Are Emergency Medicine Provider Characteristics Associated With Diagnostic Imaging for Low Back Pain?

Background Low back pain (LBP) is one of the most common reasons for presentation to the emergency department (ED). LBP is most commonly non-specific or mechanical in nature yet can be debilitating. Diagnostic imaging (DI) is commonly ordered contrary to guideline recommendations for patients with LBP. This study seeks to determine if physician characteristics are associated with ordering of DI for patients with non-specific or mechanical LBP in the ED. These characteristics include physician sex, age, experience level, location of residency training, and full-time status. Methodology We included all patients presenting to the ED of a Canadian tertiary care center with a diagnosis of non-specific or mechanical LBP between January 2015 and June 2018. We tracked the use of DI for physicians caring for patients presenting to the ED over this period. Simple and multivariable logistic regression analyses were performed, controlling for patient characteristics, to identify provider characteristics that were independently associated with DI use. Results Internationally trained physicians were less likely to order diagnostic radiographs than Canadian trained physicians (odds ratio [OR], 0.625; 95% confidence interval [CI], 0.48-0.95), while middle-aged physicians ordered more computed tomography scans (OR, 6.34; 95% CI, 1.52-26.52) compared to younger physicians; there was no significant difference between younger and older physicians. Conclusions Few physician characteristics were associated with any DI ordering for non-specific or mechanical LBP. The likelihood of receiving DI for non-specific or mechanical LBP may be more strongly related to unmeasured patient characteristics, settings, or logistical factors.

End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study.

BACKGROUND: This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS: The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction. RESULTS: Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO2<90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048). CONCLUSIONS: The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic.

OBJECTIVES: 1) To evaluate whether transient ischemic attack (TIA) management in emergency departments (EDs) of the Nova Scotia Capital District Health Authority followed Canadian Best Practice Recommendations, and 2) to assess the impact of being followed up in a dedicated outpatient neurovascular clinic. METHODS: Retrospective chart review of all patients discharged from EDs in our district from January 1, 2011 to December 31, 2012 with a diagnosis of TIA. Cox proportional hazards models, Kaplan-Meier survival curve, and propensity matched analyses were used to evaluate 90-day mortality and readmission. RESULTS: Of the 686 patients seen in the ED for TIA, 88.3% received computed tomography (CT) scanning, 86.3% received an electrocardiogram (ECG), 35% received vascular imaging within 24 hours of triage, 36% were seen in a neurovascular clinic, and 4.2% experienced stroke, myocardial infarction, or vascular death within 90 days. Rates of antithrombotic use were increased in patients seen in a neurovascular clinic compared to those who were not (94% v. 86.3%, p<0.0001). After adjustment for age, sex, vascular disease risk factors, and stroke symptoms, the risk of readmission for stroke, myocardial infarction, or vascular death was lower for those seen in a neurovascular clinic compared to those who were not (adjusted hazard ratio 0.28; 95% confidence interval 0.08-0.99, p=0.048). CONCLUSION: The majority of patients in our study were treated with antithrombotic agents in the ED and investigated with CT and ECG within 24 hours; however, vascular imaging and neurovascular clinic follow-up were underutilized. For those with neurovascular clinic follow-up, there was an association with reduced risk of subsequent stroke, myocardial infarction, or vascular death.

The consent and prescription compliance (COPRECO) study: does obtaining consent in the emergency department affect study results in a telephone follow-up study of medication compliance?

OBJECTIVES: The objectives were to determine whether mandated research requirements for consent in the emergency department (ED) falsely distorts the results of a survey of patient-reported compliance with ED prescriptions and, in addition, to ascertain the level of patient compliance to medication instructions and find out the degree of displeasure expressed by patients called without prior consent. METHODS: Patients given new prescriptions for a medicine to be taken regularly over a period of less than 30 days were eligible. A convenience sample of eligible patients was randomized to having consent obtained during their ED visit or at the time of telephone follow-up. Patients were called 7-10 days after their ED visit to determine their compliance with the prescription. Compliance rates between the two groups were compared, as was the prevalence of displeasure expressed by patients called without prior consent. RESULTS: Of 430 enrolled patients, 221 were randomized to receive ED consent for telephone follow-up, and 209 received telephone follow-up without prior ED consent. Telephone follow-up was successful in 318 patients (74%). The rate of noncompliance was slightly higher in the group without ED consent, 74/149 (50%; 95% confidence interval [CI] = 41% to 58%) than the group who gave ED consent for telephone follow-up, 67/169 (40%; 95% CI = 32% to 42%; p = 0.07). Among the two groups, 141/318 (44%) did not fill the prescription (n = 42) or took it incorrectly (n = 99). Only 1 (0.7%) of the 149 patients with successful telephone follow-up without prior ED consent expressed displeasure at this telephone call. CONCLUSIONS: Medicine noncompliance is a significant issue for patients discharged from the ED in this study. Although there was a trend toward greater compliance in patients who consented to the follow-up call, this did not reach statistical significance. ED patients do not object to receiving telephone follow-up for a research survey without giving prior consent.

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

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

Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients.

OBJECTIVE: Several randomized controlled trials have suggested that mild induced hypothermia may improve neurologic outcome in comatose cardiac arrest survivors. This systematic review of randomized controlled trials was designed to determine if mild induced hypothermia improves neurologic outcome, decreases mortality, or is associated with an increased incidence of adverse events. DATA SOURCES: The following databases were reviewed: Cochrane Controlled Trials Register (Issue 4, 2005), MEDLINE (January 1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1982 to November 2005) and Web of Science (1989 to November 2005). For each included study, references were reviewed and the primary author contacted to identify any additional studies. STUDY SELECTION: Studies that met inclusion criteria were randomized controlled trials of adult patients (>18 years of age) with primary cardiac arrest who remained comatose after return of spontaneous circulation. Patients had to be randomized to mild induced hypothermia (32 degrees C-34 degrees C) or normothermia within 24 hours of presentation. Only studies reporting pre-determined outcomes including discharge neurologic outcome, mortality or significant treatment-related adverse events were included. There were no language or publication restrictions. DATA SYNTHESIS: Four studies involving 436 patients, with 232 cooled to a core temperature of 32 degrees C-34 degrees C met inclusion criteria. Pooled data demonstrated that mild hypothermia decreased in-hospital mortality (relative ratio [RR] 0.75; 95% confidence interval [CI], 0.62-0.92) and reduced the incidence of poor neurologic outcome (RR 0.74; 95% CI, 0.62-0.84). Numbers needed to treat were 7 patients to save 1 life, and 5 patients to improve neurologic outcome. There was no evidence of treatment-limiting side effects. CONCLUSIONS: Therapeutically induced mild hypothermia decreases in-hospital mortality and improves neurologic outcome in comatose cardiac arrest survivors. The possibility of treatment-limiting side effects cannot be excluded.