Pediatric Emergency Department Return Visits: An Innovative and Systematic Approach to Promote Quality Improvement and Patient Safety.

OBJECTIVES: Emergency department (ED) return visits (RVs) leading to hospital admission are a quality measure that can potentially signal gaps in patient care. Systematic capture and investigation of RVs at a case level can provide an understanding of patient- and visit-level factors associated with RVs, and thus inform system-level quality improvement (QI) opportunities. Our objective is to describe the development of a database that enables tracking and analyzing of all pediatric ED RVs, to understand recurring themes and inform QI initiatives. METHODS: A single-center retrospective cohort study was conducted at a quaternary care children's hospital during a 3-year period (December 2013 to November 2016). All 72-hour RVs were audited for patient- and visit-level variables and clinicians completed root-cause analyses of their RVs. Using descriptive statistics, variables associated with RVs and system-level quality themes were identified. RESULTS: Of 214,047 ED patient visits, 1546 (0.7%) patients returned within 72 hours and were admitted. The RV patients had higher acuity scores on both visits compared with all ED visits, and the RV group had a higher proportion of children younger than 12 months than the overall ED visit group (25.0% vs 16.2%). The underlying cause for the majority of RVs was determined to be natural disease progression (63%), whereas 9% were callbacks for positive blood cultures or discrepant radiology results, and 6% were categorized as misdiagnoses. Several successful QI initiatives were completed as a result of the program. CONCLUSIONS: Systematic monitoring and investigation of all ED RVs provides an innovative and effective approach to seeking provider- and system-level improvement opportunities.

The Characteristics and Outcomes of Patients Who Make an Emergency Department Visit for Hypertension After Use of a Home or Pharmacy Blood Pressure Device.

STUDY OBJECTIVE: Emergency department (ED) visits for hypertension are rapidly increasing. Hypertension guidelines began recommending use of self-measurement blood pressure (BP) devices in the early 2000s, which could be contributing to the increase. We aim to examine the proportion of ED visits for hypertension that occurred after a BP measurement with a self-measuring device, and the associated outcomes. METHODS: This retrospective observational study included adults who made an ED visit and received a primary diagnosis of hypertension at 1 of 5 community and tertiary hospitals in Ontario, Canada, between April 2010 and March 2011. We categorized ED visits into 4 groups: those made after a home BP reading, a pharmacy reading, as a result of a physician referral, and all others (termed "not documented"). We examined rates of admission to the hospital, ED treatment (administration of antihypertensive medication and prescription provision), and post-ED clinical events (follow-up care, return ED visits, and long-term all-cause mortality) by group. RESULTS: Among 1,508 qualifying patients, median presenting ED BP was 182/97 mm Hg (interquartile range 164 to 200/85 to 109 mm Hg). The percentage of patients who presented to the ED after a reading at home, at a pharmacy, or by physician referral and the remaining patients not documented was 40.9%, 8.3%, 13.3%, and 37.5%, respectively. Overall, 109 patients (7.2%) were admitted to the hospital. The proportion of patients admitted after a home or pharmacy reading, after a physician referral, or who were not documented was 3.1%, 11.9%, and 11.0%, respectively. Two-year mortality rates were 5.4%, 0.0%, 6.5%, and 5.3% for the home, pharmacy, physician referral, and not documented groups, respectively. Among the 92.8% of patients who were discharged from the ED, 11% made another ED visit for hypertension within a year. CONCLUSION: In this study, half of patients with an ED visit that was primarily for hypertension presented after elevated readings on self-measurement devices. Only 3% of these patients were admitted to the hospital.

A Population-Based Analysis of Outcomes in Patients With a Primary Diagnosis of Hypertension in the Emergency Department.

STUDY OBJECTIVE: Patients treated primarily for hypertension are common in the emergency department (ED). The outcomes of these patients who were given a primary ED diagnosis of hypertension have not been described at a population level. In this study, we describe the characteristics and outcomes of these patients, as well as changes over time. METHODS: This retrospective cohort study used linked health databases from the province of Ontario, Canada, to assess ED visits made between April 1, 2002, and March 31, 2012, with a primary diagnosis of hypertension. We determined the annual number of visits, as well as the age- and sex-standardized rates. We examined visit disposition and assessed mortality outcomes and potential hypertensive complications at 7, 30, 90, and 365 days and at 2 years subsequent to the ED visit. RESULTS: There were 206,147 qualifying ED visits from 180 sites. Visits increased by 64% between 2002 and 2012, from 15,793 to 25,950 annual visits, respectively. The age- and sex-standardized rate increased from 170 per 100,000 persons to 228 per 100,000 persons during the same period, a 34% increase. Eight percent of visits ended in hospitalization, but this proportion decreased from 9.9% to 7.1% during the study period. Mortality was very low: less than 1% within 90 days, 2.5% within 1 year, and 4.1% within 2 years. Among subsequent hospitalizations for potential hypertensive complications, stroke was the most frequent admitting diagnosis, but the frequency was still less than 1% at 1 year. Together hospitalizations for stroke, heart failure, acute myocardial infarction, atrial fibrillation, renal failure, hypertensive encephalopathy, and dissection were less than 1% at 30 days. CONCLUSION: The number of visits made primarily for hypertension has increased significantly during the last decade. Although some of the increase is due to aging of the population, other forces are contributing to it as well. Subsequent mortality and complication rates are low and have declined. With current practice patterns, the feared complications of hypertension are extremely infrequent.

A blueprint for building an emergency department quality improvement and patient safety committee.

The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, "Leading Change." Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a "burning platform," select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.

RéSUMé: Le domaine de l'amélioration de la qualité de la pratique clinique et de la sécurité des patients (AQSP) s'est considérablement développé en médecine d'urgence au cours de la dernière décennie. Alors qu'il y a quelques années, les projets d'AQSP étaient autonomes, mal alignés sur le plan stratégique et conçus de manière incohérente, les responsables des services d'urgence (SU) reconnaissent aujourd'hui que la mise en place d'une infrastructure d'AQSP plus solide permet de hiérarchiser et d'organiser les projets pour qu'ils aient plus de chances de réussir et d'avoir un impact sur les patients et le système. Ce processus comprend le développement d'un comité d'AQSP départemental bien défini, responsable et soutenu. On peut y parvenir efficacement en utilisant une approche délibérée et structurée, comme celle décrite par le professeur John Kotter de la Harvard Business School dans son ouvrage phare intitulé « Leading Change ¼. Dans le présent document, nous présentons un plan à l'aide de ce cadre et incluons des exemples pratiques tirés de notre expérience de l'élaboration d'un comité et d'une infrastructure d'AQSP de SU solides et réussis. Les étapes comprennent la façon d'élaborer une « plateforme brûlante ¼, de sélectionner une coalition de dirigeants, d'élaborer une vision et des initiatives stratégiques, de recruter une armée de membres bénévoles, de permettre des actions pour le comité, de générer des succès à court terme, de maintenir le rythme du changement et enfin, permettre à l'infrastructure de soutenir les améliorations en cours. Cette feuille de route peut être reproduite par des équipes d'urgence de tailles et de contextes différents pour structurer, hiérarchiser et rendre opérationnelles leurs activités d'AQSP et, en fin de compte, améliorer les résultats de leurs patients.

Designs, facilitators, barriers, and lessons learned during the implementation of emergency department led virtual urgent care programs in Ontario, Canada.

Introduction: Virtual patient care has seen incredible growth since the beginning of the COVID-19 pandemic. To provide greater access to safe and timely urgent care, in the fall of 2020, the Ministry of Health introduced a pilot program of 14 virtual urgent care (VUC) initiatives across the province of Ontario. The objective of this paper was to describe the overall design, facilitators, barriers, and lessons learned during the implementation of seven emergency department (ED) led VUC pilot programs in Ontario, Canada. Methods: We assembled an expert panel of 13 emergency medicine physicians and researchers with experience leading and implementing local VUC programs. Each VUC program lead was asked to describe their local pilot program, share common facilitators and barriers to adoption of VUC services, and summarize lessons learned for future VUC design and development. Results: Models of care interventions varied across VUC pilot programs related to triage, staffing, technology, and physician remuneration. Common facilitators included local champions to guide program delivery, provincial funding support, and multi-modal marketing and promotions. Common barriers included behaviour change strategies to support adoption of a new service, access to high-quality information technology to support new workflow models that consider privacy, risk, and legal perspectives, and standardized data collection which underpin overall objective impact assessments. Conclusions: These pilot programs were rapidly implemented to support safe access to care and ED diversion of patients with low acuity issues during the COVID-19 pandemic. The heterogeneity of program implementation respects local autonomy yet may present challenges for sustainability efforts and future funding considerations.

The Impact of COVID-19 on a Large, Canadian Community Emergency Department.

INTRODUCTION: As the COVID-19 pandemic unfolded, emergency departments (EDs) across the world braced for surges in volume and demand. However, many EDs experienced decreased demand even for higher acuity illnesses. In this study we sought to examine the change in utilization at a large Canadian community ED, including changes in patient demographics and presentations, as well as structural and administrative changes made in response to the pandemic. METHODS: This retrospective observational study took place in Ontario, Canada, from March 17-June 30, 2020, during province-wide lockdowns in response to COVID-19. We used a control period of March 17-June 30 in 2018-2019. Differences between observed and expected values were calculated for total visits, Canadian Triage and Acuity Scale (CTAS) groups, and age groups using Fisher's exact test. Length of stay (LOS), physician initial assessment time (PIA), and top primary and admission diagnoses were also examined. RESULTS: Patient visits fell to 66.3% of expected volume in the exposure period (20,901 vs 31,525, P<0.0001). CTAS-1 (highest acuity) patient volumes dropped to 86.8% of expected (P = 0.1964) while CTAS-5 (lowest acuity) patient volumes dropped to 32.4% of expected (P <0.0001). Youth (0-17), adult (18-64), and senior (65+) visits all decreased to 37.4%, 71.7%, and 72.9% of expected volumes, respectively (P <0.0001). Median PIA and median ED LOS both decreased (1.1 to 0.6 hours and 3.3 to 3.0 hours, respectively). The most common primary diagnosis in both periods was "other chest pain." Viral syndromes were more prevalent in the exposure period. The top admission diagnoses were congestive heart failure in the control period (4.8%) and COVID-19 in the study period (3.5%). CONCLUSION: ED utilization changed drastically during COVID-19. Our ED responded with wide stakeholder engagement, spatial reorganization, and human resources changes informed by real-time data. Our experiences can help prepare for potential subsequent "waves" of COVID-19 and future pandemics.

Evolution of traumatic intracerebral hemorrhage captured with CT imaging: report of a case and the role of serial CT scans.

Delayed enlargement of a traumatic cerebral contusion can occur subsequent to an initial CT scan, and this can lead to neurological deterioration, brain herniation, and death. Herein, we describe the case of a 76-year-old male who experienced an intracerebral hemorrhage subsequent to a fall and whose injury worsened over time. We summarize the current recommendations in the literature for when to initiate follow-up imaging in patients with traumatic head injury, the risk factors for progression, and the role of close clinical monitoring and serial imaging in managing such patients. Finally, we illustrate how these recommendations were applied in our case.

Artificial intelligence in emergency medicine: A scoping review.

INTRODUCTION: Despite the growing investment in and adoption of artificial intelligence (AI) in medicine, the applications of AI in an emergency setting remain unclear. This scoping review seeks to identify available literature regarding the applications of AI in emergency medicine. METHODS: The scoping review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews using Medline-OVID, EMBASE, CINAHL, and IEEE, with a double screening and extraction process. The search included articles published until February 28, 2020. Articles were excluded if they did not self-classify as studying an AI intervention, were not relevant to the emergency department (ED), or did not report outcomes or evaluation. RESULTS: Of the 1483 original database citations, 395 were eligible for full-text evaluation. Of these articles, a total of 150 were included in the scoping review. The majority of included studies were retrospective in nature (n = 124, 82.7%), with only 3 (2.0%) prospective controlled trials. We found 37 (24.7%) interventions aimed at improving diagnosis within the ED. Among the 150 studies, 19 (12.7%) focused on diagnostic imaging within the ED. A total of 16 (10.7%) studies were conducted in the out-of-hospital environment (eg, emergency medical services, paramedics) with the remainder occurring either in the ED or the trauma bay. Of the 24 (16%) studies that had human comparators, there were 12 (8%) studies in which AI interventions outperformed clinicians in at least 1 measured outcome. CONCLUSION: AI-related research is rapidly increasing in emergency medicine. There are several promising AI interventions that can improve emergency care, particularly for acute radiographic imaging and prediction-based diagnoses. Higher quality evidence is needed to further assess both short- and long-term clinical outcomes.

Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department.

Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period.Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury-specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission).Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a 'shift' in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68).Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.

Safety of Propofol versus Nonpropofol-Based Sedation in Children Undergoing Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis.

BACKGROUND: The majority of children who undergo gastrointestinal (GI) endoscopy require anesthesia or procedural sedation for comfort, cooperation, and procedure efficiency. The safety profile of propofol is not well established in children but has been studied in the literature. OBJECTIVE: The aim of this study is to evaluate and compare the safety of propofol-only sedation for GI endoscopy procedures to other anesthetic regimes in the pediatric population. METHODS: A search was conducted in the MEDLINE, Embase, and Cochrane Library databases. Randomized clinical trials and prospective cohorts were included in the study. RESULTS: No significant difference was noted in total complications between the two cohorts with a pooled OR of 1.31 (95% CI: 0.57-3.04, chi2 = 0.053, I2 = 54.31%). The pooled rate of complications in the studies was 23.4% for those receiving propofol only and 18.2% for those receiving other anesthetic regimens. Sensitivity analysis was performed removing a study with a very different control comparison compared to the rest of the studies included. Once excluded, there was minimal heterogeneity in the remaining studies and a significant difference in overall complications was detected, with more complications seen in the propofol-only group compared to the other anesthetic groups (OR 1.87, 95% CI 1.09-3.20). CONCLUSION: Significantly higher incidence of cardiorespiratory complications was noted in the propofol-only versus other anesthetic regimens in pediatric patients undergoing GI endoscopy in this meta-analysis. However, the overall quality of the evidence is very low. HOW TO APPLY THIS KNOWLEDGE FOR ROUTINE CLINICAL PRACTICE: Clinicians providing sedation to a pediatric population for GI endoscopy should consider there may be increased risks when using a propofol-only regimen, but further study is needed.

Epidemiology of Kawasaki Disease in Canada 2004 to 2014: Comparison of Surveillance Using Administrative Data vs Periodic Medical Record Review.

BACKGROUND: We have previously documented an increase in the incidence of Kawasaki disease (KD) in Ontario followed by a stabilization from 1995 to 2006. We sought to validate the estimation of incidence of KD using administrative data and to describe the epidemiology of KD across Canada from 2004 to 2014. METHODS: We queried the Canadian Hospital Discharge Database for hospital admissions associated with a discharge diagnosis of KD. The data set was manually curated and estimates of incidence were compared with those obtained from the retrospective triennial surveillances of KD performed in 2007 and 2010. RESULTS: The average number of cases per year identified through administrative data was 245 ± 45 vs 229 ± 33 from retrospective surveillance. This overestimation, representing 7 ± 6%, is similar to the historical percentage of patients originally diagnosed with KD in whom the diagnosis is subsequently excluded. The annual incidence of KD in Canada was 19.6, 6.4, and 1.3 cases per 100,000 children younger than 5 years, 5-9 years, and 10-14 years old, respectively, with important regional and seasonal differences. The incidence remained stable over the study period in the youngest age group but increased in both older age categories. Coronary artery aneurysms affected 3.5% of all patients, and 0.8% experienced associated major cardiac complications. CONCLUSIONS: Reliance on administrative data to determine incidence of KD is feasible and accurate with manual curation of the data. The incidence of KD in Canada seems to have plateaued for younger children. Differences in annual incidence observed between provinces remain to be explained, and might reflect genetic or environmental differences.