Delirium detection in the emergency department: A diagnostic accuracy meta-analysis of history, physical examination, laboratory tests, and screening instruments

INTRODUCTION

Geriatric emergency department (ED) guidelines emphasize timely identification of delirium. This article updates previous diagnostic accuracy systematic reviews of history, physical examination, laboratory testing, and ED screening instruments for the diagnosis of delirium as well as test-treatment thresholds for ED delirium screening.

METHODS

We conducted a systematic review to quantify the diagnostic accuracy of approaches to identify delirium. Studies were included if they described adults aged 60 or older evaluated in the ED setting with an index test for delirium compared with an acceptable criterion standard for delirium. Data were extracted and studies were reviewed for risk of bias. When appropriate, we conducted a meta-analysis and estimated delirium screening thresholds.

RESULTS

Full-text review was performed on 55 studies and 27 were included in the current analysis. No studies were identified exploring the accuracy of findings on history or laboratory analysis. While two studies reported clinicians accurately rule in delirium, clinician gestalt is inadequate to rule out delirium. We report meta-analysis on three studies that quantified the accuracy of the 4 A's Test (4AT) to rule in (pooled positive likelihood ratio [LR+] 7.5, 95% confidence interval [CI] 2.7-20.7) and rule out (pooled negative likelihood ratio [LR-] 0.18, 95% CI 0.09-0.34) delirium. We also conducted meta-analysis of two studies that quantified the accuracy of the Abbreviated Mental Test-4 (AMT-4) and found that the pooled LR+ (4.3, 95% CI 2.4-7.8) was lower than that observed for the 4AT, but the pooled LR- (0.22, 95% CI 0.05-1) was similar. Based on one study the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is the superior instrument to rule in delirium. The calculated test threshold is 2% and the treatment threshold is 11%.

CONCLUSIONS

The quantitative accuracy of history and physical examination to identify ED delirium is virtually unexplored. The 4AT has the largest quantity of ED-based research. Other screening instruments may more accurately rule in or rule out delirium. If the goal is to rule in delirium then the CAM-ICU or brief CAM or modified CAM for the ED are superior instruments, although the accuracy of these screening tools are based on single-center studies. To rule out delirium, the Delirium Triage Screen is superior based on one single-center study.

Decreased patient discharges on weekends part 3: what do the leaders tell us?

BACKGROUND

Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays.

METHODS

In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions.

RESULTS

We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week.

INTERPRETATION

We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.

How well do ED physician practices align with the CAEP acute atrial fibrillation checklist for stroke prevention and disposition?

OBJECTIVES

Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition.

METHODS

This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals.

RESULTS

358 patients met inclusion criteria. The mean age was 66.9 years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11).

CONCLUSIONS

There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.

Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department

OBJECTIVES

Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL.

METHODS

This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics.

RESULTS

We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL.

CONCLUSION

ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.

Emergency physician gender and head computed tomography orders for older adults who have fallen

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.

Incidence and outcomes of emergency department patients requiring emergency general surgery: a 5-year retrospective cohort study

AIMS

Patients undergoing emergency general surgery are at high risk of complications and death. Our objectives were to estimate the incidence of emergency general surgery in a Swiss University Hospital, to describe the characteristics and outcomes of patients undergoing such procedures, and to study the impact of age on clinical outcomes.

METHODS

This was a retrospective cohort study of adult patients who visited the emergency department (ED) of Geneva University Hospitals between January 2015 and December 2019. Routinely collected data were extracted from electronic medical records. The primary outcome was the incidence of emergency general surgery among patients visiting the emergency department, defined as general surgery within three days of emergency department admission. We also assessed demographic characteristics, mortality, intensive care unit admission and patient disposition. Multivariable log-binomial regression was used to study the associations of age with intensive care unit (ICU) admission, one-year mortality and dependence at discharge. Age was modelled as a continuous variable using restricted cubic splines and we compared older patients (75th percentile) with younger patients (25th percentile).

RESULTS

Between January 2015 and December 2019, a total of 310,914 emergency department visits met our inclusion criteria. Among them, 3592 patients underwent emergency general surgery within 3 days of emergency department admission, yielding an annual incidence of 116 events per 10,000 emergency department visits (95% CI: 112-119), with a higher incidence in females and young patients. Overall, 5.3% of patients were admitted to ICU, 7.8% were dependent on rehabilitation or assisted living at discharge and 4.8% were dead after one year. Older patients had a higher risk of ICU admission (adjusted risk ratio (aRR) 2.9 [1.5-5.4]), dependence at discharge (aRR 15.3 [5.5-42.4]) and one-year mortality (aRR 5.4 [2.2-13.4]).

CONCLUSION

Emergency department visits resulting in emergency general surgery are frequent, but their incidence decreases with patient age. Mortality, ICU admission and dependence at discharge following emergency general surgery are more frequent in older patients. Taking into account the increased risk for older patients, a shared process is appropriate for making more informed decisions about their options for care.

Comparison of peer-assisted learning with expert-led learning in medical school ultrasound education: a systematic review and meta-analysis

INTRODUCTION

Teaching point-of-care ultrasonography (PoCUS) to medical students is resource intensive. Peer-assisted learning, where the teacher can be a medical student, may be a feasible alternative to expert-led learning. The objective of this systematic review and meta-analysis was to compare the PoCUS performance assessments of medical students receiving peer-assisted vs expert-led learning.

METHODS

This study was submitted to PROSPERO (CRD42023383915) and reported with PRISMA guidelines. MEDLINE, Embase, ERIC, Education Source, Scopus, and Web of Science were searched from inception to November 2022. Inclusion criteria were studies comparing peer-assisted vs expert-led PoCUS teaching for undergraduate medical students. The primary outcome was performance assessment of PoCUS skills. Two reviewers independently screened citations and extracted data. The Cochrane risk-of-bias tool for randomized trials was used to assess study quality. Studies were included in the meta-analysis if mean performance assessment scores with standard deviations and sample sizes were available. A random-effects meta-analysis was conducted to estimate the accuracy score of practical knowledge test for each group. A meta-regression evaluated difference in mean scores.

RESULTS

The search yielded 2890 citations; 1417 unique citations remained after removing duplicates. Nine randomized-controlled studies conducted in Germany, USA, and Israel, with 593 participants, were included in the meta-analysis. The included studies assessed teaching of abdominal, cardiac, thoracic, musculoskeletal, and ocular PoCUS skills. Most studies had some risk-of-bias concerns. The estimate accuracy score after weighting is 0.56 (95% CI [0.47, 0.65]) for peer-assisted learning and 0.59 (95% CI [0.49, 0.69]) for expert-led learning. The regression coefficient estimate is 0.0281 (95% CI [- 0.1121, 0.1683]); P value is 0.69.

CONCLUSION

This meta-analysis found that peer-assisted learning was a reasonable alternative to expert-led learning for teaching PoCUS skills to medical students.

RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter

BACKGROUND

We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist.

METHODS

This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED.

RESULTS

We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent.

CONCLUSIONS

We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients.

CLINICALTRIALS

GOV IDENTIFIER

NCT05468281.

Hypotension and respiratory events related to electrical cardioversion for atrial fibrillation or atrial flutter in the emergency department

INTRODUCTION

Electrical cardioversion for atrial fibrillation/atrial flutter (AF/AFL) is common in the ED. Our previous work showed that hypotension and respiratory events were important adverse events that occurred in patients undergoing electrical cardioversion for AF/AFL. The purpose of this study was to examine if (1) beta-blockers or calcium channel blocker use prior to ECV were associated with hypotension and (2) medications used for procedural sedation were associated with respiratory events.

METHODS

This was a secondary analysis of pooled study data from four previous multicentred studies on AF/AFL. We conducted a multivariable logistic regression to examine predictors of hypotension and respiratory adverse events.

RESULTS

There were 1736 patients who received ECV. A hypotensive event occurred in 62 (3.6%) patients. There was no significant difference in the odds of a hypotensive event in patients who received a beta-blocker or calcium channel blocker in the ED compared to no rate control. Procedural sedation with fentanyl (OR 2.01 95% CI 1.15-3.51) and home beta-blocker use (OR 1.92, 95% CI 1.14-3.21) were significantly associated with hypotensive events. A respiratory event occurred in 179 (10.3%) patients. Older age (OR 2.02, 95% CI 1.30- 3.15) and receiving midazolam for procedural sedation were found to be significantly associated with respiratory events (OR 1.99, 95% CI 1.02-3.88).

CONCLUSION

Beta-blocker or calcium channel blocker use prior to ECV for AF/AFL was not associated with hypotension. However, sedation with fentanyl and home beta-blocker use was associated with hypotension. The use of midazolam for procedural sedation was significantly associated with respiratory events.

Core requirements of frailty screening in the emergency department: an international Delphi consensus study

INTRODUCTION

Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.

METHODS

A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August-September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.

RESULTS

In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2-4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.

CONCLUSIONS

Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

Modern management of acute atrial fibrillation and atrial flutter

This clinical review is intended to assist emergency physicians manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation (AF) or flutter (AFL). This article is based primarily on the 2021 Canadian Association of Emergency Physicians (CAEP) Acute Atrial Fibrillation/Flutter Best Practices Checklist. We encourage readers to download the open access CAEP Checklist article (https://link.springer.com/article/10.1007/s43678-021-00167-y) and the free smartphone app (CAEP Atrial Fibrillation Guide). We focus on four key elements of ED care: assessment and risk stratification, rate and rhythm control, short-term and long-term stroke prevention, and disposition and follow-up. It is important to determine if AF/AFL with rapid ventricular response is a primary arrhythmia or secondary to medical causes. While it is unusual for patients with primary AF to be unstable, urgent cardioversion is occasionally required. The criteria for when cardioversion is safe have recently changed and it is essential that physicians are well versed in them. When rhythm control is not safe, provide effective and safe IV rate control. When rhythm control is safe, either pharmacological or electrical cardioversion acceptable, per patient and physician preference. Rapid ventricular pre-excitation (Wolff-Parkinson-White Syndrome) usually, but not always, requires urgent electrical cardioversion. ED physicians should prescribe oral anticoagulants at discharge if indicated. No specific direct oral anticoagulant is preferred, and references should be freely consulted for optimal dosing. Hospital admission is rarely required for acute AF/AFL patients, who should be given good discharge instructions.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen

BACKGROUND

Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head.

METHODS

This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression.

RESULTS

The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%).

INTERPRETATION

We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

How Emergency Medicine Residents Have Conversations About Life-Sustaining Treatments in Critical Illness: A Qualitative Study Using Inductive Thematic Analysis

STUDY OBJECTIVE

The inherent pressures of high-acuity, critical illness in the emergency department create a unique environment whereby acute goals-of-care discussions must be had with patients or substitute decision makers to rapidly decide between divergent treatment paths. Among university-affiliated hospitals, resident physicians are often conducting these highly consequential discussions. This study aimed to use qualitative methods to explore how emergency medicine residents make recommendations regarding life-sustaining treatments during acute goals-of-care discussions in critical illness.

METHODS

Using qualitative methods, semistructured interviews were conducted with a purposive sample of emergency medicine residents in Canada from August to December 2021. Inductive thematic analysis of the interview transcripts was conducted using line-by-line coding, and key themes were identified through comparative analysis. Data collection continued until thematic saturation was reached.

RESULTS

Seventeen emergency medicine residents from 9 Canadian universities were interviewed. Two factors guided residents' treatment recommendations (a duty to provide a recommendation and the balance between disease prognosis and patient values). Three factors influenced residents' comfort when making recommendations (time constraints, uncertainty, and moral distress).

CONCLUSION

While conducting acute goals-of-care discussions with critically ill patients or their substitute decision makers in the emergency department, residents felt a sense of duty to provide a recommendation informed by an intersection between the patient's disease prognosis and the patient's values. Their comfort in making these recommendations was limited by time constraints, uncertainty, and moral distress. These factors are important for informing future educational strategies.

Predictors of mortality among older major trauma patients

BACKGROUND

Older trauma patients have a higher mortality yet are more likely to be under-triaged compared to younger patients. Studies have suggested that current trauma team activation criteria are suboptimal for older patients.

OBJECTIVES

The objective was to describe trauma care delivered, patient outcomes, and to identify variables independently associated with mortality.

METHODS

We performed a health records review from 2014 to 2020 of older (age ≥ 65 years) trauma patients presenting to a level one trauma centre with any of the following: injury severity score (ISS) > 12, and all trauma team activations or admission to the trauma ward. The primary outcome was 30-day all-cause mortality. Secondary outcomes included injury mechanism and trauma care delivered. Multivariable logistic regression was used to identify factors independently associated with 30-day all-cause mortality. Multiple imputation was used to deal with missing data.

RESULTS

We enrolled 1,380 patients (mean age 80 years, mean ISS 18); 26.8% had multimorbidity (≥ 2 chronic conditions) and 65.9% met criteria for polypharmacy (≥ 5 medications). The most common mechanism was fall from standing height (61.1%). Thirty-day all-cause mortality occurred in 239 (17.3%) patients. A Glasgow coma scale (GCS) < 15 (odds ratio [OR] = 5.55; 95% CI 3.73-8.24), ISS > 15 (OR = 3.75, 95% CI 2.35-6.01), age ≥ 85 years (OR = 2.04, 95% CI 1.29-3.22), anticoagulation with a direct oral anticoagulant (DOAC) or warfarin (OR = 1.59, 95% CI 1.08-2.35) and multimorbidity (OR = 1.53, 95% CI 1.06-2.22) were significantly associated with increased risk 30-day mortality (C-statistic = 0.82, 95% CI 0.79-0.85). Dementia (OR = 0.61, 95% CI 0.40-0.95) and time to CT scan > 60 min (OR = 0.50, 95% CI 0.34-0.74) were associated with decreased mortality risk.

CONCLUSION

We identified five factors associated with increased 30-day mortality in older trauma patients: GCS < 15, ISS > 15, age ≥ 85 years, anticoagulation, and multimorbidity. These factors should be considered when developing modified trauma team activation criteria for older adults.

Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study

BACKGROUND

Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS).

METHODS

This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level.

RESULTS

A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience.

CONCLUSION

The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes.

REGISTRATION

This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).

Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial

BACKGROUND

We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation.

METHODS

A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2-3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058.

RESULTS

1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period.

CONCLUSION

In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation.

Outcomes of acute heart failure patients managed in the emergency department

BACKGROUND

Acute heart failure is a serious condition commonly seen in the emergency department (ED). The HEARTRISK6 Scale has been recently developed to identify the risk of poor outcomes but has not been tested. We sought to describe the management and outcomes of ED patients with acute heart failure and to evaluate the potential impact of the HEARTRISK6 Scale.

METHODS

We conducted a health records review of 300 consecutive acute heart failure patients presenting to two tertiary care EDs. Two evaluators abstracted clinical variables, ED management and treatment details, and patient outcomes using the electronic health records platform (EPIC) and attending physicians verified the data. The primary outcome measure was a short-term serious outcome, as shown in Results. In addition, the HEARTRISK6 score was calculated retrospectively.

RESULTS

We included 300 patients with mean age of 78.5 years, 51.0% male, 56.3% arrival by ambulance, and 67.0% admitted to hospital. 25.3% experienced a short-term serious outcome 1) after admission (N = 201): non-invasive ventilation 14.9%, intubation 1.5%, major cardiac procedure 5.0%, myocardial infarction 2.0%, death 8.5%; 2) after ED discharge (N = 99): return to ED 21.2%, death 4.0%. Those initially admitted experienced a much higher proportion of serious outcomes compared to those discharged (29.9% vs. 16.2%). A HEARTRISK6 Scale cut-point score of ≥ 1 would have had a sensitivity of 91.0%, specificity 24.5%, and negative likelihood ratio 0.37 for short-term serious outcomes and suggested hospital admission for 80.7% of cases.

CONCLUSION

There was a large range of severity of illness of acute heart failure patients and a wide variety of treatments were administered in the ED. Both admitted and discharged patients experienced a high proportion of poor outcomes. The HEARTRISK6 Scale showed a high sensitivity for short-term serious outcomes but with the potential to increase hospital admissions. Further validation of the HEARTRISK6 Scale is required before routine clinical use.

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting

BACKGROUND

Pain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity.

RESULTS

Of 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0-36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions.

CONCLUSION

Sufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Ninety-Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Agreement and prognostic accuracy of three ED vulnerability screeners: findings from a prospective multi-site cohort study

OBJECTIVES

To evaluate the agreement between three emergency department (ED) vulnerability screeners, including the InterRAI ED Screener, ER², and PRISMA-7. Our secondary objective was to evaluate the discriminative accuracy of screeners in predicting discharge home and extended ED lengths-of-stay (> 24 h).

METHODS

We conducted a nested sub-group study using data from a prospective multi-site cohort study evaluating frailty in older ED patients presenting to four Quebec hospitals. Research nurses assessed patients consecutively with the three screeners. We employed Cohen's Kappa to determine agreement, with high-risk cut-offs of three and four for the PRISMA-7, six for the ER², and five for the interRAI ED Screener. We used logistic regression to evaluate the discriminative accuracy of instruments, testing them in their dichotomous, full, and adjusted forms (adjusting for age, sex, and hospital academic status).

RESULTS

We evaluated 1855 older ED patients across the four hospital sites. The mean age of our sample was 84 years. Agreement between the interRAI ED Screener and the ER² was fair (K = 0.37; 95% CI 0.33-0.40); agreement between the PRISMA-7 and ER² was also fair (K = 0.39; 95% CI = 0.36-0.43). Agreement between interRAI ED Screener and PRISMA-7 was poor (K = 0.19; 95% CI 0.16-0.22). Using a cut-off of four for PRISMA-7 improved agreement with the ER² (K = 0.55; 95% CI 0.51-0.59) and the ED Screener (K = 0.32; 95% CI 0.2-0.36). When predicting discharge home, the concordance statistics among models were similar in their dichotomous (c = 0.57-0.61), full (c = 0.61-0.64), and adjusted forms (c = 0.63-0.65), and poor for all models when predicting extended length-of-stay.

CONCLUSION

ED vulnerability scores from the three instruments had a fair agreement and were associated with important patient outcomes. The interRAI ED Screener best identifies older ED patients at greatest risk, while the PRISMA-7 and ER² are more sensitive instruments.

Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis

BACKGROUND

Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury.

METHODS

We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam.

RESULTS

The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up.

CONCLUSIONS

Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.

Examining the utility and accuracy of the interRAI Emergency Department Screener in identifying high-risk older emergency department patients: A Canadian multiprovince prospective cohort study

Objectives

We set out to determine the accuracy of the interRAI Emergency Department (ED) Screener in predicting the need for detailed geriatric assessment in the ED. Our secondary objective was to determine the discriminative ability of the interRAI ED Screener for predicting the odds of discharge home and extended ED length of stay (>24 hours).

Methods

We conducted a multiprovince prospective cohort study in Canada. The need for detailed geriatric assessment was determined using the interRAI ED Screener and the interRAI ED Contact Assessment as the reference standard. A score of ≥5 was used to classify high-risk patients. Assessments were conducted by emergency and research nurses. We calculated the sensitivity, positive predictive value, and false discovery rate of the interRAI ED Screener. We employed logistic regression to predict ED outcomes while adjusting for age, sex, academic status, and the province of care.

Results

A total of 5629 older ED patients across 11 ED sites were evaluated using the interRAI ED Screener and 1061 were evaluated with the interRAI ED Contact Assessment. Approximately one-third of patients were discharged home or experienced an extended ED length of stay. The interRAI ED Screener had a sensitivity of 93%, a positive predictive value of 82%, and a false discovery rate of 18%. The interRAI ED Screener predicted discharge home and extended ED length of stay with fair accuracy.

Conclusion

The interRAI ED Screener is able to accurately and rapidly identify individuals with medical complexity. The interRAI ED Screener predicts patient-important health outcomes in older ED patients, highlighting its value for vulnerability screening.

High-dose cephalexin for cellulitis: a pilot randomized controlled trial

BACKGROUND

Up to 3% of all Emergency Department (ED) visits are due to skin and soft tissue infections such as non-purulent cellulitis. The current treatment failure rate is approximately 20%. Evidence is lacking regarding the optimal outpatient management of cellulitis.

OBJECTIVES

To evaluate the feasibility of a randomized trial comparing high-dose (1000 mg) to standard-dose (500 mg) cephalexin to treat ED patients with cellulitis.

METHODS

A parallel arm double-blind randomized controlled pilot trial conducted at two EDs in Canada. Eligible participants were adults (age ≥ 18 years) presenting to the ED with non-purulent cellulitis and determined by the treating emergency physician to be eligible for outpatient management with oral antibiotics. Participants were randomized to high-dose or standard-dose cephalexin four times daily for 7 days. The primary feasibility outcome was participant recruitment rate (target ≥ 35%). The preliminary primary effectiveness outcome was oral antibiotic treatment failure.

RESULTS

Of 134 eligible participants approached for trial participation, 69 (51.5%, 95% CI 43.1 to 59.8%) were recruited and randomized. After excluding three randomized participants due to an alternate diagnosis, 33 participants were included in each arm. Nineteen eligible cases (14.2%) were missed. Loss to follow-up was 6.1%. Treatment failure occurred in four patients (12.9%) in the standard-dose arm versus one patient (3.2%) in the high-dose arm. A greater proportion had minor adverse events in the high-dose arm. No patients had an unplanned hospitalization within 14 days.

CONCLUSION

This pilot randomized controlled trial comparing high-dose to standard-dose cephalexin for ED patients with cellulitis demonstrated a high participant recruitment rate and that a full-scale trial is feasible. High-dose cephalexin had fewer treatment failures but with a higher proportion of minor adverse effects. The findings of this pilot will be used to inform the design of a future large trial.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT04471246).

Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review

BACKGROUND

Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research.

METHODS

We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods.

RESULTS

A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission.

CONCLUSION

The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed.

REGISTRATION

https://doi.org/10.17605/OSF.IO/W2F8N.

Gender differences in emergency medicine resident assessment: A scoping review

Background

Growing literature within postgraduate medical education demonstrates that female resident physicians experience gender bias throughout their training and future careers. This scoping review aims to describe the current body of literature on gender differences in emergency medicine (EM) resident assessment.

Methods

We conducted a scoping review which adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. We included research involving resident physicians or fellows in EM (population and context), which focused on the impact of gender on assessments (concept). We searched seven databases from the databases' inception to April 4, 2022. Two reviewers independently screened citations, completed full-text review, and abstracted data. A third reviewer resolved any discrepancies.

Results

A total of 667 unique citations were identified; 10 studies were included, and all were conducted within the United States. Four studies reported differences in EM resident assessments attributable to gender within workplace-based assessments (qualitative comments and quantitative scores) by both attending physicians and nonphysicians. Six studies investigating clinical competency committee scores, procedural scores, and simulation-based assessments did not report any significant differences attributable to gender.

Conclusions

This scoping review found that gender bias exists within EM resident assessment most notably at the level of narrative comments typically received via workplace-based assessments. As female EM residents receive higher rates of negative or critical comments and discordant feedback documented on assessment, these findings raise concern about added barriers female EM residents may face while progressing through residency and the impact on their clinical and professional development.

The relationship between empathy and the quality of the educational environment in Canadian emergency medicine residents

Purpose

Empathy and quality of educational environment appear to be inversely correlated with burnout but the relationship between the two is largely unknown. Our primary objective was to examine the relationship between postgraduate educational environment and empathy. Secondary objectives included impact of gender, residency year and on- versus off-service context on levels of empathy and educational environment.

Methods

A modified Dillman approach was used to conduct an email survey of Canadian Royal College Emergency Medicine residents in June 2020. The survey instrument included: demographic data, Toronto Empathy Questionnaire (TEQ) and Scan of Postgraduate Educational Environment Domains (SPEED). Logistic and linear regressions evaluated the association between TEQ and SPEED, and mean SPEED scores and covariates, respectively.

Results

Response rate was 38% (138/363) with representation from all programs. Respondents were mean 30 years of age, 59% men and 25%, 20%, 18%, 24%, and 13% in postgraduate year (PGY) 1–5, respectively. There was no statistically significant association between high/low TEQ scores and mean SPEED score (p = 0.97). There were no statistically significant associations between any of the covariates and high/low TEQ scores (gender, p = 0.21; PGY, p = 0.58; on-versus off-service, p = 0.46) or mean SPEED score (gender, p = 0.95; PGY, p = 0.48; on- versus off-service, p = 0.07). Emergency medicine residents rated their educational environment on average 3.44 (+/- 0.43) out of four. 39 of 134 residents were found to have low empathy.

Conclusion

There was no association between empathy and educational environment. Further research is needed to elucidate modifiable factors contributing to the development of low empathy in emergency medicine residents.

An evaluation of emergency pain management practices in fragility fractures of the pelvis

BACKGROUND

Inadequately treated pain is associated with significant morbidity in older adults. We aimed to describe current pain management practices for patients with fragility pelvic fractures, a common emergency department (ED) presentation in older adults.

METHODS

We performed a health records' review of adults ≥ 65 years old who presented to two academic EDs with nonoperative fragility pelvic fractures between 01/2014 and 09/2018. The primary outcome measures were type and timing of analgesic medications. Secondary outcome measures included ancillary service consultation, ED length of stay, admission rate and rate of return to ED at 30 days. Data were reported using descriptive statistics.

RESULTS

We included 411 patients. The majority were female (339, 82.5%) with mean age 83.9 (SD 8.1) years. Nearly, one-third (130, 31.6%) did not receive any analgesia for their fracture. Analgesia was initiated in 123 (29.9%) patients through paramedic and nursing medical directives; 244 (59.4%) patients received physician-initiated opioids (hydromorphone 228 (55.5%); morphine 28 (6.8%)). Only 23.1% of patients received one or more ancillary services: physiotherapy (10.5%), social work (7.3%), geriatric nurse assessment (14.1%), and homecare (3.9%). Mean ED length of stay was 11.6 (SD 7.1) h; 210 (51.1%) patients were admitted; of those discharged, 45 (22.4%) returned to the ED within 30 days.

CONCLUSION

One in three older adults presenting to the ED with nonoperative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care. Barriers to quality care must be identified and processes implemented to ensure adequate pain management for this population.

Prevalence, management and outcomes of unrecognized delirium in a National Sample of 1,493 older emergency department patients: how many were sent home and what happened to them?

BACKGROUND

Retrospective studies estimate Emergency Department (ED) delirium recognition at <20%; few prospective studies have assessed delirium recognition and outcomes for patients with unrecognized delirium.

OBJECTIVES

To prospectively measure delirium recognition by ED nurses and physicians, document their confidence in diagnosis and disposition, actual dispositions, and patient outcomes.

METHODS

Prospective observational study of people ≥65 years. We assessed delirium using the Confusion Assessment Method, then asked ED staff if the patient had delirium, confidence in their assessment, if the patient could be discharged, and contacted patients 1 week postdischarge. We report proportions and 95% confidence intervals (Cls).

RESULTS

We enrolled 1,493 participants; mean age was 77.9 years; 49.2% were female, 79 (5.3%, 95% CI 4.2-6.5%) had delirium. ED nurses missed delirium in 43/78 cases (55.1%, 95% CI 43.4-66.4%). Nurses considered 12/43 (27.9%) patients with unrecognized delirium safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 7.0/10. Physicians missed delirium in 10/20 (50.0%, 95% CI 27.2-72.8) cases and considered 2/10 (20.0%) safe to discharge. Median confidence in their delirium diagnosis for patients with unrecognized delirium was 8.0/10. Fifteen patients with unrecognized delirium were sent home: 6.7% died at 1 week follow-up vs. none in those with recognized delirium and 1.1% in the rest of the cohort.

CONCLUSION

Delirium recognition by nurses and physicians was sub-optimal at ~50% and may be associated with increased mortality. Research should explore root causes of unrecognized delirium, and novel strategies to systematically improve delirium recognition and patient outcomes.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework

BACKGROUND

delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol.

OBJECTIVES

we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients.

METHODS

we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified.

RESULTS

a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture.

CONCLUSION

this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Association between mood disorders and frequent emergency department use: a cross-sectional study

OBJECTIVES

Frequent emergency department (ED) use is a growing problem that is associated with poor patient outcomes and increased health care costs. Our objective was to analyze the association between mood disorders and the incidence of frequent ED use.

METHODS

We used the Canadian Community Health Survey conducted by Statistics Canada, 2015-2016. Mood disorder was defined as depression, bipolar disorder, mania, or dysthymia. Frequent ED use was defined as 4 or more visits in the year preceding the interview. Multivariable log-binomial regression models were used to determine the associations between mood disorders and frequent ED use.

RESULTS

Among the 99,009 participants, 8.4% had mood disorders, 80.3% were younger than 65, and 2.2% were frequent ED users. Mood disorders were significantly associated with the 1-year cumulative incidence of frequent ED use (RR = 2.5, 95% CI 2.2-2.7), after adjusting for several potential confounders.

CONCLUSIONS

This national survey showed that people with a mood disorder had a three-fold risk of frequent ED use, compared to people without mood disorder. These results can inform the development of policies and targeted interventions aimed at identifying and supporting ED patients with mood disorder.

The impact of an outpatient parenteral antibiotic therapy (OPAT) clinic for adults with cellulitis: an interrupted time series study

Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective was to determine whether implementation of an OPAT clinic results in decreased hospitalizations and return ED visits for patients receiving OPAT. We conducted an interrupted time series study involving adults with cellulitis presenting to two EDs and treated with intravenous antibiotics. The intervention was the OPAT clinic, which involved follow up at 48-96 h with an infectious disease physician to determine the need for ongoing intravenous antibiotics (implemented January 1, 2014). The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after initiating OPAT) and adverse peripheral line or antibiotic events. We used an interrupted time series design with segmented regression analysis over one-year pre-intervention and one-year post-intervention. 1666 patients were included. At the end of the study period, there was a non-significant 12% absolute increase in hospital admissions (95% CI - 1.6 to 25.5%; p = 0.084) relative to what would have been expected in the absence of the intervention, but a significant 40.7% absolute reduction in return ED visits (95% CI 25.6-55.9%; p < 0.001). Treatment failure rates were < 2% and adverse events were < 6% in both groups. Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, but did not reduce hospital admission rates. An ED-to-OPAT clinic model is safe, and has a low rate of treatment failures.

Adverse Events Associated With Electrical Cardioversion in Patients With Acute Atrial Fibrillation and Atrial Flutter

BACKGROUND

We sought to evaluate safety of electrical cardioversion (ECV) for patients with acute atrial fibrillation (AF) or atrial flutter (AFL) in the emergency department (ED).

METHODS

This was an analysis of data from 4 multicentre AF/AFL studies conducted from 2008 to 2019 at 23 large EDs. We included adult patients who received attempts at ECV and who had presented acutely after symptom onset. Staff manually reviewed study and clinical records to abstract data.

RESULTS

We evaluated 1736 ECV cases with a mean age of 60.1 years and 67.1% male. The overall success of ECV was 90.2% (95% confidence interval 88.7%-91.6%), with 4.9% of patients admitted. ED physicians performed the ECV in 95.2% and provided sedation in 96.5%; 13.9% (12.3%-15.7%) of cases experienced important adverse events that required treatment, and 0.4% were classified as life threatening. Another 5.6% had adverse events that did not require treatment. Logistic regression found that the RAFF-3 study cohort (odds ratio [OR] 2.0), age ≥ 85 years (OR 2.1), coronary artery disease (OR 1.5), midazolam (OR 1.9), and fentanyl (OR 1.5) were associated with important adverse events.

CONCLUSIONS

This large evaluation of the safety of ECV for acute AF/AFL in the ED found that while serious adverse events were rare, there were a concerning number of events following sedation that required intervention. Physicians should be aware that older age, coronary artery disease, and fentanyl are associated with higher risks of important adverse events. This study provides more information for shared decision making discussions with patients when choosing between drug-shock and shock-only cardioversion strategies.

Surviving strangulation: evaluation of non-fatal strangulation in patients presenting to a tertiary care sexual assault and partner abuse care program

BACKGROUND

Non-fatal strangulation is a dangerous mechanism of injury among survivors of intimate partner violence and sexual assault, with inadequate evidence to guide investigation in the emergency department (ED). The primary objective is to identify the proportion of intimate partner violence and sexual assault where non-fatal strangulation occurs, and to describe the sequelae of injuries.

METHODS

Health records review of patients treated at the Sexual Assault and Partner Abuse Care Program (SAPACP) and/or Trauma Program at a tertiary level hospital between January 2015 and December 2018. Eligible patients were greater than 16 years old, seen by the SAPACP or trauma team for intimate partner violence and sexual assault, and had a non-fatal strangulation injury. Data were abstracted from the standardized assessment completed by the SAPACP nurse. Descriptive statistics were used.

RESULTS

We identified 209 eligible cases of non-fatal strangulation, among 1791 patient presentations to the SAPACP. Median patient age was 27 years, and 97.6% were female. Computed tomography (CT) of the head was obtained in 22.5%, and CT angiography (CTA) of the head and neck in 6.2% of cases. Eleven significant injuries were identified. Two cases of vascular abnormalities: internal carotid artery indentation with possible intramural hematoma and possible internal carotid artery dissection. Other injuries included delayed bilateral subdural hematomas, a depressed skull fracture, and six nasal fractures.

CONCLUSION

We found over 10% prevalence of non-fatal strangulation in survivors of intimate partner violence and sexual assault. There was a low rate of clinically important injury on the index ED visit secondary to non-fatal strangulation. Severe injury was primarily secondary to concomitant trauma, and utilization of CTA in this cohort was low. Increased awareness is needed among ED physicians regarding the need to consider CTA head and neck.

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

OBJECTIVES

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

DESIGN

Open-label feasibility study.

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov #02892968.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT03745755.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physician choices in pulmonary embolism testing

BACKGROUND:

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

METHODS:

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

RESULTS:

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

INTERPRETATION:

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

Rapid Fire: Acute Brain Failure in Older Emergency Department Patients

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

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

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of laboratories in animal-related disasters and emergencies

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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