Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada.

BACKGROUND: Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm. METHODS: We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon. RESULTS: We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (n = 151, 39.0%), gynecology (n = 71, 18.3%), and orthopedic surgery (n = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase (n = 171, 44.2%) than in the pre- (n = 127, 32.8%) or intra-operative (n = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team (n = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death. CONCLUSION: In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.

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.

Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association.

PURPOSE: We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern. METHODS: We included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes. RESULTS: We found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD. CONCLUSIONS: Severe patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.

RéSUMé: OBJECTIF: Nous avons analysé les dossiers d'actions civiles de l'Association canadienne de protection médicale (ACPM) conclus entre 2007 et 2016 qui impliquaient des anesthésiologistes mettaient principalement en cause la gestion des voies respiratoires. MéTHODE: Nous avons inclus tous les dossiers d'actions civiles mettant en cause la gestion des voies respiratoires et impliquant des anesthésiologistes, conclus entre 2007 et 2016. Les analystes médicaux de l'ACPM ont examiné les variables suivantes: le contexte clinique, les opinions des experts sur les facteurs contributifs, ainsi que les issues des actions en justice et les résultats cliniques pour les patients. RéSULTATS: Parmi les 406 dossiers conclus impliquant des anesthésiologistes, 46 (11%) portaient sur des problèmes liés aux voies respiratoires. Vingt-six de ces dossiers (57%) portaient sur des cas de chirurgie non urgente et 31 patients (67%) étaient considérés comme ayant un état physique relevant de la classification I ou II de l'American Society of Anesthesiologists. Dans vingt-cinq dossiers (54%), les problèmes sont survenus en dehors de la salle d'opération (par ex., salle de réveil, unité de soins intensifs, ou autre emplacement satellite). Dans 19 dossiers (42%), il y avait au moins un prédicteur de difficultés dans la prise en charge des voies respiratoires. Les experts ont relevé des erreurs de jugement dans 30 dossiers (65%), la plupart du temps liées à une évaluation inadéquate des voies respiratoires. Dans 30 dossiers (65%), le patient est décédé ou a subi des lésions cérébrales permanentes. L'issue médicolégale a été favorable au patient dans 27 dossiers (59%), montant médian [écart interquartile] du paiement étant de 422 845 [257 637-935 673] CAD. CONCLUSION: Il est fréquent que des patients subissent des préjudices graves lorsque la prise en charge des voies respiratoires fait l'objet d'une plainte médicolégale auprès de l'ACPM qui met en cause des anesthésiologistes. Dans les dossiers analysés, les patients étaient généralement considérés à faible risque en vue d'une intervention chirurgicale non urgente. Les erreurs les plus fréquentes étaient une mauvaise évaluation des voies respiratoires ou la non-modification de la prise en charge des voies respiratoires à la suite de l'évaluation ou de difficultés rencontrées. Selon nos conclusions, il est impératif de continuer d'adopter, de respecter et de mettre en pratique les lignes directrices concernant la prise en charge de voies respiratoires difficiles, anticipées ou non, lors de chaque rencontre avec un patient.

Does N-Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope?

BACKGROUND: Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope. OBJECTIVE: To evaluate whether adding N-terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs). DESIGN: Prospective cohort study. SETTING: 6 EDs in 2 Canadian provinces. PARTICIPANTS: 1452 adult ED patients with syncope. INTERVENTION: Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes. MEASUREMENTS: An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events. RESULTS: Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; P < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90; P = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs. LIMITATIONS: Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging. CONCLUSION: Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended. PRIMARY FUNDING SOURCE: Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.

Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data.

Background: Intraoperative injuries during abdominopelvic surgery can be associated with substantial patient harm. The objective of this study was to describe abdominopelvic intraoperative injuries and their contributing factors among medicolegal cases. Methods: This study was a descriptive analysis of medicolegal matters reported to a national body, with subgroup analyses by type of surgery. We reviewed medicolegal matters involving a population-based sample of physicians who were subject to a civil legal action or complaint to a regulatory authority that was closed between 2013 and 2017 in Canada. Results: Our analysis included 181 civil legal cases and 88 complaints to a regulatory authority. Among legal cases, 155 patients (85.6%) (median age 47 yr) underwent elective procedures. The most common injury site was the bowel (53 cases [29.3%]). Injuries frequently occurred during dissection (79 [43.6%]) and ligation (38 [21.0%]), were identified postoperatively (138 [76.2%]) and necessitated further surgery (139 [76.8%]). Many patients experienced severe harm (55 [30.4%]) or died (25 [13.8%]). Peer experts in nongynecologic cases were more likely than those in gynecologic cases to include criticisms of a provider in a harmful incident (79 [71.2%] v. 30 [42.9%], p < 0.01). Peer expert criticisms often related to clinical evaluation, decision-making and misidentification of anatomy. Criticisms of nontechnical skills identified documentation and communication deficiencies. Conclusion: This study confirms the importance of provider and team training to improve clinical evaluation and decision-making, documentation and communication. Effective protocols may help support clinicians in providing safer surgical care.

Contexte: Les blessures survenant durant une chirurgie abdominopelvienne peuvent être associées à d'importants préjudices chez les patients. La présente étude avait pour but de décrire les blessures peropératoires abdominopelviennes faisant l'objet d'enquêtes médicolégales et à connaître leurs facteurs contributifs. Méthodes: Cette étude comprend une analyse descriptive d'affaires médicolégales signalées à un organisme de réglementation national, ainsi que des analyses par sousgroupes selon le type de chirurgie. Nous avons examiné des cas impliquant un échantillon de médecins canadiens représentatifs de la population qui avaient fait l'objet d'une poursuite au civil ou d'une plainte auprès d'un organisme de réglementation. Toutes les poursuites et plaintes étudiées ont été résolues entre 2013 et 2017. Résultats: Notre analyse comprenait 181 poursuites au civil et 88 plaintes auprès d'un organisme de réglementation. En ce qui concerne les poursuites au civil, 155 patients (85,6 %) (âge médian 47 ans) avaient subi une intervention non urgente. Les blessures déclarées touchaient généralement les intestins (53 cas [29,3 %]). Elles sont fréquemment survenues durant la dissection (79 cas [43,6 %]) et la ligature (38 cas [21,0 %]), ont été repérées en période postopératoire (138 cas [76,2 %]) et ont nécessité une autre chirurgie (139 cas [76,8 %]). De nombreux patients ont subi de graves préjudices (55 cas [30,4 %]) ou sont décédés (25 cas [13,8 %]). Les pairs experts dans un domaine autre que la gynécologie étaient plus susceptibles que ceux experts en gynécologie de critiquer un fournisseur en cas d'incident avec préjudice (79 cas [71,2 %] c. 30 cas [42,9 %]; p < 0,01). Les critiques formulées par les pairs experts portaient souvent sur l'évaluation clinique, la prise de décision et les erreurs d'identification des structures anatomiques. Les critiques visant les habiletés non techniques avaient trait aux lacunes dans la documentation et la communication. Conclusion: Cette étude vient confirmer l'importance que revêt la formation des fournisseurs et de leur équipe dans l'amélioration de la prise de décision, de la documentation et de la communication. Des protocoles efficaces pourraient soutenir l'offre de soins chirurgicaux sûrs par les professionnels de la santé.

Benefit of hospital admission for detecting serious adverse events among emergency department patients with syncope: a propensity-score-matched analysis of a multicentre prospective cohort.

BACKGROUND: The benefit of hospital admission after emergency department evaluation for syncope is unclear. We sought to determine the association between hospital admission and detection of serious adverse events, and whether this varied according to the Canadian Syncope Risk Score (CSRS). METHODS: We conducted a secondary analysis of a multicentre prospective cohort of patients assessed in the emergency department for syncope. We compared patients admitted to hospital and discharged patients, using propensity scores to match 1:1 for risk of a serious adverse event. The primary outcome was detection of a serious adverse event in hospital for admitted patients or within 30 days after emergency department disposition for discharged patients. RESULTS: We included 8183 patients, of whom 743 (9.1%) were admitted; 658/743 (88.6%) were matched. Admitted patients had higher odds of detection of a serious adverse event (odds ratio [OR] 5.0, 95% confidence interval [CI] 3.3-7.4), nonfatal arrhythmia (OR 5.1, 95% CI 2.9-8.8) and nonarrhythmic serious adverse event (OR 6.3, 95% CI 2.9-13.5). There were no significant differences between the 2 groups in death (OR 1.0, 95% CI 0.4-2.7) or detection of ventricular arrhythmia (OR 2.0, 95% CI 0.7-6.0). Differences between admitted and discharged patients in detection of serious adverse events were greater for those with a CSRS indicating medium to high risk (p = 0.04). INTERPRETATION: Patients with syncope were more likely to have serious adverse events identified within 30 days if they were admitted to hospital rather than discharged from the emergency department. However, the benefit of hospital admission is low for patients at low risk of a serious adverse event.

Implementing Obstetrics Quality Improvement, Driven by Medico-legal Risk, is Associated With Improved Workplace Culture.

OBJECTIVE: This study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture. METHODS: The study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention. RESULTS: The majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements. CONCLUSION: This study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.

Recommendations From a National Panel on Quality Improvement in Obstetrics.

This paper describes the recommendations of a national panel on quality improvement in obstetrics to identify priorities for action among five areas of greatest medico-legal risk. Using previously conducted medico-legal data analyses and a systematic literature review, the panel reviewed existing data and developed recommendations for areas of focus in quality improvement in five obstetrical high-risk areas. The panel recommended clarification of definitions in some areas, identified needs for data collection and standardization of practices in others. The most promising interventions to improve care in the five areas were grouped into: standardized processes (such as protocols and communication tools), checklists, audit and feedback, mentoring and coaching, inter-professional communication, simulation and training, and shared decision making guides. This national panel of experts created 18 action-oriented recommendations focused on quality improvement to reduce medico-legal risk and improve the safety of care for Canadian mothers and babies.

Clinical validation of a risk scale for serious outcomes among patients with chronic obstructive pulmonary disease managed in the emergency department.

BACKGROUND: The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS), which consists of 10 criteria, was previously derived to identify patients in the emergency department with COPD who were at high risk for short-term serious outcomes. We sought to validate, prospectively and explicitly, the OCRS when applied by physicians in the emergency department. METHODS: We conducted this prospective cohort study involving patients in the emergency departments at 6 tertiary care hospitals and enrolled adults with acute exacerbation of COPD from May 2011 to December 2013. Physicians evaluated patients for the OCRS criteria, which were recorded on a data form along with the total risk score. We followed patients for 30 days and the primary outcome, short-term serious outcomes, was defined as any of death, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI) or relapse with hospital admission. RESULTS: We enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for a score of 10. Compared with current practice, an OCRS score threshold of greater than 1 would increase sensitivity for short-term serious outcomes from 51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being admitted. INTERPRETATION: In this clinical validation of a risk-stratification tool for COPD in the emergency department, we found that OCRS showed better sensitivity for short-term serious outcomes compared with current practice. This risk scale can now be used to help emergency department disposition decisions for patients with COPD, which should lead to a decrease in unnecessary admissions and in unsafe discharges.

Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study.

BACKGROUND: A minimal amount of research exists examining the extent to which patient safety events occur within paramedicine and even fewer studies investigating patient safety systems for self-reporting by paramedics. The purpose of this study was to identify barriers to paramedic self-reporting of patient safety incidents (PSIs). METHODS: We randomly distributed paper-based surveys among 1,153 paramedics in an Ontario region in Canada. The survey described one of 5 different PSI clinical scenarios (near miss, adverse event, and minor, major or critical patient care variances) and listed 18 potential barriers to self-reporting PSIs as statements presented for rating on a 5-point Likert scale (very significant = 1 - very insignificant = 5). We invited comments on PSI self-reporting with 2 open-ended questions. We analyzed data with descriptive statistics, chi-square tests and Kruskal-Wallis H test. We used an inductive approach to qualitatively analyze emerging themes. RESULTS: We received responses from 1,133 paramedics (98.3%). Almost one third (28.4%) were Advanced Care Paramedics and 45.1% had >10 years' experience. The top 5 barriers to PSI self-reporting (very significant or significant, %) were the fear of being: punished (81.4%), suspended (79.6%), terminated (79.1%), investigated by Ministry of Health and Long-Term Care (78.4%), and decertified (78.0%). Overall, 64.1% responded they would self-report a given PSI. Intention to self-report a PSI varied according to scenario (22.8% near miss, 46.6% adverse event, 74.4% minor, 92.6% major, 95.6% critical). No association was found between level of training (p = 0.55) or years of experience (p = 0.10) and intention to self-report a PSI. Seven themes to improve PSI self-reporting by paramedics emerged from the qualitative data. CONCLUSIONS: A high proportion of fear-based barriers to self-reporting of PSIs exist among this study population. This suggests that a culture change is needed to facilitate the identification of future patient safety threats.

Healthcare providers' perceptions of a situational awareness display for emergency department resuscitation: a simulation qualitative study.

IMPORTANCE: Emergency resuscitation of critically ill patients can challenge team communication and situational awareness. Tools facilitating team performance may enhance patient safety. OBJECTIVES: To determine resuscitation team members' perceptions of the Situational Awareness Display's utility. DESIGN: We conducted focus groups with healthcare providers during Situational Awareness Display development. After simulations assessing the display, we conducted debriefs with participants. SETTING: Dual site tertiary care level 1 trauma centre in Ottawa, Canada. PARTICIPANTS: We recruited by email physicians, nurses and respiratory therapist. INTERVENTION: Situational Awareness Display, a visual cognitive aid that provides key clinical information to enhance resuscitation team communication and situational awareness. MAIN OUTCOMES AND MEASURES: Themes emerging from focus groups and simulation debriefs. Three reviewers independently coded and analysed transcripts using content qualitative analysis. RESULTS: We recruited a total of 33 participants in two focus groups (n = 20) and six simulation debriefs with three 4-5 member teams (n = 13). Majority of participants (10/13) strongly endorsed the Situational Awareness Display's utility in simulation (very or extremely useful). Focus groups and debrief themes included improved perception of patient data, comprehension of context and ability to project to future decisions. Participants described potentially positive and negative impacts on patient safety and positive impacts on provider performance and team communication. Participants expressed a need for easy data entry incorporated into clinical workflow and training on how to use the display. CONCLUSION: Emergency resuscitation team participants felt the Situational Awareness Display has potential to improve provider performance, team communication and situational awareness, ultimately enhancing quality of care.

The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED.

BACKGROUND: Return ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human telephone input into digital data. Use of IVRS has been explored in many healthcare settings but to a limited extent in the ED. We determined the feasibility of using an IVRS to assess for adverse events after ED discharge. METHODS: This before and after study assessed detection of adverse events among consecutive high-acuity patients discharged from a tertiary care ED pre-IVRS and post-IVRS over two 2-week periods. The IVRS asked if the patient was having a health problem and if they wanted to speak to a nurse. Patients responding yes received a telephone interview. We searched health records for deaths, admissions to hospital and return ED visits. Three trained emergency physicians independently determined adverse event occurrence. We analysed the data using descriptive statistics. RESULTS: Of 968 patients studied, patients' age, sex, acuity and presenting complaint were comparable pre-IVRS and post-IVRS. Postimplementation, 393 (81.7%) of 481 patients had successful IVRS contact. Of these, 89 (22.6%) wanted to speak to a nurse. A total of 37 adverse events were detected over the two periods: 10 patients with 10 (6.5%) adverse events pre-IVRS and 16 patients with 27 (16.9%) adverse events post-IVRS. In the postimplementation period, the adverse events of seven patients were detected by the IVRS and five patients spontaneously requested assistance navigating post-ED care. CONCLUSIONS: This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.

Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache.

BACKGROUND: We previously derived the Ottawa Subarachnoid Hemorrhage Rule to identify subarachnoid hemorrhage (SAH) in patients with acute headache. Our objective was to validate the rule in a new cohort of consecutive patients who visited an emergency department. METHODS: We conducted a multicentre prospective cohort study at 6 university-affiliated tertiary-care hospital emergency departments in Canada from January 2010 to January 2014. We included alert, neurologically intact adult patients with a headache peaking within 1 hour of onset. Treating physicians in the emergency department explicitly scored the rule before investigations were started. We defined subarachnoid hemorrhage as detection of any of the following: subarachnoid blood visible upon computed tomography of the head (from the final report by the local radiologist); xanthochromia in the cerebrospinal fluid (by visual inspection); or the presence of erythrocytes (> 1 × 106/L) in the final tube of cerebrospinal fluid, with an aneurysm or arteriovenous malformation visible upon cerebral angiography. We calculated sensitivity and specificity of the Ottawa SAH Rule for detecting or ruling out subarachnoid hemorrhage. RESULTS: Treating physicians enrolled 1153 of 1743 (66.2%) potentially eligible patients, including 67 with subarachnoid hemorrhage. The Ottawa SAH Rule had 100% sensitivity (95% confidence interval [CI] 94.6%-100%) with a specificity of 13.6% (95% CI 13.1%-15.8%), whereas neuroimaging rates remained similar (about 87%). INTERPRETATION: We found that the Ottawa SAH Rule was sensitive for identifying subarachnoid hemorrhage in otherwise alert and neurologically intact patients. We believe that the Ottawa SAH Rule can be used to rule out this serious diagnosis, thereby decreasing the number of cases missed while constraining rates of neuroimaging.

Characteristics and outcomes for acute heart failure in elderly patients presenting to the ED.

INTRODUCTION: The first aim of this study was to investigate the characteristics for elderly patients with acute heart failure presenting to the emergency department (ED). The second aim was to determine the characteristics of these elderly patients associated with serious adverse events. METHODS: The population was divided into 2 age groups, <80 and ≥80 years. The primary outcome was the occurrence of a serious adverse event, defined as either death from any cause within 30 days of the index ED visit or any of the following events within 14 days of the index ED visit: admission to a monitored unit, intubation, need for noninvasive ventilation, myocardial infarction, major procedure, or, for patients who were discharged after the initial visit, return to the ED resulting in admission to hospital. RESULTS: This prospective cohort study included 1658 visits. Older patients had a lower heart rate and higher diastolic blood pressure. The older patients were more likely to experience hospital admission (56% vs 46%, P < .001). For patients 80 years or older, 109 (14%) experienced a serious adverse event. In this ≥80-year group, history of heart failure, current medication with antiarrhythmic, acute infarction on the arrival electrocardiography, chest x-ray with pleural effusion, and urea greater than 12 mmol/L were independently associated with short-term serious adverse events. CONCLUSIONS: Elderly patients with heart failure are a high-risk group. Careful assessment of these factors could help physicians identify those patients most at risk for adverse outcomes and, therefore, most in need of hospital admission.

Teaching M&M rounds skills: enhancing and assessing patient safety competencies using the Ottawa M&M model.

BACKGROUND: Postgraduate medical education bodies and national patient safety institutes recommend that trainees develop patient safety competencies such as those for Morbidity and Mortality (M&M) rounds, yet there exists no model for their educational delivery. OBJECTIVE: We studied the effect of a single educational intervention on emergency medicine residents' aptitudes in selecting and analysing M&M rounds cases. METHODS: In this before-and-after study, participants attended an 1 h educational session based on the previously described Ottawa Morbidity and Mortality Model (OM3). Residents were asked to submit a case suitable for M&M rounds both preintervention and postintervention. A novel M&M rounds case critique tool was developed based on OM3 and used to assign a numerical score to each submitted case. Our primary outcome was an increase in mean scores between phases using the case critique tool. An a priori score increase of 1 was defined as educationally significant. Data were analysed using a paired Student's t test. RESULTS: A total of 19 residents were recruited for our pre-intervention and 15 residents for the post-intervention analysis. Mean M&M rounds case critique scores increased from 5.53 to 8.67 (p<0.01) between phases. Residents reported higher comfort with structured case selection and analysis, with an increase in five-point Likert scale means of 2.32 and 3.69 (p<0.01). CONCLUSIONS: We found that residents were more effective at M&M rounds case selection and analysis after our focused 1 h educational intervention. Training programmes should consider an M&M rounds training model to ensure future physicians have these skills for 21st-century practice.

How do emergency physicians make discharge decisions?

BACKGROUND: One of the most important decisions that emergency department (ED) physicians make is patient disposition (admission vs discharge). OBJECTIVES: To determine how ED physicians perceive their discharge decisions for high-acuity patients and the impact on adverse events (adverse outcomes associated with healthcare management). METHODS: We conducted a real-time survey of staff ED physicians discharging consecutive patients from high-acuity areas of a tertiary care ED. We asked open-ended questions about rationale for discharge decisions and use of clinical judgement versus evidence. We searched for 30-day flagged outcomes (deaths, unscheduled admissions, ED or clinic visits). Three trained blinded ED physicians independently reviewed these for adverse events and preventability. We resolved disagreements by consensus. We used descriptive statistics and 95% CIs. RESULTS: We interviewed 88.9% (32/36) of possible ED physicians for 366 discharge decisions. Respondents were mostly male (71.9%) and experienced (53.1% >10 years). ED physicians stated they used clinical judgement in 87.6% of decisions and evidence in 12.4%. There were 69 flagged outcomes (18.8%) and 10 adverse events (2.7%, 95% CI 1.1 to 4.5%). All adverse events were preventable (1 death, 4 admissions, 5 return ED visits). No significant associations occurred between decision-making rationale and adverse events. CONCLUSIONS: Experienced ED physicians most often relied on clinical acumen rather than evidence-based guidelines when discharging patients from ED high-acuity areas. Neither approach was associated with adverse events. In order to improve the safety of discharge decisions, further research should focus on decision support solutions and feedback interventions.

Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study.

BACKGROUND: To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events. METHODS: We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission. RESULTS: We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%. INTERPRETATION: In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.