BACKGROUND Acute asthma is a common ED presentation. In a prospective, multicenter cohort study, we determined the frequency and factors associated with asthma relapse following discharge from the ...ED. METHODS Adults aged 18 to 55 years who were treated for acute asthma and discharged from 20 Canadian EDs underwent a structured ED interview and a follow-up telephone interview 4 weeks later. Standardized antiinflammatory treatment was offered at discharge. Multivariable analyses were performed. RESULTS Of 807 enrolled patients, 58% were women, and the median age was 30 years. Relapse occurred in 144 patients (18%) within 4 weeks of ED discharge. Factors independently associated with relapse occurrence were female sex (women, 22% vs men, 12%; adjusted OR aOR, 1.9; 95% CI, 1.2-3.0); symptom duration of ≥ 24 h prior to ED visit (long duration, 19% vs short duration, 13%; aOR, 1.7; 95% CI, 1.3-2.3); ever using oral corticosteroids (ever use, 21% vs never use, 12%; aOR, 1.5; 95% CI, 1.1-2.0); current use of an inhaled corticosteroid (ICS/long-acting β-agonist combination product (combination product, 25% vs ICS monotherapy,15%; aOR, 1.9; 95% CI, 1.1-3.2); and owning a spacer device (owning one, 24% vs not owning one, 15%; aOR, 1.6; 95% CI, 1.3-1.9). CONCLUSIONS Despite receiving guideline-concordant antiinflammatory treatments at ED discharge, almost one in five patients relapsed within 4 weeks. Female sex, prolonged symptoms, treatment-related factors, and markers of prior asthma severity were significantly associated with relapse. These results may help physicians target more aggressive interventions for patients at high risk of relapse.
Abstract Objective Overcrowding is an important issue facing many emergency departments (EDs). Access block (admitted patients occupying ED stretchers) is a leading contributor, and expeditious ...placement of admitted patients is an area of research interest. This review examined the effectiveness of full capacity protocols (FCPs) on mitigating ED overcrowding. Methods A comprehensive literature search was undertaken to identify potentially relevant studies between 1966 and 2009. Intervention studies in which an FCP was used to influence ED/hospital length of stay and ED/hospital access block were included as a single program or part of a systemwide intervention. Two reviewers independently assessed citation relevance, inclusion, study quality, and extracted data; because of limited data, pooling was not undertaken. Results From 14 446 potentially relevant studies, 2 abstracts from the same comparative study were included. From 29 studies on systemwide intervention, 4 contained an FCP component. The included study was a single-center ED study using a before-after design; its methodological quality was rated as weak. One of the abstracts reported that an FCP was associated with less ED length of stay (5-hour reduction) when compared with the comparison period; the other reported that an FCP decreased ED and hospital access block (28% and 37% reduction, respectively). The ED triggers, format, and implementation of FCP protocols varied widely. Conclusion Although FCPs may be a promising alternative for overcrowded EDs, the available evidence upon which to support implementation of an FCP is limited. Additional efforts are required to improve the outcome reporting of FCP research using high-quality research methods.
Abstract Purpose Evidence-based clinical practice guidelines (CPGs) for managing febrile neutropenia (FN) are widely available; however, the integration of guidelines into routine practice is often ...incomplete. This study evaluated the uptake and clinical impact of implementing an electronic CPG on the management and outcomes of patients presenting with FN at 4 urban emergency departments (ED). Methods A retrospective chart review over a 3-year period at 4 hospitals in Edmonton, Alberta, was performed. Potentially eligible patient visits were identified by searching the Ambulatory Care Classification System database using International Classification of Diseases, 10th Edition , codes and ED physician diagnoses of FN. ED patients with fever (>38°C at home or in ED) and neutropenia (white blood cell count of <1000 cells/mm3 or a neutrophil count of <500 cells/mm3 ) who received an ED diagnosis of FN were included. Results From 371 potential cases, 201 unique cases of FN were included. Overall, the electronic CPG was used in 76 (37.8%) of 201 patient visits; however, there were significant differences in CPG utilization between hospitals. Clinical practice guideline usage was greatest at the University of Alberta Hospital (57%). This finding correlated with a decrease in time from triage to first antibiotic by 1 hour compared to the 3 control hospitals (3.9 vs 4.9 hours, P = .022). Conclusions The electronic CPG is a useful clinical tool that can improve patient management in the ED, and strategies to increase its utilization in this and other regions should be pursued.
Abstract Objectives This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency ...departments (EDs). Methods All sites conducted a search of their electronic medical records using International Classification of Diseases, Tenth Revision, codes to identify ED visits for hypoglycemia between 2008 and 2010. Patient characteristics, demographics, ED management, ED resources and outcome are reported. Results A total of 1039 patients over the age of 17 years were included in the study; 347 (33.4%) were classified as type 1 diabetes and 692 (66.6%) were classified as type 2 diabetes. Type 2 diabetes patients were significantly older (73 vs. 49 years; p<0.0001) and had more chronic conditions recorded on their chart (all p<0.001). Most subjects arrived by ambulance, and triage scores revealed severe presentations in 39% of cases. Treatments for hypoglycemia were common (75.7%) during prehospital transport; 38.5% received intravenous glucose and 40.1% received glucagon. Hypoglycemia treatments in the ED included oral (76.8%), intravenous (29.6%) and continuous infusion (27.7%) of glucose. Diagnostic testing (81.9%) commonly included electrocardiograms (51.9%), chest radiography (37.5%) and head computed tomography scans (14.5%). Most patients (73.5%) were discharged; however, more subjects with type 2 diabetes required admission (30.3 vs. 8.8%). Discharge instructions were documented in only 55.5% of patients, and referral to diabetes services occurred in fewer than 20% of cases. Considerable variation existed in the management of hypoglycemia across EDs. Conclusions Patients with diabetes presenting to an ED with hypoglycemia consume considerable healthcare resources, and practice variation exists. Emergency departments should develop protocols for the management of hypoglycemia, with attention to discharge planning to reduce recurrence.
Abstract Background Sepsis is a potentially life-threatening condition that requires urgent management in an Emergency Department (ED). Evidence-based guidelines for managing sepsis have been ...developed; however, their integration into routine practice is often incomplete. Care maps may help clinicians meet guideline targets more often. Objectives To determine if electronic clinical practice guidelines (eCPGs) improve management of patients with severe sepsis and septic shock (SS/SS). Methods The impact of an eCPG on the management of patients presenting with SS/SS over a 3-year period at a tertiary care ED was evaluated using retrospective case-control design and chart review methods. Cases and controls, matched by age and sex, were chosen from an electronic database using physician sepsis diagnoses. Data were compared using McNemar tests or paired t -tests, as appropriate. Results Overall, 51 cases and controls were evaluated; the average age was 62 years, and 60% were male. eCPG patients were more likely to have a central venous pressure and central venous oxygen saturation measured; however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 h (63% vs. 41%; p = 0.03) and vasopressors (45% vs. 20%; p = 0.02) was more common in the eCPG group; however, use of corticosteroids and other interventions did not differ between the groups. Overall, survival was high and similar between groups. Conclusion A sepsis eCPG experienced variable use; however, physicians using the eCPG achieved more quality-of-care targets for SS/SS. Strategies to increase the utilization of eCPGs in Emergency Medicine seem warranted.
Abstract Introduction Some patients presenting to emergency departments (EDs) suffer from conditions requiring potentially painful treatment; procedural sedation and analgesia (PSA) are important ...components of their management. The purpose of this study was to determine the resources used during the administration of PSA. Methods This prospective observational study was conducted in a Canadian urban teaching center. Detailed data concerning the dosage of PSA medications, adverse events, and ED times for patients requiring PSA for treatment of fractures, reductions of joint dislocations, and cardioversion for atrial fibrillation were collected. Descriptive analyses included proportions, means with standard deviations, and medians with interquartile ranges. Results Of the 177 PSA cases considered for analysis, 69.5% were orthopedic manipulations and 30.5% were cardioversions. Propofol alone or combined with fentanyl was the commonest medication, and 27 minor adverse events were documented. The median number of staff used in each PSA was 4 (4, 4). The median time from triage to the start of the procedure was 175 minutes (98, 259). The median time from the end of monitoring to discharge was 186 minutes (104, 316). The median time from the start of PSA administration to the end of patient monitoring was 12 minutes for fractures/dislocations and 7 minutes for cardioversion. The total ED length of stay was 6.6 hours. Conclusion Procedural sedation and analgesia are potentially time-consuming interventions requiring the coordination of ED staff; delays in procedures represent opportunities to reduce ED overcrowding. Procedural sedation and analgesia guidelines may assist with standardization.
Abstract Objectives This retrospective chart audit examined the demographics, investigations, management and outcomes of adult patients with diabetes mellitus presenting to Canadian emergency ...departments (EDs). Methods All sites conducted a search of their electronic medical records using International Classification of Diseases, Tenth Revision, codes to identify ED visits for hypoglycemia between 2008 and 2010. Patient characteristics, demographics, ED management, ED resources and outcome are reported. Results A total of 1039 patients over the age of 17 years were included in the study; 347 (33.4%) were classified as type 1 diabetes and 692 (66.6%) were classified as type 2 diabetes. Type 2 diabetes patients were significantly older (73 vs. 49 years; p<0.0001) and had more chronic conditions recorded on their chart (all p<0.001). Most subjects arrived by ambulance, and triage scores revealed severe presentations in 39% of cases. Treatments for hypoglycemia were common (75.7%) during prehospital transport; 38.5% received intravenous glucose and 40.1% received glucagon. Hypoglycemia treatments in the ED included oral (76.8%), intravenous (29.6%) and continuous infusion (27.7%) of glucose. Diagnostic testing (81.9%) commonly included electrocardiograms (51.9%), chest radiography (37.5%) and head computed tomography scans (14.5%). Most patients (73.5%) were discharged; however, more subjects with type 2 diabetes required admission (30.3 vs. 8.8%). Discharge instructions were documented in only 55.5% of patients, and referral to diabetes services occurred in fewer than 20% of cases. Considerable variation existed in the management of hypoglycemia across EDs. Conclusions Patients with diabetes presenting to an ED with hypoglycemia consume considerable healthcare resources, and practice variation exists. Emergency departments should develop protocols for the management of hypoglycemia, with attention to discharge planning to reduce recurrence.
BACKGROUNDHeart failure (HF) exacerbations often relate to poor self-care. Education programs improve outcomes, but are resource-intensive. We developed a video-based educational intervention and ...evaluated it in patients with HF.METHODSCongestive Heart Failure Outreach Program of Education was a pragmatic multicenter randomized trial. We included subjects with HF if they were hospitalized, seen in the emergency department (ED), or high-risk outpatients, and randomized them to intervention or control. Intervention included a 20-minute video, supplementary booklet, and 3 bimonthly newsletters focusing on salt and fluid restriction, daily weights, and medications. Subjects watched the video and were encouraged to review it at home, along with the booklet/newsletters. Control subjects received the booklet only. The primary outcome was the difference in cardiovascular hospitalizations or ED visits between groups at 6 months. Secondary outcomes included clinical events and in-hospital days.RESULTSWe recruited 539 subjects from 22 centers in Canada and the United States. Baseline characteristics were similar in both groups: 64% were male and had a mean age of 66 (± 13) years, mean ejection fraction 31% (± 13.5), and 65% New York Heart Association Functional Classification III/IV. The primary outcome occurred in 57 subjects (21%) in the intervention group compared with 61 subjects (23%) in the control group (P = 0.66). There were no significant differences in prespecified secondary outcomes; however, death occurred in 18 subjects (7%) in the intervention group and 33 subjects (12%) in the control group (P = 0.03).CONCLUSIONVideo education on self-care did not reduce hospitalizations or ED visits in patients with HF. Of note, mortality was lower in the intervention group.
Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a common presentation to emergency departments (EDs); however, limited information exists about the management of this condition ...in nonurban locations. We sought to examine the diagnostic and treatment approaches for acute exacerbation of COPD in 3 rural EDs, and to determine levels of adherence to recommendations from the Canadian Thoracic Society (CTS) clinical practice guideline.
We conducted retrospective chart reviews to explore the management of patients who presented to 3 rural EDs for acute exacerbation of COPD in 2011. Data are reported as medians and interquartile ranges (IQRs) and proportions.
Over a 1-year period, 192 patients presented a total of 266 times with acute exacerbation of COPD. The median age was 68 (IQR 58-77) years, and 54.9% of the patients were women. Diagnostic testing included chest radiography in 65.0%, blood tests in 45.1%, electrocardiography in 33.5%, and arterial blood gas tests in 6.4%; only a few patients received pulmonary function testing. In the ED, 58.7% of patients were given a short-acting β-agonist, 48.9% a short-acting anticholinergic, 27.4% corticosteroids and 19.9% antibiotics. Overall, short-acting β-agonists (63.5%), anticholinergic agents (53.4%), corticosteroids (54.5%) and antibiotics (71.1%) were prescribed more commonly to discharged patients (p < 0.05 for all).
We found a low to moderate level of adherence to the CTS clinical practice guideline for the management of acute exacerbation of COPD in these rural EDs. Moreover, we identified gaps in both diagnostic and therapeutic care.
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