Quantifying Clinically Meaningful Point-of-Care Ultrasound Interpretation Discrepancies Using an Emergency Department Quality Assurance Program.

OBJECTIVES: Emergency medicine professional associations recommend that quality assurance (QA) programs be implemented wherever emergency department (ED) point-of-care ultrasound (POCUS) is in use. The purpose of this study is to identify the rate of clinically meaningful interpretation discrepancies between initial ED POCUS interpretation and a gold standard using a QA program in a Canadian academic ED. METHODS: All POCUS examinations completed in our ED are subject to a QA process. The results of all POCUS examinations undergoing this process from July 1, 2014, to June 30, 2015, were retrospectively reviewed. Four blinded abstractors collected data with a standardized tool after a training session. Information regarding patient demographics, POCUS indication, emergency physician initial POCUS interpretation, physician POCUS expertise, the presence of an interpretation discrepancy, and whether the discrepancy was clinically meaningful was abstracted. The proportion of interpretation discrepancies, clinically meaningful discrepancies, discrepancies requiring remedial action, and differences in discrepancy rates between non-expert and expert sonographers were analyzed. RESULTS: A total of 2,869 POCUS studies were included for review, with 2,668 in the final data set after exclusions. In total, only 1.4% of all scans contained an interpretation discrepancy. The rate of clinically meaningful discrepancies was 0.5%, and the rate of scans requiring remedial action was 0.1%. Overall, 85.5% of all scans were performed by four POCUS expert physicians, with the remainder by a non-expert. Scans performed by non-expert sonographers were significantly more prone to discrepancies than those performed by experts. No single scan indication was more prone to discrepancy. CONCLUSIONS: The overall ED POCUS interpretation discrepancy rate and clinically meaningful discrepancy rate identified using our QA process were very low. The findings are limited by the small group of expert sonographers completing most scans.

Evaluating the diagnostic accuracy of point-of-care ultrasound for cholelithiasis and cholecystitis in a canadian emergency department.

OBJECTIVES: Cholelithiasis and cholecystitis are common conditions that frequently require patients to come to the Emergency Department (ED) and undergo diagnostic imaging. The purpose of this study was to evaluate the test characteristics of emergency physician performed point-of-care ultrasound (POCUS) to diagnose cholelithiasis and cholecystitis in a Canadian ED. METHODS: A health records review was performed on all ED patients > 17 years of age for whom POCUS was performed to diagnose cholelithiasis and cholecystitis in a Canadian academic ED over a 5-year period. The sensitivity, specificity, predictive values, and likelihood ratios were calculated. The gold standard used for diagnosis was pathology, laparoscopy, radiology-performed comprehensive ultrasonography, followed by computed tomography scans. RESULTS: A total of 577 patients were included in the study. The sensitivity and specificity of POCUS to diagnose cholelithiasis was 95.2% (95% CI 91.1-97.8%) and 93.1% (95% CI 90.1-95.4%). The positive and negative likelihood ratios for POCUS to diagnose cholelithiasis were found to be 14 and 0.05; the negative predictive value was 97.6% (95% CI 95.5-98.7%). The sensitivity and specificity of POCUS to diagnose cholecystitis was 67.1% (95% CI 54.9-77.9%) and 97.6% (95% CI 95.9-98.8%). The positive and negative likelihood ratios for POCUS to diagnose cholecystitis were found to be 28 and 0.34; the negative predictive value was 95.6% (95% CI 93.9-96.8%). CONCLUSION: POCUS is reliable for the diagnosis of cholelithiasis and for ruling in cholecystitis. In cases where POCUS is negative or indeterminate for cholecystitis, further imaging should be obtained as clinical suspicion warrants.

RéSUMé: OBJECTIFS: La cholélithiase et la cholécystite sont des troubles médicaux courants qui obligent fréquemment les patients à se rendre aux urgences et subir une imagerie diagnostique. Le but de cette étude était d'évaluer les caractéristiques des tests de l'échographie au point d'intervention (POCUS) effectuée par des médecins urgentistes pour diagnostiquer la cholélithiase et la cholécystite dans une urgence canadienne. MéTHODES: Un examen des dossiers médicaux a été effectué sur tous les patients des services d'urgence, âgés de plus de 17 ans pour lesquels POCUS a été réalisée pour diagnostiquer la cholélithiase et la cholécystite dans un service d'urgence universitaire canadien sur une période de 5 ans. La sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance ont été calculés. L'étalon-or utilisé pour le diagnostic était la pathologie, la laparoscopie, l'échographie complète réalisée par radiologie, suivie de la tomodensitométrie. RéSULTATS: Au total, 577 patients ont été inclus dans l'étude. La sensibilité et la spécificité de POCUS pour diagnostiquer la cholélithiase étaient de 95.2% (IC 95% 91.1­97.8%) et 93.1% (IC 95% 90.1­95.4%). Les rapports de vraisemblance positifs et négatifs pour POCUS pour diagnostiquer la cholélithiase se sont révélés à 14 et 0.05; la valeur prédictive négative était de 97.6% (IC à 95% 95.5­98.7%). La sensibilité et la spécificité de POCUS pour diagnostiquer la cholécystite étaient de 67,1% (IC à 95% 54.9­77.9%) et de 97.6% (IC à 95% 95.9­98.8%). Les rapports de vraisemblance positifs et négatifs pour POCUS pour diagnostiquer la cholécystite se sont révélés à 28 et 0.34; la valeur prédictive négative était de 95.6% (IC à 9.5% 93.9­96.8%). CONCLUSION: POCUS est fiable pour le diagnostic de la cholélithiase et de la cholécystite. Dans les cas où le POCUS est négatif ou indéterminé pour la cholécystite, une imagerie supplémentaire doit être obtenue en cas de suspicion clinique.

Point-of-care ultrasound to diagnose appendicitis in a Canadian emergency department.

OBJECTIVES: Appendicitis is a common surgical condition that frequently requires diagnostic imaging. Abdominal computed tomography (CT) is the gold standard for diagnosing appendicitis. Ultrasound offers a radiation-free modality; however, its availability outside business hours is limited in many emergency departments (EDs). The purpose of this study is to evaluate the test characteristics of emergency physician-performed point-of-care ultrasound (POCUS) to diagnose appendicitis in a Canadian ED. METHODS: A health records review was performed on all ED patients who underwent POCUS to diagnose appendicitis from December 1, 2010 to December 4, 2015. The sensitivity, specificity, and likelihood ratios were calculated. The gold standard used for diagnosis was pathology, laparoscopy, CT scans, and a radiologist-performed ultrasound. RESULTS: Ninety patients were included in the study, and 24 were diagnosed with appendicitis on POCUS. Ultimately, 18 were confirmed to have appendicitis through radiologist-performed imaging, laparoscopy, and pathology. The sensitivity and specificity of POCUS to diagnose appendicitis were 69.2% (95% CI, 48.1%-84.9%) and 90.6% (95% CI, 80.0%-96.1%), respectively. CONCLUSION: POCUS has a high specificity for diagnosing acute appendicitis and has very similar characteristics to those of a radiologist-performed ultrasound. These findings are consistent with the current literature and have the potential to decrease patient morbidity, diagnostic delays, ED length of stay, and need for additional imaging.

Reflections on the Canadian MORE(OB) obstetrical risk management programme.

In, 2001, the Patient Safety Division of the Society of Obstetricians and Gynaecologists of Canada initiated and championed a new program to improve patient safety performance in Canadian hospital obstetric units. This new program was developed under the banner of Managing Obstetrical Risk Efficiently and called the MORE(OB) Programme The MORE(OB) Programme was first piloted in Canadian hospitals at the beginning of May 2002 and, by mid 2004, 33 pilot sites had been implemented. In autumn 2004, this program embarked on a national launch. In 2007, the Society of Obstetricians and Gynaecologists of Canada collaborated with the Healthcare Insurance Reciprocal of Canada to form Salus Global Corporation. The birth of this corporate entity embraced the support of rapid expansion of the program within and outside of Canada. This collaboration also enabled innovation and implementation of safety programs beyond the obstetric discipline.

Door-to-antibiotic time for pneumonia in a rural emergency department.

OBJECTIVE: The Joint Commission on Accreditation of Healthcare Organizations recommends that patients admitted to hospital with pneumonia receive their first dose of antibiotics within 6 hours of presenting to the emergency department (ED). Previous research in the United States indicates that rural hospitals may be better at achieving this benchmark than urban centres. This particular quality indicator has not yet been evaluated in Canada. The purpose of this study was to determine whether the target door-to-antibiotic (DTA) time of 6 hours or less could be met in a rural ED. METHODS: We conducted a retrospective chart review of patients admitted to hospital with a diagnosis of pneumonia. Descriptive data for each case was collected, including demographic and timeline information. We analyzed DTA time, antibiotic type, route of administration, hospital length of stay and disposition at discharge. RESULTS: We reviewed a total of 320 charts from Apr. 1, 2003, to Mar. 31, 2008. The final sample consisted of 143 patients (50.3% women) whose median age was 79 years. The median DTA time was 151 minutes and 81.8% of patients received their first dose of antibiotics within 6 hours. Patients received antibiotics either orally (47.6%), intravenously (47.6%) or both (4.8%). Single-agent respiratory fluoroquinolones were used 71.4% of the time. Median length of hospital stay was 4 days; most patients were discharged home (79.7%), 11 died, 11 were transferred and 7 were discharged to a nursing home. CONCLUSION: A DTA time of 6 hours or less is achievable in a rural ED.

Meeting Canadian emergency department triage and acuity scale benchmarks in a rural emergency department.

INTRODUCTION: The Canadian Emergency Department Triage and Acuity Scale (CTAS) was implemented in 1999. The CTAS aims to more accurately define patients' needs for timely care and provide operating objectives to standardize this care. These objectives are not being met across Ontario. The purpose of this study was to determine if the CTAS benchmarks were being met at a rural emergency department (ED). METHODS: All ED visits to South Huron Hospital from Apr. 1, 2003, to Mar. 31, 2004, were reviewed. The percentage of visits receiving each CTAS category (I-V) was calculated. The median and 90th percentile time to physician initial assessment (PIA) were quantified by CTAS level. RESULTS: There was a total of 10 286 ED visits with 113 (1.1%) excluded because of missing triage codes. The percentage of visits assigned to CTAS categories I to V was 0.3, 2.4, 16.0, 42.7 and 38.5, respectively. Time to PIA in minutes was 1, 12, 24, 28 and 27 for CTAS I to V, respectively. CONCLUSION: The CTAS guidelines for PIA were met at this rural ED.

A door-to-needle time of 30 minutes or less for myocardial infarction thrombolysis is possible in rural emergency departments.

OBJECTIVE: The Canadian Emergency Cardiac Care Coalition, the American Heart Association and similar groups have established a benchmark for the administration of thrombolytics in acute myocardial infarction (AMI) care as a door-to-needle (DTN) time of 30 minutes or less. Previous research suggests that this goal is not being achieved in Canada. The purpose of this study was to determine whether the target DTN time of 30 minutes or less for thrombolysis could be met in 2 rural Ontario emergency departments (EDs). METHODS: We conducted a retrospective chart review and obtained descriptive data for each case, including demographic information and the Canadian Emergency Department Triage and Acuity Scale (CTAS) score. Visit timeline data were also collected and included the time during which patients saw a physician, had an electrocardiogram (ECG), received thrombolytic therapy and were discharged from the ED. Relevant time intervals, such as the median DTN time, were calculated. RESULTS: A total of 454 charts were reviewed for patients with a diagnosis of AMI who were seen between 1996 and 2007. The final sample consisted of 101 patients who received thrombolytics (63% men) whose median age was 67 years and median CTAS score was Level II (Emergent). The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes. CONCLUSION: A DTN time of 30 minutes or less is achievable in rural EDs.

Oligoanalgesia in a rural emergency department.

OBJECTIVE: Multiple studies conducted over many years have demonstrated that pain is poorly managed in the emergency department (ED). This phenomenon has been referred to in the medical literature as "oligoanalgesia." However, little is known about whether oligoanalgesia occurs in a rural ED. National Ambulatory Care Reporting System data from 2003 for a small rural hospital in Ontario showed patients were satisfied with the amount of pain medicine they received in the ED. We designed a study to replicate a published urban study that investigated the use of analgesia in isolated lower limb injuries. Our objective was to see if oligoanalgesia was also a problem in a rural ED. METHODS: In 2003 we conducted a retrospective chart review of patients who presented to the South Huron Hospital ED with isolated lower extremity injuries for which radiographs of the foot, ankle or both were obtained. Demographics of the ED patients with lower extremity injuries were quantified. Other parametres included whether or not patients received analgesia in the ED; how long it took to get assessed, treated and discharged; whether patients received any analgesia upon discharge; what type of analgesia they received; and whether it required a prescription. RESULTS: A total of 189 patients met inclusion criteria, with 35 fractures identified (18.5%). Sixty-three percent of patients were male. The average age was 32.6 years. The mean Canadian Emergency Department Triage and Acuity Scale level was 4.4. The mean time to physician assessment was 31.6 minutes. The mean length of time spent in the ED was 74 minutes. Over one-half of the patients received analgesia upon discharge from the ED whether or not they had a fracture. In addition, 73% of the people in the fracture group received analgesia requiring a prescription, versus only 46% in the nonfracture group. Narcotics were used more often in the fracture group than in the nonfracture group (26% v. 6%). CONCLUSION: The phenomenon of oligoanalgesia was not observed as often in our rural ED for isolated lower limb injuries, when compared with the published urban study.