Evaluation of the Quality of ED Management for Patients with COPD.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is associated with exacerbations and high risk of serious outcomes. Our goal was to determine the appropriateness of the ED management of COPD exacerbations. METHODS: This observational cohort study incorporated a health records review and included COPD exacerbation cases seen at two large academic EDs. We included all patients with the primary diagnosis of COPD exacerbation. From the electronic medical record, demographic and clinical data were abstracted, and the Ottawa COPD Risk Score (OCRS) was calculated for each. Short-term serious outcomes (SSO) included ICU admission, intubation, myocardial infarction, non-invasive positive pressure ventilation (NIV), and death at 30 days. Cases were judged for appropriateness of treatment according to explicit indications and standards developed a priori. RESULTS: We enrolled 500 cases with mean age 71.9, female 51.2%, admitted 50.2%, and death 4.4%. The calculated OCRS score was >2 for 70.8% of patients. The treatments provided were inhaled beta-agonists (82.6%), inhaled anticholinergics (76.6%), corticosteroids (75.2%), antibiotics (71.0%), oxygen (63.8%), NIV (8.8%) and intubation (0.6%). Overall, 50.0% of cases were judged to have had inadequate management due to missing treatments. Specifically, the proportion of missing treatments were inhaled beta agonist (17.0%), inhaled anticholinergic (22.6%), corticosteroids (24.4%), antibiotics (12.8%), and NIV (2.0%). CONCLUSIONS: Adequate treatment of COPD exacerbation was lacking in 50.0% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious condition.

Decreased patient discharges on weekends part 3: what do the leaders tell us?

BACKGROUND: Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays. METHODS: In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions. RESULTS: We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week. INTERPRETATION: We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.

ABSTRAIT: CONTEXTE: Le surpeuplement des services d'urgence (SU) est un défi important pour fournir des soins sécuritaires et de qualité aux patients. Nous savons que le surpeuplement des hôpitaux et des urgences est exacerbé le lundi parce que moins de patients hospitalisés reçoivent leur congé le week-end. Nous avons évalué les obstacles et les solutions potentielles pour améliorer le flux de patients hospitalisés et diminuer les congés de fin de semaine, dans l'espoir de réduire le surpeuplement sévère observé le lundi. MéTHODES: Dans cette étude observationnelle, nous avons interviewé (a) des dirigeants de l'Hôpital d'Ottawa, un important centre universitaire des sciences de la santé (soins infirmiers, soins paramédicaux, médecins), et (b) des dirigeants d'établissements communautaires (soins de longue durée et hôpitaux de soins chroniques) qui reçoivent des patients de l'hôpital et (c) des soins à domicile. Chaque entrevue a été menée individuellement et a abordé les obstacles perçus au congé des patients hospitalisés le week-end ainsi que les solutions potentielles. Une analyse thématique inductive a été menée, dans le cadre de laquelle les thèmes ont été organisés en un tableau récapitulatif des obstacles et des solutions RéSULTATS: Nous avons interviewé 40 dirigeants, dont 30 chefs de file des soins infirmiers, des médecins et des professions paramédicales de l'hôpital, ainsi que 10 cadres supérieurs d'établissements communautaires et de soins à domicile. De nombreux obstacles aux congés de fin de semaine ont été cernés, ce qui souligne que ce problème est complexe et qu'il comporte de nombreux facteurs internes et externes interdépendants. Heureusement, de nombreuses solutions potentielles spécifiques ont été proposées, à court terme et à long terme. Bien que de nombreuses solutions exigent des ressources supplémentaires, d'autres exigent un changement de culture par lequel les intervenants hospitaliers et communautaires reconnaissent que les services doivent être fournis de façon uniforme, sept jours par semaine. INTERPRéTATION: Nous avons identifié les obstacles complexes et interdépendants aux sorties de fin de semaine des patients hospitalisés. Il existe de nombreuses possibilités précises pour le personnel et les services hospitaliers, les médecins et les établissements communautaires d'offrir les mêmes soins aux patients les fins de semaine que les jours de semaine. Cela permettra d'améliorer la circulation et la sécurité des patients, et de réduire le surpeuplement des urgences le lundi.

Presentations, management and outcomes of postoperative bariatric patients seen in the emergency department.

BACKGROUND: Bariatric surgery is becoming increasingly common and postoperative patients often present to the emergency department (ED) with complications. We sought to describe the presenting complaints, management, and outcomes of postoperative bariatric surgery patients seen in the ED. METHODS: We conducted a health records review of 300 consecutive postoperative Roux-en-Y bypass surgery patients who presented to two tertiary care EDs of a major bariatric surgery center within one year of surgery. Cases were identified using a data analytic tool, and two evaluators abstracted clinical variables, imaging, treatments, and outcomes using the electronic health record. Attending emergency physicians verified the data and an experienced bariatric surgeon interpreted the computed tomography (CT) results and surgical procedures. RESULTS: We included 300 patients with mean age 43.0 years, 89.7% female. Of these, 70.0% presented within 30 days of surgery and 41.7% were admitted to hospital. ED treatments included intravenous fluids (67.0%), antiemetics (53.3%), and analgesia (61.9%). Patients presenting within 30 days of surgery were more likely to undergo a CT (74.3% vs 63.3%; p = 0.06) and to have clinically important CT findings (31.9% vs 6.6%; p ≤0.001). More of the ≤30-day patients were admitted to hospital (46.2% vs 31.1%; p = 0.02). While a higher proportion of patients presenting after 30 days underwent a procedure, a large number of those were not directly related to bariatric surgery, such as appendectomy and cholecystectomy. Of the 34 patients undergoing a procedure, the majority presented with abdominal pain (76.5%). CONCLUSION: This is the first detailed health records review of postoperative bariatric patients seen in the ED in the emergency medicine literature. Those presenting with abdominal pain were more likely to undergo CT abdomen and a surgical procedure. Similarly, those presenting within 30 days of surgery were more likely to have significant CT findings and require hospital admission. Others presenting with primarily nausea and vomiting may improve with ED symptom management and be discharged home with bariatric team follow-up.

Assessment of physician compliance to the CAEP 2021 Atrial Fibrillation Best Practices Checklist for rate and rhythm control in the emergency department.

OBJECTIVES: Acute atrial fibrillation and flutter (AF/AFL) are common arrhythmias treated in the emergency department (ED). The 2021 CAEP Best Practices Checklist provides clear recommendations for management of patients with acute AF/AFL. This study aimed to evaluate physician compliance to Checklist recommendations for risk assessment and ED management of AF/AFL. METHODS: This health records review assessed the management of adult patients presenting to two tertiary care EDs for management of acute AF/AFL from January to August, 2022. All ECGs demonstrating AF/AFL with a heart rate greater than 100 were compiled to capture primary and secondary causes. All visits were assessed for rate and rhythm control management, adverse events, return to ED, and safety criteria. Study physicians classified safety criteria from the Checklist into high and moderate concerns. The primary outcome was the proportion of cases with safety concerns and adverse events occurring during management in the ED. Data were analyzed using simple descriptive statistics. RESULTS: We included 429 patients with a mean age of 67.7 years and 57.1% male. ED management included rate control (20.4%), electrical (40.1%), and pharmacological (20.1%) cardioversion. Adverse events occurred in 9.5% of cases: 12.5% in rate control, 13.4% in electrical cardioversion, and 6.9% in pharmacologic cardioversion. Overall, 7.9% of cases had management safety concerns. Moderate safety concerns occurred in 4.9% of cases including failure to attain recommended heart rate at time of discharge (3.9%). Severe concerns were identified in 3.0% of cases including failure to cardiovert unstable patients (1.2%). The 30-day return-to-ED rate was 16.5% secondary to AF/AFL. CONCLUSION: ED management of AF/AFL was consistent with the CAEP Checklist and was safe overall. Opportunities for optimizing care include attaining recommended targets during rate control, avoidance of calcium channel and beta blockers in patients with systolic dysfunction, and earlier cardioversion for clinically unstable patients.

ABSTRAIT: OBJECTIFS: La fibrillation auriculaire aiguë et le flutter (FA/FAT) sont des arythmies courantes traitées aux urgences (SU). La liste de vérification des pratiques exemplaires 2021 du CAEP fournit des recommandations claires pour la prise en charge des patients atteints de FA/FAT aiguës. Cette étude visait à évaluer la conformité des médecins aux recommandations de la liste de contrôle pour l'évaluation des risques et la gestion de la FA/FAT. MéTHODES: Cet examen des dossiers de santé a évalué la prise en charge des patients adultes qui se sont présentés à deux urgences de soins tertiaires pour la prise en charge des FA/FAT aiguës de janvier à août 2022. Tous les ECG démontrant une FA/FAT avec une fréquence cardiaque supérieure à 100 ont été compilés pour capturer les causes primaires et secondaires. Toutes les visites ont été évaluées pour la gestion du contrôle des taux et du rythme, les événements indésirables, le retour à l'urgence et les critères de sécurité. Les médecins de l'étude ont classé les critères d'innocuité de la liste de contrôle en préoccupations élevées et modérées. Le résultat principal était la proportion de cas présentant des préoccupations en matière de sécurité et des événements indésirables survenant pendant la prise en charge à l'urgence. Les données ont été analysées à l'aide de statistiques descriptives simples. RéSULTATS: Nous avons inclus 429 patients avec un âge moyen de 67.7 ans et 57.1% d'hommes. La prise en charge de l'urgence comprenait une cardioversion contrôlée (20.4 %), électrique (40.1 %) et pharmacologique (20.1 %). Des événements indésirables se sont produits dans 9.5% des cas : 12.5% dans le contrôle du taux, 13.4% dans la cardioversion électrique et 6.9% dans la cardioversion pharmacologique. Dans l'ensemble, 7.9 % des cas concernaient la sécurité de la direction. Des problèmes de sécurité modérés sont survenus dans 4.9 % des cas, y compris l'incapacité d'atteindre la fréquence cardiaque recommandée au moment du congé (3.9 %). Des préoccupations graves ont été identifiées dans 3.0 % des cas, y compris l'échec à cardiovert patients instables (1.2 %). Le taux de retour aux urgences après 30 jours était de 16,5 % secondaire aux FA/FAT. CONCLUSION: La gestion de l'AF/AFL par le DG était conforme à la liste de vérification du CAEP et était sécuritaire dans l'ensemble. Les possibilités d'optimisation des soins comprennent l'atteinte des cibles recommandées lors du contrôle des taux, l'évitement du canal calcique et des bêtabloquants chez les patients présentant une dysfonction systolique et une cardioversion antérieure pour les patients cliniquement instables.

RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter.

BACKGROUND: We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist. METHODS: This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED. RESULTS: We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent. CONCLUSIONS: We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients. GOV IDENTIFIER: NCT05468281.

Modern management of acute atrial fibrillation and atrial flutter.

This clinical review is intended to assist emergency physicians manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation (AF) or flutter (AFL). This article is based primarily on the 2021 Canadian Association of Emergency Physicians (CAEP) Acute Atrial Fibrillation/Flutter Best Practices Checklist. We encourage readers to download the open access CAEP Checklist article (https://link.springer.com/article/10.1007/s43678-021-00167-y) and the free smartphone app (CAEP Atrial Fibrillation Guide). We focus on four key elements of ED care: assessment and risk stratification, rate and rhythm control, short-term and long-term stroke prevention, and disposition and follow-up. It is important to determine if AF/AFL with rapid ventricular response is a primary arrhythmia or secondary to medical causes. While it is unusual for patients with primary AF to be unstable, urgent cardioversion is occasionally required. The criteria for when cardioversion is safe have recently changed and it is essential that physicians are well versed in them. When rhythm control is not safe, provide effective and safe IV rate control. When rhythm control is safe, either pharmacological or electrical cardioversion acceptable, per patient and physician preference. Rapid ventricular pre-excitation (Wolff-Parkinson-White Syndrome) usually, but not always, requires urgent electrical cardioversion. ED physicians should prescribe oral anticoagulants at discharge if indicated. No specific direct oral anticoagulant is preferred, and references should be freely consulted for optimal dosing. Hospital admission is rarely required for acute AF/AFL patients, who should be given good discharge instructions.

Outcomes of acute heart failure patients managed in the emergency department.

BACKGROUND: Acute heart failure is a serious condition commonly seen in the emergency department (ED). The HEARTRISK6 Scale has been recently developed to identify the risk of poor outcomes but has not been tested. We sought to describe the management and outcomes of ED patients with acute heart failure and to evaluate the potential impact of the HEARTRISK6 Scale. METHODS: We conducted a health records review of 300 consecutive acute heart failure patients presenting to two tertiary care EDs. Two evaluators abstracted clinical variables, ED management and treatment details, and patient outcomes using the electronic health records platform (EPIC) and attending physicians verified the data. The primary outcome measure was a short-term serious outcome, as shown in Results. In addition, the HEARTRISK6 score was calculated retrospectively. RESULTS: We included 300 patients with mean age of 78.5 years, 51.0% male, 56.3% arrival by ambulance, and 67.0% admitted to hospital. 25.3% experienced a short-term serious outcome 1) after admission (N = 201): non-invasive ventilation 14.9%, intubation 1.5%, major cardiac procedure 5.0%, myocardial infarction 2.0%, death 8.5%; 2) after ED discharge (N = 99): return to ED 21.2%, death 4.0%. Those initially admitted experienced a much higher proportion of serious outcomes compared to those discharged (29.9% vs. 16.2%). A HEARTRISK6 Scale cut-point score of ≥ 1 would have had a sensitivity of 91.0%, specificity 24.5%, and negative likelihood ratio 0.37 for short-term serious outcomes and suggested hospital admission for 80.7% of cases. CONCLUSION: There was a large range of severity of illness of acute heart failure patients and a wide variety of treatments were administered in the ED. Both admitted and discharged patients experienced a high proportion of poor outcomes. The HEARTRISK6 Scale showed a high sensitivity for short-term serious outcomes but with the potential to increase hospital admissions. Further validation of the HEARTRISK6 Scale is required before routine clinical use.

RéSUMé: ARRIèRE-PLAN: L'insuffisance cardiaque aiguë est une affection grave couramment observée à l'urgence. L'échelle HEARTRISK6 a été mise au point récemment pour identifier le risque de mauvais résultats, mais n'a pas été testée. Nous avons cherché à décrire la prise en charge et les résultats des patients atteints d'insuffisance cardiaque aiguë et à évaluer l'impact potentiel de l'échelle HEARTRISK6. MéTHODES: Nous avons effectué un examen des dossiers de santé de 300 patients atteints d'insuffisance cardiaque aiguë consécutifs qui se présentaient à deux SU de soins tertiaires. Deux évaluateurs ont résumé les variables cliniques, les détails de la gestion et du traitement des SU et les résultats pour les patients à l'aide de la plateforme de dossiers de santé électroniques (EPIC). et les médecins traitants ont vérifié les données. La principale mesure des résultats était le résultat grave à court terme, comme le montrent les résultats. De plus, le score HEARTRISK6 a été calculé rétrospectivement. RéSULTATS: Nous avons inclus 300 patients âgés en moyenne de 78,5 ans, 51,0 % d'hommes, 56,3 % d'arrivées par ambulance et 67,0 % d'hospitalisations. 25,3 % ont connu un résultat grave à court terme 1) après l'admission (N=201) : ventilation non invasive 14,9 %, intubation 1,5 %, procédure cardiaque majeure 5,0 %, infarctus du myocarde 2,0 %, décès 8,5 %; 2) après le congé de l'urgence (N=99) : retour à l'urgence 21,2 %, décès 4,0 %. Les personnes admises au départ ont connu une proportion beaucoup plus élevée de résultats graves que les personnes libérées (29,9 % contre 16,2 %). Une note de seuil de 1 sur l'échelle HEARTRISK6 aurait eu une sensibilité de 91,0 %, une spécificité de 24,5 % et un ratio de probabilité négatif de 0,37 pour les résultats graves à court terme et une admission à l'hôpital suggérée pour 80,7 % des cas. CONCLUSION: Il y avait un large éventail de gravité de la maladie des patients atteints d'insuffisance cardiaque aiguë et une grande variété de traitements ont été administrés à l'urgence. Les patients admis et libérés ont connu une forte proportion de mauvais résultats. L'échelle HEARTRISK6 a montré une sensibilité élevée pour les résultats graves à court terme, mais avec le potentiel d'augmenter les admissions à l'hôpital. Une validation plus poussée de l'échelle HEARTRISK6 est nécessaire avant l'utilisation clinique de routine.

Ninety-Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke.

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Diagnosis and management of patients who present with narrow complex tachycardia in the emergency department.

INTRODUCTION: While narrow complex tachycardia (NCT) is a common presentation to the emergency department (ED), little is known about its incidence in the ED or about emergency physician expertise in its diagnosis and management. We sought to compare cases of NCT due to primary arrhythmias to those with a rapid heart rate secondary to a medical issue, as well as to determine the accuracy of ED physician diagnosis and appropriateness of treatment. METHODS: We conducted a health records review at a large academic hospital ED staffed by 95 physicians and included consecutive adult patients over 7 months (2020-2021) with NCT (heart rate ≥ 130 bpm and QRS < 120 ms). Cases were reviewed for accuracy of ECG diagnosis and for correctness of treatment as per guidelines by an adjudication committee. RESULTS: We identified 310 ED visits (0.8% of all ED visits), mean age 65.1 years, 52.6% female. Primary arrhythmias accounted for 54.8%. ED physicians correctly interpreted 86.6% of ECGs. The most common arrhythmias and accuracy of ED physician ECG interpretation were atrial fibrillation 44.5% (95.1%), sinus tachycardia 24.2% (90.5%), atrial flutter 15.8% (61.5%), and supraventricular tachycardia (SVT) 12.9% (81.6%). Treatments were judged optimal in 96.5% of primary NCT and 99.3% in secondary NCT. Treatments were suboptimal for failure to reduce heart rate < 100 bpm prior to discharge in 2.1% of primary cases and failure to treat underlying cause in 0.7% of secondary cases. CONCLUSION: NCT was found in 0.8% of all ED visits, with more being primary NCT. ED physicians correctly interpreted 86.6% of ECGs but had difficulty differentiating atrial flutter and SVT. They implemented appropriate care in most cases but sometimes failed to adequately control heart rate or to treat the underlying condition, suggesting opportunities to improve care of NCT in the ED.

RéSUMé: INTRODUCTION: Bien que la tachycardie à complexe QRS étroite (narrow complex tachycardia [NCT]) soit une présentation courante au service des urgences (SU), on sait peu de choses sur son incidence dans le SU ou sur l'expertise des médecins urgentistes dans son diagnostic et sa prise en charge. Nous avons cherché à comparer les cas de NCT dus à des arythmies primaires à ceux avec une fréquence cardiaque rapide secondaire à un problème médical, ainsi que pour déterminer l'exactitude du diagnostic de médecin ED et la pertinence du traitement. MéTHODES: Nous avons effectué un examen des dossiers médicaux dans les urgences d'un grand hôpital universitaire où travaillent 95 médecins et avons inclus des patients adultes consécutifs sur 7 mois (2020-2021) présentant une NCT (fréquence cardiaque ≥ 130 bpm et QRS < 120 ms). Les cas ont été examinés par un comité d'adjudication pour vérifier l'exactitude du diagnostic ECG et la justesse du traitement conformément aux directives. RéSULTATS: Nous avons recensé 310 visites aux urgences (0,8 % de toutes les visites aux urgences), l'âge moyen étant de 65,1 ans, 52,6 % de femmes. Les arythmies primaires représentaient 54,8 %. Les médecins urgentistes ont correctement interprété 86,6 % des ECG. Les arythmies les plus fréquentes et la précision de l'interprétation de l'ECG par le médecin de l'urgence étaient la fibrillation auriculaire 44,5 % (95,1 %), la tachycardie sinusale 24,2 % (90,5 %), le flutter auriculaire 15,8 % (61,5 %) et la tachycardie supraventriculaire (TSV) 12,9 % (81,6 %). Les traitements ont été jugés optimaux dans 96,5 % des NCT primaires et 99,3 % des NCT secondaires. Les traitements étaient sous-optimaux en raison de l'incapacité à réduire la fréquence cardiaque < 100 bpm avant la sortie de l'hôpital dans 2,1 % des cas primaires et de l'incapacité à traiter la cause sous-jacente dans 0,7 % des cas secondaires. CONCLUSION: Une NCT a été constatée dans 0,8 % de toutes les visites aux urgences, la plupart étant des NCT primaires. Les médecins des services d'urgence ont interprété correctement 86,6 % des ECG mais ont eu des difficultés à différencier le flutter auriculaire et la TSV. Ils ont mis en œuvre des soins appropriés dans la plupart des cas, mais n'ont parfois pas réussi à contrôler adéquatement la fréquence cardiaque ou à traiter l'affection sous-jacente, ce qui laisse entrevoir des possibilités d'améliorer la prise en charge des NCT aux urgences.

Prospective Validation of Computed Tomography to Identify Patients at High Risk for Stroke After Transient Ischemic Attack or Minor Stroke.

BACKGROUND: Computed tomography (CT) findings of acute and chronic ischemia are associated with subsequent stroke risk in patients with transient ischemic attack. We sought to validate these associations in a large prospective cohort of patients with transient ischemic attack or minor stroke. METHODS: This prospective cohort study enrolled emergency department patients from 13 hospitals with transient ischemic attack who had CT imaging. Primary outcome was stroke within 90 days. Secondary outcomes were stroke within 2 or 7 days. CT findings were abstracted from radiology reports and classified for the presence of acute ischemia, chronic ischemia, or microangiopathy. Multivariable logistic regression was used to test associations with primary and secondary end points. RESULTS: From 8670 prospectively enrolled patients between May 2010 and May 2017, 8382 had a CT within 24 hours. From this total population, 4547 (54%) patients had evidence of acute ischemia, chronic ischemia, or microangiopathy on CT, of whom 175 had a subsequent stroke within 90 days (3.8% subsequent stroke rate; adjusted odds ratio [aOR], 2.33 [95% CI, 1.62-3.36]). This was in comparison to those with CT imaging without ischemia. Findings associated with an increased risk of stroke at 90 days were isolated acute ischemia (6.0%; aOR, 2.42 [95% CI, 1.03-5.66]), acute ischemia with microangiopathy (10.7%; aOR, 3.34 [95% CI, 1.57-7.14]), chronic ischemia with microangiopathy (5.2%; aOR, 1.83 [95% CI, 1.34-2.50]), and acute ischemia with chronic ischemia and microangiopathy (10.9%; aOR, 3.49 [95% CI, 1.54-7.91]). Acute ischemia with chronic ischemia and microangiopathy were most strongly associated with subsequent stroke within 2 days (aOR, 4.36 [95% CI, 1.31-14.54]) and 7 days (aOR, 4.50 [95% CI, 1.73-11.69]). CONCLUSIONS: In patients with transient ischemic attack or minor stroke, CT evidence of acute ischemia with chronic ischemia or microangiopathy significantly increases the risk of subsequent stroke within 90 days of index visit. The combination of all 3 findings results in the greatest early risk.

High-dose cephalexin for cellulitis: a pilot randomized controlled trial.

BACKGROUND: Up to 3% of all Emergency Department (ED) visits are due to skin and soft tissue infections such as non-purulent cellulitis. The current treatment failure rate is approximately 20%. Evidence is lacking regarding the optimal outpatient management of cellulitis. OBJECTIVES: To evaluate the feasibility of a randomized trial comparing high-dose (1000 mg) to standard-dose (500 mg) cephalexin to treat ED patients with cellulitis. METHODS: A parallel arm double-blind randomized controlled pilot trial conducted at two EDs in Canada. Eligible participants were adults (age ≥ 18 years) presenting to the ED with non-purulent cellulitis and determined by the treating emergency physician to be eligible for outpatient management with oral antibiotics. Participants were randomized to high-dose or standard-dose cephalexin four times daily for 7 days. The primary feasibility outcome was participant recruitment rate (target ≥ 35%). The preliminary primary effectiveness outcome was oral antibiotic treatment failure. RESULTS: Of 134 eligible participants approached for trial participation, 69 (51.5%, 95% CI 43.1 to 59.8%) were recruited and randomized. After excluding three randomized participants due to an alternate diagnosis, 33 participants were included in each arm. Nineteen eligible cases (14.2%) were missed. Loss to follow-up was 6.1%. Treatment failure occurred in four patients (12.9%) in the standard-dose arm versus one patient (3.2%) in the high-dose arm. A greater proportion had minor adverse events in the high-dose arm. No patients had an unplanned hospitalization within 14 days. CONCLUSION: This pilot randomized controlled trial comparing high-dose to standard-dose cephalexin for ED patients with cellulitis demonstrated a high participant recruitment rate and that a full-scale trial is feasible. High-dose cephalexin had fewer treatment failures but with a higher proportion of minor adverse effects. The findings of this pilot will be used to inform the design of a future large trial. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov (NCT04471246).

RéSUMé: CONTEXTE: Jusqu'à 3% de toutes les visites aux urgences sont dues à des infections de la peau et des tissus mous, comme la cellulite non purulente. Le taux actuel d'échec du traitement est d'environ 20%. Il manque des données probantes sur la gestion optimale de la cellulite en consultation externe. OBJECTIFS: Évaluer la faisabilité d'un essai randomisé comparant la céfalexine à dose élevée (1000 mg) à la céfalexine à dose normale (500 mg) pour traiter les patients des urgences atteints de cellulite. MéTHODES: Un essai pilote contrôlé randomisé en double aveugle à bras parallèles mené dans deux services d'urgence au Canada. Les participants éligibles étaient des adultes (âge ≥ 18 ans) se présentant aux urgences avec une cellulite non purulente et déterminés par l'urgentiste traitant comme pouvant bénéficier d'une prise en charge ambulatoire par antibiotiques oraux. Les participants ont été randomisés entre la céfalexine à dose élevée et la céfalexine à dose normale, quatre fois par jour pendant 7 jours. Le résultat primaire de faisabilité était le taux de recrutement des participants (objectif ≥ 35%). Le résultat primaire préliminaire d'efficacité était l'échec du traitement antibiotique oral. RéSULTATS: Sur les 134 participants éligibles sollicités pour participer à l'essai, 69 (51,5%, IC à 95% 43,1% à 59,8%) ont été recrutés et randomisés. Après avoir exclu trois participants randomisés en raison d'un autre diagnostic, 33 participants au total ont été inclus dans chaque bras. Au total, 19 cas éligibles (14,2%) ont été manqués. Le taux de perte au suivi était de 6,1%. L'échec du traitement est survenu chez quatre patients (12,9%) dans le groupe à dose standard contre un patient (3,2%) dans le groupe à dose élevée. Une plus grande proportion de patients ont eu des effets indésirables mineurs dans le groupe à forte dose. Aucun patient n'a été hospitalisé de façon imprévue dans les 14 jours. CONCLUSION: Cet essai pilote randomisé et contrôlé comparant la céphalexine à dose élevée à la céfalexine à dose normale pour les patients des urgences atteints de cellulite a démontré un taux élevé de recrutement de participants et la faisabilité d'un essai à grande échelle. La céfalexine à forte dose a entraîné moins d'échecs thérapeutiques, mais avec une proportion plus élevée d'effets indésirables mineurs. Les résultats de ce projet pilote serviront de base à la conception d'un futur essai à grande échelle. INSCRIPTION à L'ESSAI: Cet essai a été enregistré sur ClinicalTrials.gov (NCT04471246).

Implementation of the Modified Canadian C-Spine Rule by Paramedics.

STUDY OBJECTIVE: The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. METHODS: This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. RESULTS: The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. CONCLUSION: Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.

Practice Variation among Canadian Stroke Prevention Clinics: Pre, During, and Post-COVID-19.

BACKGROUND: Stroke is a common and serious disorder. With optimal care, 90-day recurrent stroke risk can be reduced from 10% to about 1%. Stroke prevention clinics (SPCs) can improve patient outcomes and resource allocation but lack standardization in patient management. The extent of variation in patient management among SPCs is unknown. Our aims were to assess baseline practice variation between Canadian SPCs and the impact of COVID-19 on SPC patient care. METHODS: We conducted an electronic survey of 80 SPCs across Canada from May to November 2021. SPC leads were contacted by email with up to five reminders. RESULTS: Of 80 SPCs contacted, 76 were eligible from which 38 (50.0%) responded. The majority (65.8%) of SPCs are open 5 or more days a week. Tests are more likely to be completed before the SPC visit if referrals were from clinic's own emergency department compared to other referring sources. COVID-19 had a negative impact on routine patient care including longer wait times (increased for 36.4% clinics) and higher number of patients without completed bloodwork prior to arriving for appointments (increased for 27.3% clinics). During COVID-19 pandemic, 87.9% of SPCs provided virtual care while 72.7% plan to continue with virtual care post-COVID-19 pandemic. CONCLUSION: Despite the time-sensitive nature of transient ischemic attack patient management, some SPCs in Canada are not able to see patients quickly. SPCs should endeavor to implement strategies so that they can see high-risk patients within the highest risk timeline and implement strategies to complete some tests while waiting for SPC appointment.

Validating emergency department cardioversion procedures in provincial administrative data in Ontario, Canada.

BACKGROUND: Cardioversion of acute-onset atrial fibrillation (AF) via electrical or pharmacological means is a common procedure performed in many emergency departments. While these procedures appear to be very safe, the rarity of subsequent adverse outcomes such as stroke would require huge sample sizes to confirm that conclusion. Big data can supply such sample sizes. OBJECTIVE: We aimed to validate several potential codes for successful emergency department cardioversion of AF patients. METHODS: This study combined 3 observational datasets of emergency department AF visits seen at one of 26 hospitals in Ontario, Canada, between 2008 and 2012. We linked patients who were eligible for emergency department cardioversion to several province-wide health administrative datasets to search for the associated cardioversion billing and procedural codes. Using the observational data as the gold standard for successful cardioversion, we calculated the test characteristics of a billing code (Z437) and of procedural codes 1.HZ.09JAFS and 1.HZ.09JAJS. Both include pharmacological and electrical cardioversions, as well as unsuccessful attempts; the latter is <10% using electricity (in Canada, standard practice is to proceed to electrical cardioversion if pharmacological cardioversion is unsuccessful). RESULTS: Of 4557 unique patients in the three datasets, 2055 (45.1%) were eligible for cardioversion. Nine hundred thirty-three (45.4%) of these were successfully cardioverted to normal sinus rhythm. The billing code had slightly better test characteristics overall than the procedural codes. Positive predictive value (PPV) of a billing was 89.8% (95% CI, 87.0-92.2), negative predictive value (NPV) 70.5% (95% CI, 68.1-72.8), sensitivity 52.1% (95% CI, 48.8-55.3), and specificity 95.1% (95% CI, 93.7-96.3). CONCLUSIONS: AF patients who have been successfully cardioverted in an emergency department can be identified with high PPV and specificity using a billing code. Studies that require high sensitivity for cardioversion should consider other methods to identify cardioverted patients.

What is the Best Agent for Rate Control of Atrial Fibrillation With Rapid Ventricular Response?

BACKGROUND: Atrial fibrillation (AF) is a common dysrhythmia associated with significant morbidity and mortality. Although many patients have stable AF, some patients can present with a rapid ventricular response (RVR). In these patients, it is important to lower their heart rate. However, there are several options available for rate control in the emergency department setting. CLINICAL QUESTION: What is the most effective agent for rate control for the patient with AF in RVR? EVIDENCE REVIEW: Studies retrieved included two prospective, randomized, double-blind studies and six retrospective cohort studies. These studies provide estimates of the efficacy and safety of calcium channel blockers and ß-blockers for rate control in those with AF with RVR. CONCLUSION: Based upon the available literature, diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for rate control.

Risk of stroke is low after transient ischemic attack presentation with isolated dizziness.

OBJECTIVE: Stroke presenting as dizziness is a diagnostic challenge in frontline settings, given the multitude of benign conditions that present similarly. The risk of stroke after episodic dizziness is unknown, leading to divergent guidance on optimal workup and management. Prior TIA risk scores have shown a history of dizziness is a negative predictor of subsequent stroke. Our objective was to assess the subsequent stroke risk within 90 days following emergency department assessment (ED) for isolated dizziness diagnosed as TIA during the index visit. METHODS: We conducted prospective, multicenter cohort studies at 13 Canadian EDs over 11 years. We enrolled patients diagnosed with TIA and compared patients with isolated dizziness to those with other neurological deficits. Our primary outcome was subsequent stroke within 90 days. Secondary outcomes were subsequent stroke within 2, 7, and 30 days, respectively, as well as subsequent TIA within 90 days. RESULTS: Only 4/483 (0.8%) patients with isolated dizziness had a stroke within 90 days compared to 320/11024 (2.9%) of those with any focal neurological sign or symptom (RR 0.29, 95% CI 0.11-0.76). Over the first 90 days, the two groups differ significantly in their probability of stroke (p = 0.007). Subsequent TIA was also significantly less common in the isolated dizziness group (1.7% vs. 5.6%, p = 0.001) with a relative risk of 0.30 (95% CI 0.15-0.60). CONCLUSION: The risk of subsequent stroke following ED presentation for TIA is low when the presenting symptoms are isolated dizziness.

RéSUMé: OBJECTIF: Les accidents vasculaires cérébraux (AVC) se présentant sous forme de vertiges constituent un défi diagnostique en première ligne, étant donné la multitude d'affections bénignes qui se présentent de la même manière. Le risque d'accident vasculaire cérébral (AVC) après des vertiges épisodiques est inconnu, ce qui donne lieu à des conseils divergents sur le bilan et la prise en charge optimaux. Des scores de risque d'AIT antérieurs ont montré que des antécédents de vertiges sont un facteur prédictif négatif d'accident vasculaire cérébral ultérieur. Notre objectif était d'évaluer le risque ultérieur d'accident vasculaire cérébral (AVC) dans les 90 jours suivant l'évaluation aux urgences d'un étourdissement isolé diagnostiqué comme un AIT lors de la visite de référence. MéTHODES: Nous avons mené des études de cohorte prospectives multicentriques dans 13 services d'urgence canadiens pendant 11 ans. Nous avons recruté des patients ayant reçu un diagnostic d'AIT et avons comparé les patients présentant des vertiges isolés à ceux présentant d'autres déficits neurologiques. Nous avons inscrit des patients ayant reçu un diagnostic d'AIT et comparé des patients ayant des étourdissements isolés à ceux présentant d'autres déficits neurologiques. Notre résultat primaire était l'AVC subséquent dans les 90 jours. Les résultats secondaires étaient l'AVC subséquent dans les 2, 7 et 30 jours, respectivement, ainsi que l'AIT subséquent dans les 90 jours. RéSULTATS: Seuls 4/483 (0,8 %) des patients présentant des vertiges isolés ont eu un AVC dans les 90 jours, contre 320/11 024 (2,9 %) de ceux présentant un signe ou symptôme neurologique focal (RR 0,29, IC 95 % 0,11-0,76). Au cours des 90 premiers jours, les deux groupes diffèrent significativement en termes de probabilité d'AVC (p = 0,007). L'AIT ultérieur était également significativement moins fréquent dans le groupe des vertiges isolés (1,7 % contre 5,6 %, p = 0,001) avec un risque relatif de 0,30 (IC 95 % 0,15-0,60). CONCLUSIONS: Le risque d'AVC ultérieur après une présentation aux urgences pour un AIT est faible lorsque les symptômes présentés sont des étourdissements isolés.

Association between antibiotics and rehospitalization in patients with acute exacerbations of chronic obstructive pulmonary disease discharged from the emergency department.

BACKGROUND: Patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are frequently discharged from the emergency department (ED) and treated with antibiotics. The role of antibiotics in the outpatient management of AECOPD is controversial and has never been studied in the ED setting. METHODS: We conducted a secondary analysis of prospectively collected data from the validation study of the Ottawa COPD Risk Scale. We included adult patients with AECOPD who were discharged from six tertiary care EDs in Canada over a two-year period and assessed rates of rehospitalization within 14 days of ED discharge. To examine the association between antibiotic treatment and rehospitalization, we performed multivariable logistic regression and propensity score-matched analyses. RESULTS: A total of 774 patients were included in the analysis. The mean age was 69.4 years, 388 patients (50.1%) were female, and 451 patients (58.3%) were discharged with antibiotics. Twenty-nine (6.4%) and 36 (11.1%) patients returned to hospital with admission in the antibiotic and no antibiotic groups, respectively (unadjusted OR 0.55; 95% CI 0.33-0.92); adjustment for prespecified baseline characteristics using logistic regression yielded OR 0.65; 95% CI 0.38-1.08. In the propensity score-matched analysis comprising of 197 matched pairs, 15 (7.6%) and 19 patients (9.6%) in the antibiotic and no antibiotic groups returned with admission, respectively (OR 0.69; 95% CI 0.29-1.62). CONCLUSION: For patients with AECOPD discharged from the ED, we did not find an association between outpatient treatment with antibiotics and lower rates of rehospitalization after accounting for differences in baseline patient characteristics. However, the small sample size and low observed rate of the primary outcome created substantial risk of Type II error. Until further evidence is available, clinicians should continue prescribing antibiotics for patients with AECOPD based on clinical judgement and current practice guidelines.

RéSUMé: CONTEXTE: Les patients présentant des exacerbations aiguës de maladie pulmonaire obstructive chronique (EAMPOC) sont fréquemment renvoyés du service des urgences (SU) et traités avec des antibiotiques. Le rôle des antibiotiques dans la prise en charge ambulatoire de l'EAMPOC est controversé et n'a jamais été étudié dans le cadre des urgences. MéTHODES: Nous avons effectué une analyse secondaire des données recueillies prospectivement dans le cadre de l'étude de validation de l'échelle de risque de MPOC d'Ottawa. Nous avons inclus des patients adultes atteints d'EAMPOC qui sont sortis de six urgences de soins tertiaires au Canada sur une période de deux ans et avons évalué les taux de réhospitalisation dans les 14 jours suivant la sortie des urgences. Pour examiner l'association entre le traitement antibiotique et la réhospitalisation, nous avons effectué une régression logistique multivariable et des analyses par appariement de score de propension. RéSULTATS: Un total de 774 patients a été inclus dans l'analyse. L'âge moyen était de 69,4 ans, 388 patients (50,1 %) étaient des femmes et 451 patients (58,3 %) sont sortis avec des antibiotiques. Vingt-neuf (6,4 %) et 36 (11,1 %) patients sont retournés à l'hôpital avec admission dans les groupes avec et sans antibiotique, respectivement (OR non ajusté 0,55 ; IC à 95 % 0,33 à 0,92) ; l'ajustement pour les caractéristiques de base préspécifiées à l'aide de la régression logistique a donné un OR de 0,65 ; IC à 95 % 0,38 à 1,08. Dans l'analyse appariée par score de propension comprenant 197 paires appariées, 15 (7,6 %) et 19 (9,6 %) patients des groupes avec et sans antibiotique sont revenus avec une admission, respectivement (OR 0,69 ; IC 95 % 0,29 à 1,62). CONCLUSION: Pour les patients atteints d'AECOPD sortis des urgences, nous n'avons pas trouvé d'association entre le traitement ambulatoire par antibiotiques et des taux plus faibles de réhospitalisation après avoir pris en compte les différences dans les caractéristiques de base des patients. Toutefois, la petite taille de l'échantillon et le faible taux observé du résultat principal ont créé un risque important d'erreur de type II. Jusqu'à ce que d'autres preuves soient disponibles, les cliniciens doivent continuer à prescrire des antibiotiques aux patients atteints d'AECOPD en se basant sur le jugement clinique et les directives de pratique actuelles.

Quality and transparency of reporting derivation and validation prognostic studies of recurrent stroke in patients with TIA and minor stroke: a systematic review.

BACKGROUND: Clinical prediction models/scores help clinicians make optimal evidence-based decisions when caring for their patients. To critically appraise such prediction models for use in a clinical setting, essential information on the derivation and validation of the models needs to be transparently reported. In this systematic review, we assessed the quality of reporting of derivation and validation studies of prediction models for the prognosis of recurrent stroke in patients with transient ischemic attack or minor stroke. METHODS: MEDLINE and EMBASE databases were searched up to February 04, 2020. Studies reporting development or validation of multivariable prognostic models predicting recurrent stroke within 90 days in patients with TIA or minor stroke were included. Included studies were appraised for reporting quality and conduct using a select list of items from the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) Statement. RESULTS: After screening 7026 articles, 60 eligible articles were retained, consisting of 100 derivation and validation studies of 27 unique prediction models. Four models were newly derived while 23 were developed by validating and updating existing models. Of the 60 articles, 15 (25%) reported an informative title. Among the 100 derivation and validation studies, few reported whether assessment of the outcome (24%) and predictors (12%) was blinded. Similarly, sample size justifications (49%), description of methods for handling missing data (16.1%), and model calibration (5%) were seldom reported. Among the 96 validation studies, 17 (17.7%) clearly reported on similarity (in terms of setting, eligibility criteria, predictors, and outcomes) between the validation and the derivation datasets. Items with the highest prevalence of adherence were the source of data (99%), eligibility criteria (93%), measures of discrimination (81%) and study setting (65%). CONCLUSIONS: The majority of derivation and validation studies for the prognosis of recurrent stroke in TIA and minor stroke patients suffer from poor reporting quality. We recommend that all prediction model derivation and validation studies follow the TRIPOD statement to improve transparency and promote uptake of more reliable prediction models in practice. TRIAL REGISTRATION: The protocol for this review was registered with PROSPERO (Registration number CRD42020201130 ).

Advanced Life Support for Out-of-Hospital Chest Pain: The OPALS Study†.

Context: As many as 14% of patients transported by ambulance with chest pain die prior to hospital discharge. To date, no high-quality controlled trials have revealed that prehospital advanced life support interventions affect survival for these patients. Objective: The Ontario Prehospital Advanced Life Support (OPALS) Study assessed the effect of adding an advance life support service to an existing basic life support emergency medical service program, on the rate of mortality and morbidity for patients with out-of-hospital chest pain. Design: Controlled clinical trial comparing survival for 9 months before and 9 after instituting an advanced life support program. Setting: Thirteen urban and suburban Ontario communities (populations ranging from 30,000 to 750,000; total, 2.5 million). Patients: All adult patients with a primary complaint of chest pain and transported by paramedics to the emergency department. Intervention: Paramedics were trained in standard advanced life support, which includes endotracheal intubation, intravenous furosemide and morphine, oral ASA, and sublingual NTG. Emergency medical services within each community had to meet predefined criteria in order to qualify for the advanced life support phase. Main Outcome Measure: Survival to hospital discharge. Results: Overall, 12,168 patients were enrolled in either the basic life support phase (N = 5,788) or the advanced life support phase (N = 6,380). The rate of mortality significantly decreased from 4.3% in the basic life support phase to 3.2% in the advanced life support phase (absolute change 1.1, 95% CI 0.4-1.8, P = 0.0013). We also demonstrated a decrease in mortality for the subgroup of patients with a discharge diagnosis of myocardial infarction (13.1 percent vs 8.2 percent, P = 0.002). Conclusions: The addition of a prehospital advanced life support program to an existing basic life support emergency medical service was associated with a significant decrease in the mortality rate among patients complaining of chest pain. Future research should clarify the most effective interventions and target specific populations.