.73, 0.79) for the paper case scenarios. The mean triage score assigned to the live cases (3.35, 95% CI = 3.25, 3.45) was significantly greater than that assigned to the paper based cases (3.17; 95% CI = 3.08, 3.26) (p < 0.001). CONCLUSIONS: There's moderate to high agreement between live cases vs. paper case scenarios and the inter-rater reliability, although significantly different, is acceptable in both cases. It is impossible to determine which triage setting provides a more accurate triage score but, in general, paper case scenarios receive lower triage scores than live cases. Key words: triage; triage tools; research methodology
Suicidal men and the emergency department: perspectives of providers regarding access and continuity of care.
Spence JM, Ball JS, Strike CS, Links PS, Bergmans Y, Rhodes AE, Watson WJ, Eynan R. St. Michael's Hospital, Division of Emergency Medicine, University of Toronto, Toronto, ON
INTRODUCTION: Using a qualitative research method, we explored the use of ED's in the mental health (MH) care of suicidal and substance-using men ages 15 to 45. ED service providers (EDP's)characterized their experiences and role in care. METHODS: Semi-structured interviews were conducted with physicians (n = 5), nurses (n = 5), and other ED staff including security, social and crisis workers (n = 7). Their average age was 40.3 years and 41.2% were male. Interviews were tape-recorded, transcribed verbatim and managed using N6. Transcripts were coded using an iterative process and memos prepared to capture emergent themes. RESULTS: Four major areas of concern were described. 1) Lack of continuity of care and collaboration among MH care providers within the ED, hospital, and community. High variability of care and lack of long term plans were discussed. Use of patient care conferences, protocols, and improved community funding were proposed solutions. 2) Location of ED based MH services. Issues of noise, integration with the general ED, lack of privacy and security were raised. Lengthy ED stays were felt to be detrimental for patient care and ED function. Suggestions for developing centralized, ED-based psychiatric units were made. 3) Lack of understanding of patient needs, and unmet needs by the ED. In contradistinction to other ED care, EDP felt patient needs were difficult to define and meet; they stated that for some, nothing could be done. They were frustrated when MH patients returned to the ED, but acknowledged visits may provide therapeutic benefit. 4) Lack of follow-up information for EDP. Staff requested patient follow-up, and worried about immediate and long-term outcomes. They failed to hear about their successes or whether interactions 'matter'. CONCLUSIONS: There is a need for improved continuity of care. EDPs perceive they have a role caring for MH patients, but feel they require specialized ED resources. EDPs request patient follow-up for this population. Key words: suicide; males; assessment; emergency medicine
Do ED triage nurses assign lower triage scores than indicated by the triage tool's criteria?
Worster A, Fernandes CMB, Eva K, Upadhye S. Division of Emergency Medicine, McMaster University, Hamilton, ON
INTRODUCTION: Down triaging by ED nurses is the process of ranking a patient's level of acuity at presentation lower than is indicated by the triage tool's criteria. This is hypothesized to occur in response to ED overcrowding when ED resources such as beds and monitors are severely limited or unavailable. METHODS: This is a multi-center, prospective, observational cohort study of population-based random sample of patients triaged at 2 EDs during a 2-month period. All patients presenting to the ED within the study periods were simultaneously and independently triaged using a five-level triage acuity scale by a triage nurse and two research triage nurses all blind to each other's assessment and to the study objective. RESULTS: The mean triage levels assigned by the triage nurses and by the research triage nurses for the 271 patients were 3.35 (95% CI: 3.24, 3.46) and 3.35 (95% CI: 3.25, 3.45) respectively (p = 0.95). The correlation of the triage level assignment between the two groups was r = 0.71 (95% CI: 0.63, 0.79) and the number down triaged by the triage nurses (49) was equal to the number up triaged (51). CONCLUSIONS: In this multi-center study of a population-based random sample of 271 patients triaged at 2 EDs we were unable to find any evidence that down triaging by ED nurses occurs. Key words: triage; triage tools; inter-observer agreement
Mental health patients have higher odds of admission to hospital than the general emergency department population.
Spence JM, Murray MJ. St. Michael's Hospital, Division of Emergency Medicine, University of Toronto, Toronto, ON
INTRODUCTION: Approximately 3% of visits emergency departments (EDs) are for patients with mental health (MH) complaints, although it is estimated that up to 30% of ED patients will have psychiatric disorders. However, there is little data describing MH triage decisions in North America. The objectives of this study were: 1) To review the demographics of MH patients presenting to a community hospital in Ontario. 2) To review systematic triage decisions for MH patients presenting to the ED using the nationally endorsed 5-level Canadian Emergency Department Triage and Acuity Scale (CTAS). METHODS: A retrospective analysis of ED visits from a community hospital for 1999 (N = 68,757) was conducted. Demographics were compared using t-test and chi square analysis. Odds ratios (OR) were defined using logistic regression. RESULTS: MH patients were older (39.3 vs. 33.1 years, p < 0.0001) and more likely to be female (51.1% vs. 48.9%, p = 0.0001). They more frequently arrived on evening and night shifts (56.6% vs. 61.7%, p < 0.0001) and during the week (75% vs. 69%, p < 0.0001). They had lower estimated incomes ($51,530 vs. $54,033, p < 0.0001). MH patients were more likely to be triaged to the higher acuity levels, CTAS 2 and 3, although none was triaged to the highest level (p < 0.0001). After adjusting for age, sex, and triage level (a marker of acuity) MH patients had a greater odds of admission than the general ED population, with an adjusted OR of 1.84 (95% confidence interval 1.66-2.04). CONCLUSIONS: MH patients have a higher likelihood of admission to hospital than the general ED population, even after adjusting for acuity. Key words: mental health; emergency medicine; epidemiology
A comparison of patterns of practice of gut decontamination by emergency physicians following toxic ingestion.
Norum JN, Blitz S, Rowe BH. Department of Emergency Medicine, University of Alberta, Edmonton, AB
INTRODUCTION: There is considerable controversy regarding the management of the poisoned patient, particularly with regard to methods of gut decontamination. This is largely due to the lack of high quality randomized controlled trial evidence in this area. As a result, wide variation in practice patterns is expected. Our objective was to identify factors associated with the choice of method of gut decontamination. METHODS: This is a multi-centre retrospective chart review conducted in Edmonton region hospitals. We report on a random sample of adult patients from one of the study sites. Dichotomous variables are analyzed with chi-square statistics and continuous variables are analyzed using the Wilcoxon test; p < 0.05 was considered significant. RESULTS: Of 106 charts reviewed at the University of Alberta Hospital from May 2003 to April 2004, the mean age of the patients was 34.5 years and 41% were male. The median time from ingestion to an emergency physician (EP) assessment was 2.5 hours. The most commonly ingested substances were antidepressants (40%), analgesics (26%), benzodiazepines (22%) and other sedatives (25%). Activated charcoal (AC) was used in 34% of all patients and was the only method of gut decontamination used; no gastric lavages were performed. 27 patients presented with a Glasgow Coma Scale (GCS) of 13 or less of which 37% were given AC (p = 0.34). There was no association between Canadian Triage Acuity Scale (CTAS) score and the use of AC (p = 0.75). The median time from ingestion to EP assessment was 2.3 hours for those given AC and 3.3 hours for those who were not (p = 0.004). CONCLUSIONS: CTAS score, initial GCS and ingested substance type do not appear to be associated with the use of AC as a decontamination method after toxic ingestion. The time from ingestion to EP assessment does seem to influence the use of AC. Future research will compare practice variation in methods and rates of decontamination used at different sites. Key words: intoxication; decontamination; activated charcoal
Emergency physician variation in the use of screening tests in suspected methanol and ethylene glycol toxicity.
Clark K, Gooch S, Purssell R, Abu-Laban RB, Brubacher J. Division of Emergency Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, BC
INTRODUCTION: Evidence-based criteria for managing suspected toxic alcohol exposure are lacking. We sought to determine the variation in the use of anion and osmolar gaps as screening tests for the diagnosis of methanol (Me) and ethylene glycol (EG) toxicity among Emergency Physicians (EPs) with different resources. METHODS: A survey was mailed to 400 British Columbia EPs with questions on clinical decision making in patients with suspected methanol (Me) or ethylene glycol (EG) exposure. Proportions and 95% confidence intervals were calculated using explicit criteria, and a series of logistic regression analyses, defined a priori, were fit to evaluate associations between hospital size and management decisions. RESULTS: EPs from 27 hospitals returned 10 (2.5%) partial and 99 (24.8%) complete surveys. Electrolytes could be measured in all hospitals, ethanol in 24/27 (88.9%) and serum osmolality in 22/27 (81.5%). The osmolar gap was used for management decisions by 94 (94.9%, 95% CI 88.6% to 98.3%) EPs, the anion gap by 81 (81.8%, 95% CI 72.8% to 88.9%) and arterial blood gases (ABG) by 67 (67.7, 95% CI 57.5% to 76.7%). EPs used 6 different formulae for osmolar gap and 5 for anion gap. Osmole gap cutoffs ranging from 0 to >20 were used to determine need for measuring Me or EG levels by 68 (68.7%) physicians, safety for discharge by 28 (28.3%), need for an antidote by 34 (34.3%) and need for dialysis by 24 (24.2%). Logistic regression analyses indicated trends that EPs in small/medium hospitals were more likely to order ABGs (p = 0.065) and to use the osmolar gap to decide if patients needed dialysis (p = 0.079) or antidote therapy (p = 0.265). CONCLUSIONS: This prospective descriptive study suggests there is substantial variability in EPs use of anion and osmolar gap as screening tests in patients with suspected toxic alcohol exposure. EPs would benefit from evidence-based guidelines for this potentially lethal poisoning. Key words: toxicology; methanol; evaluation; anion gap; osmolar gap
A pilot study to compare a short alcohol withdrawal assessment tool (HOST) to the validated clinical institute withdrawal assessment (CIWA-Ar).
Borgundvaag B, Kahan M, Gray S, Randall I. Division of Family and Community Medicine, University of Toronto, Toronto ,ON
INTRODUCTION: In previous work we demonstrated significant variability in ED management of alcohol withdrawal, higher complication rates associated with lower doses of benzodiazepines, and an average length of stay of 9.6 hours. A standardized, symptom-triggered approach to the management of alcohol withdrawal is more effective and efficient than scheduled dosing, yet the only validated tool for this purpose (CIWA-Ar) is cumbersome and not commonly used in the ED. The purpose of this pilot study was to compare a new, simplified tool (HOST) with the CIWA-Ar. METHODS: We conducted a prospective observational study comparing the HOST and the CIWA-Ar for patients in alcohol withdrawal. HOST assesses 4 symptoms (Hallucinations, Orientation, Sweating and Tremor) and assigns a total score between 0 (no withdrawal) and 10 (severe withdrawal). Emergency department staff identified patients in alcohol withdrawal, and study personnel obtained informed consent. Following baseline assessment of recent alcohol and drug use (to determine study eligibility), independent, blinded assessors administered the HOST and the CIWA-Ar immediately following each other. The Chi-square test was used to compare the proportion of individuals each tool suggested required additional treatment, and Student's t-test was used to compare means. RESULTS: Forty-one assessments were performed on 38 individual patients (mean age 52 years, 78% were male). The average BAL at presentation (for those in whom it was positive) was 46 mmol/L. The average time between blood work and withdrawal severity assessment in these patients was 6.6 hrs. The mean HOST and CIWA-Ar scores were 2.4 and 13.8 respectively. We found no statistical difference in the number of patients identified for additional treatment using either tool (n = 33 HOST, n = 29 CIWA-Ar.) The HOST was significantly faster to administer than the CIWA-Ar (mean 1.5 min vs. 5.7 min p < 0.0001). CONCLUSIONS: The HOST shows promise for assessing severity of alcohol withdrawal. Key words: ethanol; alcohol withdrawal; evaluation
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