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Kraft R, Mercuri M, Clayton N, Worster A, Mercier E, Emond M, Varner C, McLeod SL, Eagles D, Stiell I, Barbic D, Morris J, Jeanmonod R, Kagoma YK, Shoamanesh A, Engels PT, Sharma S, Papaioannou A, Parpia S, Buchanan I, Ali M, de Wit K. Emergency physician gender and head computed tomography orders for older adults who have fallen. Acad Emerg Med 2024. [PMID: 38644592 DOI: 10.1111/acem.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/25/2024] [Accepted: 04/06/2024] [Indexed: 04/23/2024]
Abstract
OBJECTIVE Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.
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Affiliation(s)
- Rhys Kraft
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Philosophy, University of Johannesburg, Auckland Park, Gauteng, South Africa
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- VITAM-Centre de Recherche en Santé Durable, Université Laval, Québec, Quebec, Canada
| | - Marcel Emond
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- VITAM-Centre de Recherche en Santé Durable, Université Laval, Québec, Quebec, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Eagles
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Barbic
- Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Québec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Québec, Canada
| | - Rebecca Jeanmonod
- Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Yoan K Kagoma
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario, Canada
| | - Ian Buchanan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mariyam Ali
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Dubucs X, Mercier É, Boucher V, Lauzon S, Balen F, Charpentier S, Emond M. Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults. J Emerg Med 2024:S0736-4679(24)00007-6. [PMID: 38714480 DOI: 10.1016/j.jemermed.2024.01.005] [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: 07/14/2023] [Revised: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 05/10/2024]
Abstract
BACKGROUND Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury. OBJECTIVE This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages. METHODS We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1-3), vulnerable-frail (CFS score 4-6), and severely frail (CFS score 7-9). RESULTS A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4-16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44-3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41-13.6; p = 0.34) in those considered severely frail. CONCLUSIONS This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.
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Affiliation(s)
- Xavier Dubucs
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; Université Laval, Québec, Québec, Canada; Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Éric Mercier
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; VITAM, Centre de Recherche en Santé Durable de l'Université Laval, Québec, Québec, Canada
| | - Valérie Boucher
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada
| | | | - Frederic Balen
- Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Sandrine Charpentier
- Centre d'Epidémiologie et de Recherche en Santé des Populations, UMR 1295, Toulouse, France; Pôle Médecine d'Urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Marcel Emond
- Centre Hospitalier Universitaire de Québec, Université Laval Research Center, Axe Santé des Populations et Pratiques Optimales en Santé, D'Estimauville, Québec, Québec, Canada; Université Laval, Québec, Québec, Canada
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Gagnon S, Nadeau A, Tanguay K, Archambault PM, Brousseau AA, Carmichael PH, Emond M, Deshaies JF, Benhamed A, Blanchard PG, Mowbray FI, Mercier E. Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study. CAN J EMERG MED 2023; 25:953-958. [PMID: 37853307 DOI: 10.1007/s43678-023-00600-4] [Citation(s) in RCA: 1] [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: 05/21/2023] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. METHODS This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65 years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. RESULTS A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). CONCLUSION When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.
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Affiliation(s)
- Samuel Gagnon
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
| | - Alexandra Nadeau
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
| | - Katherine Tanguay
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Patrick M Archambault
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière Appalaches, Lévis, QC, Canada
| | - Audrey-Anne Brousseau
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine et sciences de la santé, Université de Sherbrooke, Sherbooke, QC, Canada
| | | | - Marcel Emond
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Jean-Francois Deshaies
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière Appalaches, Lévis, QC, Canada
| | - Axel Benhamed
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hopitaux Civils de Lyon, Lyon, France
| | - Pierre-Gilles Blanchard
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada
| | - Fabrice I Mowbray
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | - Eric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Axe santé des populations et pratiques optimales en santé, Quebec, QC, Canada.
- VITAM-Centre de recherche en santé durable, Quebec, QC, Canada.
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Quebec, QC, Canada.
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Benhamed A, Batomen B, Boucher V, Yadav K, Isaac CJ, Mercier E, Bernard F, Blais-L'écuyer J, Tazarourte K, Emond M. Relationship between systolic blood pressure and mortality in older vs younger trauma patients - a retrospective multicentre observational study. BMC Emerg Med 2023; 23:105. [PMID: 37726708 PMCID: PMC10508012 DOI: 10.1186/s12873-023-00863-1] [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: 09/09/2022] [Accepted: 08/02/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts. METHODS We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions. RESULTS A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range. CONCLUSION The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor.
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Affiliation(s)
- Axel Benhamed
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
- Hospices Civils de Lyon, Service d'Accueil des Urgences - SAMU 69, Centre Hospitalier Universitaire Edouard Herriot, Lyon, 69003, France
| | - Brice Batomen
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
| | - Francis Bernard
- Critical Care Unit, Hopital du Sacre-Coeur de Montreal, Montreal, QC, Canada
| | - Julien Blais-L'écuyer
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
| | - Karim Tazarourte
- Hospices Civils de Lyon, Service d'Accueil des Urgences - SAMU 69, Centre Hospitalier Universitaire Edouard Herriot, Lyon, 69003, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, 69003, France
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada.
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada.
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Benhamed A, Fraticelli L, Claustre C, Gossiome A, Cesareo E, Heidet M, Emond M, Mercier E, Boucher V, David JS, El Khoury C, Tazarourte K. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49:1707-1715. [PMID: 36508023 DOI: 10.1007/s00068-022-02186-5] [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: 08/17/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the incidence of undertriage in major trauma, its determinant, and association with mortality. METHODS A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage. RESULTS A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36). CONCLUSIONS In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France.
| | | | - Clément Claustre
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Eric Cesareo
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Matthieu Heidet
- SAMU 94 and Emergency Department, Assistance Publique-Hôpitaux de Paris (AP-HP) University Hospital Henri Mondor, Créteil, France
- Université Paris-Est Créteil (UPEC), EA-3956 (CIR), Créteil, France
| | - Marcel Emond
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Valérie Boucher
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jean-Stéphane David
- Trauma Centre and Critical Care, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France
| | - Carlos El Khoury
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
- Emergency Department, Médipôle Hôpital Mutualiste, Villeurbanne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
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Benhamed A, Isaac CJ, Boucher V, Yadav K, Mercier E, Moore L, D'Astous M, Bernard F, Dubucs X, Gossiome A, Emond M. Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study. Eur J Emerg Med 2023; 30:271-279. [PMID: 37161755 DOI: 10.1097/mej.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | | | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Krishan Yadav
- Department of Emergency Medicine-University of Ottawa
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec
| | | | - Francis Bernard
- Services de soins intensifs, Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM)-Université de Montréal, Montréal, Québec, Canada
| | - Xavier Dubucs
- Service d'urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
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Brubacher JR, Chan H, Erdelyi S, Yuan Y, Daoust R, Vaillancourt C, Rowe B, Lee J, Mercier E, Atkinson P, Davis P, Clarke D, Taylor J, Macpherson A, Emond M, Al-Hakim D, Horwood C, Wishart I, Magee K, Rao J, Eppler J. High-'n'-dry? A comparison of cannabis and alcohol use in drivers presenting to hospital after a vehicular collision. Addiction 2023; 118:1507-1516. [PMID: 36898848 DOI: 10.1111/add.16186] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023]
Abstract
DESIGN This was a prospective observational study. BACKGROUND AND AIMS The characteristics of cannabis-involved motor vehicle collisions are poorly understood. This study of injured drivers identifies demographic and collision characteristics associated with high tetrahydrocannabinol (THC) concentrations. SETTING The study was conducted in 15 Canadian trauma centres between January 2018 and December 2021. CASES The cases (n = 6956) comprised injured drivers who required blood testing as part of routine trauma care. MEASUREMENTS We quantified whole blood THC and blood alcohol concentration (BAC) and recorded driver sex, age and postal code, time of crash, crash type and injury severity. We defined three driver groups: high THC (THC ≥ 5 ng/ml and BAC = 0), high alcohol (BAC ≥ 0.08% and THC = 0) and THC/BAC-negative (THC = 0 = BAC). We used logistic regression techniques to identify factors associated with group membership. FINDINGS Most injured drivers (70.2%) were THC/BAC-negative; 1274 (18.3%) had THC > 0, including 186 (2.7%) in the high THC group; 1161 (16.7%) had BAC > 0, including 606 (8.7%) in the high BAC group. Males and drivers aged less than 45 years had higher adjusted odds of being in the high THC group (versus the THC/BAC-negative group). Importantly, 4.6% of drivers aged less than 19 years had THC ≥ 5 ng/ml, and drivers aged less than 19 years had higher unadjusted odds of being in the high THC group than drivers aged 45-54 years. Males, drivers aged 19-44 years, rural drivers, seriously injured drivers and drivers injured in single-vehicle, night-time or weekend collisions had higher adjusted odds ratios (aORs) for being in the high alcohol group (versus THC/BAC-negative). Drivers aged less than 35 or more than 65 years and drivers involved in multi-vehicle, daytime or weekday collisions had higher adjusted odds for being in the high THC group (versus the high BAC group). CONCLUSIONS In Canada, risk factors for cannabis-related motor vehicle collisions appear to differ from those for alcohol-related motor vehicle collisions. The collision factors associated with alcohol (single-vehicle, night-time, weekend, rural, serious injury) are not associated with cannabis-related collisions. Demographic factors (young drivers, male drivers) are associated with both alcohol and cannabis-related collisions, but are more strongly associated with cannabis-related collisions.
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Affiliation(s)
- J R Brubacher
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - H Chan
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - S Erdelyi
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - Y Yuan
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - R Daoust
- Department of Emergency Medicine, University of Montréal, Montréal, QC, Canada
| | - C Vaillancourt
- Department of Emergency Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - B Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - J Lee
- Department of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - E Mercier
- Department of Emergency Medicine, Université Laval, Québec City, QC, Canada
| | - P Atkinson
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, St John, NB, Canada
| | - P Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - D Clarke
- Department of Surgery (Neurosurgery), Dalhousie University, Halifax, NS, Canada
| | - J Taylor
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - A Macpherson
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - M Emond
- Department of Emergency Medicine, Université Laval, Québec City, QC, Canada
| | - D Al-Hakim
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
| | - C Horwood
- Department of Emergency Medicine, Memorial University, St John, NB, Canada
| | - I Wishart
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - K Magee
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - J Rao
- Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - J Eppler
- Department of Emergency Medicine, University of British Columbia, Columbia, BC, Canada
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Daoust R, Paquet J, Chauny JM, Williamson D, Huard V, Arbour C, Emond M, Rouleau D, Cournoyer A. Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol. BMJ Open 2023; 13:e069230. [PMID: 37225265 PMCID: PMC10230879 DOI: 10.1136/bmjopen-2022-069230] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER NCT05555576 ClinicalTrials.Gov PRS.
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Affiliation(s)
- Raoul Daoust
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - David Williamson
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Vérilibe Huard
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Emond
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Dominique Rouleau
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Alexis Cournoyer
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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Desmeules F, Mercier É, Blanchard PG, Emond M. Do we call FAST enough when it matters the most? CAN J EMERG MED 2023; 25:361-362. [PMID: 37142855 DOI: 10.1007/s43678-023-00510-5] [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: 05/06/2023]
Affiliation(s)
- Francis Desmeules
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université Laval, 1050, Avenue de la Médecine, Local 4617, Québec, QC, G1V 0A6, Canada.
| | - Éric Mercier
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université Laval, 1050, Avenue de la Médecine, Local 4617, Québec, QC, G1V 0A6, Canada
- VITAM - Centre de recherche en santé durable, Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- CHU de Québec - Hôpital de L'Enfant-Jésus, H-608, 1401 18e rue, Québec, G1J 1Z4, Canada
| | - Pierre-Gilles Blanchard
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université Laval, 1050, Avenue de la Médecine, Local 4617, Québec, QC, G1V 0A6, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- CHU de Québec - Hôpital de L'Enfant-Jésus, H-608, 1401 18e rue, Québec, G1J 1Z4, Canada
| | - Marcel Emond
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université Laval, 1050, Avenue de la Médecine, Local 4617, Québec, QC, G1V 0A6, Canada
- VITAM - Centre de recherche en santé durable, Québec, Canada
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- CHU de Québec - Hôpital de L'Enfant-Jésus, H-608, 1401 18e rue, Québec, G1J 1Z4, Canada
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Beaumont-Boileau R, Nadeau A, Tardif PA, Malo C, Emond M, Moore L, Clément J, Mercier E. Performance of a provincial prehospital trauma triage protocol: A retrospective audit. Trauma 2023. [DOI: 10.1177/14604086231156263] [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] [Indexed: 03/17/2023]
Abstract
Objective To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec. Methods The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) < 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death. Results A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care. Conclusion The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.
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Affiliation(s)
- Roxane Beaumont-Boileau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Alexandra Nadeau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Pier-Alexandre Tardif
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Christian Malo
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Marcel Emond
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Lynne Moore
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Julien Clément
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
- Département de Chirurgie, CHU de Québec, Québec, Canada
| | - Eric Mercier
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
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Dubucs X, Lecuyer L, Balen F, Houze Cerfon CH, Emond M, Lepage B, Colineaux H, Charpentier S. Validation of the cutaneous impact location to predict intracranial lesion among elderly admitted to the Emergency Department after a ground-level fall. Injury 2023; 54:1306-1313. [PMID: 36841696 DOI: 10.1016/j.injury.2023.02.023] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/30/2023] [Accepted: 02/10/2023] [Indexed: 02/27/2023]
Abstract
INTRODUCTION In the Emergency Departments, almost one out of two head CT scans are carried out for traumatic brain injuries among elderly victims of ground level-falls. Recently, a new predictive factor for intracranial lesions in this population has been suggested: presence and location of cutaneous impact. The aim of this study was to establish determinants of intracranial lesion among older patients admitted to EDs due to ground-level falls with traumatic brain injury using the head cutaneous impact location. METHODS A retrospective, observational and monocentric study of patients admitted to Emergency Department for ground-level falls with traumatic brain injury was carried out between 01 January 2017 and 31 July 2017. The primary outcome was identification of an acute intracranial lesion. A bootstrap procedure was employed to evaluate performance and internal validity of the final model. RESULTS Among the 1036 patients included, the mean age was 85.6 (SD 7.6) years and 94/1036 (9.1%, 95% CI 7.4-10.9) patients presented with an acute intracranial lesion. Multivariable analysis adjusted by bootstrap shrinkage showed that compared with temporal-parietal or occipital impact, Odds Ratio of intracranial lesions were 0.61 (95% CI 0.39-0.95, p = 0.03) in patients with frontal impact, 0.27 (95% CI 0.12-0.59, p = 0.001) in patients with facial impact and 0.21 (95% CI 0.06-0.77, p = 0.018) in patients without cutaneous impact. Subcutaneous hematoma (OR 1.97, p = 0.007), loss of consciousness (OR 4.66, p<0.001), fall-related amnesia (OR 2.58, p = 2.6), vomiting (OR 2.62, p = 0.002) and altered Glasgow Score (OR 6.79, p<0.001) were as well associated with high risk of intracranial lesion. Taking antiplatelets or anticoagulants were not associated with an increased risk of intracranial lesions. The model discrimination was adequate (C-statistic 0.79; 95% CI 0.73 - 0.85). CONCLUSION Our results establish specific determinants of intracranial lesions among elderly after ground level-falls. The cutaneous impact location may identify patients with high risk of intracranial lesion. Further researches are needed to propose a specific score based on these determinants so as to better target Head CT scan use.
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Affiliation(s)
- Xavier Dubucs
- Emergency Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France; EQUITY Team, CERPOP, INSERM, Toulouse, France.
| | - Lucie Lecuyer
- Emergency Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France
| | - Frederic Balen
- Emergency Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France; EQUITY Team, CERPOP, INSERM, Toulouse, France
| | | | - Marcel Emond
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Benoit Lepage
- EQUITY Team, CERPOP, INSERM, Toulouse, France; Epidemiology Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France
| | | | - Sandrine Charpentier
- Emergency Department, Centre Hospitalier Universitaire de Toulouse Hospital, Toulouse, France; EQUITY Team, CERPOP, INSERM, Toulouse, France
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12
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Matifat E, Berger Pelletier E, Brison R, Hébert LJ, Roy JS, Woodhouse L, Berthelot S, Daoust R, Sirois MJ, Booth R, Gagnon R, Miller J, Tousignant-Laflamme Y, Emond M, Perreault K, Desmeules F. Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis. Trials 2023; 24:84. [PMID: 36747305 PMCID: PMC9900999 DOI: 10.1186/s13063-023-07100-x] [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: 11/11/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Advanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians' burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD). OBJECTIVES To compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs. METHODS This trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time. DISCUSSION MSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD. TRIAL REGISTRATION ClinicalTrials.gov NCT05545917 . Registered on September 19, 2022.
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Affiliation(s)
- E. Matifat
- grid.14848.310000 0001 2292 3357Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec Canada
| | - E. Berger Pelletier
- grid.23856.3a0000 0004 1936 8390Faculty of Medicine, Université Laval Québec, Québec, Canada
| | - R. Brison
- grid.410356.50000 0004 1936 8331Department of Emergency Medicine, Queen’s University, Kingston, Ontario Canada
| | - L. J. Hébert
- grid.23856.3a0000 0004 1936 8390Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Québec, Canada ,grid.23856.3a0000 0004 1936 8390Department of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - J.-S. Roy
- grid.23856.3a0000 0004 1936 8390Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Québec, Canada ,grid.23856.3a0000 0004 1936 8390Department of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - L. Woodhouse
- grid.429997.80000 0004 1936 7531Tufts University School of Medicine, Public Health and Community Medicine, Boston, Arizona USA
| | - S. Berthelot
- grid.23856.3a0000 0004 1936 8390Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - R. Daoust
- grid.23856.3a0000 0004 1936 8390Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - M.-J. Sirois
- grid.23856.3a0000 0004 1936 8390Department of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - R. Booth
- grid.410356.50000 0004 1936 8331School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, Ontario Canada
| | - R. Gagnon
- grid.23856.3a0000 0004 1936 8390Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Québec, Canada ,grid.23856.3a0000 0004 1936 8390Department of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - J. Miller
- grid.410356.50000 0004 1936 8331School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, Ontario Canada
| | - Y. Tousignant-Laflamme
- grid.86715.3d0000 0000 9064 6198School of Rehabilitation, Faculty of Medicine and Health Sciences, Sherbrooke University, Sherbrooke, Québec, Canada
| | - M. Emond
- grid.23856.3a0000 0004 1936 8390Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - K. Perreault
- grid.23856.3a0000 0004 1936 8390Center for Interdisciplinary Research in Rehabilitation and Social Integration (Cirris), Québec, Canada ,grid.23856.3a0000 0004 1936 8390Department of Rehabilitation, Faculty of Medicine, Laval University, Québec, Québec, Canada
| | - F. Desmeules
- grid.14848.310000 0001 2292 3357Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montréal, Québec Canada ,grid.14848.310000 0001 2292 3357School of Rehabilitation, Faculty of Medicine, University of Montréal, Montréal, Québec, Canada
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Benhamed A, Emond M, Mercier E, Heidet M, Gauss T, Saint-Supery P, Yadav K, David JS, Claustre C, Tazarourte K. Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults. Int J Environ Res Public Health 2023; 20:1975. [PMID: 36767343 PMCID: PMC9916137 DOI: 10.3390/ijerph20031975] [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] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Background: Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods: A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results: 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions: Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Marcel Emond
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Eric Mercier
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Matthieu Heidet
- SAMU 94, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), 75610 Paris, France
| | - Tobias Gauss
- Anaesthesia Critical Care, Grenoble Alpes University Hospital, 38700 Grenoble, France
| | - Pierre Saint-Supery
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada
| | - Jean-Stéphane David
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
| | - Clement Claustre
- RESUVal Trauma Network, Centre Hospitalier Lucien Hussel, 38200 Vienne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
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Abstract
OBJECTIVES To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED). DESIGN Scoping review. METHODS Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine. INFORMATION SOURCES MEDLINE, EMBASE, Cochrane and Web of Science. RESULTS A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes. CONCLUSION Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.
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Affiliation(s)
- Jennifer Truchot
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Quebec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Quebec, Canada
- Emergency Department, CHU Cochin- Université de Paris, APHP, Paris, France
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Valérie Boucher
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Quebec, Canada
| | - Winny Li
- 5Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Guillaume Martel
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Quebec, Canada
| | - Eva Jouhair
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Quebec, Canada
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Éliane Raymond-Dufresne
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Quebec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Andrew Petrosoniak
- 5Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marcel Emond
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Quebec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Quebec, Canada
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Quebec, Canada
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15
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Coulombe P, Tardif PA, Nadeau A, Beaumont-Boileau R, Malo C, Emond M, Blanchard PG, Moore L, Mercier E. Accuracy of Prehospital Trauma Triage to Select Older Adults Requiring Urgent and Specialized Trauma Care. J Surg Res 2022; 275:281-290. [DOI: 10.1016/j.jss.2022.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/12/2022] [Accepted: 02/12/2022] [Indexed: 10/18/2022]
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16
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Benhamed A, Ndiaye A, Emond M, Lieutaud T, Boucher V, Gossiome A, Laumon B, Gadegbeku B, Tazarourte K. Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study. PLoS One 2022; 17:e0268202. [PMID: 35522686 PMCID: PMC9075643 DOI: 10.1371/journal.pone.0268202] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 01/25/2022] [Accepted: 04/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries.
Methods
We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome.
Results
A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25–58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70–79 years age group, while this was observed in the 20–29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]).
Conclusion
Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.
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Affiliation(s)
- Axel Benhamed
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
- * E-mail:
| | - Amina Ndiaye
- IFSTTAR, Université Gustave Eiffel, Bron, France
| | - Marcel Emond
- Département d’urgences, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | | | - Valérie Boucher
- Research Centre, CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Amaury Gossiome
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
| | | | | | - Karim Tazarourte
- Service d’Accueil des Urgences–SAMU 69, Centre Hospitalier Universitaire Édouard Herriot, Lyon, Hospices Civils de Lyon, France
- INSERM U1290 (RESHAPE), Université de Lyon 1, Lyon, France
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17
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Benhamed A, Boucher V, Emond M. Pain management in emergency department older adults with pelvic fracture: still insufficient. CAN J EMERG MED 2022; 24:245-246. [PMID: 35403990 DOI: 10.1007/s43678-022-00299-9] [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] [Received: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Axel Benhamed
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,Département de Médecine d'urgence, CHU de Québec, Université Laval, Québec, QC, Canada.,Hospices Civils de Lyon, Centre Hospitalier Universitaire Édouard Herriot, 69003, Lyon, France
| | - Valérie Boucher
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Marcel Emond
- Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada. .,Département de Médecine d'urgence, CHU de Québec, Université Laval, Québec, QC, Canada. .,CHU de Québec - Hôpital de L'Enfant-Jésus, , rue, H-608, Québec, 1401, 18G1J 1Z4, Canada.
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18
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Dufour-Neyron H, Tanguay K, Nadeau A, Emond M, Harrisson J, Robert S, Capolla-Daneau N, Groulx M, Carmichael PH, Mercier E. Prehospital Use of the Esophageal Tracheal Combitube Supraglottic Airway Device: A Retrospective Cohort Study. J Emerg Med 2022; 62:324-331. [PMID: 35067394 DOI: 10.1016/j.jemermed.2021.11.005] [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: 05/10/2021] [Revised: 10/26/2021] [Accepted: 11/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the province of Quebec (Canada), paramedics use the esophageal tracheal Combitube (ETC) for prehospital airway management. OBJECTIVES Our main objective was to determine the proportion of patients with successful ventilation achieved after ETC use. Our secondary aim was to determine the number of ETC insertion attempts required to ventilate the patient. METHOD This is a retrospective cohort study. All patients who had ≥1 attempt to insert an ETC during prehospital care between January 1, 2017 and December 31, 2018 were included. Prehospital and in-hospital data were extracted. Successful ventilation was defined as thorax elevation, lung sounds on chest auscultation, or positive end-tidal capnography after ETC insertion. RESULTS A total of 580 emergency medical services interventions (99.3% cardiac arrests) were included. Most patients were men (62.5%) with a mean age 67.0 years (SD 17.6 years), and 35 (13.1%) of the 298 patients transported to emergency department survived to hospital discharge. Sufficient information to determine whether ventilation was successful or not was available for 515 interventions. Ventilation was achieved during 427 (82.7%) of these interventions. The number of ETC insertion attempts was available for 349 of the 427 successful ETC use. Overall, the first insertion resulted in successful ventilation during 294 interventions for an overall proportion of first-pass success ranging between 57.1% and 72.1%. CONCLUSION Proportions of successful ventilation and ETC first-pass success are lower than those reported in the literature with supraglottic airway devices. The reasons explaining these lower rates and their impact on patient-centered outcomes need to be studied.
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Affiliation(s)
| | | | | | - Marcel Emond
- Centre de recherche du CHU de Québec, Université Laval; VITAM - Centre de recherche en santé durable de l'Université Laval; Département de médecine d'urgence, Institut de Cardiologie et de Pneumologie de l'Université Laval; Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale
| | - Jessica Harrisson
- Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale
| | - Sébastien Robert
- Département de médecine d'urgence, Institut de Cardiologie et de Pneumologie de l'Université Laval
| | - Nicolas Capolla-Daneau
- Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale
| | | | | | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval; VITAM - Centre de recherche en santé durable de l'Université Laval; Département de médecine d'urgence, Institut de Cardiologie et de Pneumologie de l'Université Laval; Direction des services préhospitaliers d'urgence, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale
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19
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Ferguson E, Yadav K, Sharma MA, Sivilotti ML, Emond M, STIELL I, Stotts G, Lee J, Worster A, Morris J, Cheung KW, Jin AY, Oczkowski WJ, Sahlas D, Murray H, Mackey A, Verreault S, Camden MC, Yip S, Teal PA, GLADSTONE DJ, Boulos MI, Chagnon N, Shouldice E, Atzema C, Slaoui T, Teitelbaum JS, Nemnom MJ, Wells G, Nath A, Perry JJ. Abstract WP96: Computed Tomography Identifies Patients At High Risk For Stroke After Transient Ischemic Attack Or Non Disabling Stroke. A Prospective, Multicenter Validation Study. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp96] [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] [Indexed: 11/16/2022]
Abstract
Background and Objectives:
CT findings of acute and chronic ischemia are associated with stroke risk. We sought to validate these associations in a large prospective cohort of patients with TIA or minor stroke.
Methods:
We included prospectively enrolled emergency department patients from 13 centers with a final ED diagnosis of TIA or non-disabling stroke who had a computed tomography (CT) within 24 hours. Primary outcome was stroke within 90 days. Secondary outcomes were stroke within 2 or 7 days. CT findings were abstracted from the radiology report and classified for the presence of acute ischemia, chronic ischemia or microangiopathy. Multivariable logistic regression was used to test associations with primary and secondary endpoints.
Results:
In total 8,670 patients were enrolled between May 2010 to May 2017 and 8,382 had a CT within 24 hours. 4,547 patients had evidence of acute ischemia, chronic ischemia, or microangiopathy on CT imaging, of whom 175 had a subsequent stroke within 90 days (3.8% subsequent stroke rate; OR, 2.33; 95% CI, 1.62-3.36; P<0.001). Findings associated with an increased risk of stroke at 90 days were acute ischemia alone (6.0%; OR, 2.42; 95% CI, 1.03-5.66; P=0.04), acute ischemia with microangiopathy (10.7%; OR, 3.34; 95% CI, 1.57-7.14; P=0.002), chronic ischemia with microangiopathy (5.2%; OR, 1.83; 95% CI, 1.34-2.50; P<0.001), and acute ischemia with chronic ischemia and microangiopathy (10.9%; OR; 3.49; 95% CI, 1.54-7.91; P=0.003). ). Acute ischemia with chronic ischemia and microangiopathy were most strongly associated with increased risk of subsequent stroke within 2 days (OR, 4.36; 95% CI 1.31-14.54), and 7 days (OR, 4.50; 95%CI, 1.73-11.69).
Conclusion:
In patients with TIA or non-disabling stroke, CT evidence of acute ischemia with chronic ischemia and/or microangiopathy significantly increases the risk of subsequent stroke within 90 days of index visit. The combination of all 3 findings results in the greatest early risk.
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Affiliation(s)
- Emma Ferguson
- Dept of Emergency Medicine, Univ of Ottawa, Ottawa, Canada
| | - Krishan Yadav
- Dept of Emergency Medicine, Univ of Ottawa, Ottawa, Canada
| | | | | | - Marcel Emond
- Div of Emergency Medicine, Université Laval, Quebec City, Canada
| | | | | | - Jacques Lee
- Dept of Emergency Medicine, Univ of Toronto, Toronto, Canada
| | | | | | | | | | | | | | - Heather Murray
- Dept of Emergency Medicine, Queen's Univ, Kingston, Canada
| | - Ariane Mackey
- Cntr Hospier Affili?, Hopital de l'Enfant-J?sus, Quebec City, Canada
| | | | | | | | | | | | - Mark I Boulos
- Sunnybrook and Women's Health Sciences Cntr, Toronto, Canada
| | | | | | - Clare Atzema
- Institute for Clinical Evaluative S, Toronto, Canada
| | | | | | | | | | - Avik Nath
- Dept of Emergency Medicine, Univ of Ottawa, Ottawa, Canada
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20
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Daoust R, Paquet J, Huard V, Chauny JM, Lavigne G, Williamson D, Choinière M, Lang E, Yan JW, Perry JJ, Emond M, Gosselin S, Cournoyer A. Association between fentanyl treatment for acute pain in the emergency department and opioid use two weeks after discharge. Am J Emerg Med 2021; 52:137-142. [PMID: 34922233 DOI: 10.1016/j.ajem.2021.11.041] [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: 10/20/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids. METHODS Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores. RESULTS We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09). CONCLUSIONS Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.
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Affiliation(s)
- Raoul Daoust
- Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Département Médecine de Famille et Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada; Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada.
| | - Jean Paquet
- Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Centre for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Verilibe Huard
- Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Département Médecine de Famille et Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Département Médecine de Famille et Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada; Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Gilles Lavigne
- Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Faculties of Dental Medicine and Medicine, Université de Montréal, Montréal, Québec, Canada
| | - David Williamson
- Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marcel Emond
- Département Médecine de Famille et Médecine d'Urgence, Faculté de Médecine, Université Laval, Québec, Canada; Département d'urgence du Centre Hospitalier Universitaire de Québec, Université Laval, Québec, Canada
| | - Sophie Gosselin
- Department of Emergency Medicine, CISSS Montérégie-Centre, Greenfield Park, Québec, Canada
| | - Alexis Cournoyer
- Department of Emergency Medicine, Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada; Département Médecine de Famille et Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada; Research Centre, CIUSSS-Nord-de-l'Île de-Montréal, Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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21
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Hegg S, Sirois MJ, Carmichael PH, Truchot J, Jouhair EM, Nadeau A, Emond M. [Relation between grip strength of independent elders and functional decline following an emergency department visit : a pan-Canadian study]. Rev Med Liege 2021; 76:868-874. [PMID: 34881830] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine whether grip strength and fear of falling are associated with functional decline at 3 or 6 months after a minor trauma assessed in the emergency department. METHOD Prospective multicenter cohort study of patient's aged 65 years and older, independent for activities of daily living, consulting the emergency department for minor trauma. Functional status, fear of falling, and grip strength measurements were collected. Functional decline was measured at 3 and 6 months. STATISTICS Two groups were compared : one with functional decline, the other without. A ROC curve explored the predictive power of grip strength and initial fear of falling on the occurrence of functional decline. RESULTS Participants were 74.7 years old, 52 % men. Initial peak grip strengths were identical (p superior to 0.05). Grip strength and fear of falling were not predictive of functional decline (p = 0.55 and p = 0.53). However, fear of falling was associated with functional decline (OR: 1.141 95 % CI [1.032-1.261]; p = 0.009). CONCLUSION In the autonomous elder with minor trauma in the emergency department, grip strength is not associated with subsequent functional decline. But fear of falling is associated with decline at 6 months.
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Affiliation(s)
- S Hegg
- Axe Santé des Populations, CHU, Québec, Canada
- Centre Excellence sur le Vieillissement, Québec, Canada
- Université Laval, Québec, Canada
| | - M J Sirois
- Axe Santé des Populations, CHU, Québec, Canada
- Centre Excellence sur le Vieillissement, Québec, Canada
- Université Laval, Québec, Canada
| | | | | | | | - A Nadeau
- Axe Santé des Populations, CHU, Québec, Canada
- Centre Excellence sur le Vieillissement, Québec, Canada
| | - M Emond
- Axe Santé des Populations, CHU, Québec, Canada
- Centre Excellence sur le Vieillissement, Québec, Canada
- Université Laval, Québec, Canada
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22
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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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de Wit K, Mercuri M, Clayton N, Worster A, Mercier E, Emond M, Varner C, McLeod SL, Eagles D, Stiell I, Barbic D, Morris J, Jeanmonod R, Kagoma Y, Shoamanesh A, Engels PT, Sharma S, Kearon C, Papaioannou A, Parpia S. Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department. BMJ Open 2021; 11:e044800. [PMID: 34215600 PMCID: PMC8256748 DOI: 10.1136/bmjopen-2020-044800] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding. METHODS AND ANALYSIS This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule. ETHICS AND DISSEMINATION The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media. TRIAL REGISTRATION NUMBER NCT03745755.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Clayton
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Emergency Department, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Marcel Emond
- Centre de recherche du CHU de Québec, Université Laval, Québec, Quebec, Canada
- Centre de recherche sur les soins et les services de première ligne, Université Laval, Québec, Québec, Canada
| | - Catherine Varner
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
- Family and community medicine, University of Toronto, Toronto, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David Barbic
- Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Québec, Québec, Canada
| | - Rebecca Jeanmonod
- Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Yoan Kagoma
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul T Engels
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, McMaster University, Hamilton, Ontario, Canada
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Groulx M, Emond M, Boudreau-Drouin F, Cournoyer A, Nadeau A, Blanchard PG, Mercier E. Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies. Resuscitation 2021; 162:292-303. [PMID: 33766663 DOI: 10.1016/j.resuscitation.2021.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/19/2020] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA). METHODS A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered. RESULTS A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies. CONCLUSIONS No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.
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Affiliation(s)
- Mathieu Groulx
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Marcel Emond
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Felix Boudreau-Drouin
- Faculté de Médecine, Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Alexis Cournoyer
- Faculté de médecine, Université de Montréal, Québec, Canada; Département de médecine d'urgence, Hôpital du Sacré-Cœur, Montréal, Québec, Canada; Département de médecine d'urgence, Hôpital Maisonneuve-Rosemont, Montréal, Canada
| | - Alexandra Nadeau
- VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Pierre-Gilles Blanchard
- Faculté de Médecine, Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada
| | - Eric Mercier
- Faculté de Médecine, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; VITAM - Centre de recherche en santé durable de l'Université Laval, Québec, Canada.
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Truchot J, Boucher V, Raymond-Dufresne É, Malo C, Brassard É, Marcotte J, Martel G, Côté G, Garneau C, Bouchard G, Emond M. Evaluation of the feasibility and impacts of in situ simulation in emergency medicine-a mixed-method study protocol. BMJ Open 2021; 11:e040360. [PMID: 33664066 PMCID: PMC7934732 DOI: 10.1136/bmjopen-2020-040360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/04/2022] Open
Abstract
INTRODUCTION In situ simulation (ISS) consists of performing a simulation in the everyday working environment with the usual team members. The feasibility of ISS in emergency medicine is an important research question, because ISS offers the possibility for repetitive, regular simulation training consistent with specific local needs. However, ISS also raises the issue of safety, since it might negatively impact the care of other patients in the emergency department (ED). Our hypothesis is that ISS in an academic high-volume ED is feasible, safe and associated with benefits for both staff and patients. METHODS A mixed-method, including a qualitative method for the assessment of feasibility and acceptability and a quantitative method for the assessment of patients' safety and participants' psychosocial risks, will be used in this study.Two distinct phases are planned in the ED of the CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus) between March 2021 and October 2021. Phase 1: an ISS programme will be implemented with selected ED professionals to assess its acceptability and safety and prove the validity of our educational concept. The number of cancelled sessions and the reasons for cancellation will be collected to establish feasibility criteria. Semistructured interviews will evaluate the acceptability of the intervention. We will compare unannounced and announced ISS. Phase 2: the impact of the ISS programme will be measured with validated questionnaires for the assessment of psychosocial risks, self-confidence and perceived stress among nonselected ED professionals, with comparison between those exposed to ISS and those that were not. ETHICS AND DISSEMINATION The CHU de Québec-Université Laval Research ethics board has approved this protocol (#2020-5000). Results will be presented to key professionals from our institution to improve patient safety. We also aim to publish our results in peer-reviewed journals and will submit abstracts to international conferences to disseminate our findings.
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Affiliation(s)
- Jennifer Truchot
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Québec, Canada
- Research center- CHU de Québec, Université Laval, Quebec, Québec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Valérie Boucher
- Research center- CHU de Québec, Université Laval, Quebec, Québec, Canada
- VITAM - Centre de recherche en santé durable, Quebec, Québec, Canada
| | | | - Christian Malo
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Québec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Éric Brassard
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Jean Marcotte
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Guillaume Martel
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Québec, Canada
| | - Geneviève Côté
- Département de médecine familiale et de médecine d'urgence, Université Laval Faculté de médecine, Quebec, Québec, Canada
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Christian Garneau
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Gino Bouchard
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
| | - Marcel Emond
- Emergency Department, CHU de Québec-Université Laval, Quebec, Québec, Canada
- VITAM - Centre de recherche en santé durable, Quebec, Québec, Canada
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Perry JJ, Vaillancourt C, Hohl CM, Thiruganasambandamoorthy V, Morris J, Emond M, Lee J, Stiell IG. Optimizing collaborative relationships in emergency medicine research. CAN J EMERG MED 2021; 23:291-296. [PMID: 33599957 DOI: 10.1007/s43678-020-00080-w] [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: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the Canadian Association of Emergency Physicians (CAEP) 2020 Academic Symposium Panel was to present recommendations for collaboration on (1) writing a grant application; (2) conducting a study; (3) writing an abstract; and (4) writing a manuscript. METHODS We assembled an expert panel of eight experienced emergency medicine clinician scientists from across Canada. Panel members performed literature searches for each of the four topics. Draft recommendations were developed and refined in an iterative fashion by panel members. We solicited external feedback on the draft recommendations online from identified researchers known to CAEP and in person at the Network of Canadian Emergency Researchers meeting in February 2020. We obtained additional feedback during an online symposium presentation on October 15th, 2020, open to all members of the Canadian Association of Emergency Physicians. RESULTS Four sets of recommendations were established for each component including: 14 for writing a grant application including relevant timelines; 23 for conducting a study; 13 for writing an abstract; and 18 for writing a manuscript. Forming a strong team, including patients, appropriate methodologists, content experts and a mix of senior and junior investigators, establishing and following clear timelines, and proactive communications were common themes. CONCLUSIONS We offer recommendations for research collaboration for (1) writing a grant, (2) conducting a study, (3) writing an abstract, and (4) writing a manuscript. We believe these recommendations will help to improve the science, improve grant success, and improve the impact of the abstracts and manuscripts.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Marcel Emond
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada.,Division of Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Jacques Lee
- Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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O'Brien T, Mitra B, Le Sage N, Tardif PA, Emond M, D'Astous M, Mercier E. Clinically significant traumatic intracranial hemorrhage following minor head trauma in older adults: a retrospective cohort study. Brain Inj 2020; 34:834-839. [PMID: 32286890 DOI: 10.1080/02699052.2020.1753242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial hemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. METHODS This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. RESULTS From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). CONCLUSIONS In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
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Affiliation(s)
- Toby O'Brien
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,National Trauma Research Institute, Alfred Hospital , Melbourne, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Alfred Hospital , Melbourne, Australia.,Canada Département De Médecine Familiale Et Médecine d'Urgence, Faculté De Médecine, Université Laval , Québec, Canada
| | - Natalie Le Sage
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia
| | - Pier-Alexandre Tardif
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada
| | - Marcel Emond
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia.,Centre De Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval , Quebec, Canada
| | - Myreille D'Astous
- Service of Neurosurgery, Department of Surgery, CHU De Québec, Université Laval , Québec, Canada
| | - Eric Mercier
- Axe Santé Des Populations Et Pratiques Optimales En Santé, Unité De Recherche En Traumatologie - Urgence - Soins Intensifs, Centre De Recherche Du CHU De Québec, Université Laval , Québec, Canada.,School of Public Health and Preventive Medicine, Monash University , Melbourne, Australia.,Centre De Recherche Sur Les Soins Et Les Services De Première Ligne De l'Université Laval , Quebec, Canada
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Villa-Roel C, Borgundvaag B, Majumdar SR, Emond M, Campbell S, Sivilotti M, Abu-Laban RB, Stiell IG, Aaron SD, Senthilselvan A, Rowe BH. Reasons and outcomes for patients receiving ICS/LABA agents prior to, and one month after, emergency department presentations for acute asthma. J Asthma 2018; 56:985-994. [PMID: 30311821 DOI: 10.1080/02770903.2018.1508472] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Asthma is a common emergency department (ED) presentation. This study examined factors associated with inhaled corticosteroids/long-acting beta-agonist (ICS/LABA) use; and management and outcomes before and after ED presentation. Methods: Secondary analysis of a prospective cohort study; adults treated for acute asthma in Canadian EDs underwent a structured interview before discharge and were followed-up four weeks later. Patients received oral corticosteroids (OCS) at discharge and, at physician discretion, most received ICS or ICS/LABA inhaled agents. Analyses focused on ICS/LABA vs "other" treatment groups at ED presentation. Results: Of 807 enrolled patients, 33% reported receiving ICS/LABA at ED presentation; 62% were female, median age was 31 years. Factors independently associated with ICS/LABA treatment prior to ED presentation were: having an asthma action plan; using an asthma diary/peak flow meter; influenza immunization; not using the ED as usual site for prescriptions; ever using OCS and currently using ICS. Patients were treated similarly in the ED and at discharge; however, relapse was higher in the ICS/LABA group, even after adjustment. Conclusion: One-third of patients presenting to the ED with acute asthma were already receiving ICS/LABA agents; this treatment was independently associated with preventive measures. While ICS/LABA management improves control of chronic asthma, patients using these agents who develop acute asthma reflect higher severity and increased risk of future relapse.
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Affiliation(s)
- Cristina Villa-Roel
- a Departments of Emergency Medicine, University of Alberta , Edmonton , AB , Canada
| | - Bjug Borgundvaag
- e Department of Emergency Medicine, Mt. Sinai Hospital , Toronto , ON , Canada
| | | | - Marcel Emond
- f Division of Emergency Medicine, Laval University , Quebec City , PQ , Canada
| | - Sam Campbell
- g Department of Emergency Medicine, Dalhousie University , Halifax , NS , Canada
| | - Marco Sivilotti
- h Departments of Emergency Medicine and of Biomedical & Molecular Sciences, Queen's University , Kingston , ON , Canada
| | - Riyad B Abu-Laban
- i Department of Emergency Medicine, University of British Columbia , Vancouver , BC , Canada
| | - Ian G Stiell
- j Department of Emergency Medicine and Medicine, The Ottawa Hospital Research Institute, University of Ottawa , Ottawa , ON , Canada
| | - Shawn D Aaron
- j Department of Emergency Medicine and Medicine, The Ottawa Hospital Research Institute, University of Ottawa , Ottawa , ON , Canada
| | | | - Brian H Rowe
- a Departments of Emergency Medicine, University of Alberta , Edmonton , AB , Canada.,c School of Public Health, University of Alberta , Edmonton , AB , Canada.,d Alberta Health Services (AHS) all in Edmonton , Edmonton , AB , Canada
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Mercier E, Tardif PA, Emond M, Ouellet MC, de Guise É, Mitra B, Cameron P, Le Sage N. Characteristics of patients included and enrolled in studies on the prognostic value of serum biomarkers for prediction of postconcussion symptoms following a mild traumatic brain injury: a systematic review. BMJ Open 2017; 7:e017848. [PMID: 28963310 PMCID: PMC5623519 DOI: 10.1136/bmjopen-2017-017848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 12/22/2022] Open
Abstract
OBJECTIVE Mild traumatic brain injury (mTBI) has been insufficiently researched, and its definition remains elusive. Investigators are confronted by heterogeneity in patients, mechanism of injury and outcomes. Findings are thus often limited in generalisability and clinical application. Serum protein biomarkers are increasingly assessed to enhance prognostication of outcomes, but their translation into clinical practice has yet to be achieved. A systematic review was performed to describe the adult populations included and enrolled in studies that evaluated the prognostic value of protein biomarkers to predict postconcussion symptoms following an mTBI. DATA SOURCES Searches of MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, PsycBITE and PsycINFO up to October 2016. DATA SELECTION AND EXTRACTION Two reviewers independently screened for potentially eligible studies, extracted data and assessed the overall quality of evidence by outcome using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS A total of 23 298 citations were obtained from which 166 manuscripts were reviewed. Thirty-six cohort studies (2812 patients) having enrolled between 7 and 311 patients (median 89) fulfilled our inclusion criteria. Most studies excluded patients based on advanced age (n=10 (28%)), neurological disorders (n=20 (56%)), psychiatric disorders (n=17 (47%)), substance abuse disorders (n=13 (36%)) or previous traumatic brain injury (n=10 (28%)). Twenty-one studies (58%) used at least two of these exclusion criteria. The pooled mean age of included patients was 39.3 (SD 4.6) years old (34 studies). The criteria used to define a mTBI were inconsistent. The most frequently reported outcome was postconcussion syndrome using the Rivermead Post-Concussion Symptoms Questionnaire (n=18 (50%)) with follow-ups ranging from 7 days to 5 years after the mTBI. CONCLUSIONS Most studies have recruited samples that are not representative and generalisable to the mTBI population. These exclusion criteria limit the potential use and translation of promising serum protein biomarkers to predict postconcussion symptoms.
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Affiliation(s)
- Eric Mercier
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgence - Soins Intensifs, Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
- Département de Médecine Familiale et Médecine d’Urgence, Faculté de Médecine, Université Laval, Quebec, Canada
- Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Pier-Alexandre Tardif
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgence - Soins Intensifs, Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
| | - Marcel Emond
- Département de Médecine Familiale et Médecine d’Urgence, Faculté de Médecine, Université Laval, Quebec, Canada
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Vieillissement, Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
| | - Marie-Christine Ouellet
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale (CIRRIS), Quebec, Canada
| | - Élaine de Guise
- Research-Institute, McGill University Health Centre, Quebec, Canada
- Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Quebec, Canada
| | - Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Alfred Health, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Natalie Le Sage
- Axe Santé des Populations et Pratiques Optimales en Santé, Unité de recherche en Traumatologie - Urgence - Soins Intensifs, Centre de recherche du CHU de Québec, Université Laval, Quebec, Canada
- Département de Médecine Familiale et Médecine d’Urgence, Faculté de Médecine, Université Laval, Quebec, Canada
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Eagles D, Perry JJ, Sirois MJ, Lang E, Daoust R, Lee J, Griffith L, Wilding L, Neveu X, Emond M. Timed Up and Go predicts functional decline in older patients presenting to the emergency department following minor trauma†. Age Ageing 2017; 46:214-218. [PMID: 28399218 DOI: 10.1093/ageing/afw184] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 05/10/2016] [Accepted: 09/27/2016] [Indexed: 11/13/2022] Open
Abstract
Background there is no standardised test for assessing mobility in the Emergency Department (ED). Objective we wished to evaluate the relationship between the Timed Up and Go (TUG) and frailty, functional decline and falls in community dwelling elders that present to the ED following minor trauma. Methods this was a secondary analysis of a prospective cohort study conducted at eight Canadian hospitals. Evaluations included: TUG; Study of Osteoporotic Fractures Frailty Index; Older American Resources and Service Functional Scale; and self-reported falls. Of note, 3- and 6-month follow-up was conducted. Generalised linear model with log-binomial distribution was utilised. Relative risks (RR) and 95% CI were calculated. Results TUG scores were available for 911/2918 patients, mean age 76.2 (SD 7.8) and 57.9% female. There was an association between TUG scores and frailty (P < 0.05) and functional decline at 3 (P < 0.05) and 6 (P < 0.05) months but not self-reported falls. For TUG scores 10-19 seconds, 20-29 seconds and ≥30 seconds, respectively: (i) frailty RR (95% CI): 1.8 (1.3-2.4), 3.0 (2.2-4.2) and 3.7 (2.6-5.1); (ii) functional decline RR (95% CI): 2.7 (1.1-6.4), 5.5 (2.1-14.3) and 8.9 (3.0-25.8); (iii) falls RR (95% CI): 0.9 (0.5-1.5), 1.3 (0.6-2.5) and 1.1 (0.4-3.5). Conclusion in community dwelling elders presenting to the ED following minor trauma, TUG scores were associated with frailty and strongly associated with functional decline at 3 and 6 months post injury. TUG scores were not associated with self-reported falls. Use of the TUG in the ED will help identify frail patients at risk of functional decline.
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Affiliation(s)
- Debra Eagles
- Université Laval, Québec City, Québec, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Eddy Lang
- Alberta Health Science Center, Calgary, Alberta, Canada
| | - Raoul Daoust
- Hôpital du Sacre-Coeur de Montreal, Montreal, Québec, Canada
| | - Jacques Lee
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Laura Wilding
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Xavier Neveu
- Research Center, CHU de Québec, Québec City, Québec, Canada
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Lee J, Sirois MJ, Moore L, Perry J, Daoust R, Griffith L, Worster A, Lang E, Emond M. Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: predictors among independent seniors within 6 months. Age Ageing 2015; 44:624-9. [PMID: 25944869 DOI: 10.1093/ageing/afv054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 09/16/2014] [Accepted: 02/18/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND minor traumatic injuries among independent older people have received little attention to date, but increasingly the impact of such injuries is being recognised. OBJECTIVES we assessed the frequency and predictors of acute health care use, defined as return to the emergency department (ED) or hospitalisation. STUDY DESIGN national multicentre prospective observational study. SETTING eight Canadian teaching EDs between April 2009 and April 2013. PARTICIPANTS a total of 1,568 patients aged 65-100 years, independent in basic activities of daily living, discharged from ED following a minor traumatic injury. METHODS trained assessors measured baseline data including demographics, functional status, cognition, comorbidities, frailty and injury severity. We then conducted follow-up telephone interviews at 6 months to assess subsequent acute health care use. We used log-binomial regression analyses to identify predictors of acute health care use, and reported relative risks and 95% CIs. RESULTS participants' mean age was 77.0, 66.4% female, and their injuries included contusions (43.5%), lacerations (25.1%) and fractures (25.4%). The cumulative rate of acute health care use by 6 months post-injury was 21.5% (95% CI: 19.0-24.3%). The strongest predictors of acute health care use within 6 months were cognitive impairment, RR = 1.6 (95% IC: 1.2-2.1) and the mechanism of injury including pedestrian struck or recreational injuries, RR = 1.6 (95% CI 1.2-2.2). CONCLUSIONS among independent community living older persons with a minor injury, cognitive impairment and mechanism of injury were independent risk factors for acute healthcare use. Future studies should look at whether tailored discharge planning can reduce the need for acute health care use.
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Affiliation(s)
- Jacques Lee
- Department of Emergency Services and Scientist, Clinical Epidemiology Unit, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Lynne Moore
- Faculte de Medicine, Universite Laval, Quebec, Canada
| | | | - Raoul Daoust
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Lauren Griffith
- Division of Emergency Medicine, Department of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Worster
- Division of Emergency Medicine, Department of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcel Emond
- Unite de Recherché en Traumatologie-urgence-soins Intensifs du Centre de Recherché FRQ-S du CHU-Quebec, Quebec, Canada
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Provencher V, Sirois MJ, Ouellet MC, Camden S, Neveu X, Allain-Boulé N, Emond M. Decline in Activities of Daily Living After a Visit to a Canadian Emergency Department for Minor Injuries in Independent Older Adults: Are Frail Older Adults with Cognitive Impairment at Greater Risk? J Am Geriatr Soc 2015; 63:860-8. [DOI: 10.1111/jgs.13389] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Véronique Provencher
- Department of Rehabilitation; Université Laval; Québec Québec Canada
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marie-Josée Sirois
- Department of Rehabilitation; Université Laval; Québec Québec Canada
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marie-Christine Ouellet
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale; Institut de Réadaptation en Déficience Physique de Québec; Québec Québec Canada
| | - Stéphanie Camden
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Xavier Neveu
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Nadine Allain-Boulé
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
| | - Marcel Emond
- Centre de recherche du CHU de Québec; Axe Santé des Populations-Pratiques Optimales en Santé; Québec Québec Canada
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Archambault PM, Gagnon S, Gagnon MP, Turcotte S, Lapointe J, Fleet R, Côté M, Beaupré P, Le Sage N, Emond M, Légaré F. Development and validation of questionnaires exploring health care professionals' intention to use wiki-based reminders to promote best practices in trauma. JMIR Res Protoc 2014; 3:e50. [PMID: 25281856 PMCID: PMC4213801 DOI: 10.2196/resprot.3762] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 08/08/2014] [Accepted: 08/28/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Little is known about factors influencing professionals' use of wikis. OBJECTIVE We developed and validated two questionnaires to assess health care professionals' intention to use wiki-based reminders for the management of trauma patients. METHODS We developed questionnaires for emergency physicians (EPs) and allied health professions (AHPs) based on the Theory of Planned Behavior and adapted them to the salient beliefs of each, identified in an earlier study. Items measured demographics and direct and indirect theoretical constructs. We piloted the questionnaires with 2 focus groups (5 EPs and 5 AHPs) to identify problems of wording and length. Based on feedback, we adjusted the wording and combined certain items. A new convenience sample of 25 EPs and 26 AHPs then performed a test-retest of the questionnaires at a 2-week interval. We assessed internal consistency using Cronbach alpha coefficients and temporal stability of items with an agreement intraclass correlation coefficient (ICC). RESULTS Five EPs and 5 AHPs (3 nurses, 1 respiratory therapist, and 1 pharmacist) formed 2 focus groups; 25 EPs and 26 AHPs (12 nurses, 7 respiratory therapists, and 7 pharmacists) completed the test and retest. The EP questionnaire test-retest scores for consistency (Cronbach alpha) and stability (ICC) were intention (test: Cronbach alpha=.94; retest: Cronbach alpha=.98; ICC=.89), attitude (.74, .72, .70), subjective norm (.79, .78, .75), perceived behavioral control (.67, .65, .66), attitudinal beliefs (.94, .86, .60), normative beliefs (.83, .87, .79), and control beliefs barriers (.58, .67, .78) and facilitators (.97, .85, .30). The AHP questionnaire scores for consistency and stability were: intention (test Cronbach alpha=.69, retest Cronbach alpha=.81, ICC=.48), attitude (.85, .87, .83), subjective norm (.47, .82, .62), perceived behavioral control (.55, .62, .60), attitudinal beliefs (.92, .91, .82), normative beliefs (.85, .90, .74), and control beliefs barriers (.58, .55, .66) and facilitators (.72, .94, -.05). To improve the psychometric properties of both questionnaires, we reformulated poorly consistent or unstable items. CONCLUSIONS Our new theory-based questionnaires to measure health care professionals' intention to use wiki-based reminders have adequate validity and reliability for use in large surveys. In the long run, they can be used to develop a theory-based implementation intervention for a wiki promoting best practices in trauma care.
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Beliavsky A, Perry JJ, Dowlatshahi D, Wasserman J, Sivilotti MLA, Sutherland J, Worster A, Emond M, Stotts G, Jin AY, Oczkowski WJ, Sahlas DJ, Murray HE, MacKey A, Verreault S, Wells GA, Stiell IG, Sharma M. Acute isolated dysarthria is associated with a high risk of stroke. Cerebrovasc Dis Extra 2014; 4:182-5. [PMID: 25298772 PMCID: PMC4176400 DOI: 10.1159/000365169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/11/2014] [Indexed: 12/13/2022] Open
Abstract
Background Isolated dysarthria is an uncommon presentation of transient ischemic attack (TIA)/minor stroke and has a broad differential diagnosis. There is little information in the literature about how often this presentation is confirmed to be a TIA/stroke, and therefore there is debate about the risk of subsequent vascular events. Given the uncertain prognosis, it is unclear how to best manage patients presenting to the emergency department (ED) with isolated dysarthria. The objective of this study was to prospectively identify and follow a cohort of patients presenting to EDs with isolated dysarthria in order to explore their natural history and risk of recurrent cerebrovascular events. Specifically, we sought to determine early outcomes of individuals with this nonspecific and atypical presentation in order to appropriately expedite their management. Methods Patients with isolated dysarthria having presented to 8 Canadian EDs between October 2006 and April 2009 were analyzed as part of a prospective multicenter cohort study of patients with acute neurological symptoms as assessed by emergency physicians. The study inclusion criteria were age ≥18 years, a normal level of consciousness, and a symptom onset <1 week prior to presentation without an established nonvascular etiology. The primary outcome was a subsequent stroke within 90 days of the index visit. The secondary outcomes were the rate of TIA, myocardial infarction, and death. Isolated dysarthria was defined as slurring with imprecise articulation but without evidence of language dysfunction. The overall rate of stroke in this cohort was compared with that predicted by the median ABCD2 score for this group. Results Between 2006 and 2009, 1,528 patients were enrolled and had a 90-day follow-up. Of these, 43 patients presented with isolated acute-onset dysarthria (2.8%). Recurrent stroke occurred in 6/43 (14.0%) within 90 days of enrollment. The predicted maximal 90-day stroke rate was 9.8% (based on a median ABCD2 score of 5 for the isolated dysarthria cohort). After adjusting for covariates, isolated dysarthria independently predicted stroke within 90 days (aOR: 3.96; 95% CI: 1.3-11.9; p = 0.014). Conclusions The isolated dysarthria cohort carried a recurrent stroke risk comparable to that predicted by the median ABCD2 scores. Although isolated dysarthria is a nonspecific and uncommon clinical presentation of TIA, these findings support the need to view it first and foremost as a vascular presentation until proven otherwise and to manage such patients as if they were at high risk of stroke in accordance with established high-risk TIA guidelines.
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Affiliation(s)
- Alina Beliavsky
- Division of Neurology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Dar Dowlatshahi
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Division of Neurology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Jason Wasserman
- Division of Neurology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston, Ont., Canada ; Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ont., Canada
| | - Jane Sutherland
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ont., Canada
| | - Marcel Emond
- Department of Emergency and Family Medicine, Université Laval, Quebec, Que., Canada
| | - Grant Stotts
- Division of Neurology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Albert Y Jin
- Division of Neurology, Queen's University, Kingston, Ont., Canada
| | | | | | - Heather E Murray
- Department of Emergency Medicine, Queen's University, Kingston, Ont., Canada
| | - Ariane MacKey
- Department of Neurology, Hôpital de l'Enfant-Jésus, Quebec City, Quebec, Que., Canada
| | - Steve Verreault
- Department of Neurology, Hôpital de l'Enfant-Jésus, Quebec City, Quebec, Que., Canada
| | - George A Wells
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Division of Neurology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada
| | - Mukul Sharma
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont., Canada ; Division of Neurology, McMaster University, Hamilton, Ont., Canada
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Malo C, Audette-Côté JS, Emond M, Turgeon AF. Tamsulosin for treatment of unilateral distal ureterolithiasis: a systematic review and meta-analysis. CAN J EMERG MED 2014; 16:229-42. [PMID: 24852587 DOI: 10.2310/8000.2013.131012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7% for women in the United States. Tamsulosin, an α-antagonist, has been used as therapy to facilitate the expulsion of lithiasis. Whether it is a good treatment for distal lithiasis remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of tamsulosin on the passage of distal ureterolithiasis. METHODS A systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central. Trial eligibility was evaluated by two investigators. All randomized controlled trials (RCTs) comparing tamsulosin to standard therapy or placebo for the treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with renal colic confirmed by radiographic imaging were included. Data extraction was conducted in duplicate. Primary outcome was the expulsion rate, and secondary outcomes were the mean time for ureterolithiasis expulsion, analgesic requirements, and side effects. Mantel-Haenszel random effect models were used, and heterogeneity was assessed using I² statistics. Data were presented with relative risks (RRs). RESULTS The search strategy identified 685 articles, of which 22 studies were included. Combined results suggested a benefit for the expulsion of ureterolithiasis (≤ 10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95% CI 1.31-1.71], I² = 70%). A decrease in the average time of expulsion of the ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI -4.23, -2.44], I² = 67%). CONCLUSION Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis (≤ 10 mm).
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Audette JS, Emond M, Scott H, Lortie G. Investigation of myocardial contusion with sternal fracture in the emergency department: multicentre review. Can Fam Physician 2014; 60:e126-e130. [PMID: 24522690 PMCID: PMC3922581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To describe the use of initial electrocardiogram (ECG), follow-up ECG or equivalent monitoring, and troponin I in patients presenting with sternal fracture who are assessed in emergency departments or by front-line physicians. DESIGN Multicentre descriptive retrospective study. SETTING Two traumatology teaching centres in Quebec city, Que. PARTICIPANTS Fifty-four trauma patients presenting with sternal fracture. INTERVENTIONS Assessment of the use of initial ECG, ECG or equivalent monitoring 6 hours after trauma, and troponin administration. MAIN OUTCOME MEASURES In terms of ECG use, quality comparison criteria were selected on the basis of expert opinions in 4 studies. An initial ECG and a follow-up ECG 6 hours after trauma or cardiac monitoring 6 hours after trauma were recommended by most authors for diagnosing myocardial contusion in cases of sternal fracture. Serum troponin I administered 4 to 8 hours after chest trauma was also recommended by some as an effective means of detecting substantial arrhythmia secondary to myocardial contusion. Descriptive univariate analyses and tests were performed. A P < .05 was considered significant. RESULTS Thirty-nine patients (72%) were assessed initially with ECGs; after 6 hours in the emergency department, 18 of these patients (33%) had follow-up ECGs or equivalent cardiac monitoring. Sixteen patients (30%) were assessed by means of troponin I dosage. Two patients (4%) presented with ECG abnormalities and only 1 patient (2%) presented with an elevated troponin I level. CONCLUSION Emergency physicians must increase their use of ECG in initial or follow-up diagnosis for trauma patients presenting with sternal fracture to detect myocardial contusion and arrhythmia. The use of troponin in conjunction with ECG is also suggested for this population in order to identify patients at risk of complications secondary to myocardial contusion.
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Affiliation(s)
- Jean-Sébastien Audette
- Laval University, Department of Emergency Medicine, 750 Calixa-Lavallée Ave, Unit 7, Quebec, QC G1S 3G6.
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Ryan D, Emond M, Lamontagne ME. Social network analysis as a metric for the development of an interdisciplinary, inter-organizational research team. J Interprof Care 2013; 28:28-33. [DOI: 10.3109/13561820.2013.823385] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Moore L, Lavoie A, Sirois MJ, Swaine B, Murat V, Sage NL, Emond M. Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system. J Emerg Trauma Shock 2013; 6:3-10. [PMID: 23492970 PMCID: PMC3589856 DOI: 10.4103/0974-2700.106318] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [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: 03/14/2012] [Accepted: 04/08/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data. MATERIALS AND METHODS Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005). RESULTS Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03). CONCLUSION This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Laval University, Quebec (Qc), Canada ; Unité de Traumatologie-urgence-soins Intensifs, Center de Recherche du CHA (Hôpital de l'Enfant-Jésus), Laval University, Quebec (Qc), Canada
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Perry J, Sharma M, Sivilotti ML, Sutherland J, Symington C, Emond M, Worster A, Grant S, Wells GA, Stiell IG. Abstract 132: The Canadian TIA Rule - A Decision Rule to Predict the Risk Of Stroke Within Seven Days In The Emergency Department. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.a132] [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] [Indexed: 11/16/2022]
Abstract
Background:
Stroke prevention after TIA is dependent on rapid intervention in those at highest risk. Previous risk scores have not been prospectively developed and thus do not consider all relevant variables. The goal of this study was to derive a clinical score for TIA patients to identify those at high risk for stroke ≤ 7 days.
Methods:
We conducted a prospective cohort study in 8 academic Canadian EDs. We enrolled consecutive adult ED patients diagnosed with a TIA. Standardized clinical variables were recorded by physicians on data forms prior to discharge/admission. Our
primary outcome was
stroke ≤ 7 days of TIA diagnosis. We derived a clinical score using logistic regression analysis.
Results:
We prospectively enrolled 3,903 patients including 85 patients with a subsequent stroke ≤ 7 days. From this cohort we derived the
Canadian TIA Score
. The Canadian TIA Score identifies patients at minimal risk of subsequent stroke ≤ 7 days (probability < 0.5%), low risk (0.5-2.5%), high risk (2.6-10.0%), and critical risk (>10.0%). This score contains 13 variables; 9
clincal:
1) initial TIA (in lifetime) 2) symptoms lasting ≥10 minutes, 3) already on an antiplatelet agent, 4) history of carotid stensosis, 5) history of gait disturbance, 6) unilateral weakness, 7) vertigo, 8) initial diastolic blood pressure ≥110 mmHg, 9) history or exam finding of dysarthria or aphasia; and four from
investigations:
1) atrial fibrillation on electrocardiogram, 2) infarction on CT head, 3) platelets ≥400 x 10
9
/L, 4) glucose ≥15 mmol/L. Variables were assigned point values ranging from 4 to -3, and added, obtaining a score from -3 to 19. This model has good discrimination with a c-statistic of 0.77 (95%CI: 0.73-0.82).
Importance:
The Canadian TIA Score identifies the subsequent stroke risk at 7 days following a TIA. Following validation, the Canadian TIA Score will allow physicians to selectively expedite investigations/specialist assessment and allow for safe less urgent follow-up of patients at low risk. Appropriate intervention is contingent on appropriate risk assessment.
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Malo C, Neveu X, Archambault PM, Emond M, Gagnon MP. Exploring nurses' intention to use a computerized platform in the resuscitation unit: development and validation of a questionnaire based on the theory of planned behavior. Interact J Med Res 2012; 1:e5. [PMID: 23611903 PMCID: PMC3626134 DOI: 10.2196/ijmr.2150] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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: 04/30/2012] [Revised: 06/28/2012] [Accepted: 07/30/2012] [Indexed: 11/14/2022] Open
Abstract
Background In emergency department resuscitation units, writing down information related to interventions, physical examination, vital signs, investigations, and treatments ordered is a crucial task carried out by nurses. To facilitate this task, a team composed of emergency physicians, nurses, and one computer engineer created a novel electronic platform equipped with a tactile screen that allows systematic collection of critical data. This electronic platform also has medical software (ReaScribe+) that functions as an electronic medical record and a clinical decision support system. Objective To develop and validate a questionnaire that can help evaluate nurses’ intention to use a novel computerized platform in an emergency department resuscitation unit, based on Ajzen’s theory of planned behavior (TPB). Methods The sample for this study was composed of 87 nurses who worked in the resuscitation unit of a tertiary trauma center. We held three focus groups with nurses working in the resuscitation unit to identify the salient modal beliefs regarding their intended use of a new electronic medical charting system for the care of trauma patients. The system included a clinical decision support tool. We developed a questionnaire in which salient modal beliefs were used as items to evaluate the TPB constructs. We also added 13 questions to evaluate nurses’ computer literacy. The final questionnaire was composed of 46 questions to be answered on a 7-point Likert scale. All nurses in the resuscitation unit and present during a regular work shift were individually contacted by the principal investigator or a research assistant (phase 1). A subsample of the nurses who completed the questionnaire was invited to complete it a second time 2 weeks later (phase 2). Results In phase 1, we received 62 of the 70 questionnaires administered (89% response rate). Of the 27 questionnaires administered in phase 2 (retest phase), 25 were completed (93% response rate). The questionnaire showed very good internal consistency, as Cronbach alpha was higher than .7 for all constructs. Temporal stability was acceptable with intraclass correlations between .41 and .66. The intention to use the electronic platform to chart the resuscitation of trauma patients was very high among the respondents. In the logistic regression model, the only construct that predicted nurses’ intention to adopt the computerized platform was the professional norm (odds ratio 3.31, 95% confidence interval 1.41–7.78). Conclusions We developed and validated a questionnaire that can now be used in other emergency departments prior to implementation of the computerized platform. The intention to adopt was very high among the respondents, which suggests that the implementation of this innovation could be successful at our institution.
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Affiliation(s)
- Christian Malo
- Département de médecine familiale et de médecine d'urgence, Faculté de Médecine, Université Laval, Québec, QC, Canada.
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McIntyre LA, Fergusson DA, Cook DJ, Rowe BH, Bagshaw SM, Easton D, Emond M, Finfer S, Fox-Robichaud A, Gaudert C, Green R, Hebert P, Marshall J, Rankin N, Stiell I, Tinmouth A, Pagliarello J, Turgeon AF, Worster A, Zarychanski R. Fluid Resuscitation with 5% albumin versus Normal Saline in Early Septic Shock: a pilot randomized, controlled trial. J Crit Care 2011; 27:317.e1-6. [PMID: 22176806 DOI: 10.1016/j.jcrc.2011.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/26/2011] [Accepted: 10/19/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE Randomized, controlled trials of fluid resuscitation in early septic shock face many logistic challenges. We describe the Fluid Resuscitation with 5% albumin versus Normal Saline in Early Septic Shock (PRECISE) pilot trial study design and report feasibility of patient recruitment. MATERIALS AND METHODS Six Canadian academic centers enrolled adult patients with early suspected septic shock from the emergency department and intensive care unit department. Consent was deferred. Using concealed allocation, participants were randomized to either 5% albumin or 0.9% sodium chloride. Blinded fluid resuscitation started immediately and continued for 7 days in the intensive care unit. Target recruitment was established a priori at 2 patients per site per month. RESULTS Fifty-one patients were enrolled; 50 patients received study fluid. We recruited a median of 2.5 patients (interquartile range [IQR], 1.5-3.0) per site per month into the trial. Median age and Acute Physiology and Chronic Health Evaluation II scores were 64.5 (IQR, 55.0-78.0) and 25.0 (IQR, 20.0-29.0), respectively. Most patients (n = 37 [74.0%]) were enrolled from the emergency department for a median of 1.6 hours (IQR, 0.8-3.5 hours) from their first hypotensive event and received a median of 2.4 L (IQR, 1.5-3.0 L) of resuscitation fluid before inclusion. Consent was deferred for 44 patients (89.8%). CONCLUSIONS Patient recruitment into the PRECISE pilot trial met our prespecified feasibility targets, and the PRECISE team is planning the larger trial.
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Affiliation(s)
- Lauralyn A McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa,Ottawa, Ontario, Canada.
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Perry JJ, Stiell IG, Sivilotti MLA, Bullard MJ, Emond M, Symington C, Sutherland J, Worster A, Hohl C, Lee JS, Eisenhauer MA, Mortensen M, Mackey D, Pauls M, Lesiuk H, Wells GA. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011; 343:d4277. [PMID: 21768192 PMCID: PMC3138338 DOI: 10.1136/bmj.d4277] [Citation(s) in RCA: 191] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. DESIGN Prospective cohort study. SETTING 11 tertiary care emergency departments across Canada, 2000-9. PARTICIPANTS Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. MAIN OUTCOME MEASURES Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. RESULTS Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). CONCLUSION Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada.
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Amini R, Lavoie A, Moore L, Sirois MJ, Emond M. Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system. J Emerg Trauma Shock 2011; 4:12-9. [PMID: 21633561 PMCID: PMC3097560 DOI: 10.4103/0974-2700.76824] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [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: 12/15/2009] [Accepted: 09/06/2010] [Indexed: 11/22/2022] Open
Abstract
Background: Previous studies have shown divergent results regarding the survival of injured children treated at pediatric trauma centers (PTC) and adult trauma centers (ATC). Aims: (1) To document, in a regionalized inclusive trauma system, at which level of trauma centers were the injured children treated and (2) to compare the in-hospital mortality over five levels of trauma care, ranging from pediatric level I trauma centers (PTC) to designated local trauma hospitals (level IV) for the whole study sample and for subgroups of severely injured children and head trauma. Materials and Methods: A retrospective analysis included data on 11,053 injured children (age ≤16 years) treated between April 1998 and March 2005 in 58 designated trauma hospitals in the province of Quebec, Canada. Multiple imputation was used to handle missing physiological data and multivariate logistic regression was used to compare mortality over levels of care. Results: PTC treated 52.2% of the children. Children treated at PTC were more often transferred from another hospital (73%) and were more severely injured. ATC level I, II, III and IV centers treated, respectively, 3.0%, 16.2%, 24.3% and 4.3% of children. Compared with children treated at a PTC, the risk of mortality was higher for children treated at each other ATC, i.e. level I (adjusted odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.3–7.5), level II (OR = 2.5; 95% CI: 1.3–5.0), level III (OR = 5.2; 95% CI: 2.1–13.1) and level IV (OR = 9.9; 95% CI: 2.4–41.3). Similar findings were observed among the subsamples of children who were more severely injured (Injury Severity Score >15) and who sustained head injuries. Conclusions: In our trauma system, PTC cared for more than half of the injured children and patients treated there have better survival than those treated at all other levels of ATC.
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Affiliation(s)
- Rachid Amini
- Unit of Traumatology, Emergency Medicine and Intensive Care, Research Centre of CHA (Enfant-Jésus Hospital), Quebec (QC), Canada
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Shields JF, Emond M, Guimont C, Pigeon D. Acute minor thoracic injuries: evaluation of practice and follow-up in the emergency department. Can Fam Physician 2010; 56:e117-e124. [PMID: 20228291 PMCID: PMC2837707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To review the management and follow-up of patients with minor thoracic injuries (MTI) treated by emergency or primary care physicians. DESIGN A multicentre, retrospective study. SETTING Three university-affiliated emergency departments of the metropolitan region of Quebec city, Que. PARTICIPANTS Patients older than 16 years of age with suspected or proven rib fractures following traumatic events. MAIN OUTCOME MEASURES Differences in admission and discharge proportions and disposition management following MTI. RESULTS Four hundred and forty-seven charts were analyzed. Only 23 patients (5.2%) were admitted during the study period. Admission and discharge proportions were significantly different among the 3 surveyed hospitals, ranging from 1.3% to 15.2% (P < or = .001). There were no recommendations of follow-up noted in most (53.5%) of the charts and there were no differences after hospital stratification. Planned follow-up visits were scheduled for 5.7% of discharged patients. Being older than 65 years of age or having multiple rib fractures had no influence on management and follow-up recommendations. Eighty-two patients (18.6%) had unplanned follow-up visits in the emergency department, with inadequate pain relief as the principal reason for consultation (56.1%). There was no significant difference after stratification for age and type of analgesia. Other clinically significant delayed complications were recorded in 8.3% of all MTI patients. CONCLUSION The proportion of patients admitted for rib fractures was lower than the expected 25%, based on previous publications, and varied across surveyed hospitals. A very low proportion of patients was offered planned follow-up visits or even any follow-up recommendations in view of possible delayed complications and disabilities. Further studies are needed to identify predictors of delayed MTI complications and enhance appropriate use of follow-up resources.
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Moore L, Hanley JA, Turgeon AF, Lavoie A, Emond M. A multiple imputation model for imputing missing physiologic data in the national trauma data bank. J Am Coll Surg 2009; 209:572-9. [PMID: 19854396 DOI: 10.1016/j.jamcollsurg.2009.07.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 07/17/2009] [Accepted: 07/17/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Like most trauma registries, the National Trauma Data Bank (NTDB) is limited by the problem of missing physiologic data. Multiple imputation (MI) has been proposed to simulate missing Glasgow Coma Scale (GCS) scores, respiratory rate (RR), and systolic blood pressure (SBP). The aim of this study was to develop an MI model for missing physiologic data in the NTDB and to provide guidelines for its implementation. STUDY DESIGN The NTDB 7.0 was restricted to patients admitted in 2005 with at least one anatomic injury code. A series of auxiliary variables thought to offer information for the imputation process was selected from the NTDB by literature review and expert opinion. The relation of these variables to physiologic variables and to the fact that they were missing was examined using logistic regression. The MI model included all auxiliary variables that had a statistically significant association with physiologic variables or with the fact that they were missing (Bonferroni-corrected p value <0.05). RESULTS The NTDB sample included 373,243 observations. Glasgow Coma Scale, respiratory rate, and systolic blood pressure were missing for 20.3%, 3.9%, and 8.5% of data observations, respectively. The MI model included information on the following: gender, age, anatomic injury severity, transfer status, injury mechanism, intubation status, alcohol and drug test results, emergency department disposition, total length of stay, ICU length of stay, duration of mechanical ventilation, and discharge disposition. The MI model offered good discrimination for predicting the value of physiologic variables and the fact that they were missing (areas under the receiver operating characteristic curve between 0.832 and 0.999). CONCLUSIONS This article proposes an MI model for imputing missing physiologic data in the NTDB and provides guidelines to facilitate its use. Implementation of the model should improve the quality of research involving the NTDB. The methodology can also be adapted to other trauma registries.
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Affiliation(s)
- Lynne Moore
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
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Moore L, Lavoie A, Le Sage N, Bergeron E, Emond M, Liberman M, Abdous B. Using information on preexisting conditions to predict mortality from traumatic injury. Ann Emerg Med 2008; 52:356-364.e2. [PMID: 18282639 DOI: 10.1016/j.annemergmed.2007.09.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [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: 05/16/2007] [Revised: 09/04/2007] [Accepted: 09/13/2007] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Preexisting conditions have been found to be an independent predictor of mortality after trauma. However, no consensus has been reached as to what indicator of preexisting condition status should be used, and the contribution of preexisting conditions to mortality prediction models is unclear. This study aims to identify the most accurate way to model preexisting condition status to predict inhospital trauma mortality and to evaluate the potential gain of adding preexisting condition status to a standard trauma mortality prediction model. METHODS The study comprised all patients from the trauma registries of 4 Level I trauma centers. Information provided by individual preexisting conditions was compared to 3 commonly used summary measures: (1) absence/presence of any preexisting condition, (2) number of preexisting conditions, and (3) Charlson Comorbidity Index. The impact of adding preexisting condition status to 2 baseline risk models, the current standard Trauma and Injury Severity Score model and an improved model based on nonparametric transformations of quantitative variables, was evaluated by the area under the receiver operating characteristics curve. RESULTS Discrimination for predicting mortality in the improved model was as follows: baseline risk model: area under the receiver operating characteristics curve=0.935; baseline risk model+individually modeled preexisting conditions: area under the receiver operating characteristics curve=0.941; baseline risk model+presence of any preexisting condition: area under the receiver operating characteristics curve=0.937; baseline risk model+number of preexisting conditions: area under the receiver operating characteristics curve=0.939; baseline risk model+Charlson Comorbidity Index: area under the receiver operating characteristics curve=0.938. CONCLUSION Preexisting condition status is an independent predictor of mortality from trauma that provides a modest improvement in mortality prediction. The total number of preexisting conditions is a good summary measure of preexisting condition status. The Charlson Comorbidity Index is no better than the total number of preexisting conditions and is therefore not recommended for use in trauma mortality modeling.
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Affiliation(s)
- Lynne Moore
- Trauma and Emergency Medicine Research Unit, Centre Hospitalier Affilié Universitaire Québec, Enfant-Jésus Hospital, Quebec City, Quebec, Canada.
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Emond M, Ferguson J. The effects of a conditioned taste aversion on food intake and flavor preference in the presence of a stressor in female rats. Appetite 2007. [DOI: 10.1016/j.appet.2007.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Moore L, Lavoie A, Bergeron E, Emond M. Modeling Probability-Based Injury Severity Scores in Logistic Regression Models: The Logit Transformation Should Be Used. ACTA ACUST UNITED AC 2007; 62:601-5. [PMID: 17414334 DOI: 10.1097/ta.0b013e31803245b2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The International Classification of Disease Injury Severity Score (ICISS) and the Trauma Registry Abbreviated Injury Scale Score (TRAIS) are trauma injury severity scores based on probabilities of survival. They are widely used in logistic regression models as raw probability scores to predict the logit of mortality. The aim of this study was to evaluate whether these severity indicators would offer a more accurate prediction of mortality if they were used with a logit transformation. METHODS Analyses were based on 25,111 patients from the trauma registries of the four Level I trauma centers in the province of Quebec, Canada, abstracted between 1998 and 2005. The ICISS and TRAIS were calculated using survival proportions from the National Trauma Data Bank. The performance of the ICISS and TRAIS in their widely used form, proportions varying from 0 to 1, was compared with a logit transformation of the scores in logistic regression models predicting in-hospital mortality. Calibration was assessed with the Hosmer-Lemeshow statistic. RESULTS Neither the ICISS nor the TRAIS had a linear relation with the logit of mortality. A logit transformation of these scores led to a near-linear association and consequently improved model calibration. The Hosmer-Lemeshow statistic was 68 (35-192) and 69 (41-120) with the logit transformation compared with 272 (227-339) and 204 (166-266) with no transformation, for the ICISS and TRAIS, respectively. CONCLUSIONS In logistic regression models predicting mortality, the ICISS and TRAIS should be used with a logit transformation. This study has direct implications for improving the validity of analyses requiring control for injury severity case mix.
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Affiliation(s)
- Lynne Moore
- Center Hospitalier Affilié Universitaire de Québec Enfant-Jésus Hospital, Laval University, Quebec City, Canada.
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Abstract
BACKGROUND The Revised Trauma Score (RTS) calculated with Major Outcome Trauma Study weights (MTOS-RTS) is currently the standard physiologic severity score in trauma research and quality control. It is often confused with the Triage-RTS (T-RTS), a version that is easier to calculate but only intended for clinical triage. OBJECTIVES To compare the accuracy of the MTOS-RTS to the RTS calculated with weights derived from the study population (POP-RTS) and the T-RTS, for predicting mortality in a trauma population. METHODS The study population consists of 22,388 patients, drawn from the trauma registries of three Level I trauma centers. The predictive accuracy of the MTOS-RTS, POP-RTS, and the T-RTS were compared using measures of discrimination and model fit from logistic regression models. RESULTS The MTOS-RTS, the POP-RTS, and the T-RTS had the same discrimination (Area under the Receiver Operating Curve [AUC] = 0.841). The POP-RTS and the T-RTS had a slightly better model fit than the MTOS-RTS (AIC = 8010, 8010, and 8067, respectively). The T-RTS had equal discrimination and equal or better model fit than the MTOS-RTS in the whole sample, in each of the three trauma centers and in the population of patients with severe head trauma. The T-RTS was also equivalent to the POP-RTS in all of these population sub-groups. CONCLUSIONS The T-RTS could replace the MTOS-RTS as the standard physiologic severity score for trauma outcome prediction. The advantages of using the T-RTS over the MTOS-RTS are ease of calculation, the need for only one measure for triage and mortality prediction purposes and universal adaptation to a broad range of trauma populations.
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Affiliation(s)
- Lynne Moore
- Unité de Recherche en Traumatologie, Centre Hospitalier Affilié Universitaire de Québec, Quebec City, Canada.
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Abstract
BACKGROUND To validate the accuracy of the Revised Trauma Score (RTS) and its components for predicting in-hospital mortality. METHODS Analyses were based on 22,388 patients from the trauma registries of three urban Level I trauma centers in the province of Quebec, Canada. The accuracy of RTS coded variables for the Glasgow Coma Score (GCSc), Systolic Blood Pressure (SBPc), and Respiratory Rate (RRc) for predicting mortality was evaluated in logistic regression models with measures of discrimination and model fit and compared with Fractional Polynomial (FP) transformations of each component. RESULTS RTS coded variables were associated with sparse data distributions and did not accurately represent the relation of GCS, SBP, and RR to mortality. FP models were always associated with significantly better discrimination (all p < 0.00001) and model fit. Survival probability estimates generated by the model with FP transformations were significantly different to those generated by the model with RTS-coded variables. CONCLUSIONS The RTS in its present form does not accurately describe the relation of GCS, SBP, and RR to mortality. FP transformation would improve the accuracy of predicted survival probabilities used for performance evaluation and may improve control of confounding caused by of physiologic severity case mix in trauma research.
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Affiliation(s)
- Lynne Moore
- Centre hospitalier affilié universitaire de Québec, Enfant-Jésus Hospital, Quebec City, Canada.
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