Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training

OBJECTIVES

Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium.

DESIGN

Open-label feasibility study.

SETTING

An academic tertiary care Canadian ED (annual visits 60 000).

PARTICIPANTS

Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year.

INTERVENTION

A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968).

RESULTS

Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications.

CONCLUSION

Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov #02892968.

Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department

INTRODUCTION

Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding.

METHODS AND ANALYSIS

This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule.

ETHICS AND DISSEMINATION

The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media.

TRIAL REGISTRATION NUMBER

NCT03745755.

Impact of a geriatric consultation service on outcomes in older trauma patients: a before-after study

PURPOSE

Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit.

METHODS

We completed a health records review of trauma unit patients, age ≥ 75 years old with Injury Severity Score (ISS) ≥ 12, before (11/2015-10/2017) and after (11/2017-10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken.

RESULTS

157 patients pre-implementation and 172 post-implementation with mean age 83.8 years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31-1.58)] or length of stay [ß 0.68 (95%CI - 1.35-2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24-3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively.

CONCLUSION

Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.

Rapid Fire: Acute Brain Failure in Older Emergency Department Patients

Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study

STUDY OBJECTIVE

We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope.

METHODS

This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes.

RESULTS

Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses.

CONCLUSION

Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.

Physician choices in pulmonary embolism testing

BACKGROUND

Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE.

METHODS

We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.

RESULTS

We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.

INTERPRETATION

Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.

The role of laboratories in animal-related disasters and emergencies

This paper outlines the role of laboratories in animal-health-related disasters and emergencies, with a particular focus on biological threats - intentional, accidental and natural. Whilst multisectoral coordination is increasingly recognised as necessary for effective preparedness and response to all kinds of disasters, the role of the laboratory is often overlooked. The laboratories' involvement, not just in the response, but across all phases of disaster management - mitigation, planning, response and recovery - is essential, not only for improved animal health but for preservation of livelihoods and for food security, social cohesion and economic stability.

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients

OBJECTIVE

This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians.

METHODS

We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement.

RESULTS

Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67.

DISCUSSION

This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers

BACKGROUND

delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients.

OBJECTIVES

to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients.

DESIGN

a prospective observational multicenter cohort study.

SETTING

four Quebec EDs.

PARTICIPANTS

independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation.

MEASUREMENTS

eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated.

RESULTS

we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%).

CONCLUSION

serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department

BACKGROUND

Geriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients.

METHODS

From June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care.

RESULTS

Eleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except Optimism). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients.

CONCLUSION

This study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.

Evaluation of an emergency department to outpatient parenteral antibiotic therapy program for cellulitis

OBJECTIVE

Emergency department (ED) patients with non-purulent skin and soft tissue infections (SSTIs) requiring intravenous antibiotics may be managed via outpatient parenteral antibiotic therapy (OPAT). Prospective studies describing the performance of an ED-to-OPAT clinic program are lacking. The primary objective was to determine the OPAT treatment failure rate for ED patients with non-purulent SSTIs.

METHODS

We conducted a prospective observational cohort study of adults with non-purulent SSTIs managed via an ED-to-OPAT clinic program. OPAT treatment failure was defined as hospitalization after a minimum of 48 h of OPAT for: worsening infection; intravenous line complications; or adverse antibiotic effects. Secondary outcomes were to describe OPAT clinic processes, patient satisfaction, and physician rationale for selecting intravenous antibiotics.

RESULTS

We enrolled a consecutive sample of 153 patients [mean age 60.5 years, 82 male (53.6%)]; 137 patients (89.5%) attended their clinic appointment. OPAT treatment failure was 4.4%. None of the adverse intravenous line (10.9%) and adverse antibiotic (8.0%) events required hospitalization. Patients reported high satisfaction with timeliness of referral (median score 9 out of 10) and overall care received (median score of 10). The top five reasons given by physicians for selecting intravenous therapy were: clinical impression (52.9%); failed oral therapy (41.8%); diabetes (17.6%); severe pain (7.8%); and peripheral vascular disease (7.8%).

CONCLUSIONS

This prospective study demonstrates that an ED-to-OPAT clinic program for non-purulent SSTIs is safe, has a low rate of treatment failures and results in high patient satisfaction. The rationale for selecting intravenous antibiotics showed significant variability among ED physicians.

Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-analysis

BACKGROUND

Dementia is underrecognized in older adult emergency department (ED) patients, which threatens operational efficiency, diagnostic accuracy, and patient satisfaction. The Society for Academic Emergency Medicine geriatric ED guidelines advocate dementia screening using validated instruments.

OBJECTIVES

The objective was to perform a systematic review and meta-analysis of the diagnostic accuracy of sufficiently brief screening instruments for dementia in geriatric ED patients. A secondary objective was to define an evidence-based pretest probability of dementia based on published research and then estimate disease thresholds at which dementia screening is most appropriate. This systematic review was registered with PROSPERO (CRD42017074855).

METHODS

PubMed, EMBASE, CINAHL, CENTRAL, DARE, and SCOPUS were searched. Studies in which ED patients ages 65 years or older for dementia were included if sufficient details to reconstruct 2 × 2 tables were reported. QUADAS-2 was used to assess study quality with meta-analysis reported if more than one study evaluated the same instrument against the same reference standard. Outcomes were sensitivity, specificity, and positive and negative likelihood ratios (LR+ and LR-). To identify test and treatment thresholds, we employed the Pauker-Kassirer method.

RESULTS

A total of 1,616 publications were identified, of which 16 underwent full text-review; nine studies were included with a weighted average dementia prevalence of 31% (range, 12%-43%). Eight studies used the Mini Mental Status Examination (MMSE) as the reference standard and the other study used the MMSE in conjunction with a geriatrician's neurocognitive evaluation. Blinding to the index test and/or reference standard was inadequate in four studies. Eight instruments were evaluated in 2,423 patients across four countries in Europe and North America. The Abbreviated Mental Test (AMT-4) most accurately ruled in dementia (LR+ = 7.69 [95% confidence interval {CI} = 3.45-17.10]) while the Brief Alzheimer's Screen most accurately ruled out dementia (LR- = 0.10 [95% CI = 0.02-0.28]). Using estimates of diagnostic accuracy for AMT-4 from this meta-analysis as one trigger for more comprehensive geriatric vulnerability assessments, ED dementia screening benefits patients when the prescreening probability of dementia is between 14 and 36%.

CONCLUSIONS

ED-based diagnostic research for dementia screening is limited to a few studies using an inadequate criterion standard with variable masking of interpreter's access to the index test and the criterion standard. Standardizing the geriatric ED cognitive assessment methods, measures, and nomenclature is necessary to reduce uncertainties about diagnostic accuracy, reliability, and relevance in this acute care setting. The AMT-4 is currently the most accurate ED screening instrument to increase the probability of dementia and the Brief Alzheimer's Screen is the most accurate to decrease the probability of dementia. Dementia screening as one marker of vulnerability to initiate comprehensive geriatric assessment is warranted based on test-treatment threshold calculations.

Predictors of Oral Antibiotic Treatment Failure for Nonpurulent Skin and Soft Tissue Infections in the Emergency Department

BACKGROUND

Current guideline recommendations for optimal management of nonpurulent skin and soft tissue infections (SSTIs) are based on expert consensus. There is a lack of evidence to guide emergency physicians regarding selection of patients for oral versus intravenous antibiotic therapy. The primary objective was to identify predictors associated with oral antibiotic treatment failure.

METHODS

We performed a health records review of adults (age ≥ 18 years) with nonpurulent SSTIs treated at two tertiary care emergency departments (EDs). Oral antibiotic treatment failure was defined as any of the following after a minimum of 48 hours of oral therapy due to worsening infection: 1) hospitalization, 2) change in class of oral antibiotic, or 3) switch to intravenous therapy. Multivariable logistic regression was used to identify predictors independently associated with oral antibiotic treatment failure.

RESULTS

We identified 500 patients (mean ± SD age = 64 ± 19 years, 279 male [55.8%], and 126 [25.2%] with diabetes). Of 288 patients who had received a minimum of 48 hours of oral antibiotics, there were 85 oral antibiotic treatment failures (29.5%). Tachypnea at triage (odds ratio [OR] = 6.31, 95% confidence interval [CI] = 1.80 to 22.08), chronic ulcers (OR = 4.90, 95% CI = 1.68-14.27), history of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection (OR = 4.83, 95% CI = 1.51 to 15.44), and cellulitis in the past 12 months (OR = 2.23, 95% CI = 1.01 to 4.96) were independently associated with oral antibiotic treatment failure CONCLUSION: This is the first study to evaluate predictors of oral antibiotic treatment failure for nonpurulent SSTIs treated in the ED. Tachypnea at triage, chronic ulcers, history of MRSA colonization or infection, and cellulitis within the past year were independently associated with oral antibiotic treatment failure. Emergency physicians should consider these risk factors when deciding on oral versus intravenous antimicrobial therapy for outpatient management of nonpurulent SSTIs.

Heart failure and palliative care in the emergency department

OBJECTIVES

Heart failure is a common ED presentation that is underserved by palliative care services and is associated with significant morbidity and mortality. We sought to evaluate use of palliative care services in patients with heart failure presenting to the ED. The primary outcome studied was palliative care involvement. Secondary outcomes of the study were: (1) 1-year mortality, (2) ED visits, (3) hospital admissions and (4) heart failure clinic involvement.

METHODS

We conducted a health records review of 500 patients with heart failure who presented to two Canadian academic hospital EDs from January to August 2013.

RESULTS

Patients were of mean age 80.7 years, women (53.2%) and had significant comorbidities. Only 41% of all deceased patients at 1 year had any palliative care involvement. Of those with palliative care, 44 (76%) patients had less than 2 weeks of palliative care involvement prior to death. Compared with those with no palliative care, the 79 (15.8%) patients with palliative care involvement had a higher 1-year mortality rate (70.9% vs 18.8%) and more hospital admissions/year (1.4 vs 0.85) for heart failure.

CONCLUSIONS

We found that few patients with heart failure had palliative care services. Additionally, the majority of those who have palliative care involvement do not meet current recommendations for early palliative care involvement in heart failure. This study suggests that the ED may be an appropriate setting to identify and refer high-risk patients with heart failure who could benefit from earlier palliative care involvement.

Emergency Department Stay Associated Delirium in Older Patients

BACKGROUND

Caring for older patients can be challenging in the Emergency Department (ED). A > 12 hr ED stay could lead to incident episodes of delirium in those patients. The aim of this study was to assess the incidence and impacts of ED-stay associated delirium.

METHODS

A historical cohort of patients who presented to a Canadian ED in 2009 and 2011 was randomly constituted. Included patients were aged ≥ 65 years old, admitted to any hospital ward, non-delirious upon arrival and had at least a 12-hour ED stay. Delirium was detected using a modified chart-based Confusion Assessment Method (CAM) tool. Hospital length of stay (LOS) was log-transformed and linear regression assessed differences between groups. Adjustments were made for age and comorbidity profile.

RESULTS

200 records were reviewed, 55.5% were female, median age was 78.9 yrs (SD:7.3). 36(18%) patients experienced ED-stay associated delirium. Nearly 50% of episodes started in the ED and within 36 hours of arrival. Comorbidity profile was similar between the positive CAM group and the negative CAM group. Mean adjusted hospital LOS were 20.5 days and 11.9 days respectively (p<.03).

CONCLUSIONS

1 older adult out of 5 became delirious after a 12 hr ED stay. Since delirium increases hospital LOS by more than a week, better screening and implementation of preventing measures for delirium could reduce LOS and overcrowding in the ED.

Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†

Background

there is no standardised test for assessing mobility in the Emergency Department (ED).

Objective

we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma.

Methods

this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated.

Results

TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5).

Conclusion

in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.

Prospective Validation of the Ottawa 3DY Scale by Geriatric Emergency Management Nurses to Identify Impaired Cognition in Older Emergency Department Patients

STUDY OBJECTIVE

Assessment of older emergency department (ED) patients with cognitive impairment is challenging because few tools exist that can be quickly administered by front-line practitioners. Our objective is to validate the Ottawa 3DY Scale, a 4-question screening tool for cognitive impairment, in older ED patients and compare its performance with that of the Animal Fluency Test.

METHODS

We conducted a prospective cohort study in 2 EDs and enrolled a convenience sample of patients aged 75 years or older with no history of cognitive impairment. Eligible patients were assessed by geriatric emergency management nurses who administered the Mini-Mental State Examination, ordered with the Ottawa 3DY Scale questions first, followed by the Animal Fluency Test. Mini-Mental State Examination score less than 25 was our criterion standard for cognitive impairment.

RESULTS

Study patients (N=238) had a mean age of 81.9 years and were 60.1% women, and 26.5% were admitted to the hospital. The Ottawa 3DY Scale and Mini-Mental State Examination were in agreement for 75.6% of cases, with a sensitivity of 93.8% (95% confidence interval [CI] 77.8% to 98.9%) and specificity of 72.8% (95% CI 66.1% to 78.7%). The Animal Fluency Test score less than 15 and Mini-Mental State Examination score were in agreement for 46.2% of cases, with sensitivity 90.6% (95% CI 73.8% to 97.5%) and specificity 39.3% (95% CI 32.7% to 46.4%).

CONCLUSION

Both the Ottawa 3DY Scale and the Animal Fluency Test demonstrated excellent sensitivity versus the Mini-Mental State Examination; however, the Animal Fluency Test exhibited poor specificity. The Ottawa 3DY Scale is an effective tool to screen for cognitive impairment in older ED patients, and its use may facilitate improved care in this vulnerable population.

Modelling spatio-temporal patterns of long-distance Culicoides dispersal into northern Australia

Novel arboviruses, including new serotypes of bluetongue virus, are isolated intermittently from cattle and insects in northern Australia. These viruses are thought to be introduced via windborne dispersal of Culicoides from neighbouring land masses to the north. We used the HYSPLIT particle dispersal model to simulate the spatio-temporal patterns of Culicoides dispersal into northern Australia from nine putative source sites across Indonesia, Timor-Leste and Papua New Guinea. Simulated dispersal was found to be possible from each site, with the islands of Timor and Sumba highlighted as the likely principal sources and February the predominant month of dispersal. The results of this study define the likely spatial extent of the source and arrival regions, the relative frequency of dispersal from the putative sources and the temporal nature of seasonal winds from source sites into arrival regions. Importantly, the methodology and results may be applicable to other insect and pathogen incursions into northern Australia.

Evaluation of long-distance dispersal of Culicoides midges into northern Australia using a migration model

The introduction of novel bluetongue serotypes and genotypes into northern Australia is considered possible via the long-distance windborne dispersal of Culicoides (Diptera: Ceratopogonidae) vectors from Southeast Asia. Initial findings from simulation modelling of potential dispersal over a 15-year period revealed that the greatest risk for incursion of windborne Culicoides from the island of Timor into northern Australia occurs during December-March. The regions at greatest risk for incursion include the top end of the Northern Territory and the Kimberley region in Western Australia, but there is potential for more widespread dispersal into northern Australia based on Timor as the putative source. The establishment of a more pathogenic strain of the virus, or of a novel Culicoides vector introduced by such inter-continental dispersal events, could dramatically alter Australia's current bluetongue disease status.

Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries

Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.

H5N1 highly pathogenic avian influenza in Southeast Asia

Since the first H5N1 highly pathogenic avian influenza virus (HPAIV) infection in the region in August 2003, Cambodia, Laos, Malaysia, Myanmar, Indonesia, Thailand and Vietnam have all recorded outbreaks of the disease. The HPAIV continues to occur in some countries in Southeast Asia despite control programmes encompassing surveillance, vaccination and stamping out strategies. A number of strains have been circulating in the region since the first outbreaks in 2003, and although the source of the initial outbreaks in domestic poultry is not known, the continuing propagation of disease in the region is primarily the result of the movement of domestic poultry and poultry products, and people. A comprehensive approach using all the strategies available to break the chain of transmission of the virus in poultry will be needed to achieve lasting disease control.