Anaphylactoid reaction to recombinant tissue plasminogen activator.

Anaphylactoid reaction to recombinant tissue plasminogen activator for the thrombolytic treatment of acute ischemic stroke is an uncommon complication. An increased risk of anaphylaxis may be found in patients concomitantly being treated with angiotensin-converting enzyme inhibitors, as illustrated by this case report describing a patient who experienced an urticaric rash, hypotension, tachycardia, orolingual angioedema, and airway obstruction following intravenous administration of alteplase. Possible pharmacologic interactions resulting in excessive serum bradykinin and subsequent systemic hypersensitivity responses are discussed.

How does fast track affect quality of care in the emergency department?

STUDY OBJECTIVES: Use of fast track has been shown to improve the emergency department flow of less urgent patients. It has been speculated, however, that this could negatively affect the care of urgent patients. The objective of this study was to determine whether a dedicated fast track for less urgent patients [Canadian Triage and Acuity scale category 4/5 (CTAS 4/5)] affected (1) the time to assessment for urgent patients (CTAS 3), (2) the length of stay for less urgent patients (CTAS 4 and 5), and (3) the left-without-being-seen rate. METHODS: In June 2003, fast track was opened in our emergency department from 13:00 to 19:00 h. A before-after intervention comparison analysis was completed for 1 week in Aug 2002 and the same week in Aug 2003. Data collected included (1) time to assessment of CTAS 3 patients, (2) the length of stay for CTAS 4/5 patients, and (3) percentage of patients who left without being seen. RESULTS: A total of 368 patients were reviewed for 2002 and 380 patients were reviewed for 2003. Median time to assessment of CTAS 3 patients presenting from 13:00 to 19:00 h was reduced from 66 min (Interquartile range: 40, 94 min) in 2002 to 60 min (IQR: 38, 108 min) after fast track was open in 2003 (P = 0.95). Median length of stay of CTAS 4 and 5 patients was reduced from 170 min (IQR: 111, 256 min) to 110 min (IQR: 69, 185 min) (P < 0.001). The overall left-without-being-seen rate decreased from 5% (20/368) to 2% (9/380). CONCLUSION: A dedicated fast track for CTAS 4/5 patients can reduce the length of stay and the left-without-being-seen rate with no impact on CTAS 3 patients seen in the main emergency department.

The impact of computerized provider order entry on emergency department flow.

OBJECTIVES: Computerized provider order entry (CPOE) has been established as a method to improve patient safety by avoiding medication errors; however, its effect on emergency department (ED) flow remains undefined. We examined the impact of CPOE implementation on three measures of ED throughput: wait time (WT), length of stay (LOS), and the proportion of patients that left without being seen (LWBS). METHODS: We conducted a retrospective cohort study of all ED patients of 18 years and older presenting to London Health Sciences Centre during July and August 2013 and 2014, before and after implementation of a CPOE system. The three primary variables were compared between time periods. Subgroup analyses were also conducted within each Canadian Triage and Acuity Scale (CTAS) level (1-5) individually, as well as for admitted patients only. RESULTS: A significant increase in WT of 5 minutes (p=0.036) and LOS of 10 minutes (p=0.001), and an increase in LWBS from 7.2% to 8.1% (p=0.002) was seen after CPOE implementation. Admitted patients' LOS increased by 63 minutes (p<0.001), the WT of CTAS 3 and 5 patients increased by 6 minutes (p=0.001) and 39 minutes (p=0.005), and LWBS proportion increased significantly for CTAS 3-5 patients, from 24.3% to 42.0% (p<0.001) for CTAS 5 patients specifically. CONCLUSIONS: CPOE implementation detrimentally impacted all patient flow throughput measures that we examined. The most striking clinically relevant result was the increase in LOS of 63 minutes for admitted patients. This raises the question as to whether the potential detrimental effects to patient safety of CPOE implementation outweigh its benefits.

Spinal epidural abscess.

Spinal epidural abscess is an uncommon condition. Predisposing factors include spinal surgery, recent trauma, immunosuppression, a distal site of infection and intravenous drug use; however, these are not always present, as illustrated by this case report describing a patient who had repeated emergency department visits and delayed diagnosis that was ultimately confirmed via magnetic resonance imaging.

Adult epiglottitis: a five-year retrospective chart review in a major urban centre.

OBJECTIVE: There is an increasing awareness of unvaccinated adults presenting with epiglottitis to the emergency department. This study examines the clinical presentations and outcomes of diagnosed cases of adult epiglottitis presenting to all emergency departments in Hamilton, Ont., between 1999 and 2003. METHODS: We employed explicit protocols with defined variables, trained abstractors and standardized abstraction forms, and reviewed all diagnosed cases of adult epiglottitis during a 5-year period. Inter-rater agreement was measured using a kappa statistic. RESULTS: Inter-rater reliability for data abstraction was kappa = 1. From a total of 1 million emergency department admissions, 54 cases of epiglottitis were identified. The mean age was 49, and 69% of the patients were male. The 3 most frequently documented symptoms were sore throat (100%) odynophagia (94%) and inability to swallow secretions (63%). The 2 most frequently documented signs were swelling of the epiglottis/supraglottis (100%), and tachycardia (53%). Organisms were isolated from blood in 11% of the cases. There was a white blood cell count >20 x 10(9)/L in 4 of the cases (7.4%). From the 54 cases, 9 of the patients were intubated and all patients were safely discharged from hospital. CONCLUSION: Adults presenting with epiglottitis to the emergency department in Hamilton have good outcomes, with less airway management required than previously reported in children. Further study is needed to see if these conclusions are similar in other populations.

Root cause analysis of laboratory turnaround times for patients in the emergency department.

INTRODUCTION: Laboratory investigations are essential to patient care and are conducted routinely in emergency departments (EDs). This study reports the turnaround times at an academic, tertiary care ED, using root cause analysis to identify potential areas of improvement. Our objectives were to compare the laboratory turnaround times with established benchmarks and identify root causes for delays. METHODS: Turnaround and process event times for a consecutive sample of hemoglobin and potassium measurements were recorded during an 8-day study period using synchronized time stamps. A log transformation (ln [minutes + 1]) was performed to normalize the time data, which were then compared with established benchmarks using one-sample t tests. RESULTS: The turnaround time for hemoglobin was significantly less than the established benchmark (n = 140, t = -5.69, p < 0.001) and that of potassium was significantly greater (n = 121, t = 12.65, p < 0.001). The hemolysis rate was 5.8%, with 0.017% of samples needing recollection. Causes of delays included order-processing time, a high proportion (43%) of tests performed on patients who had been admitted but were still in the ED waiting for a bed, and excessive laboratory process times for potassium. CONCLUSIONS: The turnaround time for hemoglobin (18 min) met the established benchmark, but that for potassium (49 min) did not. Root causes for delay were order-processing time, excessive queue and instrument times for potassium and volume of tests for admitted patients. Further study of these identified causes of delays is required to see whether laboratory TATs can be reduced.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department.

OBJECTIVES: The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED. METHODS: Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured. RESULTS: There was a higher level of agreement (κ  =  0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ  =  0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ  =  0.80; 95% CI 0.76-0.84). CONCLUSION: The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Triage tool inter-rater reliability: a comparison of live versus paper case scenarios.

BACKGROUND: Published studies of triage scale inter-rater reliability assessment have been conducted mostly using paper case scenarios. OBJECTIVE: To determine if this method of inter-rater reliability assessment generated significantly different measures from those generated from live triage cases. METHODS: This was a multicenter, prospective, observational cohort study of a population-based random sample of patients triaged at 2 emergency departments during a period of 4 months. All patients presenting to the emergency department within the study periods were simultaneously and independently triaged using a 5-level triage acuity scale by 2 to 3 research triage nurses blinded to each other's assessment and to the study objective. After 6 months, the same nurses were asked to assign triage scores to paper case scenarios of the same patients that they had each previously triaged. RESULTS: Each of the 9 research nurses triaged approximately 90 cases. The inter-rater reliabilities as measured by an intraclass correlation coefficient were 0.9 (95% CI = 0.87 to 93) for the live triage assessments and 0.76 (95% CI = 0.73 to 0.79) for the paper case scenarios. The mean triage score assigned to the live cases was significantly less than that assigned to the paper-based cases (3.17; 95% CI = 3.08 to 3.26) (p < 0.001). CONCLUSIONS: There is moderate to high agreement between live cases and paper case scenarios, and the inter-rater reliabilities, although significantly different, are acceptable in both cases. It is impossible to determine which triage setting provides a more accurate triage score but paper case scenarios generally receive lower triage scores than live cases.

Predictive validity of the triage risk screening tool for elderly patients in a Canadian emergency department.

PURPOSE: We sought to externally evaluate the predictive validity of the Triage Risk Screening Tool (TRST) for elderly patients in a Canadian setting. METHODS: A prospective, observational cohort study of a convenience sample of patients more than 64 years old was assessed using the TRST before discharge. The composite outcome of any emergency department (ED) revisit, hospital admission, or long-term care placement at 30 and 120 days was measured. Likelihood ratios (LRs) and 95% confidence intervals (CIs) were calculated. MAIN FINDINGS: Of 218 patients screened, 120 patients were enrolled. At 30 and 120 days, the positive LRs were 1.4 (95% CI, 0.9-2.0) and 1.4 (95% CI, 1.0-1.9), respectively. The negative LRs were 0.7 (95% CI, 0.4-1.3) and 0.7 (95% CI, 0.4-1.0), respectively. CONCLUSION: The TRST cannot be used as a single diagnostic test to predict whether Canadian ED elders will have an ED revisit, hospital admission, or long-term care placement at 30 or 120 days.

Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.

BACKGROUND: Diagnostic imaging of patients in the emergency department offers numerous opportunities for delay. In an era of ED overcrowding, it is important to identify causes of delay in caring for patients to minimize patient length of stay in the emergency department. OBJECTIVES: This study was intended to: (1) identify each of the steps involved in completing emergency diagnostic imaging investigations; (2) identify points of delay in the process; (3) identify the root causes for delay; and (4) perform a barrier analysis to provide insight into the contribution of the work environment and existing processes to delays. METHODS: This prospective, cross-sectional, modified time-in-motion study was conducted simultaneously at 3 urban emergency departments of a Canadian academic center over a 3-week period. Turnaround and process event times were recorded and a log transformation was performed to normalize the time data. Analysis of variance was used to examine individual time intervals between sites. Root cause and barrier analyses were conducted on the summary data. RESULTS: Analysis of 2297 cases revealed the mean turnaround time for one site was 50 minutes and significantly greater (P < .05) than the means of the other 2 sites (approximately 33 and 37 minutes, respectively). Root cause analysis identified 3 root causes of delay: (1) processing of radiograph request order by registered nurse; (2) transport times; and (3) radiology suite location. Barrier analysis indicated that current practices are responsible for the first 2 causes of delay. CONCLUSION: Both radiology and emergency department staffing considerations and workload contribute to delays in turnaround times of diagnostic imaging investigations.

Pneumatic tube delivery system for blood samples reduces turnaround times without affecting sample quality.

STUDY OBJECTIVES: In this study, blood samples from ED patients that were delivered to the laboratory by a pneumatic tube delivery system and by a human courier were compared for timeliness and quality of results. METHODS: We studied all consecutive measurements of serum hemoglobin and potassium ordered from 2 emergency departments of a multisite tertiary care hospital system, one with a pneumatic tube system and the other using human couriers. Turnaround time was measured from the time that the test was ordered by the physician to the time the result was reported on the hospital information system. Hemolysis was measured with use of a standardized, validated method. ANALYSIS: Times were normalized by log transformation (ln [minutes + 1]), and a comparison of sites was conducted using analysis of variance. Hemolysis rates of the 2 delivery systems were compared by chi2. RESULTS: There was no significant difference in hemolysis rate between the 2 methods of delivery (7/121 [5.79%] with a pneumatic tube system and 20/200 [10%] with a human courier). When delivered with a pneumatic tube system, the mean turnaround times (with ranges) for both hemoglobin (33 minutes [4-230]) and potassium (64 [34-208]) were shorter than those delivered by a human courier (43 minutes [3-150] and 72 [28-213], respectively). CONCLUSION: The use of a pneumatic tube delivery system for transporting blood samples from the emergency department to the laboratory can significantly reduce the turnaround times of results without a reduction in sample quality.

Coded Chief Complaints--automated analysis of free-text complaints.

OBJECTIVES: To describe a new chief-complaint categorization schema, the development of a computer text-parsing algorithm to automatically classify free-text chief complaints into this schema, and use of these coded chief complaints to describe the case mix of a community emergency department (ED). METHODS: Coded Chief Complaints for Emergency Department Systems (CCC-EDS) is a new and untested schema of 228 chief complaints, grouped within dimensions of type and system. A computerized text-parsing algorithm for automatically reading and classifying free-text chief complaints into 1 of these 228 coded chief complaints was developed by using a consecutive derivation sample of 46,602 patients who presented to a community teaching-hospital ED in 2004. Descriptive statistics included frequency of patients presenting with the 228 coded chief complaints; percentage of free-text complaints not categorizable by the CCC-EDS; and admission rate, age, and gender differences by chief complaint. RESULTS: In the derivation sample, the text-parsing algorithm classified 87.5% of 45,329 ED visits with non-null free-text chief complaints into 1 of 194 coded chief complaints. The text-parsing algorithm successfully classified 87.3% of the free-text chief complaints in a validation sample. The five most common coded chief complaints were Abdominal Pain (3,734 visits), Fever (2,234), Chest Pain (2,183), Breathing Difficulty (2,030), and Cuts-Lacerations (2,028). CONCLUSIONS: The CCC-EDS is a new comprehensive, granular, and useful classification schema for categorizing chief complaints in an ED. A CCC-EDS text-parsing algorithm successfully classified the majority of free-text chief complaints from an ED computer log. These coded chief complaints were used to describe the case mix of a community teaching-hospital ED.

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.