Success and complications of endotracheal intubation in critical care settings under COVID-19 protocols.

INTRODUCTION: The Covid-19 pandemic has required new protocols for endotracheal intubation mandating cumbersome personal protective equipment and modifications to prior intubation procedures. We assessed the success and complications of endotracheal intubation under such protocols. METHODS: We conducted a prospective study of endotracheal intubation in the emergency department, intensive care unit, or ward between September 11, 2018 and June 11, 2020 at two urban hospitals. Using a standardized form, we included basic demographics, intubation techniques, and success, and pre-specified complications, defined as critical (cardiac arrest or failure to intubate) or non-critical. At both sites, Covid-19 intubation protocols took effect on March 11, 2020, and we compared pre-post patients. The primary outcome was first-pass success without complications. Secondary outcomes included first-pass success and complications. We analysed by descriptive techniques. RESULTS: Overall, we collected 1534 patients before March 11, 2020 and 227 after; groups were similar in age and sex distribution. Staff endotracheal intubation increased from 37 to 63%. First pass success was 1262/1534 (82.3%) pre versus 195/227 (85.9%) post, for a difference of 3.6% (95% CI - 1.8-8.0%). First pass success without complications was 1116/1534 (72.8%) pre versus 168/227 (74.0%) post, for a difference of 1.3%, (95% CI - 5.2-7.0%). There were 226 complications pre (14.7%) versus 47 (20.7%) post, for a difference of 6.0%. (95% CI 0.6-12.1%). CONCLUSIONS: New pandemic endotracheal intubation protocols did not result in a decrease in first-pass success, or first-pass success without complications.

RéSUMé: INTRODUCTION: La Pandémie de Covid-19 a nécessité de nouveaux protocoles d'intubation endotrachéale exigeant un équipement de protection individuelle encombrant et des modifications aux procédures d'intubation antérieures. Nous avons évalué le succès et les complications de l'intubation endotrachéale dans le cadre de tels protocoles. MéTHODES: Nous avons mené une étude prospective de l'intubation endotrachéale dans le service des urgences, l'unité de soins intensifs ou dans un service de soins intensifs entre le 11 septembre 2018 et le 11 juin 2020 dans deux hôpitaux urbains. À l'aide d'un formulaire standardisé, nous avons inclus les données démographiques de base, les techniques et le succès d'intubation, ainsi que les complications pré-spécifiées, définies comme critiques (arrêt cardiaque ou échec d'intubation) ou non critiques. Sur les deux sites, les protocoles d'intubation Covid-19 sont entrés en vigueur le 11 mars 2020 et nous avons comparé les patients avant et après. Le principal résultat a été un premier passage réussi sans complications. Les résultats secondaires comprenaient le succès au premier passage et les complications. Nous avons analysé par des techniques descriptives. RéSULTATS: Dans l'ensemble, nous avons recueilli 1534 patients avant le 11 mars 2020 et 227 après; les groupes étaient similaires en termes de répartition par âge et par sexe. L'intubation endotrachéale par le personnel est passée de 37 % à 63 %. Le succès du premier passage était de 1262/1534 (82,3 %) avant contre 195/227 (85,9 %) après, soit une différence de 3,6 % (IC à 95 % ­1,8 à 8,0 %). Le succès du premier passage sans complications était de 1116/1534 (72,8 %) avant contre 168/227 (74,0 %) après, soit une différence de 1,3 %, (IC à 95 % -5,2 à 7,0 %). Il y avait 226 complications avant (14,7 %) contre 47 (20,7 %) après, pour une différence de 6,0 %. (IC à 95 % de 0,6 à 12,1 %). CONCLUSIONS: Les nouveaux protocoles d'intubation endotrachéale pandémique n'ont pas entraîné de diminution du succès du premier passage ou du succès du premier passage sans complications.

The association of pH values during the first 24 h with neurological status at hospital discharge and futility among patients with out-of-hospital cardiac arrest.

STUDY OBJECTIVE: Post-resuscitation prognostic biomarkers for out-of-hospital cardiac arrest (OHCA) outcomes have not been fully elucidated. We examined the association of acid-base blood values (pH) with patient outcomes and calculated the pH test performance to predict prognosis. METHODS: This was a post-hoc analysis of data from the continuous chest compression trial, which enrolled non-traumatic adult emergency medical system-treated OHCA in Canada and the United States. We examined cases who survived a minimum of 24 h post hospital arrival. The independent variables of interest were initial pH, final pH, and the change in pH (δpH). The primary outcome was neurological status at hospital discharge, with favorable status defined as modified Rankin Scale (mRS) ≤ 3. We reported adjusted odds ratios for favorable neurological outcome using multivariable logistic regression models. We calculated the test performance of increasing pH thresholds in 0.1 increments to predict unfavorable neurological status (defined as mRS >3) at hospital discharge. RESULTS: We included 4189 patients. 32% survived to hospital discharge with favorable neurological status. In the adjusted analysis, higher initial pH (OR 6.82; 95% CI 3.71-12.52) and higher final pH (OR 7.99; 95% CI 3.26-19.62) were associated with higher odds of favorable neurological status. pH thresholds with highest positive predictive values were initial pH < 6.8 (92.5%; 95% CI 86.2 %-98.8%) and final pH < 7.0 (100%; 95% CI 95.2 %-100%). CONCLUSION: In patients with OHCA, pH values were associated with patients' subsequent neurological status at hospital discharge. Final pH may be clinically useful to predict unfavorable neurological status at hospital discharge.

Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department.

OBJECTIVES: To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool. STUDY DESIGN: We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents' self-assessment, against a clinician's standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening. RESULTS: We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians' sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up. CONCLUSIONS: Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care.

MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth.

BACKGROUND: Paediatric mental health-related visits to the emergency department are rising. However, few tools exist to identify concerns early and connect youth with appropriate mental healthcare. Our objective was to develop a digital youth psychosocial assessment and management tool (MyHEARTSMAP) and evaluate its inter-rater reliability when self-administered by a community-based sample of youth and parents. METHODS: We conducted a multiphasic, multimethod study. In phase 1, focus group sessions were used to inform tool development, through an iterative modification process. In phase 2, a cross-sectional study was conducted in two rounds of evaluation, where participants used MyHEARTSMAP to assess 25 fictional cases. RESULTS: MyHEARTSMAP displays good face and content validity, as supported by feedback from phase 1 focus groups with youth and parents (n=38). Among phase 2 participants (n=30), the tool showed moderate to excellent agreement across all psychosocial sections (κ=0.76-0.98). CONCLUSIONS: Our findings show that MyHEARTSMAP is an approachable and interpretable psychosocial assessment and management tool that can be reliably applied by a diverse community sample of youth and parents.

Impact of physician payment mechanism on emergency department operational performance.

OBJECTIVE: Fee-for-service payment may motivate physicians to see more patients and achieve higher productivity. In 2015, emergency physicians at one Vancouver hospital switched to fee-for-service payment, while those at a sister hospital remained on contract, creating a natural experiment where the compensation method changed, but other factors remained constant. Our hypothesis was that fee-for-service payment would increase physician efficiency and reduce patient wait times. METHODS: This interrupted time series with concurrent control analysed emergency department (ED) performance during a 42-week period, encompassing the intervention (fee for service). Data were aggregated by week and plotted in a time series fashion. We adjusted for autocorrelation and developed general linear regression models to assess level and trend changes. Our primary outcome was the wait time to physician. RESULTS: Data from 142,361 ED visits were analysed. Baseline wait times rose at both sites during the pre-intervention phase. Immediately post-intervention, the median wait time increased by 2.4 minutes at the control site and fell by 7.2 minutes at the intervention site (difference=9.6 minutes; 95% confidence interval, 2.9-16.4; p=0.007). The wait time trend (slope) subsequently deteriorated by 0.5 minutes per week at the intervention site relative to the expected counterfactual (p for the trend difference=0.07). By the end of the study, cross-site differences had not changed significantly from baseline. CONCLUSION: Fee-for-service payment was associated with a 9.6-minute (24%) reduction in wait time, compatible with an extrinsic motivational effect; however, this was not sustained, and the intervention had no impact on other operational parameters studied. Physician compensation is an important policy issue but may not be a primary determinant of ED operational efficiency.

Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

OBJECTIVES: Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. METHODS: This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. RESULTS: In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. CONCLUSION: There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Reliability testing of the HEARTSMAP psychosocial assessment tool for multidisciplinary use and in diverse emergency settings.

OBJECTIVE: HEARTSMAP is a tool developed to facilitate assessment and management of paediatric mental health (MH) patients by emergency department (ED) clinicians. We evaluate the inter-rater reliability of HEARTSMAP when administered by clinicians of various backgrounds. METHODS: In a cross-sectional study initiated in 2016, collaborating clinician evaluators (n=16) applied the HEARTSMAP tool to evaluate a set of 50 fictional clinical vignettes, digitally in an approach consistent with the anticipated tool's access and usage in clinical settings. Evaluators came from different types of health centres from across the province of British Columbia (Canada), including remote/rural, regional and urban academic health centres. RESULTS: We report moderate to near excellent agreement, overall among clinicians for all 10 of the tool's psychosocial sections (κ=0.43 to 0.93) and domain scores (κ=0.75 to 0.90), with acceptable agreement across all tool-triggered service recommendations (κ=0.36 to 0.65). CONCLUSIONS: Our findings show that HEARTSMAP may be reliably used by ED clinicians in assessing MH issues among youth. Results from this study will assist in informing the wider clinical implementation of HEARTSMAP as a standard assessment tool, in diverse emergency care settings.

Prevalence of HIV infection and acceptability of point-of-care testing in a Canadian inner-city emergency department.

OBJECTIVES: The objective of this study was to estimate the seroprevalence of HIV infection and the acceptability of point-of-care HIV testing in an innercity Canadian emergency department. METHODS: We conducted a prospective cohort study in an urban tertiary care emergency department between August 2009 and January 2011. Randomly selected patients were enrolled using probabilistic sampling based on patient volumes. Inclusion criteria were age 19-75 years and ability to provide informed consent. Patients who were intoxicated or in extremis were excluded. After informed consent and brief pre-test counselling, participants' HIV status was obtained using the INSTI HIV-1/HIV-2 Antibody Test. Participants completed a questionnaire on HIV risk behaviours and satisfaction with emergency department HIV testing. Participants with a positive result or those having other blood tests received confirmatory Western blot testing. HIV-positive participants were offered immediate referral to an HIV specialty clinic. RESULTS: A total of 2,077 patients were approached, and 1,402 (67.5%) agreed to participate. Participants' mean age was 43.3 years, and 58.4% of participants were male. The HIV antibody seroprevalence based on the point-of-care test was 65/1,402 (4.6%; 95% confidence interval: 3.5%-5.8%). No new diagnoses of HIV were identified in our cohort. Patient satisfaction with point-of-care HIV testing was high (mean satisfaction score 9.6/10). CONCLUSION: On the basis of a rapid, point-of-care HIV antibody test, the seroprevalence rate of HIV in an inner city emergency department was 4.6%. Point-of-care testing in the emergency department is acceptable, and patients' satisfaction with the testing procedure was high.

Moxifloxacin Use and Its Association on the Diagnosis of Pulmonary Tuberculosis in An Inner City Emergency Department.

BACKGROUND: Moxifloxacin can be used in the treatment of tuberculosis, its effect on the diagnosis and treatment of pulmonary tuberculosis is not well characterized. OBJECTIVE: To identify patients from the St. Paul's Hospital emergency department (ED) treated with moxifloxacin who also had sputum sent for investigation of possible tuberculosis and the impact on sensitivity of acid-fast bacilli (AFB) smears and time to initiation of tuberculosis treatment. METHODS: We conducted a retrospective single-center cohort study on patients that were prescribed moxifloxacin in the ED during a 5-year period and had samples collected for pulmonary tuberculosis. All AFB samples obtained throughout the hospital in patients not exposed to moxifloxacin during the same time period were also examined. RESULTS: Two-thousand six hundred and seventy-three patients who were admitted to St. Paul's Hospital through the ED received moxifloxacin during the study period. 273 (10.2%) of these patients were subsequently investigated for tuberculosis, with 9 positive cases of Mycobacterium tuberculosis (3.3%). One-thousand three hundred and sixty-nine patients not exposed to moxifloxacin were screened for tuberculosis with 33 active cases (2.4%). The false-negative rate for AFB smears in the exposed group was 85.2% vs. 53.8% in the unexposed group (relative risk of false-negative AFB = 1.55; 95% CI 1.24-2.03). Time to initiation of anti-tuberculosis therapy was significantly delayed in the exposed group, with median time to initiation of 14 days vs. 2 days (p = 0.013). CONCLUSIONS: Exposure to moxifloxacin is associated with significantly increased rates of false-negative AFB smears and was associated with a significant delay in the initiation of anti-tuberculosis therapy.

A regional survey to determine factors influencing patient choices in selecting a particular emergency department for care.

OBJECTIVES: Increases in regional emergency department (ED) efficiencies might be obtained by shifting patients to less crowded EDs. The authors sought to determine factors associated with a patient's decision to choose a specific regional ED. Based on prior focus group discussions with volunteers, the hypothesis was that distance to a specific ED and perceived ED wait times would be important. METHODS: A cross-sectional survey was developed using qualitative focus group methodology. The resulting survey was composed of 17 questions relating to patient decisions in choosing a specific ED and was administered in each of six EDs in a single urban Canadian health region at all hours of the day. Ambulatory patients with a Canadian Triage and Acuity Scale (CTAS) level 3 to 5 and aged ≥19 years were surveyed. The primary outcome was the proportion of patients whose main motivation for attending a specific ED was either distance traveled to reach the ED or perceived ED waiting time. Multivariable logistic regression was performed to assess factors influencing both of these reasons. RESULTS: A total of 757 patients were approached and 634 surveys (83.8%) were completed. Distance from the ED (named by 44.0% of respondents as their primary reason) and perceived ED wait times (9.3%) were the main motivations for patients to attend a specific ED. Multivariable analysis of factors associated with choosing distance revealed that ED distance < 10 km (adjusted odds ratio [OR] = 2.20, 95% confidence interval [CI] = 1.45 to 3.33; p = 0.001) and age ≥ 60 years (adjusted OR = 1.58, 95% CI = 1.12 to 2.26; p = 0.04) were significant in choosing a particular ED. Multivariable analysis of factors influencing wait times demonstrated that having a painful complaint (adjusted OR = 1.42, 95% CI = 1.05 to 1.98; p = 0.047) and age < 60 years (OR = 1.47, 95% CI = 1.02 to 2.14; p = 0.049) were significant in choosing a particular ED. CONCLUSIONS: In a multicenter survey of patients from an urban health region, distance to a specific ED and perceived ED wait times were the most important reasons for choosing that ED. Younger patients and those with painful conditions appear to place greater priority on wait times.

Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness.

OBJECTIVES: Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. METHODS: This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. RESULTS: A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. CONCLUSIONS: In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

Alcohol and drug use as predictors of intentional injuries in two emergency departments in British Columbia.

BACKGROUND: While a substantial literature exists demonstrating a strong association of alcohol and intentional injury, less is known about the association of intentional injury with recreational drug use, either alone, or in combination with alcohol. OBJECTIVES: The risk of intentional injury due to alcohol and other drug use prior to injury is analyzed in a sample of emergency department (ED) patients. METHODS: Logistic regression was used to examine the predictive value of alcohol and drug use on intentional versus non-intentional injury in a probability sample of ED patients in Vancouver, BC (n = 436). RESULTS: Those reporting only alcohol use were close to four times more likely (OR = 3.73) to report an intentional injury, and those reporting alcohol combined with other drug(s) almost 18 times more likely (OR = 17.75) than those reporting no substance use. Those reporting both alcohol and drug use reported drinking significantly more alcohol (15.7 drinks) than those reporting alcohol use alone (5 drinks). CONCLUSIONS: These data suggest that alcohol in combination with other drugs may be more strongly associated with intentional injury than alcohol alone. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The strong association of alcohol combined with other drug use on injury may be due to the increased amount of alcohol consumed by those using both substances, and is an area requiring more research with larger samples of intentional injury patients.

Emergency Physician Patterns Related to Anticoagulation of Patients with Recent-Onset Atrial Fibrillation and Flutter.

Guidelines strongly recommend long-term anticoagulation with warfarin for patients with newly recognized AF who have high embolic risk by virtue of a CHADS2 (Congestive Heart Failure, Hypertension, Age >65, Diabetes, History of Stroke) score ≥ 2. The goal of this study was to determine patterns of emergency department-initiated anticoagulation among eligible patients discharged from Canadian centers with an episode of recent-onset atrial fibrillation and flutter (RAFF) and determine if decision-making is driven by the CHADS2 score or other factors. This was accomplished by examining health records using uniform case identification and data abstraction as well as centralized quality control; it was conducted in 8 Canadian university emergency departments over a 12-month period. Eligible patients for this analysis demonstrated RAFF requiring emergency management, were not already taking warfarin and were not admitted to hospital. Univariate analyses were conducted using T-test or Chi-square to select factors associated with anticoagulation initiation at a significance level of p < 0.15 and multiple logistic regression was employed to evaluate independent predictors after adjustment for confounders. Among 633 eligible patients, only 21 out of 120 patients (18%) with a CHADS2 score ≥ 2 received anticoagulation and among 70 patients who were given anticoagulation only 21 (30%) had a CHADS2 score ≥ 2. Independent predictors of anticoagulation included age by 10-year strata: (OR = 1.7; 95% CI 1.3 - 2.1), heparin use in the anticoagulation (OR = 9.6; 95% CI 4.9 - 18.9), a new prescription for metoprolol (OR = 9.6; 95% CI 4.9 - 18.9) and being referred to cardiology for follow-up (OR = 5.6; 95% CI 2.6 - 12.0). CHADS2 ≥ 2 doubled the likelihood of being prescribed anticoagulation (OR= 2.0; 95% CI 1.5 - 3.5) but was not an independent predictor. It was thus determined that patients discharged from the emergency department in this study were not prescribed anticoagulation in keeping with current recommendations. This practice gap merits further investigation and may benefit from educational efforts or enhanced support for anticoagulation use from the emergency department.

Thirty-day and 1-year outcomes of emergency department patients with atrial fibrillation and no acute underlying medical cause.

STUDY OBJECTIVE: Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. RESULTS: Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. CONCLUSION: In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients-regardless of treatment approach or conversion to sinus rhythm-were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates.

OBJECTIVE: It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion. METHODS: This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion. RESULTS: A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2 score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74). CONCLUSION: We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.

A collaborative quality improvement model and electronic community of practice to support sepsis management in emergency departments: investigating care harmonization for provincial knowledge translation.

Emergency medicine departments within several organizations are now advocating the adoption of early intervention guidelines for patients with the signs and symptoms of sepsis. This proposed research will lead to a comprehensive understanding of how diverse emergency department (ED) sites across British Columbia (BC), Canada, engage in a quality improvement collaborative to lead to improvements in time-based process measures and clinical outcomes for septic patients in EDs. To address the challenge of sepsis management, in 2007, the BC Ministry of Health began working with emergency health professionals, including health administrators, to establish a provincial ED collaborative: Evidence to Excellence (E2E). The E2E initiative employs the Institute for Healthcare Improvement (IHI) model and is supported by a Web-based community of practice (CoP) in emergency medicine. It aims to (1) support clinicians in accessing and applying evidence to clinical practice in emergency medicine, (2) support system change and clinical process improvement, and (3) develop resources and strategies to facilitate knowledge translation and process improvement. Improving sepsis management is one of the central foci of the E2E initiative. The primary purpose of our research is to investigate whether the application of sepsis management protocols leads to improved time-based process measures and clinical outcomes for patients presenting to EDs with sepsis. Also, we seek to investigate the implementation of sepsis protocols among different EDs. For example: (1) How can sepsis protocols be harmonized among different EDs? (2) What are health professionals' perspectives on interprofessional collaboration with various EDs? and (3) What are the factors affecting the level of success among EDs? Lastly, working in collaboration with the BC Ministry of Health as our policy-maker partner, the research will investigate how the demonstrated efficacy of this research can be applied on a provincial and national level to establish a template for policy makers from other jurisdictions to translate knowledge into action for EDs. This research study will employ the IHI model for improvement, incorporate the principles of participatory action research, and use the E2E online CoP to engage ED practitioners (eg, physicians, nurses, and administrators, exchanging ideas, engaging in discussions, sharing resources, and amalgamating knowledge) from across BC to (1) share the evidence of early intervention in sepsis, (2) adapt the evidence to their patterns of practice, (3) develop a common set of orders for implementing the sepsis pathway, and (4) agree on common indicators to measure clinical outcomes. Our hypothesis is that combining the social networking ability of an electronic CoP and its inherent knowledge translation capacity with the structured project management of the IHI model will result in widespread and sustained improvement in the emergency and overall care of patients with severe sepsis presenting to EDs throughout BC.

Risk of injury from alcohol and drug use in the emergency department: a case-crossover study.

INTRODUCTION AND AIMS: A substantial literature exists demonstrating the risk of injury from alcohol, but less is known about the association of alcohol in combination with other drugs and injury. This study examined the risk of injury associated with alcohol and drug use prior to the event. DESIGN AND METHODS: Case-crossover analysis was used to estimate the relative risk (RR) of injury due to alcohol use alone, compared with alcohol in combination with other drug use in a sample of emergency department injured patients from two sites in Vancouver, British Columbia (n = 443). Alcohol and drug use in the 6 h prior to injury was compared with the patient's use of these substances during the same 6 h period the day prior and the week prior to injury. RESULTS: Using multiple matching for the two control time periods, RR of injury was significantly related to both alcohol use (RR = 3.3) and to alcohol combined with drug use (RR = 3.0), but not to drug use alone. Effect modification was found only for age for alcohol combined with drug use, with a significant increase in injury risk (P = 0.087) for those over 30. DISCUSSION AND CONCLUSION: While a similar elevated risk of injury was found for alcohol use alone and alcohol used with other drugs, the literature suggests that alcohol in combination with some drugs may be potentially more risky for injury occurrence. Findings suggest the need for future research on risk of injury for specific alcohol and drug combinations.

Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments.

STUDY OBJECTIVE: Although recent-onset atrial fibrillation and flutter are common arrhythmias managed in the emergency department (ED), there is insufficient evidence to help physicians choose between 2 competing treatment strategies, rate control and rhythm control. We seek to evaluate variation in ED management practices for recent-onset atrial fibrillation and flutter patients at multiple Canadian sites and to determine whether hospital site was an independent predictor of attempted cardioversion. METHODS: We conducted a cross-sectional survey by health records review on an observational cohort of all eligible adult recent-onset atrial fibrillation and flutter cases, with onset of symptoms less than 48 hours, treated at 8 academic hospital EDs during a 12-month period, and evaluated the variation in practice among sites for important management strategies. RESULTS: Among the 1,068 study patients, 88.3% had atrial fibrillation and 11.7% had atrial flutter. The proportion of cases managed with rhythm control was 59.4% (interhospital range 42% to 85%) and, among these, electrocardioversion was attempted first for 44.2% (range 7% to 69%). There was variation in most management strategies, including use of rate control drugs 54.9% (range 37% to 65%), choice of procainamide as rhythm control drug 62.1% (range 15% to 89%), referral to cardiology in the ED 30.7% (range 16% to 64%), use of heparin 13.7% (range 1% to 29%), and outpatient cardiology referral 43.0% (range 30% to 65%). Adverse events were relatively uncommon and transient for patients undergoing attempts at pharmacologic (13.0%) or electrocardioversion (12.1%). Overall, 83.3% of patients were discharged home from the ED (range 73% to 90%). After controlling for 12 covariates, multivariate logistic regression found that factors independently associated with attempted cardioversion were age (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95 to 0.98), history of electrocardioversion (OR 2.73; 95% CI 1.56 to 4.80), associated heart failure (OR 0.29; 95% CI 0.09 to 0.95), and hospital site (ORs ranged from 0.38 to 3.05). CONCLUSION: We demonstrated a high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital EDs. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.