Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program.

The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.

Door-To-Triage Time in a Canadian Tertiary-Care Center.

BACKGROUND: The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional. OBJECTIVE: We sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada. METHODS: Data were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance. RESULTS: Seven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1-86 min) with a median of 12 min (interquartile range [IQR] 6-21 min). Patients in the 5th percentile with the longest DTT waited a median of 54 min (IQR 48-63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11-43] min) and the shortest on Sunday (median 8 [IQR 5-12] min). There was no relationship between DTT and CTAS (p = 0.12). CONCLUSIONS: DTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.

Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure.

BACKGROUND: Improved risk stratification of acute heart failure in the emergency department may inform physicians' decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality. METHODS: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals. We surveyed physicians for their estimates of 7-day mortality risk, obtained for each patient before knowledge of the model predictions, and compared these with EHMRG7 for discrimination and net reclassification improvement. We also prospectively examined discrimination of the EHMRG30-ST model, which incorporates all components of EHMRG7 as well as the presence of ST-depression on the 12-lead ECG. RESULTS: We recruited 1983 patients seeking emergency department care for acute heart failure. Mortality rates at 7 days in the 5 risk groups (very low, low, intermediate, high, and very high risk) were 0%, 0%, 0.6%, 1.9%, and 3.9%, respectively. At 30 days, the corresponding mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%. Compared with physician-estimated risk of 7-day mortality (PER7; c-statistic, 0.71; 95% CI, 0.64-0.78) there was improved discrimination with EHMRG7 (c-statistic, 0.81; 95% CI, 0.75-0.87; P=0.022 versus PER7) and with EHMRG7 combined with physicians' estimates (c-statistic, 0.82; 95% CI, 0.76-0.88; P=0.003 versus PER7). Model discrimination increased nonsignificantly by 0.014 (95% CI, -0.009-0.037) when physicians' estimates combined with EHMRG7 were compared with EHMRG7 alone ( P=0.242). The c-statistic for EHMRG30-ST alone was 0.77 (95% CI, 0.73-0.81) and 30-day model discrimination increased nonsignificantly by addition of physician-estimated risk to 0.78 (95% CI, 0.73-0.82; P=0.187). Net reclassification improvement with EHMRG7 was 0.763 (95% CI, 0.465-1.062) when assessed continuously and 0.820 (0.560-1.080) using risk categories compared with PER7. CONCLUSIONS: A clinical model allowing simultaneous prediction of mortality at both 7 and 30 days identified acute heart failure patients with a low risk of events. Compared with physicians' estimates, our multivariable model was better able to predict 7-day mortality and may guide clinical decisions. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02634762.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool.

STUDY OBJECTIVE: The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS. METHODS: This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs). RESULTS: A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds). CONCLUSION: A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients.

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.

The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less.

BACKGROUND: Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between out-of-hospital intubation and increased mortality for severe traumatic brain injury. OBJECTIVES: To explore the relationship between out-of-hospital intubation attempts and outcome among trauma patients with Glasgow Coma Scale (GCS) scores ≤ 8 across sites participating in the Resuscitation Outcomes Consortium (ROC). METHODS: The ROC Epistry-Trauma, an epidemiologic database of prehospital encounters with critically injured trauma victims, was used to identify emergency medical services (EMS)-treated patients with GCS scores ≤ 8. Multiple logistic regression was used to explore the association between intubation attempts and vital status at discharge, adjusting for the following covariates: age, gender, GCS score, hypotension, mechanism of injury, and ROC site. Sites were then stratified by frequency of intubation attempts and chi-square test for trend was used to associate the frequency of intubation attempts with outcome. RESULTS: A total of 1,555 patients were included in this analysis; intubation was attempted in 758 of these. Patients in whom intubation was attempted had higher mortality (adjusted odds ratio [OR] 2.91, 95% confidence interval [CI] 2.13-3.98, p < 0.01). However, sites with higher rates of attempted intubation had lower mortality across all trauma victims with GCS scores ≤ 8 (OR 1.40, 95% CI 1.15-1.72, p < 0.01). CONCLUSIONS: Patients in whom intubation is attempted have higher adjusted mortality. However, sites with a higher rate of attempted intubation have lower adjusted mortality across the entire cohort of trauma patients with GCS scores ≤ 8. Coma Scale score.

A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments.

BACKGROUND: The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments. METHODS: We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head. RESULTS: Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the "before" period (62.8%) to the "after" period (76.2%) (difference +13.3%, 95% CI 9.7%-17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%-10.8%). The change in mean imaging rates from the "before" period to the "after" period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes. INTERPRETATION: Our knowledge-translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252).

The impact of delays to admission from the emergency department on inpatient outcomes.

BACKGROUND: We sought to determine the impact of delays to admission from the Emergency Department (ED) on inpatient length of stay (LOS), and IP cost. METHODS: We conducted a retrospective analysis of 13,460 adult (>or= 18 yrs) ED visits between April 1 2006 and March 30 2007 at a tertiary care teaching hospital with two ED sites in which the mode of disposition was admission to ICU, surgery or inpatient wards. We defined ED Admission Delay as ED time to decision to admit > 12 hours. The primary outcomes were IP LOS, and total IP cost. RESULTS: Approximately 11.6% (n = 1558) of admitted patients experienced admission delay. In multivariate analysis we found that admission delay was associated with 12.4% longer IP LOS (95% CI 6.6% - 18.5%) and 11.0% greater total IP cost (6.0% - 16.4%). We estimated the cumulative impact of delay on all delayed patients as an additional 2,183 inpatient days and an increase in IP cost of $2,109,173 at the study institution. CONCLUSIONS: Delays to admission from the ED are associated with increased IP LOS and IP cost. Improving patient flow through the ED may reduce hospital costs and improve quality of care. There may be a business case for investments to reduce emergency department admission delays.

Comparison of the Cerebral Performance Category score and the Health Utilities Index for survivors of cardiac arrest.

STUDY OBJECTIVE: The Cerebral Performance Category score is an easy to use but unvalidated measure of functional outcome after cardiac arrest. We evaluate the comparability of results from the Cerebral Performance Category scale versus those of the validated but more complex Health Utilities Index scale for health-related quality of life. METHODS: This prospective substudy of the Ontario Prehospital Advanced Life Support (OPALS) Study included adult out-of-hospital cardiac arrest patients treated in 20 cities. This prospective cohort study included all survivors of out-of-hospital adult cardiac arrest enrolled in phase II (rapid basic life support with defibrillation) and phase III (advanced life support) of the OPALS Study, as well as the intervening run-in phase. Survivors were interviewed at 12 months for Cerebral Performance Category Score and the Health Utilities Index Mark 3 (Health Utilities Index). RESULTS: Of 8,196 eligible out-of-hospital cardiac arrest patients between 1995 and 2002, 418 (5.1%) survived to discharge, and 305 (3.7%) completed the Health Utilities Index interview and had Cerebral Performance Category scored at 12 months. The 305 patients had the following data: mean age 63.9 years; male 78.0%; paramedic-witnessed arrest 25.6%; bystander cardiopulmonary resuscitation 32.1%; initial rhythm ventricular fibrillation/ventricular tachycardia 86.9%, Cerebral Performance Category 1 267, Cerebral Performance Category 2 26, Cerebral Performance Category 3 12. Overall, the median scores (interquartile range) were Cerebral Performance Category 1 (1 to 1) and Health Utilities Index 0.84 (0.61 to 0.97). The Cerebral Performance Category score ruled out good quality of life (Health Utilities Index >0.80), with a sensitivity of 100% (95% confidence interval [CI] 98% to 100%) and specificity 27.1% (95% CI 20% to 35%); thus, when the Cerebral Performance Category score was 2 or 3, it was unlikely that the Health Utilities Index score would be good. The Cerebral Performance Category score had sensitivity 55.6% (95% CI 42% to 67%) and specificity 96.8% (95% CI 94% to 98%) for predicting poor quality of life (Health Utilities Index >0.40); ie, when Cerebral Performance Category was 1, it was highly unlikely that the Health Utilities Index score would be poor. The weighted kappa was 0.39 and the interclass correlation was 0.51. CONCLUSION: This represents the largest study yet conducted of the performance of the Cerebral Performance Category score in 1-year survivors of out-of-hospital cardiac arrest. Overall, the Cerebral Performance Category score classified patients well for their quality of life, ruling out a good Health Utilities Index score with high sensitivity and ruling in poor Health Utilities Index score with high specificity. The Cerebral Performance Category is an important tool in that it indicates broad functional outcome categories that are useful for a number of key clinical and research applications but should not be considered a substitute for the Health Utilities Index.

Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers.

STUDY OBJECTIVE: To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest. METHODS: Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation. RESULTS: A total of 18,987 patients met criteria and 15,559 (81.9%) had complete data for analysis (study group). Return of spontaneous circulation was achieved in 2,299 patients (14.8%), and 689 (4.4%) survived to hospital discharge. Median transport interval was 4.0 minutes (25th quartile 3.0 minutes; 75th quartile 6.2 minutes) for survivors and 4.2 minutes (25th quartile 3.0, 75th quartile 6.2) for nonsurvivors. Logistic regression revealed multiple factors that were independently associated with survival: witnessed arrest (odds ratio 2.61; 95% confidence interval [CI] 2.05 to 3.34), bystander cardiopulmonary resuscitation (odds ratio 2.22; 95% CI 1.82 to 2.70), initial rhythm of ventricular fibrillation/tachycardia (odds ratio 2.22; 95% CI 1.97 to 2.50), and shorter emergency medical services (EMS) response interval (odds ratio 1.26; 95% CI 1.20 to 1.33). There was no association between transport interval and survival in either the study group (odds ratio 1.01; 95% CI 0.99 to 1.05) or the return of spontaneous circulation subgroup (odds ratio 1.04; 95% CI 0.99, 1.08). CONCLUSION: In a large out-of-hospital cardiac arrest study from demographically diverse EMS systems, longer transport interval was not associated with decreased survival. Given the growing evidence showing major influence from specialized postarrest care, these findings support conducting clinical trials that assess the effectiveness and safety of bypassing local hospitals to take patients to regional cardiac arrest centers.

Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis.

BACKGROUND: Several diagnostic strategies using ultrasound imaging, measurement of D-dimer, and assessment of clinical probability of disease have proved safe in patients with suspected deep-vein thrombosis, but they have not been compared in randomized trials. METHODS: Outpatients presenting with suspected lower-extremity deep-vein thrombosis were potentially eligible. Using a clinical model, physicians evaluated the patients and categorized them as likely or unlikely to have deep-vein thrombosis. The patients were then randomly assigned to undergo ultrasound imaging alone (control group) or to undergo D-dimer testing (D-dimer group) followed by ultrasound imaging unless the D-dimer test was negative and the patient was considered clinically unlikely to have deep-vein thrombosis, in which case ultrasound imaging was not performed. RESULTS: Five hundred thirty patients were randomly assigned to the control group, and 566 to the D-dimer group. The overall prevalence of deep-vein thrombosis or pulmonary embolism was 15.7 percent. Among patients for whom deep-vein thrombosis had been ruled out by the initial diagnostic strategy, there were two confirmed venous thromboembolic events in the D-dimer group (0.4 percent; 95 percent confidence interval, 0.05 to 1.5 percent) and six events in the control group (1.4 percent; 95 percent confidence interval, 0.5 to 2.9 percent; P=0.16) during three months of follow-up. The use of D-dimer testing resulted in a significant reduction in the use of ultrasonography, from a mean of 1.34 tests per patient in the control group to 0.78 in the D-dimer group (P=0.008). Two hundred eighteen patients (39 percent) in the D-dimer group did not require ultrasound imaging. CONCLUSIONS: Deep-vein thrombosis can be ruled out in a patient who is judged clinically unlikely to have deep-vein thrombosis and who has a negative D-dimer test. Ultrasound testing can be safely omitted in such patients.

Outpatient oral prednisone after emergency treatment of chronic obstructive pulmonary disease.

BACKGROUND: In this randomized, double-blind, placebo-controlled trial, we studied the effectiveness of prednisone in reducing the risk of relapse after outpatient exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We enrolled 147 patients who were being discharged from the emergency department after an exacerbation of COPD and randomly assigned them to 10 days of treatment with 40 mg of oral prednisone once daily or identical-appearing placebo. All patients received oral antibiotics for 10 days, plus inhaled bronchodilators. The primary end point was relapse, defined as an unscheduled visit to a physician's office or a return to the emergency department because of worsening dyspnea, within 30 days after randomization. RESULTS: The overall rate of relapse at 30 days was lower in the prednisone group than in the placebo group (27 percent vs. 43 percent, P=0.05), and the time to relapse was prolonged in those taking prednisone (P=0.04). After 10 days of therapy, patients in the prednisone group had greater improvements in forced expiratory volume in one second than did patients in the placebo group (mean [+/-SD] increase from base line, 34+/-42 percent vs. 15+/-31 percent; P=0.007). Patients in the prednisone group also had significant improvements in dyspnea, as measured by the transitional dyspnea index (P=0.04) and by the dyspnea domain of the Chronic Respiratory Disease Index Questionnaire (P=0.02), but not in health-related quality of life (P=0.14). CONCLUSIONS: Outpatient treatment with oral prednisone offers a small advantage over placebo in treating patients who are discharged from the emergency department with an exacerbation of COPD.

The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.

BACKGROUND: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance. METHODS: We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography. RESULTS: Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries. CONCLUSIONS: For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.

Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis.

BACKGROUND: We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions. METHODS: Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators. RESULTS: Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26). CONCLUSIONS: These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.

CONTEXT: Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists. OBJECTIVE: To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury. DESIGN, SETTING, AND PATIENTS: In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15. MAIN OUTCOME MEASURES: Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview. RESULTS: Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The kappa values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. CONCLUSION: For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.

The University of Michigan Student Health Physics Society's Radiation and Health Physics World Wide Web Site.

The University of Michigan Student Health Physics Society's (UMSHPS) Radiation and Health Physics World Wide Web Site is an informative database of radiation and health physics related topics. With over 1,000 visitors each day, the UMSHPS web site provides professionals and the general public with a valuable resource for information and research. Users of this site can either search for information by topic or submit questions directly to the qualified members the national Health Physics Society. During the past year, progress has been made in replacing the site's older, less versatile framework with new search engines and refined submittal forms, as well as a "Frequently Asked Questions" section. Within the database, references will include brief summaries of the site's available information and target audience. Although these changes have been beneficial for the site, the UMSHPS continuously seeks professional opinions and ideas to further the services that this online resource can provide to the profession and to the general public.

Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments.

STUDY OBJECTIVE: We evaluate the accuracy, reliability, and potential impact of the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria for cervical spine radiography, when applied in Canadian emergency departments (EDs). METHODS: The Canadian C-Spine Rule derivation study was a prospective cohort study conducted in 10 Canadian EDs that recruited alert and stable adult trauma patients. Physicians completed a 20-item data form for each patient and performed interobserver assessments when feasible. The prospective assessments included the 5 individual NEXUS criteria but not an explicit interpretation of the overall need for radiography according to the criteria. Patients underwent plain radiography, flexion-extension views, and computed tomography at the discretion of the treating physician. Patients who did not have radiography were followed up with a structured outcome assessment by telephone to determine clinically important cervical spine injury, a previously validated outcome measurement. Analyses included sensitivity and specificity with 95% confidence interval (CI), kappa coefficient, and potential radiography rates. RESULTS: Among 8,924 patients, 151 (1.7%) patients had an important cervical spine injury. The combined NEXUS criteria identified important cervical spine injury with a sensitivity of 92.7% (95% CI 87% to 96%) and a specificity of 37.8% (95% CI 37% to 39%). Application of the NEXUS criteria would have potentially reduced cervical spine radiography rates by 6.1% from the actual rate of 68.9% to 62.8%. Of 11 patients with important injuries not identified, 2 were treated with internal fixation and 3 with a halo. CONCLUSION: This retrospective validation found the NEXUS low-risk criteria to be less sensitive than previously reported. The NEXUS low-risk criteria should be further explicitly and prospectively evaluated for accuracy and reliability before widespread clinical use outside of the United States.

Transport refusal by hypoglycemic patients after on-scene intravenous dextrose.

OBJECTIVES: Administration of intravenous (IV) dextrose to hypoglycemic patients is delegated to advanced care paramedics in Ontario. Following a quality assurance review, which revealed that 47% of patients refused transport after receiving IV dextrose, the authors studied whether such patients seek additional medical care in the three days following the initial refusal. METHODS: Sequential ambulance call reports for on-scene treatments of hypoglycemia were examined, and a standardized telephone survey of the patients was conducted. Patient satisfaction was assessed using a five-point Likert scale. Data were collected from April 1999 to March 2000. RESULTS: One hundred patients were studied, with ages ranging from 20 to 92 years (mean 53.2 years). The average Glasgow Coma Scale (GCS) score on presentation was 8.7 +/- 3.5. The average blood glucose level before administration of IV dextrose was 1.91 +/- 0.63 mmol/L. Sixty-eight percent of the patients refused transport. Significant differences between the transported group and the refusal group were age (transported 64.7 years, refused 47.8 years, p = 0.002) and initial blood glucose (transported 1.8, refused 2.1, p = 0.001). No difference was found in terms of repeat access to health care for related complaints. Patient satisfaction was high in both groups, with no difference in the overall satisfaction with paramedics' care (4.76 +/- 0.58 vs 4.75 +/- 0.45). CONCLUSIONS: The practice of treating patients for symptomatic hypoglycemia and leaving them at the scene appears to be safe. Further study is required to confirm this.

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice.

OBJECTIVE: To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE). METHODS: An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs. RESULTS: The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5-2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4-9.4]). CONCLUSIONS: Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.

Differential survival for men and women from out-of-hospital cardiac arrest varies by age: results from the OPALS study.

BACKGROUND: The effect of sex on survival in out-of-hospital cardiac arrest (OHCA) is controversial. Some studies report more favorable outcomes in women, while others suggest the opposite, citing disparities in care. Whether sex predicts differential age-specific survival is still uncertain. OBJECTIVES: The objective was to study the sex-associated variation in survival to hospital discharge in OHCA patients as well as the relationship between age and sex for predicting survival. METHODS: The Ontario Prehospital Advanced Life Support (OPALS) registry, collected in a large study of rapid defibrillation and advanced life support programs, is Utstein-compliant and has data on OHCA patients (1994 to 2002) from 20 communities in Ontario, Canada. All adult OHCAs not witnessed by emergency medical services (EMS) and treated during one of the three main OPALS phases were included. Clinically significant variables were chosen a priori (age, sex, witnessed arrest, initial cardiopulmonary resuscitation [CPR], shockable rhythm, EMS response interval, and OPALS study phase) and entered into a multivariable logistic regression model with survival to hospital discharge as the outcome, with sex and age as the primary risk factors. Fractional polynomials were used to explore the relationship between age and survival by sex. RESULTS: A total of 11,479 (out of 20,695) OPALS cases met inclusion criteria and 10,862 (94.6%) had complete data for regression analysis. As a group, women were older than men (median age = 74 years vs. 69 years, p < 0.01), had fewer witnessed arrests (43% vs. 49%; p < 0.01), had fewer initial ventricular fibrillation/ventricular tachycardia rhythms (24% vs. 42%; p < 0.01), had a lower rate of bystander CPR (12% vs. 17%; p < 0.01), and had lower survival (1.7% vs. 3.2%; p < 0.01). Survival to hospital admission and return of spontaneous circulation did not differ between women and men (p > 0.05). The relationship between age, sex, and survival to hospital discharge could not be analyzed in a single regression model, as age did not have a linear relationship with survival for men, but did for women. Thus, age was kept as a continuous variable for women but was transformed for men using fractional polynomials [ln(age) + age(3) ]. In sex-stratified regression models, the adjusted probability of survival for women decreased as age increased (adjusted odds ratio = 0.88, 95% confidence interval = 0.81 to 0.96, per 5-year increase in age) while for men, the probability of survival initially increased with age until age 65 years and then decreased with increasing age. Women had a higher probability of survival until age 47 years, after which men maintained a higher probability of survival. CONCLUSIONS: Overall OHCA survival for women was lower than for men in the OPALS study. Factors related to the sex differences in survival (rates of bystander CPR and shockable rhythms) may be modifiable. The probability of survival differed across age for men and women in a nonlinear fashion. This differential influence of age on survival for men and women should be considered in future studies evaluating survival by sex in OHCA population.