Impact of a high sensitivity troponin accelerated diagnostic protocol on the safety and emergency department length of stay of chest pain in an academic tertiary hospital: a quality improvement study.

PURPOSE: High-sensitivity troponin (hsTn) accelerated diagnostic protocols are highly recommended for evaluating acute coronary syndromes. Our goal was to improve care for chest pain patients through the safe adoption of an accelerated diagnostic protocol in our academic Emergency Department (ED) with an aim to reduce mean ED length of stay for chest pain patients by 1 h over 1.5 years. Pre-accelerated diagnostic protocol, our mean ED length of stay for chest pain patients was 9.0 h. METHODS: Using the Model for Improvement, we implemented a two-hour accelerated diagnostic protocol and conducted two Plan-Do-Study-Act cycles and education efforts to improve accelerated diagnostic protocol compliance and decrease ED length of stay. Using control charts, we measured the mean monthly ED length of stay for chest pain patients to look for special cause evidence of improvement. Process measures measured compliance with the accelerated diagnostic protocol. Balancing measures included the ED length of stay for abdominal pain patients and the number of admissions and deaths at 7 days for chest pain patients. RESULTS: Mean ED length of stay for chest pain patients decreased from 9.0 to 8.2 h post-accelerated diagnostic protocol. The mean time between troponins decreased from 3.9 to 3.0 h, and the percentage of second troponins repeated at < 2.75 h increased from 22.3% to 58.6%. For abdominal pain patients, ED length of stay decreased from 10.8 to 10.5 h. No chest pain patients died within 7 days pre- or post-accelerated diagnostic protocol. Pre-accelerated diagnostic protocol, 0.84% (41/4,905) were admitted within 7 days. Post-accelerated diagnostic protocol and accelerated diagnostic protocol compliant, 0.70% (13/1,844) were admitted. Post-accelerated diagnostic protocol and accelerated diagnostic protocol non-compliant, 1.1% (13/1,183) were admitted. CONCLUSION: We safely introduced a hsTn accelerated diagnostic protocol in an academic ED. ED length of stay decreased for chest pain patients but did not meet our 1-h goal.

RéSUMé : OBJECTIF : Les protocoles de diagnostic accélérés à haute sensibilité de la troponine (hsTn) sont fortement recommandés pour évaluer les syndromes coronariens aigus. Notre objectif était d'améliorer les soins pour les patients souffrant de douleurs thoraciques grâce à l'adoption en toute sécurité d'un protocole de diagnostic accéléré dans notre service d'urgence universitaire (ED) dans le but de réduire la durée moyenne de séjour des patients souffrant de douleurs thoraciques d'une heure sur 1,5 an. Protocole de diagnostic pré-accéléré, notre durée moyenne de séjour aux urgences pour les patients souffrant de douleurs thoraciques était de 9 heures. MéTHODES: À l'aide du Modèle d'amélioration, nous avons mis en œuvre un protocole de diagnostic accéléré de deux heures et mené deux cycles Plan-Do-Study-Act et des efforts d'éducation pour améliorer la conformité du protocole de diagnostic accéléré et réduire la durée du séjour aux urgences. À l'aide de tableaux de contrôle, nous avons mesuré la durée moyenne mensuelle du séjour aux urgences pour les patients souffrant de douleurs thoraciques afin de rechercher des preuves d'amélioration de cause spéciale. Le processus mesure la conformité au protocole de diagnostic accéléré. Les mesures d'équilibrage comprenaient la durée du séjour aux urgences pour les patients souffrant de douleurs abdominales et le nombre d'admissions et de décès à sept jours pour les patients souffrant de douleurs thoraciques. RéSULTATS: La durée moyenne du séjour aux urgences chez les patients souffrant de douleurs thoraciques a diminué de 9,0 à 8,2 heures après le protocole de diagnostic accéléré. Le temps moyen entre les troponines a diminué de 3,9 à 3,0 heures, et le pourcentage de deuxième troponines répétées à moins de 2,75 heures a augmenté de 22,3 % à 58,6 %. Pour les patients souffrant de douleurs abdominales, la durée du séjour aux urgences a diminué de 10,8 à 10,5 heures. Aucun patient souffrant de douleurs thoraciques n'est décédé dans les sept jours précédant ou suivant le protocole de diagnostic accéléré. Protocole de diagnostic pré-accéléré, 0,84 % (41/4905) ont été admis dans les sept jours. Protocole de diagnostic post-accéléré et protocole de diagnostic accéléré conforme, 0,70% (13/1844) ont été admis. Le protocole diagnostique post-accéléré et le protocole diagnostique accéléré non conforme, 1,1% (13/1,183) ont été admis. CONCLUSION: Nous avons introduit en toute sécurité un protocole de diagnostic accéléré hsTn dans un ED académique. La durée de séjour des patients souffrant de douleurs thoraciques a diminué, mais n'a pas atteint notre objectif d'une heure.

Implementation of the YEARS algorithm to optimise pulmonary embolism diagnostic workup in the emergency department.

BACKGROUND: Excessive use of CT pulmonary angiography (CTPA) to investigate pulmonary embolism (PE) in the emergency department (ED) contributes to adverse patient outcomes. Non-invasive D-dimer testing, in the context of a clinical algorithm, may help decrease unnecessary imaging but this has not been widely implemented in Canadian EDs. AIM: To improve the diagnostic yield of CTPA for PE by 5% (absolute) within 12 months of implementing the YEARS algorithm. MEASURES AND DESIGN: Single centre study of all ED patients >18 years investigated for PE with D-dimer and/or CTPA between February 2021 and January 2022. Primary and secondary outcomes were the diagnostic yield of CTPA and frequency of CTPA ordered compared with baseline. Process measures included the percentage of D-dimer tests ordered with CTPA and CTPAs ordered with D-dimers <500 µg/L Fibrinogen Equivalent Units (FEU). The balancing measure was the number of PEs identified on CTPA within 30 days of index visit. Multidisciplinary stakeholders developed plan- do-study-act cycles based on the YEARS algorithm. RESULTS: Over 12 months, 2695 patients were investigated for PE, of which 942 had a CTPA. Compared with baseline, the CTPA yield increased by 2.9% (12.6% vs 15.5%, 95% CI -0.06% to 5.9%) and the proportion of patients that underwent CTPA decreased by 11.4% (46.4% vs 35%, 95% CI -14.1% to -8.8%). The percentage of CTPAs ordered with a D-dimer increased by 26.3% (30.7% vs 57%, 95% CI 22.2% 30.3%) and there were two missed PE (2/2695, 0.07%). IMPACT: Implementing the YEARS criteria may safely improve the diagnostic yield of CTPAs and reduce the number of CTPAs completed without an associated increase in missed clinically significant PEs. This project provides a model for optimising the use of CTPA in the ED.

Prevalence and Antimicrobial Sensitivity Patterns of Uropathogens, in Tikur Anbessa Specialized Hospital Emergency Medicine Department Addis Ababa, Ethiopia.

Background: Empirical treatment of infections remains a major contributing factor to the emergence of pathogens that are resistant to antibiotics. The study aimed to assess the prevalence and anti-microbial sensitivity patterns of uropathogens in the Emergency Medicine Department of Tikur Anbessa Hospital, Ethiopia. Methods: Urine sample data collected over two years from January 2015 to January 2016 at Tikur Anbessa Hospital's laboratory were retrospectively analyzed for bacterial pathogens, and their antimicrobial susceptibility. Antimicrobial sensitivity tests were done using the disc diffusion technique as per the standard of the Kirby-Bauer method. Results: Of the total 220 samples that were collected, 50 (22.7%) were culture-positive. Male to female data ratio was 1:1.1. Escherichia coli was the dominant isolate (50%) followed by Enterococcus species (12%), Enterobacter species (12%), and Klebsiella species (8%). Overall resistance rates to Cotrimoxazole, Ampicillin, Augmentin, and Ceftriaxone were 90.4%, 88.8%, 82.5%, and 79.3%, respectively. The sensitivity rates for Chloramphenicol, Amikacin, Vancomycin, Meropenem, Cefoxitin, and Nitrofurantoin ranged from 72% to 100%. The antibiogram of isolates showed that 43 (86%) isolates were resistant to two or more antimicrobials, and 49 (98%) were resistant to at least one antibiotic. Conclusion and Recommendation: Urinary tract infections are mostly caused by Gram-negative bacteria predominantly in females and Escherichia coli are the most common isolates. Resistance rates to Cotrimoxazole, Ampicillin, Augmentin, and Ceftriaxone were high. Chloramphenicol, Amikacin, Vancomycin, Meropenem, Cefoxitin, and Nitrofurantoin are considered appropriate antimicrobials for the empirical treatment of complicated urinary tract infections in the emergency department. Yet, using antibiotics indiscriminately for patients with complicated UTIs may increase the resistance rate and also lead to treatment failure, hence the prescriptions should be revised following the culture and sensitivity results.

CAEP 2021 Academic Symposium: recommendations for addressing racism and colonialism in emergency medicine.

PURPOSE: Racism and colonialism impact health, physician advancement, professional development and medical education in Canada. The Canadian Association of Emergency Physicians (CAEP) has committed to addressing inequities in health in their recent statement on racism. The objective of this project was to develop recommendations for addressing racism and colonialism in emergency medicine. METHODS: The authors, in collaboration with a 40 member working group, conducted a literature search, held a community consultation, solicited input from expert medical, academic and community advisors, conducted a national survey of emergency physicians, and presented draft recommendations at the 2021 CAEP Academic Symposium on Equity, Diversity and Inclusion for a live facilitated discussion with a post-session survey. RESULTS: Sixteen recommendations were generated in the areas of patient care, hospital and departmental commitment to Equity, Diversity, and Inclusion, physician advancement, and professional development and medical education. CONCLUSION: Emergency physicians are uniquely positioned to promote equity at each encounter with patients, peers and learners. The 16 recommendations presented here are practical steps to countering racism and colonialism everyday in emergency medicine.

RéSUMé: OBJECTIF: Le racisme et le colonialisme ont une incidence sur la santé, l'avancement des médecins, le développement professionnel et l'éducation médicale au Canada. L'Association canadienne des médecins d'urgence (ACMU) s'est engagée à lutter contre les inégalités en matière de santé dans sa récente déclaration sur le racisme. L'objectif de ce projet était d'élaborer des recommandations pour lutter contre le racisme et le colonialisme en médecine d'urgence. MéTHODES: Les auteurs, en collaboration avec un groupe de travail de 40 membres, ont effectué une recherche documentaire, tenu une consultation communautaire, sollicité les commentaires d'experts en médecine, en enseignement et en services communautaires, mené une enquête nationale auprès des médecins d'urgence et ont présenté des ébauches de recommandations lors du Symposium académique de l'ACMU 2021 sur l'Équité, la Diversité et l'inclusion pour une discussion animée en direct avec un sondage après la séance. RéSULTATS: Seize recommandations ont été formulées dans les domaines des soins aux patients, de l'engagement de l'hôpital et du service en matière d'Équité, de Diversité et d'Inclusion, de l'avancement des médecins, du développement professionnel et de l'éducation médicale. CONCLUSION: Les médecins urgentistes sont particulièrement bien placés pour promouvoir l'équité à chaque rencontre avec les patients, les pairs et les apprenants. Les 16 recommandations présentées ici sont des mesures pratiques pour contrer le racisme et le colonialisme au quotidien dans la médecine d'urgence.

Facilitators of and barriers to buprenorphine initiation for people with opioid use disorder in the emergency department: protocol for a scoping review.

INTRODUCTION: Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation. METHODS AND ANALYSIS: We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation. ETHICS AND DISSEMINATION: This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.

Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90.

PURPOSE: Benefits of overnight attending radiologist final reports are debated, often stating low resident discrepancy rates, usually assessed retrospectively. The objective of this study was to assess the impact of overnight final reporting on the recall rates for patients in the emergency department (ED) receiving overnight imaging. METHODS: Retrospective matched cohorts of two separate years prior (prior-16 and prior-17) and 1 year after (post-18) introduction of overnight attending radiologist final reporting. Patients receiving imaging between 22:00 and 07:00 h and returned to ED within 48 h of initial visit discharge were electronically identified. String matching identified return visits possibly related to imaging completed on first visit. Identified return visit notes were scored by three observers individually. Unclear and discrepant cases were resolved by consensus meeting, using full patient charts where needed. Incidences were provided and logistic regression analysis defined if coverage model was a predictor for recall. Odds ratios were calculated. RESULTS: ED patient count with imaging completed overnight in prior-16 was 9200, in prior-17 was 9543, and in post-18 was 9992. The number of overnight imaging studies performed was respectively 13,883, 14,463, and 15,112. Imaging-related ED recalls were respectively 54, 61, and 7, a decrease with the new coverage model of 89% to true and at least 90% of expected recalls.Logistic regression demonstrated that coverage model was a significant predictor of ED recalls with chi-square of 59.86 and p < 0.001, an R2 of 0.03 (Hosmer and Lemeshow). Compared to post-18, ED patients had an odds ratio of 8.42 (prior-16) and 9.18 (prior-17) to be called back to ED. CONCLUSION: Overnight final reporting significantly decreases ED recalls for patients receiving diagnostic imaging overnight. While numbers are low even prior to rollout, the number should be minimized wherever possible to diminish patient anxiety and discomfort, reduce ED overcrowding and expedite definitive management. KEY MESSAGES/WHAT THIS PAPER ADDS: Section 1: What is already known on this subject • Radiology resident preliminary report discrepancy rates are low. • Overnight attending radiologist coverage is a model increasingly applied in academic and large non-academic centers. • Patient recalls to the ED are a burden to the patient and impact patient throughput in (over)crowded EDs. Section 2: What this study adds • First study to look at the impact of overnight attending final reports on the recall rate for ED patients with overnight imaging performed. • While absolute numbers are low, there is a significant decrease in patients returning to ED for imaging related issues after introducing overnight attending coverage. • Resident autonomy can be preserved and training enhanced while increasing patient safety and comfort.

Reducing redundant creatine kinase testing in cardiac injury.

BACKGROUND: Creatine kinase (CK) testing in the setting of suspected cardiac injury is commonly performed yet rarely provides clinical value beyond troponin testing. We sought to evaluate and reduce CK testing coupled with troponin testing by 50% or greater. METHODS: We performed root cause analysis to study prevailing processes and patterns of CK testing. We developed new institutional guidelines, removed CK from high-volume paper and electronic order bundles and conducted academic detailing for departments with highest ordering frequency. We evaluated consecutive patients at Sunnybrook Health Sciences Centre between 1 January 2018 and 31 March 2020 who had either a CK or troponin level measured. We prespecified successful implementation as a reduction of 50% in total CK orders and a decrease in the ratio of CK-to-troponin tests to one-third or less. We retained additional data beyond our study period to assess for sustained reductions in testing. RESULTS: Total CK tests decreased over the study period from 3963 to 2111 per month, amounting to a 46.7% reduction (95% CI 33.2 to 60.2; p<0.001) equalling 61 fewer tests per hospital day. Troponin testing did not significantly change during the intervention. Ratio of CK-to-troponin tests decreased from 0.91 to 0.49 (p<0.001). The reduction coincided with changes to order-sets, was observed across all clinical units and was sustained during additional months beyond the study period. These reductions in testing resulted in a projected annual cost savings of C$28 446. CONCLUSIONS: We demonstrate that a low-cost and feasible quality improvement initiative may lead to significant reduction in unnecessary CK testing and substantial savings in healthcare costs for patients with suspected cardiac injury.

Case Report of Methemoglobinemia: An Illustration That It Is Time to Report all Results with Arterial and Venous Blood Gas Result Reporting.

BACKGROUND: Methemoglobinemia and carbon monoxide poisoning are potentially life-threatening conditions that can present with nonspecific clinical features. This lack of specificity increases the probability of misdiagnosis or avoidable delays in diagnosis and management. These conditions are both treatable with antidotes of methylene blue and oxygen, respectively. Modern blood gas analyzers have the ability to measure carboxyhemoglobin (COHb) and methemoglobin (MetHb) levels without any additional resources. However, these results, although readily available from the machine used to perform the analysis, are not fully reported by some hospital clinical laboratories. CASE REPORT: A 49-year-old male presented with shortness of breath and cyanosis after inhaling cocaine via a nasal route ("snorting"). Methemoglobinemia was not initially considered in the differential diagnosis. However, the diagnosis of methemoglobinemia was made once newly routinely reported laboratory results revealed an elevated MetHb level. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Routinely reporting MetHb and COHb levels with arterial and venous blood gas results will facilitate making the diagnoses of these infrequently diagnosed causes of hypoxia more quickly so that early treatment of these uncommon but potentially lethal conditions can be initiated promptly.

Appropriate use of CT for patients presenting with suspected renal colic: a quality improvement study.

Introduction: CT use for renal colic has increased costs, radiation exposure and frequently does not alter management. Consequently, choosing wisely (CW) recommends avoiding CT imaging of otherwise healthy patients younger than 50 years presenting with symptoms of recurrent, uncomplicated renal colic. We evaluated the utilisation of CT imaging for this subgroup of patients and subsequently implemented a quality improvement initiative with an aim to reduce unnecessary radiation exposure. Methods: A retrospective chart review was performed for all patients younger than 50 years who visited Sunnybrook Health Sciences Centre emergency department (ED) between December 2015 and May 2016 with a discharge diagnosis of renal colic. After the audit period, emergency physicians were engaged to perform a root cause analysis and a driver diagram was developed. In December 2016, a clinical decision tool was introduced to standardise the imaging for patients with presumed renal colic. In May 2017, a separate electronic order was created for low-dose CT for renal colic, including a prompt to remind clinicians of the CW recommendation. The impact of these changes was measured over 15 months. Results: Over the initial audit period, 17/63 (27%) of our target population received a CT to rule out renal colic. Many patients received multiple CT scans for renal colic during past ED visits, while one received a total of 13 CTs. At the time of our interventions, the baseline rate of CT scans in our target population was 37%, which reduced to 29% after our project began. Conclusion: CT is often used as an initial diagnostic modality for suspected recurrent renal colic despite current guidelines. While this initiative caused only a modest change in management, it led to the introduction of a new low-dose CT scan order specifically to reduce radiation exposure in patients at risk for repeat scans.

Improving quality of care for patients with iron deficiency anemia presenting to the emergency department.

BACKGROUND: Patients presenting to the emergency department (ED) with iron deficiency anemia (IDA) are underrecognized, undertreated with iron, and overtransfused. A 3-month audit of red blood cell (RBC) transfusions at the Sunnybrook Health Sciences Centre ED in 2013 showed that only 53% of transfusions for IDA were appropriate. The aim of this quality improvement project was to increase the rate of appropriate transfusion to greater than 80%. STUDY DESIGN AND METHODS: Since November 2013, several quality improvement interventions have been implemented, including educational presentations, development of an algorithm on IDA management in the ED, and development of an ED IDA toolkit. The primary outcome was appropriateness of RBC transfusions per month. The process measure was monthly intravenous (IV) iron use in IDA patients managed exclusively by ED staff. Balancing measures included IV iron use according to the algorithm and undertransfusion. RESULTS: Over a 24-month period beginning January 2014, assessment of 193 units transfused in the ED showed an improvement of RBC appropriateness to 91% (range 50%-100%). IV iron use increased from one dose in the 3-month audit to an average of 2.6 and 4.7 per month in 2014 and 2015, respectively. IV iron use did not follow the algorithm in 19% (18 of 93) of cases: 12 were given to patients with less severe iron deficiency or bleeding. CONCLUSION: Improved RBC transfusion appropriateness for IDA in the ED can be achieved and maintained with the implementation of simple educational and practical interventions.

Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation.

OBJECTIVES: Three are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED. METHODS: A retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution. RESULTS: Over the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED. CONCLUSIONS: This assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

Availability of ambulance patient care reports in the emergency department.

Clinical handovers of patient care among healthcare professionals is vulnerable to the loss of important clinical information. A verbal report is typically provided by paramedics and documented by emergency department (ED) triage nurses. Paramedics subsequently complete a patient care report which is submitted electronically. This emergency medical system (EMS) patient care report often contains details of paramedic assessment and management that is not all captured in the nursing triage note. EMS patient care reports are often unavailable for review by emergency physicians and nurses. Two processes occur in the distribution of EMS patient care reports. The first is an external process to the ED that is influenced by the prehospital emergency medical system and results in the report being faxed to the ED. The second process is internal to the ED that requires clerical staff to distribute the fax report to accompany patient charts. A baseline audit measured the percentage of EMS patient care reports that were available to emergency physicians at the time of initial patient assessments and showed a wide variation in the availability of EMS reports. Also measured were the time intervals from patient transfer from EMS to ED stretcher until the EMS report was received by fax (external process measure) and the time from receiving the EMS fax report until distribution to patient chart (internal process measure). These baseline measures showed a wide variation in the time it takes to receive the EMS reports by fax and to distribute reports. Improvement strategies consisted of: 1. Educating ED clerical staff about the importance of EMS reports 2. Implementing a new process to minimize ED clerical staff handling of EMS reports for nonactive ED patients 3. Elimination of the automatic retrieval of old hospital charts and their distribution for ED patients 4. Introduction of an electronic dashboard for patients arriving by ambulance to facilitate more efficient distribution of EMS reports. Implementation of change strategies did not result in a significant improvement in the percentage of EMS reports available to emergency physicians at the time of initial patient assessment. However, tracking both external and internal processes that influence EMS report availability showed the internal process time from fax report receipt to distribution significantly improved. This improvement reflected the change strategies that were all directed at improving the internal process. EMS patient care reports are more efficiently processed and distributed in the ED due to change strategies implemented that targeted the ED's internal process of EMS report distribution. The external process responsible for transmitting EMS reports to the ED is the limiting factor that prevents consistent timely access of EMS reports by emergency physicians and will require dedicated improvement strategies.