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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.
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Serviço Hospitalar de Emergência , Tomografia Computadorizada por Raios X , Humanos , Feminino , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adulto , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Cirurgia Bariátrica , Estudos Retrospectivos , Obesidade Mórbida/cirurgiaRESUMO
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.
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BACKGROUND: Syncope is transient loss of consciousness, and in presyncope, patients experience same prodromal symptoms without losing consciousness. While studies have extensively reported the risk of serious outcome among emergency department (ED) syncope, the outcome for patients with presyncope and their management are not well studied. We undertook a systematic review to assess the occurrence/identification of short-term (30-day) serious outcomes among ED patients with presyncope. METHODS: ED studies that enrolled patients with presyncope and reported any short-term serious outcome were included. Studies that enrolled patients without presyncope (e.g., hypoglycemia, seizure, and stroke) were excluded. We restricted our study to only English publications and searched the MEDLINE, Embase, Scopus, and Web of Science from the inception date to July 2023. We used SIGN 50 tool for assessment of risk of bias. RESULTS: In total, 1788 articles were screened by two reviewers and 32 articles were selected for full-text assessment. Five (four prospective and one retrospective) studies with 2741 presyncope patients were included. Four studies were from North America and the fifth one was from Europe. Included studies had weaknesses due to risk of bias, but all had acceptable quality. The prevalence of overall adverse outcome varied 4.4%-26.8% for all adults and 5.5%-18.7% among older patients; arrhythmia was the most prevalent (17.4% in one study), followed by anemia/hemorrhage as reported in different studies. Among older patients, myocardial infarction was the third most common serious outcome reported in one study. CONCLUSIONS: The prevalence of short-term serious outcomes varies from 4% to 27% among ED patients with presyncope in our review, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as syncope.
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BACKGROUND: We believe that hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. In part 1 of 3 concurrent studies, we documented the number of weekend discharges and the extent of hospital and ED crowding on the days following weekends. METHODS: We conducted a data analysis study at The Ottawa Hospital, a major academic health sciences center with two EDs. We created reports of the 18-month period (January 1, 2022-June 30, 2023) regarding the status of in-patients at the two campuses. We compared the total admissions, discharges, and hospital occupancy on weekends (or long weekends), the Monday following weekends (or Tuesday following long weekends), or Tuesdays-Fridays. For these three time periods, we also compared the proportion of ED beds occupied by admitted patients to all ED beds, as well as the proportion of days with > 70% admitted patients housed in the ED at 8:00am. RESULTS: Our data for 55,692 patients demonstrated that on weekends compared to weekdays, there were almost 50% fewer discharges with the ratio of admissions to discharges averaging 1.16 (95% CI 1.10-1.22). This was accompanied by a 2.4% absolute increase (P < 0.001) in hospital occupancy on Mondays or Tuesdays, often exceeding 100%. Both EDs are particularly crowded on these Mondays and Tuesdays with the proportion of admitted patients to regular ED beds averaging 68%. We observed serious crowding with > 70% occupancy with admitted patients on almost 50% of Mondays. INTERPRETATION: We have demonstrated that there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This blocks safe and timely access to beds for newly arriving patients in the ED. These results should spur Canadian hospitals to evaluate their own data and seek solutions to this important problem.
ABSTRAIT: CONTEXTE: Nous croyons que le surpeuplement des hôpitaux et des services d'urgence (SU) est exacerbé le lundi parce que moins de patients hospitalisés reçoivent leur congé le week-end. Dans la partie 1 de trois études simultanées, nous avons documenté le nombre de congés de fin de semaine et l'ampleur du surpeuplement des hôpitaux et des urgences les jours suivants. MéTHODES: Nous avons mené une étude d'analyse des données à l'Hôpital d'Ottawa, un important centre universitaire des sciences de la santé qui compte deux urgences. Nous avons créé des rapports sur la période de 18 mois (du 1er janvier 2022 au 30 juin 2023) concernant l'état des patients hospitalisés sur les deux campus. Nous avons comparé le total des admissions, des sorties et de l'occupation de l'hôpital les fins de semaine (ou les longues fins de semaine), le lundi suivant les fins de semaine (ou le mardi suivant les longues fins de semaine) ou les mardis et vendredis. Pour ces trois périodes, nous avons également comparé la proportion de lits d'urgence occupés par des patients admis à tous les lits d'urgence, ainsi que la proportion de jours avec plus de 70 % de patients admis logés à l'urgence à 8 h. RéSULTATS: Nos données pour 55692 patients ont démontré que les week-ends par rapport aux jours de semaine, il y avait près de 50% moins de sorties avec un ratio d'admissions par rapport aux sorties de 1,16 (IC à 95% 1,10-1,22). Cela s'est accompagné d'une augmentation absolue de 2,4 % (p<0,001) de l'occupation des hôpitaux le lundi ou le mardi, souvent supérieure à 100 %. Les deux urgences sont particulièrement bondées ces lundis et mardis, la proportion de patients admis dans les lits réguliers d'urgence s'établissant en moyenne à 68 %. Nous avons observé un surpeuplement sérieux avec >70% d'occupation chez les patients admis sur près de 50% des lundis. INTERPRéTATION: Nous avons démontré qu'il y a beaucoup moins de congés la fin de semaine, ce qui est associé à une importante affluence d'hôpitaux et d'urgences le lundi. Cela bloque l'accès sécuritaire et rapide aux lits pour les patients nouvellement arrivés à l'urgence. Ces résultats devraient inciter les hôpitaux canadiens à évaluer leurs propres données et à chercher des solutions à ce problème important.
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BACKGROUND: Hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged during the weekend. We evaluated the experiences and attitudes of in-patient ward nurses to better understand the challenges they face when considering the weekend discharge of their patients. METHODS: We conducted a qualitative study of in-patient ward nurses, using the theoretical domains framework (TDF), at two campuses of a major academic health sciences centre. The interview guides consisted of, first, a series of questions to explore the typical processes involved for safe patient discharges and, second, exploration of the influence of the 14 TDF domains. All interviews were audio-recorded, transcribed verbatim, and anonymized and then imported into NVivo qualitative software for data management and analysis. Analysis was conducted in three stages (coding, generation of specific beliefs, identification of relevant and nonrelevant domains). RESULTS: The 28 interviewed nurses represented a variety of medical, surgical and other wards, and reported being acutely aware of the pressures to discharge patients on weekends (knowledge). They believed that increasing weekend discharges would improve hospital flow and aid in decanting the ED (beliefs about consequences). However, they also acknowledged that the weekend discharge pressures might result in patients being discharged prematurely and bouncing back to the hospital (beliefs about consequences). Overall, the nurses reported that as a hospital culture, discharging patients was not much of a priority (goals; environmental context and resources). CONCLUSION: We know there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This study has illuminated the many challenges faced by in-patient ward nurses when considering the discharge of admitted patients on weekends. In order to decrease ED and hospital crowding related to decreased weekend discharges, hospitals will need to effect a culture change amongst all staff.
ABSTRAIT: CONTEXTE: Le surpeuplement des hôpitaux et des services d'urgence (SU) est exacerbé le lundi parce que moins de patients hospitalisés sont libérés pendant la fin de semaine. Nous avons évalué les expériences et les attitudes des infirmières en salle afin de mieux comprendre les défis auxquels elles font face lorsqu'elles envisagent le congé de fin de semaine de leurs patients. MéTHODES: Nous avons mené une étude qualitative sur les infirmières en salle, en utilisant le cadre des domaines théoriques (TDF), sur deux campus d'un grand centre universitaire des sciences de la santé. Les guides d'entrevue ont consisté, d'une part, en une série de questions visant à explorer les processus typiques de sortie sécuritaire des patients et, d'autre part, en une exploration de l'influence des 14 domaines du TDF. Toutes les entrevues ont été enregistrées, transcrites mot à mot et rendues anonymes, puis importées dans le logiciel qualitatif NVivo pour la gestion et l'analyse des données. L'analyse a été menée en trois étapes (codage, génération de croyances spécifiques, identification de domaines pertinents et non pertinents). RéSULTATS: Les 28 infirmières interrogées représentaient une variété de services médicaux, chirurgicaux et autres, et ont déclaré être très conscientes des pressions exercées sur les patients pour qu'ils quittent la clinique les fins de semaine (connaissance). Ils croyaient que l'augmentation des congés de fin de semaine améliorerait le flux hospitalier et aiderait à décanter le DE (croyances sur les conséquences). Cependant, ils ont également reconnu que les pressions de sortie du week-end pourraient entraîner le renvoi prématuré des patients à l'hôpital (croyances sur les conséquences). Dans l'ensemble, les infirmières ont indiqué qu'en tant que culture hospitalière, le congé des patients n'était pas une grande priorité (objectifs ; contexte environnemental et ressources). CONCLUSION: Nous savons qu'il y a beaucoup moins de congés la fin de semaine, et cela est associé à un grand nombre d'hôpitaux et de services d'urgence le lundi. Cette étude a mis en lumière les nombreux défis auxquels font face les infirmières en salle lorsqu'elles envisagent de quitter les patients admis les fins de semaine. Afin de réduire le surpeuplement des urgences et des hôpitaux liés à la diminution des congés de fin de semaine, les hôpitaux devront effectuer un changement de culture parmi tout le personnel.
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OBJECTIVE: We sought to evaluate the impact of a medical directive allowing nurses to use defibrillators in automated external defibrillator-mode (AED) on in-hospital cardiac arrest (IHCA) outcomes. METHODS: We completed a health record review of consecutive IHCA for which resuscitation was attempted using a pragmatic multi-phase before-after cohort design. We report Utstein outcomes before (Jan.2012-Aug.2013;Control) the implementation of the AED medical directive following usual practice (Sept.2013-Aug.2016;Phase 1), and following the addition of a theory-based educational video (Sept.2016-Dec.2017;Phase 2). RESULTS: There were 753 IHCA with the following characteristics (Before n = 195; Phase 1n = 372; Phase 2n = 186): mean age 66, 60.0% male, 79.3% witnessed, 29.1% noncardiac-monitored medical ward, 23.9% cardiac cause, and initial ventricular fibrillation/tachycardia (VF/VT) 27.2%. Comparing the Before, Phase 1 and 2: an AED was used 0 time (0.0%), 21 times (5.7%), 15 times (8.1%); mean times to 1st analysis were 7 min, 3 min and 1 min (p < 0.0001); mean times to 1st shock were 12 min, 10 min and 8 min (p = 0.32); return of spontaneous circulation (ROSC) was 63.6%, 59.4% and 58.1% (p = 0.77); survival was 24.6%, 21.0% and 25.8% (p = 0.37). Among IHCA in VF/VT (n = 165), time to 1st analysis and 1st shock decreased by 5 min (p = 0.01) and 6 min (p = 0.23), and ROSC and survival increased by 3.0% (p = 0.80) and 15.6% (p = 0.31). There was no survival benefit overall (1.2%; p = 0.37) or within noncardiac-monitored areas (-7.2%; p = 0.24). CONCLUSIONS: The implementation of a medical directive allowing for AED use by nurses successfully improved key outcomes for IHCA victims, particularly following the theory-based education video and among the VF/VT group.
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Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca , Taquicardia Ventricular , Humanos , Masculino , Feminino , Desfibriladores/efeitos adversos , Fibrilação Ventricular/complicações , Fibrilação Ventricular/terapia , Taquicardia Ventricular/complicações , Hospitais , Reanimação Cardiopulmonar/efeitos adversosRESUMO
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.
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Background: There are high rates of computed tomography (CT) utilization in the emergency department (ED) for patients with inflammatory bowel disease (IBD), despite guidelines recommending judicious use. We performed a national survey to better understand perceptions and practice patterns of Canadian physicians related to CT imaging in the ED. Methods: Our survey was developed by a multistep iterative process with input from key stakeholders between 2021 and 2022. It evaluated Canadian gastroenterologists', surgeons', and emergency physicians' (1) perceived rates of IBD findings detected by CT, (2) likelihood of performing CT for specific presentations and (3) comfort in diagnosing IBD phenotypes/complications without CT. Results: A total of 208 physicians responded to our survey: median age 44 years (IQR, 37-50), 63% male, 68% academic, 44% emergency physicians, 39% gastroenterologists, and 17% surgeons. Compared with emergency physicians and surgeons, gastroenterologists more often perceived that CT would detect inflammation alone and less often IBD complications. Based on established rates in the literature, 13 (16%) gastroenterologists, 33 (40%) emergency physicians, and 21 (60%) surgeons overestimated the rates of at least one IBD complication. Although most physicians were more comfortable diagnosing inflammation compared to IBD complications without CT, gastroenterologists were significantly less likely to recommend CT imaging for non-obstructive/penetrating presentations compared with emergency physicians and surgeons with results that varied by IBD subtype. Conclusion: This national survey demonstrates differences in physician perceptions and practices regarding CT utilization in the ED and can be used as a framework for educational initiatives regarding appropriate usage of this modality.
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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.
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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.
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Fibrilação Atrial , Lista de Checagem , Serviço Hospitalar de Emergência , Fidelidade a Diretrizes , Humanos , Fibrilação Atrial/terapia , Masculino , Feminino , Idoso , Frequência Cardíaca/fisiologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Eletrocardiografia , Cardioversão Elétrica/métodos , Antiarrítmicos/uso terapêutico , Medição de RiscoRESUMO
OBJECTIVES: Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition. METHODS: This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals. RESULTS: 358 patients met inclusion criteria. The mean age was 66.9 years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11). CONCLUSIONS: There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.
RéSUMé: OBJECTIFS: La fibrillation auriculaire aiguë (FA)/flutter (FAT) est une présentation courante aux urgences (SU). En 2021, une version mise à jour de la liste de vérification des pratiques exemplaires en matière de FA/FAT aiguë du CAEP a été publiée, dans le but de guider la direction. Nous avons évalué l'harmonisation et la sécurité de l'application de la liste de contrôle en ce qui concerne la prévention et la disposition des AVC. MéTHODES: Cet examen des dossiers de santé comprenait des adultes qui se sont présentés à deux urgences universitaires de soins tertiaires entre janvier et août 2022 avec un diagnostic d'AF/AFL aigu. Les patients étaient exclus si leur fréquence cardiaque initiale était inférieure à 100 ou s'ils étaient hospitalisés. Les données extraites comprenaient les données démographiques, le score CHADS-65, les caractéristiques cliniques, le traitement et la disposition des urgences, ainsi que les prescriptions et les références ambulatoires. Notre résultat principal était la proportion de patients qui rencontraient un ou plusieurs problèmes de sécurité identifiés. Chaque cas a été évalué selon sept critères prédéterminés à partir des éléments de la liste de vérification du PPVE et jugé « sécuritaire ¼ ou comportant un ou plusieurs problèmes de sécurité. Nous avons utilisé des statistiques descriptives avec des intervalles de confiance de 95 %. RéSULTATS: 358 patients répondaient aux critères d'inclusion. L'âge moyen était de 66.9 ans, 59.2% étaient des hommes et 77.4% des patients avaient au moins un des critères CHADS-65. 169 (47.2%) n'étaient pas déjà sous anticoagulation et 99 (27.6%) ont été renvoyés à la maison avec une nouvelle prescription d'anticoagulation. Le critère de jugement principal a été identifié dans 6.4 % (IC à 95 % 4.39.5) des rencontres, ce qui représente 28 problèmes d'innocuité chez 23 personnes. Parmi les préoccupations en matière d'innocuité, mentionnons l'omission de prescrire un anticoagulant lorsque cela est indiqué (n = 6), l'administration inappropriée d'un anticoagulant oral direct (n = 2), la prescription inappropriée d'un médicament pour contrôler le rythme ou le rythme (n = 9), et l'omission de recommander un suivi bien chronométré vers le haut pour le nouveau médicament de contrôle de taux (n = 11). CONCLUSIONS: Il y avait un très haut niveau d'harmonisation des médecins de l'urgence avec la liste de vérification des pratiques exemplaires de l'ACMU en ce qui concerne la disposition et la prévention des accidents vasculaires cérébraux. Il est possible d'améliorer davantage les soins en ce qui concerne la recommandation d'anticoagulation et de réduire les prescriptions inappropriées de médicaments à taux ou à rythme.
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Fibrilação Atrial , Lista de Checagem , Serviço Hospitalar de Emergência , Acidente Vascular Cerebral , Humanos , Fibrilação Atrial/terapia , Feminino , Masculino , Idoso , Acidente Vascular Cerebral/prevenção & controle , Padrões de Prática Médica , Estudos Retrospectivos , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Pessoa de Meia-Idade , Doença Aguda , Fidelidade a DiretrizesRESUMO
Background: Acute heart failure (AHF) is a common emergency department (ED) presentation that may have poor outcomes but often does not require hospital admission. There is little evidence to guide dispositional decisions. Objectives: The authors sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF. Methods: We pooled data from 3 prospective cohorts: 2 published studies and 1 new cohort. The 3 cohorts prospectively enrolled patients who required treatment for AHF at 10 tertiary care hospital EDs. The primary outcome was SSO, defined as death <30 days, intubation or noninvasive ventilation (NIV), myocardial infarction, or relapse to ED <14 days. The logistic regression model evaluated 13 predictors, used an AIC-based step-down procedure, and bootstrapped internal validation. Results: Of the 2,246 patients in the 3 cohorts (N = 559; 1,100; 587), the mean age was 77.4 years, 54.5% were male, 3.1% received intravenous nitroglycerin, 5.2% received ED NIV, and 48.6% were admitted to the hospital. There were 281 (12.5%) SSOs including 70 deaths (3.1%) with many in discharged patients. The final HEARTRISK6 Scale included 6 variables: valvular heart disease, tachycardia, need for NIV, creatinine, troponin, and failed reassessment (walk test). Choosing HEARTRISK6 total-point admission thresholds of ≥1 or ≥2 would yield, respectively, sensitivities of 88.3% (95% CI: 83.9%-91.8%) and 71.5% (95% CI: 65.9%-76.7%) and specificities of 24.7% (95% CI: 22.8%-26.7%) and 50.1% (95% CI: 47.9%-52.4%) for SSO. Conclusions: Using 3 large prospectively collected datasets, we created a concise and sensitive risk scale for patients with AHF in the ED. Implementation of the HEARTRISK6 scale could lead to safer and more efficient disposition decisions.
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OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.