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McRae AD, Chartier LB, Atzema CL. Measuring and improving atrial fibrillation and flutter care in Canadian emergency departments. CAN J EMERG MED 2024; 26:293-294. [PMID: 38713359 DOI: 10.1007/s43678-024-00701-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Affiliation(s)
- Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, Cumming School of Medicine, Rm C231 Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Clare L Atzema
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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O'Rielly CM, Andruchow JE, McRae AD. Correction: External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. CAN J EMERG MED 2024; 26:366. [PMID: 38526842 DOI: 10.1007/s43678-024-00671-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Affiliation(s)
- Connor M O'Rielly
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - James E Andruchow
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada.
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Dunne CL, Cirone J, McRae AD, Blanchard I, Holroyd-Ledu J, Sauro K. Validation of ICD-10 codes for studying foreign body airway obstructions: A health administrative data cohort study. Resusc Plus 2023; 16:100479. [PMID: 37840908 PMCID: PMC10568271 DOI: 10.1016/j.resplu.2023.100479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Aim To validate a case definition for foreign body airway obstructions (FBAO) using International Classification of Diseases version 10 (ICD-10) codes to accurately identify patients in administrative health databases and improve reporting on this injury. Methods We identified prehospital patient encounters in Alberta, Canada between Jan 1, 2018 and Dec 31, 2021 by querying the provincial emergency medical services' (EMS) patient care records for FBAO-related presentations, EMS protocols, or treatments. We deterministically linked EMS patient encounters to data on emergency department visits and hospital admissions, which included ICD-10 codes. Two physicians independently reviewed encounters to determine true FBAO cases. We then calculated diagnostic accuracy measures (sensitivity, specificity, likelihood ratios) of various algorithms. Results We identified 3677 EMS patient encounters, 2121 were linked to hospital administrative databases. Of these encounters, 825 (38.9%) were true FBAO. The combination of two ICD-10 codes (T17 = foreign body in the respiratory tract or T18.0 = foreign body in the mouth) was the most specific algorithm (96.9% [95%CI 95.8-97.8%]), while the combination of all FBAO-related ICD-10 codes and R06.8 (other breathing abnormalities) was the most sensitive (75.0% [95%CI 71.9-78.0]). We identified an additional 453 (35.4%) FBAO cases not transported by EMS (due to death or transport refusal), and therefore not linked to the hospital administrative databases. Of these unlinked encounters, 44 (9.7%) cases resulted in the patient's death. Conclusions FBAO can be identified with reasonable accuracy using health administrative data and ICD-10 codes. All algorithms had a trade-off between sensitivity and specificity, and failed to identify a third of FBAO cases, of which 10% resulted in death.
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Affiliation(s)
- Cody L Dunne
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Julia Cirone
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ian Blanchard
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Emergency Medical Services, Alberta Health Services, AB, Canada
| | - Jayna Holroyd-Ledu
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Khara Sauro
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology & Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada
- Department of Surgery, University of Calgary, Calgary, AB, Canada
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Rosychuk RJ, Chen AA, Ospina MB, McRae AD, Hu XJ, McLane P. Transitions in health care settings for frequent and infrequent users of emergency departments: a population-based retrospective cohort study. BMC Health Serv Res 2023; 23:1250. [PMID: 37964274 PMCID: PMC10644485 DOI: 10.1186/s12913-023-10260-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 10/31/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Efforts to reduce emergency department (ED) volumes often target frequent users. We examined transitions in care across ED, hospital, and community settings, and in-hospital death, for high system users (HSUs) compared to controls. METHODS Population-based databases provided ED visits and hospitalizations in Alberta and Ontario, Canada. The retrospective cohort included the top 10% of all the ED users during 2015/2016 (termed HSUs) and a random sample of controls (4 per each HSU) from the bottom 90% per province. Rates of transitions among ED, hospitalization, community settings, and in-hospital mortality were adjusted for sociodemographic and ED variables in a multistate statistical model. RESULTS There were 2,684,924 patients and 579,230 (21.6%) were HSUs. Patient characteristics associated with shorter community to ED transition times for HSUs included Alberta residence (ratio of hazard ratio [RHR] = 1.11, 95% confidence interval [CI] 1.11,1.12), living in areas in the lower income quintile (RHR = 1.06, 95%CI 1.06,1.06), and Ontario residents without a primary health care provider (RHR = 1.13, 95%CI 1.13,1.14). Once at the ED, characteristics associated with shorter ED to hospital transition times for HSUs included higher acuity (e.g., RHR = 1.70, 95% CI 1.61, 1.81 for emergent), and for many diagnoses including chest pain (RHR = 1.71, 95%CI 1.65,1.76) and gastrointestinal (RHR = 1.66, 95%CI 1.62,1.71). Once admitted to hospital, HSUs did not necessarily have longer stays except for conditions such as chest pain (RHR = 0.90, 95% CI 0.86, 0.95). HSUs had shorter times to death in the ED if they presented for cancer (RHR = 2.51), congestive heart failure (RHR = 1.93), myocardial infarction (RHR = 1.53), and stroke (RHR = 1.84), and shorter times to death in-hospital if they presented with cancer (RHR = 1.29). CONCLUSIONS Differences between HSUs and controls in predictors of transitions among care settings were identified. Co-morbidities and limitations in access to primary care are associated with more rapid transitions from community to ED and hospital among HSUs. Interventions targeting these challenges may better serve patients across health systems.. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, T6G 1C9, Canada.
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada.
| | - Anqi A Chen
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Maria B Ospina
- Department of Public Health Sciences, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, T2N 4Z6, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Patrick McLane
- Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, AB, T5J 3E4, Canada
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, T6G 2R7, Canada
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McAlister FA, Hau JP, Atzema C, McRae AD, Morrison LJ, Grant L, Cheng I, Rosychuk RJ, Hohl CM. The burden of incidental SARS-CoV-2 infections in hospitalized patients across pandemic waves in Canada. Sci Rep 2023; 13:6635. [PMID: 37095174 PMCID: PMC10123574 DOI: 10.1038/s41598-023-33569-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023] Open
Abstract
Many health authorities differentiate hospitalizations in patients infected with SARS-CoV-2 as being "for COVID-19" (due to direct manifestations of SARS-CoV-2 infection) versus being an "incidental" finding in someone admitted for an unrelated condition. We conducted a retrospective cohort study of all SARS-CoV-2 infected patients hospitalized via 47 Canadian emergency departments, March 2020-July 2022 to determine whether hospitalizations with "incidental" SARS-CoV-2 infection are less of a burden to patients and the healthcare system. Using a priori standardized definitions applied to hospital discharge diagnoses in 14,290 patients, we characterized COVID-19 as (i) the "Direct" cause for the hospitalization (70%), (ii) a potential "Contributing" factor for the hospitalization (4%), or (iii) an "Incidental" finding that did not influence the need for admission (26%). The proportion of incidental SARS-CoV-2 infections rose from 10% in Wave 1 to 41% during the Omicron wave. Patients with COVID-19 as the direct cause of hospitalization exhibited significantly longer LOS (mean 13.8 versus 12.1 days), were more likely to require critical care (22% versus 11%), receive COVID-19-specific therapies (55% versus 19%), and die (17% versus 9%) compared to patients with Incidental SARS-CoV-2 infections. However, patients hospitalized with incidental SARS-CoV-2 infection still exhibited substantial morbidity/mortality and hospital resource use.
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Affiliation(s)
- Finlay A McAlister
- The Division of General Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-134C Clinical Sciences Building, 11350 83 Avenue, Edmonton, AB, T6G 2G3, Canada.
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Canada.
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Clare Atzema
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Laurie J Morrison
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Ivy Cheng
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
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Hudek N, Brehaut JC, Rowe BH, Nguyen PA, Ghaedi B, Ishimwe AC, Fabian C, Yan JW, Sivilotti MLA, Ohle R, Le Sage N, Mercier E, Archambault PM, Plourde M, Davis P, McRae AD, Hegdekar M, Thiruganasambandamoorthy V. Development of practice recommendations based on the Canadian Syncope Risk Score and identification of barriers and facilitators for implementation. CAN J EMERG MED 2023; 25:434-444. [PMID: 37058217 DOI: 10.1007/s43678-023-00498-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Wide variations in emergency department (ED) syncope management exist. The Canadian Syncope Risk Score (CSRS) was developed to predict the probability of 30-day serious outcomes after ED disposition. Study objectives were to evaluate the acceptability of proposed CSRS practice recommendations among providers and patients, and identify barriers and facilitators for CSRS use to guide disposition decisions. METHODS We conducted semi-structured interviews with 41 physicians involved in ED syncope and 35 ED patients with syncope. We used purposive sampling to ensure a variety of physician specialties and CSRS patient risk levels. Thematic analysis was completed by two independent coders with consensus meetings to resolve conflicts. Analysis proceeded in parallel with interviews until data saturation. RESULTS The majority (97.6%; 40/41) of physicians agreed with discharge of low risk (CSRS ≤ 0) but opined that 'no follow up' changed to 'follow-up as needed'. Physicians indicated current practices do not align with the medium-risk recommendation to discharge patients with 15-day monitoring (CSRS = 1-3; due to lack of access to monitors and timely follow-up) and the high-risk recommendation (CSRS ≥ 4) to potentially discharge patients with 15-day monitoring. Physicians recommended brief hospitalization of high-risk patients due to patient safety concerns. Facilitators included the CSRS-based patient education and scores supporting their clinical gestalt. Patients reported receiving varying levels of information regarding syncope and post-ED care, were satisfied with care received and preferred less resource intensive options. CONCLUSION Our recommendations based on the study results were: discharge of low-risk patients with physician follow-up as needed; discharge of medium-risk patients with 15-day cardiac monitoring and brief hospitalization of high-risk patients with 15-day cardiac monitoring if discharged. Patients preferred less resource intensive options, in line with CSRS recommended care. Implementation should leverage identified facilitators (e.g., patient education) and address the barriers (e.g., monitor access) to improve ED syncope care.
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Affiliation(s)
- Natasha Hudek
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | | | | | - Christopher Fabian
- Department of Emergency Medicine, The Montfort Hospital, Ottawa, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Robert Ohle
- Departments of Emergency Medicine, Health Science North, Sudbury, ON, Canada
- Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- VITAM-Centre de recherche en santé durable, Québec, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
| | - Patrick M Archambault
- Departments of Family Medicine and Emergency Medicine and Anesthesiology and Intensive Care Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Miville Plourde
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Family Medicine and Emergency Medicine, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program-Emergency Medicine, Department of Emergency Medicine, Clinical Epidemiology Unit, The Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, F6K1Y 4E9, Canada.
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O'Rielly CM, Harrison TG, Andruchow JE, Ronksley PE, Sajobi T, Robertson HL, Lorenzetti D, McRae AD. Risk Scores for Clinical Risk Stratification of Emergency Department Patients With Chest Pain but No Acute Myocardial Infarction: A Systematic Review. Can J Cardiol 2023; 39:304-310. [PMID: 36641050 DOI: 10.1016/j.cjca.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/11/2022] [Accepted: 12/11/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Chest pain is a common cause for emergency department (ED) presentations. After myocardial infarction (MI) has been ruled out by means of electrocardiography and troponin testing, decisions around anatomic or functional testing may be informed by clinical risk scores. We conducted a systematic review to synthesize evidence of the prognostic performance of chest pain risk scores among ED patients who have had MI ruled out by means of a high-sensitivity troponin assay. METHODS We queried multiple databases from inception to May 17, 2022. We included studies that quantified risk of 30-day major adverse cardiac events (MACE), at different cutoffs of clinical risk scores, among adult patients who had MI ruled out by means of a high-sensitivity troponin assay. Prognostic performance of each score was synthesized and described, but meta-analysis was not possible. RESULTS Six studies met inclusion criteria. Short-term MACE risk among patients who had MI ruled out by means of high-sensitivity cardiac troponin assays was very low. The HEART score, with a cutoff of 3 or less, predicted a very low risk of MACE among the greatest proportion of patients. Other scores had lower sensitivity or classified fewer patients as low risk. CONCLUSIONS The HEART score with a cutoff value of 3 or less accurately identified the greatest number of patients at low risk of 30-day MACE. However, MACE risk among patients who have MI ruled out by means of high-sensitivity troponin testing is sufficiently low that clinical risk stratification or noninvasive testing may be of little additional value in identifying patients with coronary disease.
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Affiliation(s)
- Connor M O'Rielly
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G Harrison
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James E Andruchow
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tolu Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Diane Lorenzetti
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Lin K, Xu K, Daoust R, Taylor J, Rosychuk RJ, Hau JP, Davis P, Clark G, McRae AD, Hohl CM. Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study. CAN J EMERG MED 2023; 25:134-142. [PMID: 36624252 PMCID: PMC9838465 DOI: 10.1007/s43678-022-00440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The primary objective was to quantify the prognostic association between various D-dimer thresholds and 30-day PE diagnosis among emergency department (ED) patients with suspected SARS-CoV-2 infection. METHODS This was a retrospective study of patients enrolled in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) registry from March 1, 2020 to July 2, 2021. We included consecutive adults (≥ 18 years) presenting to 49 EDs with chest pain, shortness of breath, hypoxia, syncope, presyncope, or hemoptysis who were tested for both SARS-CoV-2 and D-dimer at index ED visit. The primary outcome measure was the sensitivity, specificity, and negative predictive value of D-dimer test thresholds for the outcome of 30-day PE diagnosis. RESULTS Among 10,837 patients included in our study, 404 (3.7%) were diagnosed with PE at 30-days. A standard D-Dimer threshold of 500 ng/mL had a sensitivity of 97.8% (95% confidence interval [CI] 95.8-99.0%), specificity of 40.9% (95% CI 39.9-41.8%), and negative predictive value of 99.8% (95% CI 99.6-99.9%). An age-adjusted D-dimer threshold had a sensitivity of 96.0% (95% CI 93.6-97.7%), specificity of 48.5% (95% CI 47.5-49.4%), and negative predictive value of 99.7% (95% CI 99.5-99.8%). D-dimer testing had slightly lower prognostic performance among SARS-CoV-2 positive compared to SARS-CoV-2 negative patients in predicting 30-day PE diagnosis. CONCLUSIONS Among ED patients with suspected SARS-CoV-2, the standard 500 ng/mL and age-adjusted D-dimer thresholds were comparable for the prediction of PE at 30-days. The prognostic performance of D-dimer was lower among SARS-CoV-2 positive patients. TRIAL REGISTRATION Clinicaltrials.gov, NCT04702945.
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Affiliation(s)
- Katie Lin
- Department of Emergency Medicine, Room C231 Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada. .,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
| | - Ke Xu
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
| | - Raoul Daoust
- grid.14848.310000 0001 2292 3357Department of Family Medicine and Emergency Medicine, University of Montreal, Quebec, Canada
| | - John Taylor
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada
| | - Rhonda J. Rosychuk
- grid.17089.370000 0001 2190 316XDepartment of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Jeffrey P. Hau
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
| | - Phil Davis
- grid.25152.310000 0001 2154 235XDepartment of Emergency Medicine, University of Saskatchewan, Saskatoon, SK Canada
| | - Greg Clark
- grid.14709.3b0000 0004 1936 8649Department of Emergency Medicine, McGill University, Montreal, QC Canada
| | - Andrew D. McRae
- grid.22072.350000 0004 1936 7697Department of Emergency Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Corinne M. Hohl
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
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9
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Le Sage N, Chauny JM, Berthelot S, Archambault P, Neveu X, Moore L, Boucher V, Frenette J, De Guise É, Ouellet MC, Lee J, McRae AD, Lang E, Émond M, Mercier É, Tardif PA, Swaine B, Cameron P, Perry JJ. Post-Concussion Symptoms Rule: Derivation and Validation of a Clinical Decision Rule for Early Prediction of Persistent Symptoms after a Mild Traumatic Brain Injury. J Neurotrauma 2022; 39:1349-1362. [PMID: 35765917 PMCID: PMC9529302 DOI: 10.1089/neu.2022.0026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a common problem. Depending on diagnostic criteria, 13 to 62% of those patients develop persistent post-concussion symptoms (PPCS). The main objective of this prospective multi-center study is to derive and validate a clinical decision rule (CDR) for the early prediction of PPCS. Patients aged ≥14 years were included if they presented to one of our seven participating emergency departments (EDs) within 24 h of an mTBI. Clinical data were collected in the ED, and symptom evolution was assessed at 7, 30 and 90 days post-injury using the Rivermead Post-Concussion Questionnaire (RPQ). The primary outcome was PPCS at 90 days after mTBI. A predictive model called the Post-Concussion Symptoms Rule (PoCS Rule) was developed using the methodological standards for CDR. Of the 1083 analyzed patients (471 and 612 for the derivation and validation cohorts, respectively), 15.6% had PPCS. The final model included the following factors assessed in the ED: age, sex, history of prior TBI or mental health disorder, headache in ED, cervical sprain and hemorrhage on computed tomography. The 7-day follow-up identified additional risk factors: headaches, sleep disturbance, fatigue, sensitivity to light, and RPQ ≥21. The PoCS Rule had a sensitivity of 91.4% and 89.6%, a specificity of 53.8% and 44.7% and a negative predictive value of 97.2% and 95.8% in the derivation and validation cohorts, respectively. The PoCS Rule will help emergency physicians quickly stratify the risk of PPCS in mTBI patients and better plan post-discharge resources.
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Affiliation(s)
- Natalie Le Sage
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
- VITAM-Centre de recherche en santé durable, Université Laval, Québec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Simon Berthelot
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Patrick Archambault
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Xavier Neveu
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Jérôme Frenette
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Élaine De Guise
- Department of Emergency Medicine, McGill University, Québec, Canada
| | | | - Jacques Lee
- Department of Emergency Medicine, University of Toronto, Ontario, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Alberta, Canada
| | - Marcel Émond
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | - Éric Mercier
- CHU de Québec-Université Laval Research Centre, Université Laval, Québec, Canada
| | | | - Bonnie Swaine
- Department of Emergency Medicine, Université de Montréal, Quebec, Canada
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Jeffrey J. Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ontario, Canada
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10
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Davis P, Rosychuk R, Hau JP, Cheng I, McRae AD, Daoust R, Lang E, Turner J, Khangura J, Fok PT, Stachura M, Brar B, Hohl CM. Diagnostic yield of screening for SARS-CoV-2 among patients admitted to hospital for alternate diagnoses: an observational cohort study. BMJ Open 2022; 12:e057852. [PMID: 35948378 PMCID: PMC9378945 DOI: 10.1136/bmjopen-2021-057852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the diagnostic yield of screening patients for SARS-CoV-2 who were admitted with a diagnosis unrelated to COVID-19 and to identify risk factors for positive tests. DESIGN Cohort from the Canadian COVID-19 Emergency Department Rapid Response Network registry. SETTING 30 acute care hospitals across Canada. PARTICIPANTS Patients hospitalised for non-COVID-19-related diagnoses who were tested for SARS-CoV-2 between 1 March and 29 December 2020. MAIN OUTCOME Positive nucleic acid amplification test for SARS-CoV-2. OUTCOME MEASURE Diagnostic yield. RESULTS We enrolled 15 690 consecutive eligible adults who were admitted to hospital without clinically suspected COVID-19. Among these patients, 122 tested positive for COVID-19, resulting in a diagnostic yield of 0.8% (95% CI 0.64% to 0.92%). Factors associated with a positive test included presence of fever, being a healthcare worker, having a positive household contact or institutional exposure, and living in an area with higher 7-day average incident COVID-19 cases. CONCLUSIONS Universal screening of hospitalised patients for COVID-19 across two pandemic waves had a low diagnostic yield and should be informed by individual-level risk assessment in addition to regional COVID-19 prevalence. TRIAL REGISTRATION NUMBER NCT04702945.
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Affiliation(s)
- Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatchewan, Saskatoon, Canada
| | - Rhonda Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey P Hau
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ivy Cheng
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Emergency Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raoul Daoust
- Département Médecine de Famille et Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joel Turner
- Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada
| | - Jaspreet Khangura
- Department of Emergency Medicine, Northeast Community Health Centre, Edmonton, Alberta, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maja Stachura
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Baljeet Brar
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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11
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Hohl CM, McRae AD. Antiviral treatment for COVID-19: ensuring evidence is applicable to current circumstances. CMAJ 2022; 194:E996-E997. [PMID: 35878901 PMCID: PMC9328461 DOI: 10.1503/cmaj.221012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl), University of British Columbia; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC; Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta
| | - Andrew D McRae
- Department of Emergency Medicine (Hohl), University of British Columbia; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC; Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.
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12
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McRae AD, Archambault P, Fok P, Wiemer H, Morrison LJ, Herder M. Reducing barriers to accessing administrative data on SARS-CoV-2 vaccination for research. CMAJ 2022; 194:E943-E947. [PMID: 35851526 PMCID: PMC9299746 DOI: 10.1503/cmaj.211712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS.
| | - Patrick Archambault
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Patrick Fok
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Hana Wiemer
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Laurie J Morrison
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Matthew Herder
- Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Departments of Family Medicine, Emergency Medicine, Anesthesiology and Intensive Care Medicine (Archambault), Université Laval, Québec, Que.; Department of Emergency Medicine (Fok, Wiemer), Dalhousie University, Halifax, NS; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto; Health Law Institute (Herder), Schulich School of Law; Department of Pharmacology (Herder), Faculty of Medicine, Dalhousie University, Halifax, NS
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13
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Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Emergencias 2022; 34:64-65. [PMID: 35103445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Kenneth K Chan
- Department of Emergency Medicine, University of Calgary, Calgary, Canadá
| | - Daniel A Joo
- Department of Emergency Medicine, University of Calgary, Calgary, Canadá
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Canadá
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, RU
| | - Zahra A Premji
- Libraries and Cultural Resources, University of Calgary, Calgary, Canadá
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Canadá
| | - Abel Wakai
- Department of Emergency Medicine, Beaumont Hospital, Dublín, Irlanda
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14
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McRae AD, Rowe BH, Usman I, Lang ES, Innes GD, Schull MJ, Rosychuk R. A comparative evaluation of the strengths of association between different emergency department crowding metrics and repeat visits within 72 hours. CAN J EMERG MED 2022; 24:27-34. [PMID: 34921658 DOI: 10.1007/s43678-021-00234-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to compare strengths of association among multiple emergency department (ED) input, throughput and output metrics and the outcome of 72-h ED re-visits. METHODS This database analysis used healthcare administrative data from three urban, university-affiliated EDs in Calgary, Canada, calendar years 2010-2014. We used data from all patients presenting to participating EDs during the study period, and the primary analysis was performed on patients discharged from the ED. Regression models quantified the association between input, throughput and output metrics and the risk of return ED visit within 72 h of discharge from the index ED encounter. Strength of association between the crowding metrics and 72-h ED re-visits was compared using Akaike's Information Criterion. RESULTS The findings of this study are based on data from 845,588 patient encounters ending in discharge. The input metric with the strongest association with 72-h re-visits was median ED waiting time. The throughput metric with the strongest association with 72-h re-visits was the ED occupancy. The output metric with the strongest association with 72-h re-visits was the median inpatient boarding time. CONCLUSION Input, throughput and output metrics are all associated with 72-h re-visits. Delays in any of these operational phases have detrimental effects on patient outcomes. ED waiting time, ED occupancy, and boarding times are the most meaningful input, throughput and output metrics. These should be the preferred metrics for quantifying ED crowding in research and quality improvement efforts, and for clinicians to monitor ED crowding in real time.
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Affiliation(s)
- Andrew D McRae
- Department of Emergency Medicine, Rm C231 Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Iram Usman
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Eddy S Lang
- Department of Emergency Medicine, Rm C231 Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Grant D Innes
- Department of Emergency Medicine, Rm C231 Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michael J Schull
- Institute for Clinical and Evaluative Sciences and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rhonda Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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15
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O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. CAN J EMERG MED 2022; 24:68-74. [PMID: 34273102 DOI: 10.1007/s43678-021-00159-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/05/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). METHODS This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. RESULTS Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. CONCLUSIONS A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.
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Affiliation(s)
- Connor M O'Rielly
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - James E Andruchow
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada.
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16
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McRae AD, O'Rielly CM, Lang ES. High-Sensitivity Cardiac Troponins and Clinical Decision Making in Caring for Patients With Chest Pain. Ann Intern Med 2022; 175:137-138. [PMID: 34807715 DOI: 10.7326/m21-4342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Connor M O'Rielly
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy S Lang
- Departments of Emergency Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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17
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McRae AD, Hohl CM, Rosychuk R, Vatanpour S, Ghaderi G, Archambault PM, Brooks SC, Cheng I, Davis P, Hayward J, Lang E, Ohle R, Rowe B, Welsford M, Yadav K, Morrison LJ, Perry J. CCEDRRN COVID-19 Infection Score (CCIS): development and validation in a Canadian cohort of a clinical risk score to predict SARS-CoV-2 infection in patients presenting to the emergency department with suspected COVID-19. BMJ Open 2021; 11:e055832. [PMID: 34857584 PMCID: PMC8640195 DOI: 10.1136/bmjopen-2021-055832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To develop and validate a clinical risk score that can accurately quantify the probability of SARS-CoV-2 infection in patients presenting to an emergency department without the need for laboratory testing. DESIGN Cohort study of participants in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. Regression models were fitted to predict a positive SARS-CoV-2 test result using clinical and demographic predictors, as well as an indicator of local SARS-CoV-2 incidence. SETTING 32 emergency departments in eight Canadian provinces. PARTICIPANTS 27 665 consecutively enrolled patients who were tested for SARS-CoV-2 in participating emergency departments between 1 March and 30 October 2020. MAIN OUTCOME MEASURES Positive SARS-CoV-2 nucleic acid test result within 14 days of an index emergency department encounter for suspected COVID-19 disease. RESULTS We derived a 10-item CCEDRRN COVID-19 Infection Score using data from 21 743 patients. This score included variables from history and physical examination and an indicator of local disease incidence. The score had a c-statistic of 0.838 with excellent calibration. We externally validated the rule in 5295 patients. The score maintained excellent discrimination and calibration and had superior performance compared with another previously published risk score. Score cut-offs were identified that can rule-in or rule-out SARS-CoV-2 infection without the need for nucleic acid testing with 97.4% sensitivity (95% CI 96.4 to 98.3) and 95.9% specificity (95% CI 95.5 to 96.0). CONCLUSIONS The CCEDRRN COVID-19 Infection Score uses clinical characteristics and publicly available indicators of disease incidence to quantify a patient's probability of SARS-CoV-2 infection. The score can identify patients at sufficiently high risk of SARS-CoV-2 infection to warrant isolation and empirical therapy prior to test confirmation while also identifying patients at sufficiently low risk of infection that they may not need testing. TRIAL REGISTRATION NUMBER NCT04702945.
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Affiliation(s)
- Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Rhonda Rosychuk
- Department of Paediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gelareh Ghaderi
- Department of Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Patrick M Archambault
- Department of Emergency Medicine, Universite Laval Faculte de medecine, Quebec, Quebec, Canada
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Ivy Cheng
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Brian Rowe
- Department of Emergency Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Michelle Welsford
- Department of Emergency Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Laurie J Morrison
- Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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18
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McRae AD, Laupacis A. SARS-CoV-2 vaccination should be required to practise medicine in Canada. CMAJ 2021; 193:E1816-E1817. [PMID: 34753806 PMCID: PMC8654896 DOI: 10.1503/cmaj.211839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrew D McRae
- Editorial Fellow, CMAJ (McRae); Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Senior Deputy Editor, CMAJ (Laupacis)
| | - Andreas Laupacis
- Editorial Fellow, CMAJ (McRae); Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Senior Deputy Editor, CMAJ (Laupacis)
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19
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Thiruganasambandamoorthy V, Yan JW, Rowe BH, Mercier É, Le Sage N, Hegdekar M, Finlayson A, Huang P, Mohammad H, Mukarram M, Nguyen PAI, Syed S, McRae AD, Nemnom MJ, Taljaard M, Silviotti MLA. Personalised risk prediction following emergency department assessment for syncope. Emerg Med J 2021; 39:501-507. [PMID: 34740890 DOI: 10.1136/emermed-2020-211095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne Finlayson
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Huang
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hassan Mohammad
- Faculty of Technology and Trades, Algonquin College, Ottawa, Ontario, Canada
| | - Muhammad Mukarram
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Phuong Anh Iris Nguyen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shahbaz Syed
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Marco LA Silviotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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20
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Innes GD, Teichman JMH, Scheuermeyer FX, McRae AD, Grafstein E, Andruchow J, Cheng L, Law MR. Does early intervention improve outcomes for patients with acute ureteral colic? CAN J EMERG MED 2021; 23:679-686. [PMID: 34491558 DOI: 10.1007/s43678-020-00016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Early surgical intervention is increasingly employed for patients with ureteral colic, but guidelines and current practice are variable. We compared 60-day outcomes for matched patients undergoing early intervention vs. spontaneous passage. METHODS This multicentre propensity-matched cohort analysis used administrative data and chart review to study all eligible emergency department (ED) patients with confirmed 2.0-9.9 mm ureteral stones. Those having planned stone intervention within 5 days comprised the intervention cohort. Controls attempting spontaneous passage were matched to intervention patients based on age, sex, stone width, stone location, hydronephrosis, ED site, ambulance arrival and acuity level. The primary outcome was treatment failure, defined as rescue intervention or hospitalization within 60 days, using a time to event analysis. Secondary outcome was ED revisit rate. RESULTS Among 1154 matched patients, early intervention did not reduce the risk of treatment failure (adjusted hazard ratio 0.94; P = 0.61). By 60 days, 21.8% of patients in both groups experienced the composite primary outcome (difference 0.0%; 95% confidence interval - 4.8 to 4.8%). Intervention patients required more hospitalizations (20.1% vs. 12.8%; difference 7.3%; 95% CI 3.0-11.5%) and ED revisits (36.1% vs. 25.5%; difference 10.6%; 95% CI 5.3-15.9%), but (insignificantly) fewer rescue interventions (18.9% vs. 21.3%; difference - 2.4%; 95% CI - 7.0 to 2.2%). CONCLUSIONS In matched patients with 2.0-9.9 mm ureteral stones, early intervention was associated with similar rates of treatment failure but greater patient morbidity, evidenced by hospitalizations and emergency revisits. Physicians should adopt a selective approach to interventional referral and consider that spontaneous passage probably provides better outcomes for many low-risk patients.
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Affiliation(s)
- Grant D Innes
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Room C231, Foothills Medical Centre, 1403, 29 Street NW, Calgary, AB, T2N 2T9, Canada.
| | - Joel M H Teichman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine and Center for Healthcare Evaluation and Outcome Sciences, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Room C231, Foothills Medical Centre, 1403, 29 Street NW, Calgary, AB, T2N 2T9, Canada
| | - Eric Grafstein
- Department of Emergency Medicine and Center for Healthcare Evaluation and Outcome Sciences, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - James Andruchow
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Room C231, Foothills Medical Centre, 1403, 29 Street NW, Calgary, AB, T2N 2T9, Canada
| | - Lucy Cheng
- Centre for Health Services and Policy Research, School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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21
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Stiell IG, Eagles D, Nemnom MJ, Brown E, Taljaard M, Archambault PM, Birnie D, Borgundvaag B, Clark G, Davis P, Godin D, Hohl C, Mathieu B, McRae AD, Mercier E, Morris J, Parkash R, Perry JJ, Rowe BH, Thiruganasambandamoorthy V, Scheuermeyer F, Sivilotti MLA, Vadeboncoeur A. Adverse Events Associated With Electrical Cardioversion in Patients With Acute Atrial Fibrillation and Atrial Flutter. Can J Cardiol 2021; 37:1775-1782. [PMID: 34474123 DOI: 10.1016/j.cjca.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND We sought to evaluate safety of electrical cardioversion (ECV) for patients with acute atrial fibrillation (AF) or atrial flutter (AFL) in the emergency department (ED). METHODS This was an analysis of data from 4 multicentre AF/AFL studies conducted from 2008 to 2019 at 23 large EDs. We included adult patients who received attempts at ECV and who had presented acutely after symptom onset. Staff manually reviewed study and clinical records to abstract data. RESULTS We evaluated 1736 ECV cases with a mean age of 60.1 years and 67.1% male. The overall success of ECV was 90.2% (95% confidence interval 88.7%-91.6%), with 4.9% of patients admitted. ED physicians performed the ECV in 95.2% and provided sedation in 96.5%; 13.9% (12.3%-15.7%) of cases experienced important adverse events that required treatment, and 0.4% were classified as life threatening. Another 5.6% had adverse events that did not require treatment. Logistic regression found that the RAFF-3 study cohort (odds ratio [OR] 2.0), age ≥ 85 years (OR 2.1), coronary artery disease (OR 1.5), midazolam (OR 1.9), and fentanyl (OR 1.5) were associated with important adverse events. CONCLUSIONS This large evaluation of the safety of ECV for acute AF/AFL in the ED found that while serious adverse events were rare, there were a concerning number of events following sedation that required intervention. Physicians should be aware that older age, coronary artery disease, and fentanyl are associated with higher risks of important adverse events. This study provides more information for shared decision making discussions with patients when choosing between drug-shock and shock-only cardioversion strategies.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Patrick M Archambault
- Département de Médecine Familiale et de Médicine d'Urgence, Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada; Département d'Anesthésiologie et de Soins Intensifs, Centre de Recherche du Centre Intégré de Santé et de Services Sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, University of Toronto, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gregory Clark
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Corinne Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernard Mathieu
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric Mercier
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Université Laval, Québec City, Québec, Canada; Département de Médecine Familiale et de Médecine d'Urgence, Centre de Recherche du CHU de Québec, Université Laval, Québec City, Québec, Canada
| | - Judy Morris
- Département de Médecine de Famille et de Médecine d'Urgence, Université de Montréal, Montréal, Québec, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie University, Dartmouth, Nova Scotia, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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22
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Stiell IG, de Wit K, Scheuermeyer FX, Vadeboncoeur A, Angaran P, Eagles D, Graham ID, Atzema CL, Archambault PM, Tebbenham T, McRae AD, Cheung WJ, Parkash R, Deyell MW, Baril G, Mann R, Sahsi R, Upadhye S, Brown E, Brinkhurst J, Chabot C, Skanes A. 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist. CAN J EMERG MED 2021; 23:604-610. [PMID: 34383280 PMCID: PMC8423652 DOI: 10.1007/s43678-021-00167-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Unit, The Ottawa Hospital, F657, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alain Vadeboncoeur
- Université de Montréal, Montreal, QC, Canada
- Department of Emergency Medicine, Montreal Heart Institute, Montreal, QC, Canada
| | - Paul Angaran
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Clare L Atzema
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Patrick M Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
| | - Troy Tebbenham
- Peterborough Regional Health Centre, Peterborough, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ratika Parkash
- Division of Cardiology, Dalhousie University, Halifax, NS, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | - Rick Mann
- Trillium Health Partners, Mississauga Hospital, Mississauga, ON, Canada
| | - Rupinder Sahsi
- Division of Emergency Medicine, Department of Family Medicine, McMaster University, Hamilton, ON, Canada
- St. Mary's General Hospital, Kitchener, ON, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Erica Brown
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | - Allan Skanes
- Division of Cardiology, Western University, London, ON, Canada
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23
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Andruchow JE, Grigat D, McRae AD, Innes G, Vatanpour S, Wang D, Taljaard M, Lang E. Decision support for computed tomography in the emergency department: a multicenter cluster-randomized controlled trial. CAN J EMERG MED 2021; 23:631-640. [PMID: 34351598 DOI: 10.1007/s43678-021-00170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). METHODS Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. RESULTS A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. CONCLUSION Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | | | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Foothills Medical Centre Room C-231, 1403-29st NW, Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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24
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Innes GD, Scheuermeyer FX, McRae AD, Teichman JMH, Lane DJ. Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic. CAN J EMERG MED 2021; 23:687-695. [PMID: 34304393 DOI: 10.1007/s43678-021-00168-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure. METHODS We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group. RESULTS Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk. CONCLUSIONS Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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Affiliation(s)
- Grant D Innes
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joel M H Teichman
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Daniel J Lane
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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25
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Harrison TG, Ronksley PE, James MT, Brindle ME, Ruzycki SM, Graham MM, McRae AD, Zarnke KB, McCaughey D, Ball CG, Dixon E, Hemmelgarn BR. The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients. Can J Surg 2021; 64:E381-E390. [PMID: 34296705 PMCID: PMC8410465 DOI: 10.1503/cjs.002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.
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Affiliation(s)
- Tyrone G Harrison
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Paul E Ronksley
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Matthew T James
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Mary E Brindle
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Shannon M Ruzycki
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Michelle M Graham
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Andrew D McRae
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Kelly B Zarnke
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Deirdre McCaughey
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Chad G Ball
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Elijah Dixon
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Brenda R Hemmelgarn
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
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Lee JS, Bhandari T, Simard R, Emond M, Topping C, Woo M, Perry J, Eagles D, McRae AD, Lang E, Wong C, Sivilotti M, Newbigging J, Borgundvaag B, McLeod SL, Melady D, Chernoff L, Kiss A, Chenkin J. 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. BMJ Open 2021; 11:e047113. [PMID: 34226222 PMCID: PMC8258568 DOI: 10.1136/bmjopen-2020-047113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jacques Simon Lee
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tina Bhandari
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert Simard
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Marcel Emond
- Axe Santé des populations et pratiques optimales en santé, Universite Laval, Quebec, Québec, Canada
- Departément de medécine d'urgence, Universite Laval, Quebec, Québec, Canada
| | - Claude Topping
- Axe Santé des populations et pratiques optimales en santé, Universite Laval, Quebec, Québec, Canada
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Québec, Canada
| | - Michael Woo
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charles Wong
- Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marco Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Joseph Newbigging
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Donald Melady
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lan Chernoff
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Krishnan RJ, Mukarram M, Ghaedi B, Sivilotti MLA, Le Sage N, Yan JW, Huang P, Hegdekar M, Mercier E, Nemnom MJ, Calder LA, McRae AD, Rowe BH, Wells GA, Thiruganasambandamoorthy V. Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort. CMAJ 2021; 192:E1198-E1205. [PMID: 33051314 DOI: 10.1503/cmaj.191637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). METHODS We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. RESULTS We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). INTERPRETATION Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.
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Affiliation(s)
- Rohin J Krishnan
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Muhammad Mukarram
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Bahareh Ghaedi
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Marco L A Sivilotti
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Natalie Le Sage
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Justin W Yan
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Paul Huang
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Mona Hegdekar
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Eric Mercier
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Marie-Joe Nemnom
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Lisa A Calder
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Andrew D McRae
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Brian H Rowe
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - George A Wells
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta
| | - Venkatesh Thiruganasambandamoorthy
- John A. Burns School of Medicine (Krishnan), University of Hawai'i at Mānoa, Honolulu, Hawaii; Ottawa Hospital Research Institute (Krishnan, Mukarram, Ghaedi, Nemnom, Calder, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.; Departments of Emergency Medicine (Sivilotti) and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Le Sage, Mercier), Laval University-Centre hospitalier universitaire de Québec - Université Laval Research Centre, Québec, Que.; Division of Emergency Medicine (Yan), Western University, London, Ont.; Department of Emergency Medicine (Huang), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Hegdekar), University of Manitoba, Winnipeg, Man.; Department of Emergency Medicine (Calder, Thiruganasambandamoorthy) and School of Epidemiology and Public Health (Wells, Thiruganasambandamoorthy), University of Ottawa, Ottawa, Ont.; Departments of Emergency Medicine (McRae) and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Rowe) and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.
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Lane DJ, Blanchard IE, Buick JE, Shaw M, McRae AD. Changes in presentation, presenting severity and disposition among patients accessing emergency services during the first months of the COVID-19 pandemic in Calgary, Alberta: a descriptive study. CMAJ Open 2021; 9:E592-E601. [PMID: 34074633 PMCID: PMC8177906 DOI: 10.9778/cmajo.20200313] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has resulted in unique pressures on the emergency services system. This study describes changes in the presentation, presenting severity and disposition of patients accessing emergency services in Calgary, Alberta, during the first wave of the pandemic. METHODS In this descriptive study, we constructed a population cohort of all patients who accessed emergency services by calling emergency medical services (EMS) (ambulance service that provides prehospital treatment and transport to medical facilities) or presenting directly to an emergency department (4 adult and 1 pediatric) or 2 urgent care centres in Calgary during the exposure period (December 2019 to June 2020) compared to 2 historical control periods (December to June, 2017-2018 and 2018-2019) combined. Outcomes included frequency of presentation, system flow indicators, patient severity, disposition and mortality. We used a locally estimated scatterplot smoothing function to visualize trends. We described differences at the maximum and minimum point of the exposure period compared to the control period. RESULTS A total of 1 127 014 patient encounters were included. Compared to the control period, there was a 61% increase in the number of patients accessing EMS and a 35% decrease in the number of those presenting to an adult emergency department or urgent care centre in the COVID-19 period. The proportion of EMS calls for the highest-priority patients remained stable, whereas the proportion of patients presenting to an emergency department or urgent care centre with the highest-priority triage classification increased transiently by 0.9 percentage points (increase of 89%). A smaller proportion of patients were transported by EMS (decrease of 21%), and a greater proportion of emergency department patients were admitted to hospital (increase of 25%). After the first case was reported, the mortality rate among EMS patients increased by 265% (3.4 v. 12.4 per 1000 patient encounters). INTERPRETATION The first wave of the COVID-19 pandemic was associated with substantial changes in the frequency and disposition of patients accessing emergency services. Further research examining the mechanism of these observations is important for mitigating the impact of future pandemics.
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Affiliation(s)
- Daniel J Lane
- Cumming School of Medicine (Lane, Blanchard, Shaw, McRae), University of Calgary; Department of Emergency Medical Services (Blanchard), Alberta Health Services; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Buick), University of Toronto, Toronto, Ont.
| | - Ian E Blanchard
- Cumming School of Medicine (Lane, Blanchard, Shaw, McRae), University of Calgary; Department of Emergency Medical Services (Blanchard), Alberta Health Services; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Buick), University of Toronto, Toronto, Ont
| | - Jason E Buick
- Cumming School of Medicine (Lane, Blanchard, Shaw, McRae), University of Calgary; Department of Emergency Medical Services (Blanchard), Alberta Health Services; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Buick), University of Toronto, Toronto, Ont
| | - Marta Shaw
- Cumming School of Medicine (Lane, Blanchard, Shaw, McRae), University of Calgary; Department of Emergency Medical Services (Blanchard), Alberta Health Services; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Buick), University of Toronto, Toronto, Ont
| | - Andrew D McRae
- Cumming School of Medicine (Lane, Blanchard, Shaw, McRae), University of Calgary; Department of Emergency Medical Services (Blanchard), Alberta Health Services; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Buick), University of Toronto, Toronto, Ont
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29
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Calder LA, Perry J, Yan JW, De Gorter R, Sivilotti MLA, Eagles D, Myslik F, Borgundvaag B, Émond M, McRae AD, Taljaard M, Thiruganasambandamoorthy V, Cheng W, Forster AJ, Stiell IG. Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study. Ann Emerg Med 2021; 77:561-574. [PMID: 33612283 DOI: 10.1016/j.annemergmed.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Ria De Gorter
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcel Émond
- Département de médecine Familiale et d'Urgence, Université Laval, Québec City, Quebec, Canada
| | - Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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30
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Morris J, Mercier E, Macle L, Brison RJ, Thiruganasambandamoorthy V, Rowe BH, Borgundvaag B, Clement CM, Brinkhurst J, Brown E, Nemnom MJ, Wells GA, Perry JJ. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. CAN J EMERG MED 2021; 23:314-324. [PMID: 33959925 DOI: 10.1007/s43678-020-00067-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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31
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Hohl CM, Rosychuk RJ, McRae AD, Brooks SC, Archambault P, Fok PT, Davis P, Jelic T, Turner JP, Rowe BH, Mercier É, Cheng I, Taylor J, Daoust R, Ohle R, Andolfatto G, Atzema C, Hayward J, Khangura JK, Landes M, Lang E, Martin I, Mohindra R, Ting DK, Vaillancourt S, Welsford M, Brar B, Dahn T, Wiemer H, Yadav K, Yan JW, Stachura M, McGavin C, Perry JJ, Morrison LJ. Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study. CMAJ Open 2021; 9:E261-E270. [PMID: 33731427 PMCID: PMC8096396 DOI: 10.9778/cmajo.20200290] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION Clinicaltrials.gov, no. NCT04702945.
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Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Rhonda J Rosychuk
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Andrew D McRae
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Steven C Brooks
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Patrick Archambault
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Patrick T Fok
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Philip Davis
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Tomislav Jelic
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Joel P Turner
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Brian H Rowe
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Éric Mercier
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Ivy Cheng
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - John Taylor
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Raoul Daoust
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Robert Ohle
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Gary Andolfatto
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Clare Atzema
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jake Hayward
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jaspreet K Khangura
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Megan Landes
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Eddy Lang
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Ian Martin
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Rohit Mohindra
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Daniel K Ting
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Samuel Vaillancourt
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Michelle Welsford
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Baljeet Brar
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Tara Dahn
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Hana Wiemer
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Krishan Yadav
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Justin W Yan
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Maja Stachura
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Colleen McGavin
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jeffrey J Perry
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Laurie J Morrison
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
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Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, Wakai A. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev 2020; 7:CD013031. [PMID: 32702777 PMCID: PMC7390330 DOI: 10.1002/14651858.cd013031.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes. OBJECTIVES To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy. SEARCH METHODS We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed. SELECTION CRITERIA We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non-radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta-analyses by using a bivariate model to estimate and compare summary sensitivities and specificities. MAIN RESULTS We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax. AUTHORS' CONCLUSIONS The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.
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Affiliation(s)
- Kenneth K Chan
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Daniel A Joo
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zahra A Premji
- Libraries and Cultural Resources, University of Calgary, Calgary, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Abel Wakai
- Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland
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Thiruganasambandamoorthy V, McRae AD, Rowe BH, Sivilotti MLA, Mukarram M, Nemnom MJ, Booth RA, Calder LA, Stiell IG, Wells GA, Cheng W, Taljaard M. Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope? Ann Intern Med 2020; 172:648-655. [PMID: 32340039 DOI: 10.7326/m19-3515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. OBJECTIVE To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). DESIGN Prospective cohort study. SETTING 6 EDs in 2 Canadian provinces. PARTICIPANTS 1452 adult ED patients with syncope. INTERVENTION Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. MEASUREMENTS An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. RESULTS Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. LIMITATIONS Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. CONCLUSION Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. PRIMARY FUNDING SOURCE Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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Affiliation(s)
| | - Andrew D McRae
- University of Calgary, Calgary, Alberta, Canada (A.D.M.)
| | - Brian H Rowe
- University of Alberta, Edmonton, Alberta, Canada (B.H.R.)
| | | | | | | | - Ronald A Booth
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Lisa A Calder
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - Ian G Stiell
- University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada (V.T., L.A.C., I.G.S.)
| | - George A Wells
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Wei Cheng
- University of Ottawa, Ottawa, Ontario, Canada (R.A.B., G.A.W., W.C.)
| | - Monica Taljaard
- The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (M.T.)
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Thiruganasambandamoorthy V, Sivilotti MLA, Le Sage N, Yan JW, Huang P, Hegdekar M, Mercier E, Mukarram M, Nemnom MJ, McRae AD, Rowe BH, Stiell IG, Wells GA, Krahn AD, Taljaard M. Multicenter Emergency Department Validation of the Canadian Syncope Risk Score. JAMA Intern Med 2020; 180:737-744. [PMID: 32202605 PMCID: PMC7091474 DOI: 10.1001/jamainternmed.2020.0288] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use. OBJECTIVE To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018. MAIN OUTCOMES AND MEASURES Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated. RESULTS A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively. CONCLUSIONS AND RELEVANCE The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada.,CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Paul Huang
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada.,CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Marie-Joe Nemnom
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - George A Wells
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.,University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Rowe BH, Brison RJ, Thiruganasambandamoorthy V, Macle L, Borgundvaag B, Morris J, Mercier E, Clement CM, Brinkhurst J, Sheehan C, Brown E, Nemnom MJ, Wells GA, Perry JJ. Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet 2020; 395:339-349. [PMID: 32007169 DOI: 10.1016/s0140-6736(19)32994-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 11/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, University of Toronto, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Connor Sheehan
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Stiell IG, Perry JJ, Clement CM, Brison RJ, Rowe BH, Aaron SD, McRae AD, Borgundvaag B, Calder LA, Forster AJ, Brinkhurst J, Wells GA. Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department. CMAJ 2019; 190:E1406-E1413. [PMID: 30510045 DOI: 10.1503/cmaj.180232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS), which consists of 10 criteria, was previously derived to identify patients in the emergency department with COPD who were at high risk for short-term serious outcomes. We sought to validate, prospectively and explicitly, the OCRS when applied by physicians in the emergency department. METHODS We conducted this prospective cohort study involving patients in the emergency departments at 6 tertiary care hospitals and enrolled adults with acute exacerbation of COPD from May 2011 to December 2013. Physicians evaluated patients for the OCRS criteria, which were recorded on a data form along with the total risk score. We followed patients for 30 days and the primary outcome, short-term serious outcomes, was defined as any of death, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI) or relapse with hospital admission. RESULTS We enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for a score of 10. Compared with current practice, an OCRS score threshold of greater than 1 would increase sensitivity for short-term serious outcomes from 51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being admitted. INTERPRETATION In this clinical validation of a risk-stratification tool for COPD in the emergency department, we found that OCRS showed better sensitivity for short-term serious outcomes compared with current practice. This risk scale can now be used to help emergency department disposition decisions for patients with COPD, which should lead to a decrease in unnecessary admissions and in unsafe discharges.
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Affiliation(s)
- Ian G Stiell
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta.
| | - Jeffrey J Perry
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Catherine M Clement
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Robert J Brison
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Brian H Rowe
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Shawn D Aaron
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Andrew D McRae
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Bjug Borgundvaag
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Lisa A Calder
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Alan J Forster
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - Jennifer Brinkhurst
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
| | - George A Wells
- Departments of Emergency Medicine (Stiell, Calder, Perry) and Medicine (Aaron, Forster), Clinical Epidemiology Program, Ottawa Hospital Research Institute (Stiell, Perry, Clement, Aaron, Forster, Brinkhurst), University of Ottawa Heart Institute (Wells), University of Ottawa, Ottawa, Ont.; Division of Emergency Medicine, Department of Family and Community Medicine (Borgundvaag), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Brison), Kingston Health Sciences Centre, Kingston, Ont.; Department of Emergency Medicine (McRae), University of Calgary, Calgary, Alta.; Department of Emergency Medicine and School of Public Health, University of Alberta, and Alberta Health Services (Rowe), Edmonton, Alta
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Thiruganasambandamoorthy V, Rowe BH, Sivilotti MLA, McRae AD, Arcot K, Nemnom MJ, Huang L, Mukarram M, Krahn AD, Wells GA, Taljaard M. Response by Thiruganasambandamoorthy et al to Letters Regarding Article, "Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope". Circulation 2019; 140:e655-e656. [PMID: 31525105 DOI: 10.1161/circulationaha.119.041639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Departments of Emergency Medicine (V.T.), University of Ottawa, ON, Canada.,School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Canada (B.H.R.)
| | - Marco L A Sivilotti
- Departments of Emergency Medicine (M.L.A.S.), Queen's University, Kingston, ON, Canada.,Biomedical and Molecular Sciences (M.L.A.S.), Queen's University, Kingston, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, AB, Canada (A.D.M.)
| | - Kirtana Arcot
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Marie-Joe Nemnom
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Longlong Huang
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada (A.D.K.)
| | - George A Wells
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, ON, Canada.,Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
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Andruchow JE, Boyne T, Innes G, Vatanpour S, Seiden-Long I, Wang D, Lang E, McRae AD. Low High-Sensitivity Troponin Thresholds Identify Low-Risk Patients With Chest Pain Unlikely to Benefit From Further Risk Stratification. CJC Open 2019; 1:289-296. [PMID: 32159123 PMCID: PMC7063640 DOI: 10.1016/j.cjco.2019.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 01/20/2023] Open
Abstract
Background Very low high-sensitivity cardiac troponin T (hs-cTnT) thresholds on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods This prospective cohort study enrolled patients with chest pain presenting to the emergency department with nonischemic electrocardiograms who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3 hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated on the basis of review of medical records and telephone follow-up. Results Of 1167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) had AMI on the index visit. More than one-third of patients (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5 ng/L), which was 94.4% (95% confidence interval [CI], 88.8-97.7) sensitive for 30-day MACE and 99.0% (95% CI, 94.5-100) sensitive for index AMI. Of 292 patients (25.0%) with hs-cTnT < 5 ng/L and at least 3 hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%; 95% CI, 93.2-100) and none had AMI within 30 days (sensitivity 100%; 95% CI, 96.3-100). Conclusions Among patients with nonischemic electrocardiograms and > 3 hours since symptom onset, low hs-cTnT thresholds on presentation confer a very low risk of 30-day MACE. In the absence of a high-risk clinical presentation, further risk stratification is likely to be low yield.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Timothy Boyne
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isolde Seiden-Long
- Department of Pathology and Laboratory Medicine, University of Calgary and Alberta Public Laboratories, Calgary, Alberta, Canada
| | - Dongmei Wang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Thiruganasambandamoorthy V, Rowe BH, Sivilotti ML, McRae AD, Arcot K, Nemnom MJ, Huang L, Mukarram M, Krahn AD, Wells GA, Taljaard M. Duration of Electrocardiographic Monitoring of Emergency Department Patients With Syncope. Circulation 2019; 139:1396-1406. [DOI: 10.1161/circulationaha.118.036088] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine (V.T.), University of Ottawa, Canada
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Brian H. Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Canada (B.H.R.)
| | - Marco L.A. Sivilotti
- Departments of Emergency Medicine, and Biomedical and Molecular Sciences, Queen’s University, Kingston, Canada (M.L.A.S.)
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Canada (A.D.M.)
| | - Kirtana Arcot
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Marie-Joe Nemnom
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Longlong Huang
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
| | - Andrew D. Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada (A.D.K.)
| | - George A. Wells
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health (V.T., G.A.W., M.T.), University of Ottawa, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Canada (V.T., K.A., M.-J.N., L.H., M.M., M.T.)
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Thiruganasambandamoorthy V, Sivilotti MLA, Rowe BH, McRae AD, Mukarram M, Malveau S, Yagapen AN, Sun BC. Prevalence of Pulmonary Embolism Among Emergency Department Patients With Syncope: A Multicenter Prospective Cohort Study. Ann Emerg Med 2019; 73:500-510. [PMID: 30691921 DOI: 10.1016/j.annemergmed.2018.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/09/2018] [Accepted: 12/03/2018] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE The prevalence of pulmonary embolism among patients with syncope is understudied. In accordance with a recent study with an exceptionally high pulmonary embolism prevalence, some advocate evaluating all syncope patients for pulmonary embolism, including those with another clear cause for their syncope. We seek to evaluate the pulmonary embolism prevalence among emergency department (ED) patients with syncope. METHODS We combined data from 2 large prospective studies enrolling adults with syncope from 17 EDs in Canada and the United States. Each study collected the results of pulmonary embolism-related investigations (ie, D-dimer, ventilation-perfusion scan, or computed tomography [CT] pulmonary angiography) and 30-day adjudicated outcomes: pulmonary embolism or nonpulmonary embolism outcome (arrhythmia, myocardial infarction, serious hemorrhage, and death). RESULTS Of the 9,374 patients enrolled, 9,091 (97.0%; median age 66 years, 51.9% women) with 30-day follow-up were analyzed: 547 (6.0%) were evaluated for pulmonary embolism (278 [3.1%] had D-dimer, 39 [0.4%] had ventilation-perfusion scan, and 347 [3.8%] had CT pulmonary angiography). Overall, 874 patients (9.6%) experienced 30-day serious outcomes: 818 patients (9.0%) with nonpulmonary embolism serious outcomes and 56 (prevalence 0.6%; 95% confidence interval 0.5% to 0.8%) with pulmonary embolism (including 8 [0.2%] out of 3521 patients diagnosed during the index hospitalization and 7 [0.1%] diagnosed after the index visit). Eighty-six patients (0.9%) died, and 4 deaths (0.04%) were related to pulmonary embolism. Only 11 patients (0.1%) with a nonpulmonary embolism serious condition had a concomitant pulmonary embolism. CONCLUSION The prevalence of pulmonary embolism is very low among ED patients with syncope, including those hospitalized after syncope. Although an underlying pulmonary embolism may cause syncope, clinicians should be cautious about indiscriminate investigations for pulmonary embolism.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Marco L A Sivilotti
- Department of Emergency Medicine and Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Susan Malveau
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Annick N Yagapen
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
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Kavsak PA, Andruchow JE, McRae AD, Worster A. Profile of Roche’s Elecsys Troponin T Gen 5 STAT blood test (a high-sensitivity cardiac troponin assay) for diagnosing myocardial infarction in the emergency department. Expert Rev Mol Diagn 2018; 18:481-489. [DOI: 10.1080/14737159.2018.1476141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James E. Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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Kavsak PA, Worster A, Shortt C, Ma J, Clayton N, Sherbino J, Hill SA, McQueen M, Griffith LE, Mehta SR, McRae AD, Devereaux PJ. Performance of high-sensitivity cardiac troponin in the emergency department for myocardial infarction and a composite cardiac outcome across different estimated glomerular filtration rates. Clin Chim Acta 2018; 479:166-170. [PMID: 29366835 DOI: 10.1016/j.cca.2018.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/11/2018] [Accepted: 01/19/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinicians regularly observe increased high-sensitivity cardiac troponin (hs-cTn) concentrations in patients with low estimated glomerular filtration rate (eGFR). The challenge is to differentiate acute coronary syndrome (ACS) from increased hs-cTn results across a range of eGFR. The objective of this study was to determined the optimal hs-cTn concentrations for acute myocardial infarction (MI) and a composite cardiovascular outcome across different eGFR ranges and to assess the utility of a low hs-cTn cutoff to rule-out events. METHODS We undertook an observational study in the emergency department of patients (n = 1212) with symptoms suggestive of ACS who had an eGFR and at least one Roche hs-cTnT and one Abbott hs-cTnI result. The 7-day outcomes were MI or a composite of MI, unstable angina, congestive heart failure, serious ventricular cardiac arrhythmia, or death. The maximum hs-cTn concentration was assessed across different eGFR ranges (<30,30-59,60-89,≥90 ml/min/1.73m2) by spearman correlation, ROC-curve analyses, and sensitivity and negative predictive value (NPV) for the proposed rule-out hs-cTn cutoffs (hs-cTnI<5 ng/l and hs-cTnT<6 ng/l) for the outcomes. RESULTS Both hs-cTnI and hs-cTnT concentrations were negatively correlated with eGFR. The lower the eGFR, the lower the AUC and the higher the optimal hs-cTn cutoffs for both MI and the composite outcome. The highest combined sensitivity (100%), NPV (100%) and proportion of low-risk for MI (45% of group) was observed for patients with hs-cTnT<6 ng/l with an eGFR≥90. CONCLUSION The test performance for hs-cTn for diagnosing or ruling-out an acute cardiac event varies per the eGFR. Accurate risk stratification requires knowledge of the eGFR.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Colleen Shortt
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shamir R Mehta
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P J Devereaux
- Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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Michaud AM, Parker SIA, Ganshorn H, Ezekowitz JA, McRae AD. Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review. Can J Cardiol 2018; 34:168-179. [PMID: 29287944 DOI: 10.1016/j.cjca.2017.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/01/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Acute heart failure (AHF) accounts for a substantial proportion of Emergency Department (ED) visits and hospitalizations. Previous studies have shown that emergency physicians' clinical gestalt is not sufficient to stratify patients with AHF into severe and requiring hospitalization vs nonsevere and safe to be discharged. Various prognostic algorithms have been developed to risk-stratify patients with AHF, however there is no consensus as to the best-performing risk assessment tool in the ED. METHODS A systematic review of Medline, PubMed, and Embase up to May 2016 was conducted using established methods. Major cardiology and emergency medicine conference proceedings from 2010 to 2016 were also screened. Two independent reviewers identified studies that evaluated clinical risk scores in adult (ED) patients with AHF, with risk prognostication for mortality or significant morbidity within 7-30 days. Studies included patients who were discharged or admitted. RESULTS The systematic review search generated 2950 titles that were screened according to title and abstract. Nine articles, describing 6 risk prediction tools met full inclusion criteria, however, prognostic performance and ease of bedside application is limited for most. Because of clinical heterogeneity in the prognostic tools and study outcomes, a meta-analysis was not performed. CONCLUSIONS Several risk scores exist for predicting short-term mortality or morbidity in ED patients with AHF. No single risk tool is clearly superior, however, the Emergency Heart Failure Mortality Risk Grade might aid in prognostication of mortality and the Ottawa Heart Failure Risk Score might provide useful prognostic information in patients suitable for ED discharge.
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Affiliation(s)
- Allison M Michaud
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Heather Ganshorn
- Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Justin A Ezekowitz
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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Andruchow JE, Kavsak PA, McRae AD. Contemporary Emergency Department Management of Patients with Chest Pain: A Concise Review and Guide for the High-Sensitivity Troponin Era. Can J Cardiol 2017; 34:98-108. [PMID: 29407013 DOI: 10.1016/j.cjca.2017.11.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022] Open
Abstract
This article synthesizes current best evidence for the evaluation of patients with suspected acute coronary syndrome (ACS) using high-sensitivity troponin assays, enabling physicians to effectively incorporate them into practice. Unlike conventional assays, high-sensitivity assays can precisely measure blood cardiac troponin concentrations in the vast majority of healthy individuals, facilitating the creation of rapid diagnostic algorithms. Very low troponin concentrations on presentation accurately rule out acute myocardial infarction (AMI) and enable the discharge of approximately 20% of patients after a single test, whereas an additional 30%-40% of patients can be safely discharged after short-interval serial sampling in as little as 1 or 2 hours. In contrast, highly abnormal troponin concentrations on presentation (more than 5 times the upper reference limit) or rapidly rising levels on serial testing can rapidly rule in AMI with high specificity. However, approximately one-third of patients remain in a biomarker-indeterminate "observation zone" even after serial sampling. These patients pose a disposition challenge to clinicians because although the differential diagnosis of elevated troponin concentrations is broad, these patients have an increased risk for short-term major adverse cardiac events. Use of repeated serial troponin sampling and structured clinical prediction tools may assist disposition for these patients, because no validated pathways currently exist to guide clinicians. Ongoing research to tailor diagnostic thresholds to individual patient characteristics may enable improved diagnostic accuracy and usher in a new era of personalized medicine in the evaluation of suspected ACS.
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Affiliation(s)
- James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada.
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada
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Thiruganasambandamoorthy V, Stiell IG, Sivilotti MLA, Rowe BH, Mukarram M, Arcot K, Kwong K, McRae AD, Wells GA, Taljaard M. Predicting Short-term Risk of Arrhythmia among Patients With Syncope: The Canadian Syncope Arrhythmia Risk Score. Acad Emerg Med 2017; 24:1315-1326. [PMID: 28791782 DOI: 10.1111/acem.13275] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Syncope can be caused by serious occult arrhythmias not evident during initial emergency department (ED) evaluation. We sought to develop a risk tool for predicting 30-day arrhythmia or death after ED disposition. METHODS We conducted a multicenter prospective cohort study at six tertiary care EDs and included adults (≥16 years) with syncope. We collected standardized variables from clinical evaluation and investigations including electrocardiogram and troponin at index presentation. Adjudicated outcomes included death or arrhythmias including procedural interventions for arrhythmia within 30 days. We used multivariable logistic regression to derive the prediction model and bootstrapping for interval validation to estimate shrinkage and optimism. RESULTS A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years, 54.8% females, and 9.5% hospitalized) were enrolled with 106 (2.1%) patients suffering 30-day arrhythmia/death after ED disposition. We examined 39 variables and eight were included in the final model: lack of vasovagal predisposition, heart disease, any ED systolic blood pressure < 90 or > 180 mm Hg, troponin (>99th percentile), QRS duration > 130 msec, QTc interval > 480 msec, and ED diagnosis of cardiac/vasovagal syncope (optimism corrected C-statistic 0.90 [95% CI = 0.87-0.93]; Hosmer-Lemeshow p = 0.08). The Canadian Syncope Arrhythmia Risk Score had a risk ranging from 0.2% to 74.5% for scores of -2 to 8. At a threshold score of ≥0, the sensitivity was 97.1% (95% CI = 91.6%-99.4%) and specificity was 53.4% (95% CI = 52.0%-54.9%). CONCLUSIONS The Canadian Syncope Arrhythmia Risk Score can improve patient safety by identification of those at risk for arrhythmias and aid in acute management decisions. Once validated, the score can identify low-risk patients who will require no further investigations.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine; University of Ottawa; Ottawa ON
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Ian G. Stiell
- Department of Emergency Medicine; University of Ottawa; Ottawa ON
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Marco L. A. Sivilotti
- Department of Emergency Medicine; Queen's University; Kingston ON
- Department of Biomedical and Molecular Sciences; Queen's University; Kingston ON
| | - Brian H. Rowe
- Department of Emergency Medicine and School of Public Health; Edmonton AB
| | | | - Kirtana Arcot
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Kenneth Kwong
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
| | - Andrew D. McRae
- Department of Emergency Medicine; University of Calgary; Calgary AB Canada
| | - George A. Wells
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON
- Ottawa Hospital Research Institute; The Ottawa Hospital; Ottawa ON
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McRae AD, Innes G, Graham M, Lang E, Andruchow JE, Ji Y, Vatanpour S, Abedin T, Yang H, Southern DA, Wang D, Seiden-Long I, DeKoning L, Kavsak P. Undetectable Concentrations of a Food and Drug Administration-approved High-sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival. Acad Emerg Med 2017; 24:1267-1277. [PMID: 28544100 PMCID: PMC5656889 DOI: 10.1111/acem.13229] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/09/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022]
Abstract
Background The objective of this study was to quantify the sensitivity of very low concentrations of high‐sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real‐world clinical practice. Methods This retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs, excluding those with ST‐elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes were AMI at 7, 30, and 90 days. Secondary outcomes included major adverse cardiac events (MACE; all‐cause mortality, AMI, and revascularization) and the individual MACE components. Test characteristics were calculated for hsTnT values from 3 to 200 ng/L . Results A total of 7,130 patients met inclusion criteria. AMI incidences at 7, 30, and 90 days were 5.8, 6.0, and 6.2%. When the hsTnT assay was performed at ED arrival, the limit of blank of the assay (3 ng/L) ruled out 7‐day AMI in 15.5% of patients with 100% sensitivity and negative predictive value (NPV). The limit of detection of the assay (5 ng/L) ruled out AMI in 33.6% of patients with 99.8% sensitivity and 99.95% NPV for 7‐day AMI. The limit of quantification (the Food and Drug Administration [FDA]‐approved cutoff for lower the reportable limit) of 6 ng/L ruled out AMI in 42.2% of patients with 99.8% sensitivity and 99.95% NPV. The sensitivities of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.6, 97.4, and 96.6%, respectively. The NPVs of the cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 99.5, and 99.4%, respectively. A secondary analysis was performed in a subgroup of 3,549 higher‐risk patients who underwent serial troponin testing. In this subgroup, a cutoff of 3 ng/L ruled out 7‐day AMI in 9.6% of patients with 100% sensitivity and NPV, a cutoff of 5 ng/L ruled out 7‐day AMI in 23.3% of patients with 99.7% sensitivity and 99.9% NPV, and a cutoff of 6 ng/L ruled out 7‐day AMI in 29.8% of patients with 99.7 and 99.9% NPV. In the higher‐risk subgroup, the sensitivities of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.8, 97.4, and 96.6%, respectively. In this higher‐risk subgroup, the NPV of cutoffs of <3, <5, and <6 ng/L for 7‐day MACE were 99.7, 98.5, and 98.4%, respectively. Conclusions When used in real‐world clinical practice conditions, hsTnT concentrations < 6 ng/L (below the lower reportable limit for an FDA‐approved assay) at the time of ED arrival can rule out AMI with very high sensitivity and NPV. The sensitivity for MACE is unacceptably low, and thus a single‐troponin rule‐out strategy should only be used in the context of a structured risk evaluation.
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Affiliation(s)
- Andrew D. McRae
- Department of Emergency Medicine; University of Calgary; Calgary Alberta
- Department of Community Health Sciences; University of Calgary; Calgary Alberta
| | - Grant Innes
- Department of Emergency Medicine; University of Calgary; Calgary Alberta
- Department of Community Health Sciences; University of Calgary; Calgary Alberta
| | - Michelle Graham
- Department of Cardiology; University of Alberta; Edmonton Alberta
| | - Eddy Lang
- Department of Emergency Medicine; University of Calgary; Calgary Alberta
- Department of Community Health Sciences; University of Calgary; Calgary Alberta
| | - James E. Andruchow
- Department of Emergency Medicine; University of Calgary; Calgary Alberta
| | - Yunqi Ji
- Alberta Health Services; Calgary Alberta
| | - Shabnam Vatanpour
- Department of Emergency Medicine; University of Calgary; Calgary Alberta
| | | | - Hong Yang
- Department of Community Health Sciences; University of Calgary; Calgary Alberta
| | | | | | | | | | - Peter Kavsak
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton Ontario Canada
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Yu AYX, Quan H, McRae AD, Wagner GO, Hill MD, Coutts SB. A cohort study on physician documentation and the accuracy of administrative data coding to improve passive surveillance of transient ischaemic attacks. BMJ Open 2017; 7:e015234. [PMID: 28674141 PMCID: PMC5734423 DOI: 10.1136/bmjopen-2016-015234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Administrative health data are valuable in health research and disease surveillance, but have low to moderate sensitivity in identifying transient ischaemic attacks (TIA) in the emergency department (ED). We aimed to identify the predictors of coding accuracy for TIA. METHODS The study population was obtained from two ongoing studies on the diagnosis of TIA, minor stroke and stroke mimic. ED charts were manually reviewed by a stroke neurologist to obtain the clinical diagnosis, patient characteristics and content of physician documentation. Administrative data codes were compared with the chart-adjudicated diagnosis to determine cases of misclassification by administrative data. Univariable regression was used to evaluate candidate predictors of disagreement, and the significant variables were tested in a multivariable model to obtain an adjusted estimate of effect. RESULTS Among 417 patients (39.1% TIA, 37.2% minor stroke and 23.7% stroke mimics), there were 122 cases of disagreement between adjudications and administrative data codes for the diagnosis of TIA. The majority of disagreement (n=103/122, 84.4%) arose from adjudicated TIA cases that were misclassified as non-TIA in administrative data coding. There were 78 (18.7%) charts with documented uncertain diagnosis, and 73 (17.5%) charts had no definite diagnosis. The relative risk of disagreement between chart adjudication and administrative data coding when the final diagnosis was uncertain or absent was 1.82(1.36, 2.44) and the risk difference was 18.5%. Multivariable logistic regression analyses confirmed this association using different case definition algorithms. CONCLUSIONS In suspected patients with TIA and minor stroke presenting to the ED, physician documentation was the dominant factor in coding accuracy, supporting the concept that physicians are active participants in administrative data coding. Strategies to improve chart documentation are predicted to have a positive effect on coding accuracy.
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Affiliation(s)
- Amy Y X Yu
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Andrew D McRae
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gabrielle O Wagner
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
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McRae AD, Innes G, Graham M, Lang E, Andruchow JE, Yang H, Ji Y, Vatanpour S, Southern DA, Wang D, Seiden-Long I, DeKoning L, Kavsak P. Comparative Evaluation of 2-Hour Rapid Diagnostic Algorithms for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin T. Can J Cardiol 2017; 33:1006-1012. [PMID: 28669701 DOI: 10.1016/j.cjca.2017.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/27/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Symptoms of acute coronary syndrome account for a large proportion of emergency department (ED) visits and hospitalizations. High-sensitivity troponin can rapidly rule out or rule in acute myocardial infarction (AMI) within a short time of ED arrival. We sought to validate test characteristics and classification performance of 2-hour high-sensitivity troponin T (hsTnT) algorithms for the rapid diagnosis of AMI. METHODS We included consecutive patients from 4 academic EDs with suspected cardiac chest pain who had hsTnT assays performed 2 hours apart (± 30 minutes) as part of routine care. The primary outcome was AMI at 7 days. Secondary outcomes included major adverse cardiac events (mortality, AMI, and revascularization). Test characteristics and classification performance for multiple 2-hour algorithms were quantified. RESULTS Seven hundred twenty-two patients met inclusion criteria. Seven-day AMI incidence was 10.9% and major adverse cardiac event incidence was 13.7%. A 2-hour rule-out algorithm proposed by Reichlin and colleagues ruled out AMI in 59.4% of patients with 98.7% sensitivity and 99.8% negative predictive value (NPV). The 2-hour rule-out algorithm proposed by the United Kingdom National Institute for Health and Care Excellence ruled out AMI in 50.3% of patients with similar sensitivity and NPV. Other exploratory algorithms had similar sensitivity but marginally better classification performance. According to Reichlin et al., the 2-hour rule-in algorithm ruled in AMI in 16.5% of patients with 92.4% specificity and 58.5% positive predictive value. CONCLUSIONS Two-hour hsTnT algorithms can rule out AMI with very high sensitivity and NPV. The algorithm developed by Reichlin et al. had superior classification performance. Reichlin and colleagues' 2-hour rule-in algorithm had poor positive predictive value and might not be suitable for early rule-in decision-making.
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Affiliation(s)
- Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Grant Innes
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Michelle Graham
- Department of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - James E Andruchow
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hong Yang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunqi Ji
- Alberta Health Services, Calgary, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Danielle A Southern
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Dongmei Wang
- Alberta Health Services, Calgary, Alberta, Canada
| | | | | | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Stiell IG, Perry JJ, Clement CM, Brison RJ, Rowe BH, Aaron SD, McRae AD, Borgundvaag B, Calder LA, Forster AJ, Wells GA. Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP. Acad Emerg Med 2017; 24:316-327. [PMID: 27976497 DOI: 10.1111/acem.13141] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/29/2016] [Accepted: 12/03/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS. METHODS This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days. RESULTS We enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score > 1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold score > 1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS. CONCLUSION Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.
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Affiliation(s)
- Ian G. Stiell
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | - Catherine M. Clement
- Clinical Epidemiology Program Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario
| | - Robert J. Brison
- Department of Emergency Medicine Queen's University Kingston Ontario
| | - Brian H. Rowe
- Department of Emergency Medicine and School for Public Health University of Alberta and Alberta Health Services Edmonton Alberta Canada
| | - Shawn D. Aaron
- Department of Medicine University of Ottawa Ottawa Ontario
| | - Andrew D. McRae
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta
| | - Bjug Borgundvaag
- Division of Emergency Medicine University of Toronto Toronto Ontario
| | - Lisa A. Calder
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | | | - George A. Wells
- University of Ottawa Heart Institute University of Ottawa Ottawa Ontario
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Innes GD, Scheuermeyer FX, Law MR, McRae AD, Weber BA, Boyda HN, Lonergan K, Andruchow JE. Sex-related Differences in Emergency Department Renal Colic Management: Females Have Fewer Computed Tomography Scans but Similar Outcomes. Acad Emerg Med 2016; 23:1153-1160. [PMID: 27357754 DOI: 10.1111/acem.13041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/12/2016] [Accepted: 06/27/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sex-related differences occur in many areas of medicine. Emergency department (ED) studies have suggested differences in access to care, diagnostic imaging use, pain management, and intervention. We investigated sex-based differences in the care and outcomes for ED patients with acute renal colic. METHODS This was a multicenter population-based retrospective observational cohort study using administrative data and supplemented by structured chart review. All patients seen in Calgary Health Region EDs between January 1 and December 31, 2014, with an ED diagnosis of renal colic based on the following ICD-10 codes were eligible for inclusion: calculus of kidney (N200), calculus of ureter (N201), calculus of kidney with calculus of ureter (N202), hydronephrosis with renal and ureteral calculous obstruction (N132), unspecified renal colic (N23), and unspecified urinary calculus (N209). ED visit data and test results were accessed in the regional ED clinical database. Stone characteristics were captured from diagnostic imaging reports. Regional hospital databases were used to identify subsequent ED encounters, hospital admissions, and surgical procedures within 60 days. Outcomes were stratified by sex. The primary outcome, intended as a marker of overall effectiveness of ED care, was the unscheduled 7-day ED revisit rate among patients who were discharged home after their index ED visit. Secondary outcomes included ED pain management as reflected by administration of narcotics or intravenous nonsteroidals, the performance of advanced imaging-either ultrasound (US) or computed tomography (CT), and the proportion of patients who required hospitalization or surgical intervention within 60 days. RESULTS From January 1 to December 31, 2014, a total of 3,104 eligible patients were studied: 1,111 women (35.8%) and 1,993 men (64.2%). Baseline characteristics, access times, analgesic use, and admission rates were similar in both groups. Men were more likely to have CT (68.9% vs. 58.5%, difference = 10.4%, 95% confidence interval [CI] = 6.8 to 14.0) while women were more likely to have US (20.8% vs. 9.6%, difference = 11.2%, 95% CI = 8.4 to 13.9). At 7 days, 17.9% of women and 19.0% of men who were discharged after their index ED visit required an ED revisit (difference = 1.1%, 95% CI = -2.8 to 4.9). Men were more likely to be hospitalized at 7 days (9.8% vs. 6.5%, difference = 3.3%, 95% CI = 0.6 to 6.0). CONCLUSION This study shows greater reliance on US in females but no other sex-specific differences in the management of ED patients with acute renal colic. Higher CT use in men was not associated with improved outcomes, and we found no important differences in access to care, diagnostic or treatment intensity, or revisit rates as a marker of care effectiveness.
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Affiliation(s)
- Grant D. Innes
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Rockyview General Hospital Calgary Alberta Canada
| | - Frank X. Scheuermeyer
- Department of Emergency Medicine St. Paul's Hospital Vancouver British Columbia Canada
| | - Michael R. Law
- School for Population and Public Health and the Centre for Health Services and Policy Research University of British Columbia Vancouver British Columbia Canada
| | - Andrew D. McRae
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Department of Community Health Sciences Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Rockyview General Hospital Calgary Alberta Canada
| | - Bryce A. Weber
- Rockyview General Hospital Calgary Alberta Canada
- Division of Urological Sciences Cumming School of Medicine University of Calgary Calgary Alberta Canada
| | - Heidi N. Boyda
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
| | | | - James E. Andruchow
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta Canada
- Rockyview General Hospital Calgary Alberta Canada
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