Validity of an ICD-10 Coding Algorithm for Acute Heat Illness in the Emergency Department: A Retrospective Cohort Study.

Acute heat illness (AHI) from extreme environmental heat exposure can lead to emergency department (ED) visits, hospitalization, and even death. While the ICD ninth revision codes for AHI have been validated in the U.S., there have been no studies on the validity of ICD-10 codes for AHI in Canada. The objective of this study was to assess the validity of an ICD-10 coding algorithm for ED encounters for AHI. We conducted a retrospective cohort study of children and adults who had ED encounters at two large academic, tertiary hospitals in London, Canada, between May and September 2014-2018. We developed an algorithm of ICD-10 codes for AHI based upon a literature review and clinical expertise. Our "gold-standard" definition of AHI was patient-reported heat exposure and documentation of at least one heat-related complaint. To establish positive predictive value (PPV), we reviewed 62 algorithm-positive records and noted which met our "gold-standard" definition. To calculate negative predictive value (NPV), sensitivity (Sn), and specificity (Sp), we randomly reviewed 964 ED records for associated ICD-10 codes and diagnoses. Two independent reviewers completed blinded data abstraction, with duplicate abstraction in 20% of the sample. Of the 62 algorithm-positive records, mean (SD) age was 38.8 (23.8) years; 37% were female. PPV was 61.3 ± 12.1% (95% CI). Of the 964 randomly selected records, mean (SD) age was 41.7 (26.5) years; 51.1% were female. The NPV was 99.7 ± 0.4%, sensitivity 25.0 ± 42.4%, and specificity 100.0 ± 0.0%. An ICD-10 coding algorithm for AHI had high specificity but was limited in sensitivity. This algorithm can be used to assemble and study cohorts of patients who have had an AHI, but may underestimate the true incidence of AHI presentations in the ED.

The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients.

Background: Acute heart failure (AHF) is a common emergency department (ED) presentation that may have poor outcomes but often does not require hospital admission. There is little evidence to guide dispositional decisions. Objectives: The authors sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We pooled data from 3 prospective cohorts: 2 published studies and 1 new cohort. The 3 cohorts prospectively enrolled patients who required treatment for AHF at 10 tertiary care hospital EDs. The primary outcome was SSO, defined as death <30 days, intubation or noninvasive ventilation (NIV), myocardial infarction, or relapse to ED <14 days. The logistic regression model evaluated 13 predictors, used an AIC-based step-down procedure, and bootstrapped internal validation. Results: Of the 2,246 patients in the 3 cohorts (N = 559; 1,100; 587), the mean age was 77.4 years, 54.5% were male, 3.1% received intravenous nitroglycerin, 5.2% received ED NIV, and 48.6% were admitted to the hospital. There were 281 (12.5%) SSOs including 70 deaths (3.1%) with many in discharged patients. The final HEARTRISK6 Scale included 6 variables: valvular heart disease, tachycardia, need for NIV, creatinine, troponin, and failed reassessment (walk test). Choosing HEARTRISK6 total-point admission thresholds of ≥1 or ≥2 would yield, respectively, sensitivities of 88.3% (95% CI: 83.9%-91.8%) and 71.5% (95% CI: 65.9%-76.7%) and specificities of 24.7% (95% CI: 22.8%-26.7%) and 50.1% (95% CI: 47.9%-52.4%) for SSO. Conclusions: Using 3 large prospectively collected datasets, we created a concise and sensitive risk scale for patients with AHF in the ED. Implementation of the HEARTRISK6 scale could lead to safer and more efficient disposition decisions.

Utility of serial troponin testing for emergency department patients with syncope.

BACKGROUND: For emergency department (ED) patients with syncope, cardiac troponin can identify acute coronary syndrome (ACS) and prognosticate for 30-day serious adverse events. However, it is unclear if serial testing improves diagnostic yield and prognostication. METHODS: This was a secondary analysis of data from two prospective studies conducted to develop the Canadian Syncope Risk Score. Adults (age ≥ 16 years) with syncope were enrolled, and patient characteristics, vital signs, physician diagnostic impression, electrocardiogram and troponin results, and adjudicated 30-day serious adverse event were collected. The primary outcome was the detection of a serious adverse event within 30 days of ED disposition. The secondary outcome was comparison of ED length of stay among patients with single versus serial troponin measurements. RESULTS: 4996 patients [mean age 64.5 (SD 18.8) years, 52.2% male] were included: 4397 (89.8%) with single troponin [232 (5.3%) with serious adverse event in the ED and 203 (4.6%) after ED disposition]; 499 (10.2%) patients with > 1 troponin measurement [39 (7.8%) with serious adverse event in ED and 60 (12.0%) after ED disposition]. Among those with serial measurements, 10 patients (2.0%) had a rise from below to above the 99th percentile threshold, of whom 4 patients (0.8%) suffered serious adverse event: two with arrhythmias diagnosed on electrocardiogram, one with ACS and one suffered respiratory failure. Nine patients (1.8%) had Canadian Syncope Risk Score risk reclassification based on serial measurement, and none suffered 30-day serious adverse event. Median ED length of stay was significantly longer for patients with serial testing (5.6 vs. 3.8 h, p < 0.001). CONCLUSIONS: The initial troponin measurement was sufficient for serious adverse event detection and in-ED risk stratification. Serial troponin testing does not improve the diagnostic yield or prognostication and should be reserved for patients with ongoing symptoms or electrocardiogram findings suggestive of cardiac ischemia.

ABSTRAIT: CONTEXTE: Pour les patients du service des urgences (DE) atteints de syncope, la troponine cardiaque peut identifier le syndrome coronarien aigu (SCA) et le pronostic pour les événements indésirables graves de 30 jours. Cependant, il n'est pas clair si les tests en série améliorent le rendement diagnostique et le pronostic. MéTHODES: Il s'agissait d'une analyse secondaire des données de deux études prospectives menées pour élaborer le Canadian Syncope Risk Score. Des adultes (âgés de 16 ans) atteints de syncope ont été recrutés, et les caractéristiques du patient, les signes vitaux, l'empreinte diagnostique du médecin, les résultats de l'électrocardiogramme et de la troponine, ainsi que les événements indésirables graves évalués à 30 jours ont été recueillis. Le critère de jugement principal était la détection d'un événement indésirable grave dans les 30 jours suivant la décision de l'urgence. Le critère de jugement secondaire était la comparaison de la durée de séjour à l'urgence chez les patients ayant une seule mesure de troponine par rapport à la mesure en série. RéSULTATS: 4 996 patients [âge moyen 64,5 (ET 18,8) ans, 52,2 % d'hommes] ont été inclus : 4 397 (89,8 %) avec une seule troponine [232 (5,3 %) avec un événement indésirable grave à l'urgence et 203 (4,6 %) après l'urgence]; 499 (10,2 %) patients avec > 1 mesure de la troponine [39 (7,8 %) avec événement indésirable grave à l'urgence et 60 (12,0 %) après la décision à l'urgence]. Parmi les patients ayant fait l'objet de mesures en série, 10 (2,0 %) présentaient une augmentation du seuil inférieur à supérieur au seuil du 99e percentile, dont 4 (0,8 %) ont subi un événement indésirable grave : deux avec arythmies diagnostiquées par électrocardiogramme, un avec SCA et un avec insuffisance respiratoire. Neuf patients (1,8 %) ont présenté une reclassification du risque selon le score canadien de risque de syncope en fonction de la mesure en série, et aucun n'a subi d'événement indésirable grave de 30 jours. La durée médiane de séjour aux urgences était significativement plus longue pour les patients ayant subi des tests en série (5,6 vs. 3,8 heures, p < 0,001). CONCLUSIONS: La mesure initiale de la troponine était suffisante pour la détection des effets indésirables graves et la stratification des risques aux urgences. Les tests de troponine en série n'améliorent pas le rendement diagnostique ou le pronostic et doivent être réservés aux patients présentant des symptômes continus ou des résultats d'électrocardiogramme suggérant une ischémie cardiaque.

Opioid prescribing requirements to minimize unused medications after an emergency department visit for acute pain: a prospective cohort study.

BACKGROUND: Unused opioid prescriptions can be a driver of opioid misuse. Our objective was to determine the optimal quantity of opioids to prescribe to patients with acute pain at emergency department discharge, in order to meet their analgesic needs while limiting the amount of unused opioids. METHODS: In a prospective, multicentre cohort study, we included consecutive patients aged 18 years and older with an acute pain condition present for less than 2 weeks who were discharged from emergency department with an opioid prescription. Participants completed a pain medication diary for real-time recording of quantity, doses, and names of all analgesics consumed during a 14-day follow-up period. RESULTS: We included 2240 participants, who had a mean age of 51 years; 48% were female. Over 14 days, participants consumed a median of 5 (quartiles, 1-14) morphine 5 mg tablet equivalents, with significant variation across pain conditions (p < 0.001). Most opioid tablets prescribed (63%) were unused. To meet the opioid need of 80% of patients for 2 weeks, we found that those experiencing renal colic or abdominal pain required fewer opioid tablets (8 morphine 5 mg tablet equivalents) than patients who had fractures (24 tablets), back pain (21 tablets), neck pain (17 tablets), or other musculoskeletal pain (16 tablets). INTERPRETATION: Two-thirds of opioid tablets prescribed at emergency department discharge for acute pain were unused, whereas opioid requirements varied significantly based on the cause of acute pain. Smaller, cause-specific opioid prescriptions could provide adequate pain management while reducing the risk of opioid misuse. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT03953534.

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study.

OBJECTIVES: This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia. METHODS: Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. RESULTS: There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. CONCLUSIONS: This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

ABSTRAIT: OBJECTIFS: Les objectifs de cette étude étaient de décrire les résultats des patients diabétiques présentant leur première visite aux urgences pour hyperglycémie, et d'identifier les prédicteurs des visites récurrentes aux urgences pour hyperglycémie. MéTHODES: À l'aide de bases de données couplées, nous avons mené une étude de cohorte basée sur la population de patients adultes et pédiatriques atteints de diabète de type 1 et 2 présentant une première visite aux urgences pour l'hyperglycémie d'avril 2010 à mars 2020 en Ontario, au Canada. Nous avons déterminé la proportion de patients présentant une visite récurrente à l'urgence pour hyperglycémie dans les 30 jours suivant la visite d'index. À l'aide d'une analyse de régression multivariée, nous avons examiné les prédicteurs cliniques et socioéconomiques des visites récurrentes. RéSULTATS: Il y avait 779 632 patients avec une première visite à l'urgence pour hyperglycémie. L'âge moyen (ET) était de 64,3 (15,2) ans; 47,7% étaient des femmes. 11,0 % avaient une visite récurrente pour hyperglycémie dans les 30 jours. Les prédicteurs statistiquement significatifs d'une visite récurrente comprenaient le sexe masculin, le diabète de type 1, les régions comptant moins de groupes de minorités visibles et ayant moins d'études ou d'emploi, une hémoglobine A1C plus élevée, plus de visites chez un médecin de famille ou un interniste au cours de la dernière année, être inscrit auprès d'un médecin de famille, consulter le service d'urgence au cours de la dernière année, être hospitalisé au cours des 14 derniers jours, avoir accès à des services de soins à domicile et avoir été confronté à une hyperglycémie au cours des 5 dernières années. L'alcoolisme et la dépression ou l'anxiété étaient des prédicteurs positifs pour le groupe des 18-65 ans. CONCLUSIONS: Cette étude au niveau de la population identifie des prédicteurs de visites récurrentes aux urgences pour l'hyperglycémie, y compris le sexe masculin, le diabète de type 1, les régions avec moins de groupes de minorités visibles et avec moins d'études ou d'emploi, plus d'hémoglobine A1C, l'utilisation antérieure plus élevée du système de soins de santé (visites aux urgences et hospitalisation) pour l'hyperglycémie, le fait d'être inscrit auprès d'un médecin de famille et l'accès aux services de soins à domicile. La connaissance de ces prédicteurs peut être utilisée pour élaborer des interventions ciblées afin d'améliorer les résultats pour les patients et de réduire les coûts du système de santé.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial.

BACKGROUND: Current diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study's objective was to determine the feasibility of a future multicentred randomised controlled trial (RCT) comparing intravenous Ringer's lactate (RL) with NS in managing ED patients with DKA. METHODS: We conducted a parallel-arm, triple-blind, pilot RCT of adults (≥18 years) with DKA at a Canadian academic tertiary care ED. The primary feasibility outcome was recruitment rate (target ≥41.3% of eligible participants over the 1-year study period); the primary efficacy outcome was time elapsed from ED presentation to DKA resolution. The superiority margin for a clinically significant difference was chosen to be a 40% time reduction to DKA resolution. We also assessed the need to break allocation concealment and loss to follow-up. Patients with clinical suspicion for DKA were screened for inclusion and enrolled patients were randomised 1:1 to receive RL or NS. Patients, clinicians and outcome assessors were blinded to allocation. RESULTS: We enrolled 52 (25 RL, 27 NS) of 60 eligible patients (86.7%), exceeding our target recruitment rate. There were more patients in the NS group with type 1 diabetes, and more patients in the RL group had an admission co-diagnosis in addition to DKA. For the 44 participants with confirmed laboratory evidence of resolution, median (IQR) time to DKA resolution for RL versus NS was 15.7 (10.4-18.8) and 12.7 (7.9-19.2) hours, respectively. There were no cases where blinding was broken, and there was no loss to follow-up. CONCLUSIONS: This pilot trial demonstrated our protocol's feasibility by exceeding our target recruitment rate. Our results may be used to inform future multicentre trials to compare the safety and efficacy of RL and NS in managing DKA in the ED. TRIAL REGISTRATION NUMBER: NCT04926740.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial.

BACKGROUND: Current guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer's Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA. METHODS: We describe a protocol for BRISK-ED (Balanced crystalloids [RInger's lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada. Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS. The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann-Whitney U, or chi-square tests will be used to compare groups as appropriate. DISCUSSION: The results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Development of practice recommendations based on the Canadian Syncope Risk Score and identification of barriers and facilitators for implementation.

BACKGROUND: Wide variations in emergency department (ED) syncope management exist. The Canadian Syncope Risk Score (CSRS) was developed to predict the probability of 30-day serious outcomes after ED disposition. Study objectives were to evaluate the acceptability of proposed CSRS practice recommendations among providers and patients, and identify barriers and facilitators for CSRS use to guide disposition decisions. METHODS: We conducted semi-structured interviews with 41 physicians involved in ED syncope and 35 ED patients with syncope. We used purposive sampling to ensure a variety of physician specialties and CSRS patient risk levels. Thematic analysis was completed by two independent coders with consensus meetings to resolve conflicts. Analysis proceeded in parallel with interviews until data saturation. RESULTS: The majority (97.6%; 40/41) of physicians agreed with discharge of low risk (CSRS ≤ 0) but opined that 'no follow up' changed to 'follow-up as needed'. Physicians indicated current practices do not align with the medium-risk recommendation to discharge patients with 15-day monitoring (CSRS = 1-3; due to lack of access to monitors and timely follow-up) and the high-risk recommendation (CSRS ≥ 4) to potentially discharge patients with 15-day monitoring. Physicians recommended brief hospitalization of high-risk patients due to patient safety concerns. Facilitators included the CSRS-based patient education and scores supporting their clinical gestalt. Patients reported receiving varying levels of information regarding syncope and post-ED care, were satisfied with care received and preferred less resource intensive options. CONCLUSION: Our recommendations based on the study results were: discharge of low-risk patients with physician follow-up as needed; discharge of medium-risk patients with 15-day cardiac monitoring and brief hospitalization of high-risk patients with 15-day cardiac monitoring if discharged. Patients preferred less resource intensive options, in line with CSRS recommended care. Implementation should leverage identified facilitators (e.g., patient education) and address the barriers (e.g., monitor access) to improve ED syncope care.

RéSUMé: CONTEXTE: La prise en charge des syncopes par les services d'urgence varie considérablement. Le Canadian Syncope Risk Score (CSRS) a été mis au point pour prédire la probabilité d'une issue grave à 30 jours après la prise en charge par le service des urgences. Les objectifs de l'étude étaient d'évaluer l'acceptabilité des recommandations pratiques proposées par le CSRS parmi les prestataires et les patients, et d'identifier les barrières et les facilitateurs de l'utilisation du CSRS pour guider les décisions de disposition. MéTHODES: Nous avons mené des entretiens semi-structurés avec 41 médecins impliqués dans la syncope aux urgences et 35 patients souffrant de syncope aux urgences. Nous avons utilisé un échantillonnage raisonné pour assurer une variété de spécialités médicales et de niveaux de risque pour les patients du CSRS. L'analyse thématique a été réalisée par deux codeurs indépendants, avec des réunions de consensus pour résoudre les conflits. L'analyse s'est déroulée parallèlement aux entretiens jusqu'à saturation des données. RéSULTATS: La majorité (97,6 % ; 40/41) des médecins étaient d'accord avec la sortie des patients à faible risque (CSRS ≤ 0), mais ont estimé que " pas de suivi " devait être remplacée par " suivi en fonction des besoins ". Les médecins ont indiqué que leurs pratiques actuelles ne sont pas conformes à la recommandation à risque moyen de faire sortir les patients avec une surveillance de 15 jours (CSRS = 1-3 ; en raison du manque d'accès aux moniteurs et au suivi en temps opportun) et à la recommandation à risque élevé (CSRS ≥ 4) de potentiellement faire sortir les patients avec une surveillance de 15 jours. Les médecins ont recommandé une brève hospitalisation des patients à haut risque pour des raisons de sécurité. Les facilitateurs comprenaient l'éducation des patients basée sur le CSRS et les scores soutenant leur gestalt clinique. Les patients ont déclaré avoir reçu différents niveaux d'information concernant la syncope et les soins post-urgence, étaient satisfaits des soins reçus et préféraient des options moins gourmandes en ressources. CONCLUSIONS: Nos recommandations basées sur les résultats de l'étude sont les suivantes : sortie des patients à faible risque avec suivi par un médecin si nécessaire ; la sortie des patients à risque moyen avec une surveillance cardiaque de 15 jours et une brève hospitalisation des patients à risque élevé avec une surveillance cardiaque de 15 jours en cas de sortie. Les patients ont préféré des options moins gourmandes en ressources, conformément aux soins recommandés par le CSRS. La mise en œuvre devrait s'appuyer sur les facilitateurs identifiés (par exemple, l'éducation des patients) et s'attaquer aux obstacles (par exemple, le contrôle de l'accès) pour améliorer les soins aux urgences en cas de syncope.

Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

OBJECTIVE: Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS: We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS: Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS: During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.

RéSUMé: OBJECTIF: Les pratiques d'intubation ont changé au cours de la pandémie de COVID-19 afin de protéger le personnel de santé contre la transmission de la maladie. Nos objectifs étaient de décrire les caractéristiques de l'intubation et les résultats pour les patients testés pour l'infection par le CoV-2 du SRAS. Nous avons comparé les résultats entre les patients testés positifs au SARS COV-2 et ceux testés négatifs. MéTHODES: Nous avons effectué un examen des dossiers de santé à l'aide du registre du Réseau canadien d'intervention rapide dans les services d'urgence pour la COVID-19 (RCIRSUC). Nous avons inclus les patients éligibles consécutifs qui se sont présentés à l'un des 47 services d'urgence du Canada entre le 1er mars 2020 et le 20 juin 2021, qui ont été testés pour le SRAS-CoV-2 et qui ont été intubés dans le service d'urgence. Le résultat principal était la proportion de patients ayant subi un événement indésirable après l'intubation pendant leur séjour aux urgences. Les critères de jugement secondaires comprenaient le succès du premier passage, les pratiques d'intubation et la mortalité hospitalière. Nous avons utilisé des statistiques descriptives pour résumer les variables avec des différences de sous-groupes examinées à l'aide de tests t, de tests z ou de tests du chi carré, le cas échéant, avec des IC à 95%. RéSULTATS: Sur les 1720 patients suspects de COVID-19 qui ont été intubés aux urgences pendant la période de l'étude, 337 (19,6%) ont été testés positifs au SARS-CoV-2 et 1383 (80,4%) négatifs au SARS-CoV-2. Les patients positifs au SRAS-CoV-2 se sont présentés à l'hôpital avec des niveaux d'oxygène inférieurs à ceux des patients négatifs pour le SRAS-CoV-2 (oxymètre de pouls moyen SaO2 86% contre 94%, p < 0,001). Au total, 8,5% des patients ont présenté un événement indésirable après l'intubation. Un plus grand nombre de patients du sous-groupe positif au SRAS-CoV-2 ont présenté une hypoxémie post-intubation (4,5% vs 2,2%, p = 0,019). La mortalité hospitalière était plus élevée chez les patients ayant subi des événements indésirables liés à l'intubation (43,2% vs 33,2%, p = 0,018). Il n'y avait pas de différence significative dans la mortalité associée aux événements indésirables selon le statut du SRAS-CoV-2. Le succès du premier passage a été obtenu dans 92,4% de toutes les intubations, sans différence selon le statut SARS-CoV-2 CONCLUSIONS: Pendant la pandémie de COVID-19, nous avons observé un faible risque d'événements indésirables associés à l'intubation, même si l'hypoxémie était fréquente chez les patients atteints de SRAS-CoV-2 confirmé. Nous avons observé des taux élevés de réussite du premier passage et des taux faibles d'incapacité à intuber. Le nombre limité d'événements indésirables a empêché les ajustements multivariés. Les résultats de l'étude devraient rassurer les praticiens de la médecine d'urgence que les modifications apportées aux processus d'intubation en réponse à la pandémie de COVID-19 ne semblent pas être associées à des résultats plus défavorables que les pratiques antérieures à la pandémie de COVID-19.

Impact of Ontario's Harmonized Heat Warning and Information System on emergency department visits for heat-related illness in Ontario, Canada: a population-based time series analysis.

INTERVENTION: Ontario's Harmonized Heat Warning and Information System (HWIS) brings harmonized, regional heat warnings and standard heat-health messaging to provincial public health units prior to periods of extreme heat. RESEARCH QUESTION: Was implementation of the harmonized HWIS in May 2016 associated with a reduction in emergency department (ED) visits for heat-related illness in urban locations across Ontario, Canada? METHODS: We conducted a population-based interrupted time series analysis from April 30 to September 30, 2012-2018, using administrative health and outdoor temperature data. We used autoregressive integrated moving average models to examine whether ED rates changed following implementation of the harmonized HWIS, adjusted for maximum daily temperature. We also examined whether effects differed in heat-vulnerable groups (≥65 years or <18 years, those with comorbidities, those with a recent history of homelessness), and by heat warning region. RESULTS: Over the study period, heat alerts became more frequent in urban areas (6 events triggered between 2013 and 2015 and 14 events between 2016 and 2018 in Toronto, for example). The mean rate of ED visits was 47.5 per 100,000 Ontarians (range 39.7-60.1) per 2-week study interval, with peaks from June to July each year. ED rates were particularly high in those with a recent history of homelessness (mean rate 337.0 per 100,000). Although rates appeared to decline following implementation of HWIS in some subpopulations, the change was not statistically significant at a population level (rate 0.04, 95% CI: -0.03 to 0.1, p=0.278). CONCLUSION: In urban areas across Ontario, ED encounters for heat-related illness may have declined in some subpopulations following HWIS, but the change was not statistically significant. Efforts to continually improve HWIS processes are important given our changing Canadian climate.

RéSUMé: INTERVENTION: Le système d'avertissement et d'information de chaleur harmonisé pour l'Ontario (SAIC) transmet des alertes régionales harmonisées sur la chaleur et des messages normalisés sur la chaleur et la santé aux unités de santé publique provinciales, avant les périodes de chaleur extrême. QUESTION DE RECHERCHE: La mise en œuvre du SAIC harmonisé en mai 2016 a-t-elle été associée à une réduction des visites aux urgences pour des maladies liées à la chaleur dans les zones urbaines de l'Ontario, au Canada? MéTHODES: Nous avons effectué une analyse de séries chronologiques interrompues basée sur la population du 30 avril au 30 septembre, 2012­2018, en utilisant des données administratives sur la santé et la température extérieure. Nous avons utilisé des modèles autorégressifs à moyenne mobile intégrée pour examiner si le taux de visites des urgences avait changé après la mise en œuvre du SAIC harmonisé, ajusté pour tenir compte de la température maximale quotidienne. Nous avons également examiné si les effets différaient pour les groupes vulnérables à la chaleur (≥65 ans ou <18 ans, les personnes ayant des comorbidités et les personnes avec un passé récent de sans-abri), et selon la région d'alerte de chaleur. RéSULTATS: Au cours de la période d'étude, les alertes de chaleur sont devenues plus fréquentes dans les zones urbaines (6 événements déclenchés entre 2013 et 2015 et 14 événements déclenchés entre 2016 et 2018 à Toronto, par exemple). Le taux moyen de visites aux urgences était de 47,5 pour 100 000 Ontariens (de 39,7 à 60,1) par intervalle de deux semaines, avec des pointes chaque année en juin et juillet. Le taux de visites aux urgences était particulièrement élevé chez les personnes avec un passé récent de sans-abri (taux moyen de 337,0 pour 100 000). Malgré une baisse du taux après la mise en œuvre du SAIC dans certaines sous-populations, le changement n'était pas statistiquement significatif au niveau de la population (taux 0,04, IC 95 % : -0,03 à 0,1, p=0,278). CONCLUSION: Dans les zones urbaines de l'Ontario, le nombre de consultations aux urgences pour des maladies liées à la chaleur a diminué dans certaines sous-populations après la mise en place du SAIC, mais le changement n'était pas statistiquement significatif. Les efforts visant à améliorer continuellement les processus du SAIC sont importants compte tenu de l'évolution du climat canadien.

Comparison of Adult Diabetic Ketoacidosis Treatment Protocols From Canadian Emergency Departments.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management. METHODS: ED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared. RESULTS: Thirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer's lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration. CONCLUSIONS: This is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.

Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

BACKGROUND: Treatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves. METHODS: This observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes. RESULTS: We enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2-8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4-0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6-0.8) and critical care admission (OR 0.7; 95% CI 0.6-0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5-1.1). INTERPRETATION: In patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

RéSUMé: CONTEXTE: Le traitement de la maladie à coronavirus 2019 (COVID-19) a évolué entre les vagues pandémiques. Notre objectif était de comparer les traitements, l'utilisation des soins aigus et les résultats des patients atteints de la maladie COVID-19 se présentant aux urgences à travers les vagues de pandémie. MéTHODES: Cette étude observationnelle a recruté des patients COVID-19 éligibles consécutifs se présentant à 46 services d'urgence participant au Réseau canadien de réponse rapide aux services d'urgence COVID-19 (CCEDRRN) entre le 1er mars et le 31 décembre 2020. Nous avons recueilli des données au moyen d'un examen rétrospectif des dossiers. Notre principal résultat a été la mortalité à l'hôpital. Les résultats secondaires incluaient les traitements, les admissions à l'hôpital et aux soins intensifs, les revisites aux urgences et les réadmissions. La modélisation par régression logistique a évalué l'impact de la vague de pandémie sur les résultats. RéSULTATS: Nous avons recruté 9 967 patients dans 8 provinces, 3 336 de la première vague et 6 631 de la deuxième vague. Les patients de la deuxième vague étaient plus jeunes, moins nombreux à répondre aux critères de gravité de la COVID-19 et plus nombreux à quitter les urgences. Après ajustement en fonction des caractéristiques des patients et de la gravité de la maladie, le recours aux stéroïdes a augmenté (rapport de cotes [RC] 7.4 ; intervalle de confiance à 95 % [IC] 6.2­8.9) et la ventilation mécanique invasive a diminué (RC 0.5 ; IC à 95 % 0.4­0.7) lors de la deuxième vague par rapport à la première. Après ajustement pour tenir compte des différences dans les caractéristiques des patients et la gravité de la maladie, les probabilités d'hospitalisation (RC 0.7 ; IC à 95 % 0.6­0.8) et d'admission en soins intensifs (RC 0.7 ; IC à 95 % 0.6­0.9) ont diminué, tandis que la mortalité est restée inchangée (RC 0.7 ; IC à 95 % 0.5­1.1). INTERPRéTATION: Chez les patients se présentant dans les établissements de soins de santé, nous avons observé une adoption rapide des thérapies fondées sur des données probantes et un moindre recours aux thérapies expérimentales lors de la deuxième vague. Nous avons observé une augmentation des taux de sortie des services d'urgence et une diminution de l'utilisation des ressources hospitalières et des soins intensifs au fil du temps. Les réductions substantielles de la ventilation mécanique n'étaient pas associées à une augmentation de la mortalité. Les progrès réalisés dans les stratégies de traitement ont permis d'améliorer l'efficacité des systèmes de santé sans compromettre les résultats pour les patients.

Association between fentanyl treatment for acute pain in the emergency department and opioid use two weeks after discharge.

BACKGROUND: Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids. METHODS: Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores. RESULTS: We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09). CONCLUSIONS: Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.

Personalised risk prediction following emergency department assessment for syncope.

BACKGROUND: Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS: We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS: 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.

Definition of a critical bleed in patients with immune thrombocytopenia: Communication from the ISTH SSC Subcommittee on Platelet Immunology.

BACKGROUND: Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. In preparation for an upcoming guideline, the ITP Emergency Management Guideline Panel, including clinical experts in hematology, emergency medicine, research methodology, and patient representatives, identified the need for a standardized definition of a critical ITP bleed. The goal of the definition was to distinguish critical bleeds from bleeds that may not require urgent treatment, typically in the context of severe thrombocytopenia. METHODS: The panel met in person and virtually to achieve consensus on the criteria for critical bleeding events among patients with ITP. Existing ITP bleeding scores and published definitions of major bleeds in patients receiving anticoagulation informed the definition of a critical ITP bleed. The Platelet Immunology Scientific Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis endorsed the definition. RESULTS: A critical ITP bleed was defined as: (a) a bleed in a critical anatomical site including intracranial, intraspinal, intraocular, retroperitoneal, pericardial, or intramuscular with compartment syndrome; or (2) an ongoing bleed that results in hemodynamic instability or respiratory compromise. CONCLUSION: The definition of a critical ITP bleed was developed by the ITP Emergency Management Guideline Panel and endorsed by the Platelet Immunology SSC. It incorporates both anatomic and physiologic risk and pertains to patients with confirmed or suspected ITP who typically have severe thrombocytopenia (platelet count below 20 × 109 /L).

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study.

BACKGROUND: Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS: This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION: Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT04702945.