Patient management in the emergency department by advanced care paramedics.

We describe an emergency department process using Advanced Care Paramedics in the management of patients identified as ambulatory and low acuity, or those able to be managed without an emergency nurse. Patients streamed in this way had shorter stays than other emergency patients, without affecting the care of the latter. The process was associated with improved patient flow indicators in spite of an increased patient burden.

Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series.

OBJECTIVES: To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. METHODS: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. RESULTS: Hypotension (systolic blood pressure < or = 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO2 < or = 90) in 14 of 979 (1.4%; Cl 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. CONCLUSIONS: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Utility of follow-up recommendations for patients discharged with community-acquired pneumonia.

INTRODUCTION: The joint Canadian Infectious Diseases Society and Canadian Thoracic Society guidelines for community-acquired pneumonia (CAP) recommend 48-72 hour telephone follow-up of patients discharged from the emergency department (ED). The guidelines provide no evidence supporting this practice, and neither the clinical utility nor the effectiveness of such recommendations has been assessed. Our objective was to assess the utility of a 48-72 hour telephone follow-up protocol for patients discharged from the ED with CAP. METHODS: This was a retrospective chart audit covering a 2-year period (Jan. 3, 1999 to Jan. 3, 2001) after the introduction of a clinical practice guideline (CPG) that included routine 48-72 hour telephone follow-up of patients discharged from the ED with CAP. Eligible patients were identified in the ED database, rates of referral for telephone follow-up were recorded, and 30-day outcomes (death and readmission) for patients referred versus not referred were compared. RESULTS: During the study period, 867 patients were identified as being eligible for the study. The mean age was 55.7 years (range 16-98 yr), and mean pneumonia severity index (PSI) was 68.9 (range 6-187). Despite the CPG, only 148 patients (17.1%) were referred for telephone follow-up. Age, demographics, comorbidity, clinical status and pneumonia severity were similar for referred and non-referred patients. Thirty-day death (2.5%) and readmission rates (3%) were strongly related to PSI score, but did not differ significantly in the 2 comparison groups. CONCLUSION: In this setting, physicians were poorly compliant with a routine telephone follow-up protocol. The likelihood of referral for follow-up did not correlate with pneumonia severity, and follow-up referral did not appear to affect patient outcome. These findings do not support recommendations for routine early follow-up mechanisms beyond those already existing in the community.