"They heard our voice!" patient engagement councils in community-based primary care practices: a participatory action research pilot study.

BACKGROUND: Patient engagement could improve the quality of primary care practices. However, we know little about effective patient engagement strategies. We aimed to assess the acceptability and feasibility of embedding advisory councils of clinicians, managers, patients and caregivers to conduct patient-oriented quality improvement projects in primary care practices. METHODS: Using a participatory action research approach, we conducted our study in two non-academic primary care practices in Quebec City (Canada). Patient-experts (patients trained in research) were involved in study design, council recruitment and meeting facilitation. Advisory councils were each to include patients and/or caregivers, clinicians and managers. Over six meetings, councils would identify quality improvement priorities and plan projects accordingly. We assessed acceptability and feasibility of the councils using non-participant observations, audio-recordings and self-administered questionnaires. We used descriptive analyses, triangulated qualitative data and performed inductive thematic analysis. RESULTS: Between December 2017 and June 2018, two advisory councils were formed, each with 11 patients (36% male, mean age 53.8 years), a nurse and a manager practising as a family physician (25% male, mean age 45 years). The six meetings per practice occurred within the study period with a mean of eight patients per meeting. Councils worked on two projects each: the first council on a new information leaflet about clinic organization and operation, and on communications about local public health programs; the second on methods to further engage patients in the practice, and on improving the appointment scheduling system. Median patient satisfaction was 8/10, and 66.7% perceived councils had an impact on practice operations. They considered involvement of a manager, facilitation by patient-experts, and the fostering of mutual respect as key to this impact. Clinicians and managers liked having patients as facilitators and the respect among members. Limiting factors were difficulty focusing on a single feasible project and time constraints. Managers in both practices were committed to pursuing the councils post-study. CONCLUSION: Our results indicated that embedding advisory councils of clinicians, managers, patients and caregivers to conduct patient-oriented quality improvement projects in primary care practices is both acceptable and feasible. Future research should assess its transferability to other clinical contexts.

Potential benefits of incentive spirometry following a rib fracture: a propensity score analysis.

CLINICIAN'S CAPSULEWhat is known about the topic?Literature regarding the impact of incentive spirometry on patients with rib fractures is unclear; there are no recommendations for its use in the emergency department (ED).What did this study ask?The objective of this study was to assess the impact of incentive spirometry on delayed complications in patients with rib fractures in the ED.What did this study find?Unsupervised incentive spirometry use does not have a protective effect against delayed pulmonary complications after a rib fracture.Why does this study matter to clinicians?Clear guidelines for incentive spirometry use for patients with rib fractures and further research to assess its usefulness in other ED populations are needed.

OBJECTIFS: La spirométrie incitative est parfois prescrite en vue d'encourager le rétablissement de la fonction respiratoire. Toutefois, peut de littérature est disponible sur la spirométrie incitative et ses effets chez les patients avec fracture de côtes, et il n'existe pas de recommandation sur son utilisation au département des urgences (DU), tout particulièrement pour les fractures de côtes, qui sont reconnues pour accroître le risque de complications pulmonaires. Cette étude visait donc à évaluer l'utilisation de la spirométrie incitative et à mesurer son impact sur l'incidence de complications tardives chez les patients ayant été libéré de l'urgence après une confirmation de fracture de côtes. MÉTHODE: Il s'agit d'une sous-étude planifiée d'une étude observationnelle de cohorte prospective, qui a eu lieu dans 4 DU au Canada, entre novembre 2006 et mai 2012. Des patients âgés de 16 ans et plus, non hospitalisés, avec au moins une fracture de côte confirmée par radiographie ont été sélectionnés. La décision de prescrire la spirométrie incitative était laissée à la discrétion du médecin traitant. Les principaux résultats consistaient en l'apparition d'une pneumonie, d'atélectasie ou d'un hémothorax dans les 14 jours suivant le traumatisme. Des analyses d'appariement des coefficients de propension ont été réalisées. RÉSULTATS: Un total de 439 patients ont participé à l'étude, dont 182 (41,5%) ont été reçu la spirométrie incitative. 99 cas d'hémothorax (22,6%), 103 cas d'atélectasie (23,5%) et 4 cas de pneumonie (0,9%) ont été observés. Nos résultats indiquent que la spirométrie incitative ne semble pas un moyen de protection contre l'hémothorax (risque relatif [RR] = 1,03 [0,66­1,64]) ni contre l'atélectasie ou la pneumonie (RR = 1,07 [0,68­1,72]). CONCLUSION: Nos résultats suggèrent que la spirométrie incitative non supervisée n'offrirait pas d'effet protecteur contre l'apparition tardive de complications pulmonaires à la suite d'une fracture de côtes. D'autres recherches sont nécessaires afin de valider la pertinence de prescrire la spirométrie incitative au DU, chez certains groupes de blessés plus spécifiques.

How to engage patients in research and quality improvement in community-based primary care settings: protocol for a participatory action research pilot study.

PLAIN ENGLISH SUMMARY: Making primary care clinics more patient-centered is key to improving patients' experience of care. If patients themselves were engaged in helping define priorities and suggesting quality improvements in the clinic, care would respond better to their needs. However, patient engagement is a new phenomenon, particularly in community based primary care clinics. How to engage patients in quality improvement in these clinics, or what effect this might have, is not well known. The involvement of patients needs to be adapted to the way these clinics function. The aim of this study is to create and evaluate a new model of patient engagement for quality improvement in community based primary care clinics. Patients, primary care professionals and researchers will create advisory councils in two primary care clinics in Quebec City (Canada). In each clinic, the advisory council will include 12 patients or caregivers registered at the clinic, a clinician and a clinic manager. The advisory council will meet every 6 weeks for a total of six meetings. Two patient-experts will facilitate meetings. During meetings, members of the council will list their needs in order of importance. Then they will suggest improvements in line with these needs. We will study if our advisory council model is well adapted to community based primary care settings and meets participants' expectations. At the end of the study we will be able to offer guidance about engaging patients with health professionals in quality improvement in primary care clinics. ABSTRACT: Background Involvement of end-users, including patients, managers and clinicians, in identifying quality improvement and research priorities might improve the relevance of projects and increase their impact. Few patient engagement initiatives have taken place in community based primary care practices (CBPCPs) and best practices for engaging patients in such settings are not well defined. The aim of this pilot study is to develop and assess the feasibility of a new collaborative model of advisory council involving clinicians, managers, patients and caregivers in CBPCP to strengthen their capacity to conduct quality improvement and patient-oriented research projects. Methods We will conduct a participatory action research project in two non-academic CBPCPs in Quebec City (Canada). In each CBPCP, the advisory council will include 12 patients or caregivers, a clinician and a clinic manager. Patients or their caregivers will be identified by clinicians and contacted by patient-experts. They will be eligible if they are registered at the practice, motivated, and available to attend meetings. The council will meet every 6 weeks for a total of six meetings. Two patient-experts will guide council members to identify quality improvement priorities and patient-oriented research questions based on their experience in the clinic. They will then be supported to plan actions to target these priorities. Analysis of meetings will be based on feasibility criteria, notes by non-participant observers in log books, audio-recording of the meetings and questionnaires to evaluate council members' perceptions and the likelihood they would engage in such councils. Discussion The results of this study will  be a model of patient engagement and a discussion of factors to improve the model to fit the needs of primary care patients and professionals. This will lay the foundation for a sustainable structure for long-term patient engagement and contribute to the development of a patient-centered and quality-improvement culture in CBPCPs.

Clinical prediction rule for delayed hemothorax after minor thoracic injury: a multicentre derivation and validation study.

BACKGROUND: About 75% of patients with minor thoracic injury are discharged after an emergency department visit. However, complications such as delayed hemothorax can occur. We sought to derive and validate a clinical decision rule to predict hemothorax in patients discharged from the emergency department. METHODS: We conducted a 6-year prospective cohort study in 4 university-affiliated emergency departments. Patients aged 16 years or older presenting with a minor thoracic injury were assessed at 5 time points (initial visit and 7, 14, 30 and 90 d after the injury). Radiologists' reports were reviewed for the presence of hemothorax. We used log-binomial regression models to identify predictors of hemothorax. RESULTS: A total of 1382 patients were included: 830 in the derivation phase and 552 in the validation phase. Of these, 151 (10.9%) had hemothorax at the 14-day follow-up. Patients 65 years of age or older represented 25.3% (210/830) and 23.7% (131/552) of the derivation and validation cohorts, respectively. The final clinical decision rule included a combination of age (> 70 yr, 2 points; 45-70 yr, 1 point), fracture of any high to mid thorax rib (ribs 3-9, 2 points) and presence of 3 or more rib fractures (1 point). Twenty (30.8%) of the 65 high-risk patients (score ≥ 4) experienced hemothorax during the follow-up period. The clinical decision rule had a high specificity (90.7%, 95% confidence interval 87.7%-93.1%) in this high-risk group, thus guiding appropriate post-emergency care. INTERPRETATION: One patient out of every 10 presented with delayed hemothorax after discharge from the emergency department. Implementation of this validated clinical decision rule for minor thoracic injury could guide emergency discharge plans.

Effect of measuring vital signs on recognition and treatment of septic children.

BACKGROUND AND OBJECTIVES: A majority of children presenting with sepsis do not receive adequate fluid resuscitation and have a delay in antibiotic administration despite recommendations from the Surviving Sepsis Campaign. The objective of this study was to evaluate the association of measuring a complete set of five vital signs in the emergency department (ED) with recognition and treatment of septic children presenting to the ED. METHODS: Records of 218 patients aged 1 month to 17 years treated between February 2011 and December 2011 in a single academic centre with clinical criteria of sepsis, severe sepsis or septic shock were retrospectively evaluated. The presence or absence of complete vital signs was analyzed in relation to timing of fluid resuscitation, and if antibiotics were given in the first hour of medical evaluation. RESULTS: Seventy-six per cent of children who had all five vital signs measured in the ED received fluid resuscitation in the first hour after medical evaluation as opposed to 61% of those who had an incomplete set of vital signs (P<0.04). Twenty per cent of children who had all five vital signs measured received antibiotics in the first hour as opposed to 9% in children who had fewer vital signs measured (P<0.02). CONCLUSION: In our study population, the measurement of all vital signs in the ED, including blood pressure, was associated with faster administration of antibiotics and improved compliance with existing fluid bolus recommendations, which may have been the result of better recognition of sepsis in children through vital signs measurement.

L'effet de la mesure des signes vitaux pour dépister et traiter les enfants atteints de sepsis. HISTORIQUE ET OBJECTIFS: La majorité des enfants ayant un sepsis ne reçoivent pas de solutés de réanimation et doivent attendre avant de se faire administrer des antibiotiques, malgré les recommandations de la Surviving Sepsis Campaign. La présente étude visait à évaluer l'association entre la mesure de l'ensemble des cinq signes vitaux à la salle d'urgence (SU) et le dépistage et le traitement des enfants atteints de sepsis qui s'y présentaient. MÉTHODOLOGIE: Les dossiers de 218 patients de 11 mois à 17 ans traités entre février et décembre 2011 dans un seul centre universitaire en raison de critères cliniques de sepsis, de grave sepsis ou de choc septique ont fait l'objet d'une évaluation rétrospective. Les chercheurs ont analysé le lien entre la présence ou l'absence de tous les signes vitaux et le moment d'administrer des solutés de réanimation et ont vérifié si des antibiotiques avaient été administrés dans l'heure suivant l'évaluation médicale. RÉSULTATS: Au total, 76 % des enfants dont les cinq signes vitaux avaient été mesurés à la SU avaient reçu des solutés de réanimation dans l'heure suivant leur évaluation médicale, par rapport à 61 % de ceux dont les signes vitaux n'avaient pas tous été mesurés (P<0,04). De plus, 20 % des enfants dont les cinq signes vitaux avaient été mesurés à la SU avaient reçu des antibiotiques dans l'heure suivant leur évaluation médicale, par rapport à 9 % de ceux dont les signes vitaux n'avaient pas tous été mesurés (P<0,02). CONCLUSION: Au sein de la population à l'étude, la mesure de tous les signes vitaux en SU, y compris la tension artérielle, s'associait à une administration plus rapide d'antibiotiques et à une meilleure compliance aux recommandations sur le bolus de liquide, ce qui peut être attribuable à un meilleur dépistage du sepsis chez les enfants grâce à la mesure des signes vitaux.

Feasibility of emergency department point-of-care ultrasound for rib fracture diagnosis in minor thoracic injury.

OBJECTIVES: The main objective of this study was to evaluate the feasibility of emergency department (ED) point-of-care ultrasound (PoCUS) for rib fracture diagnosis in patients with minor thoracic injury (mTI). Secondary objectives were to 1) evaluate patients' pain during the PoCUS procedure, 2) identify the limitations of the use of PoCUS technique, and 3) compare the diagnosis obtained with PoCUS to radiography results. METHODS: Adult patients who presented with clinical suspicion of rib fractures after mTI were included. All patients underwent PoCUS performed by emergency physicians (EPs) prior to a rib view X-ray. A visual analogue scale (VAS) ranging from 0 to 100 was used to ascertain feasibility, patients' pain and clinicians' degree of certitude. Feasibility was defined as a score of more than 50 on the VAS. We documented the radiologists' interpretation of rib view X-ray. Radiologists were blinded to the PoCUS results. RESULTS: Ninety-six patients were included. A majority (65%) of EPs concluded that the PoCUS technique to diagnose rib fracture was feasible (VAS score > 50). Median score for feasibility was 63. Median score was 31 (Interquartile range [IQR] 5-57) for patients' pain related to the PoCUS. The main limiting factor of the PoCUS technique was pain during patient examination (15%). CONCLUSION: PoCUS examination appears to be a feasible technique for a rib fracture diagnosis in the ED.

Adverse Events Following Diagnostic Urethral Catheterization in the Pediatric Emergency Department.

OBJECTIVES: The purpose of this study was to assess adverse events associated with diagnostic urethral catheterization (UC) in young children and to determine their impact on the patient and their family. METHODS: This was a prospective cohort study conducted in the emergency department of a tertiary-care pediatric hospital. All 3- to 24-month-old children with fever who had a diagnostic UC were eligible. Parents who consented to participate were contacted by phone within 7 to 10 days after the UC to answer a standardized questionnaire inquiring about complications. The primary outcome was the occurrence of an unfavourable event in the seven days following UC, defined as painful urination, genital pain, urinary retention, hematuria or secondary urinary tract infection. Secondary outcomes included the need for further medical care and the need for parents to miss school or work. RESULTS: Of the 199 patients who completed the study, 41 (21%) reported a complication: painful urination in 19 (10%) children, genital pain in 16 (8%), urinary retention in 11 (6%), gross hematuria in 9 (5%), and secondary urinary tract infection in 1 (0.5%). Three (1%) parents reported the need for further medical care and three (1%) missed work. Two independent variables (male sex and age 12-23 months) were associated with a higher risk of adverse events. CONCLUSIONS: Urethral catheterization is associated with adverse events in 21% of young children in the week following the procedure. Accordingly, this procedure should be used judiciously in children, considering its potential to cause unfavourable events.

Delayed complications and functional outcome of isolated sternal fracture after emergency department discharge: a prospective, multicentre cohort study.

OBJECTIVE: The aim of this study was to determine the incidence of delayed complications, specifically hemothorax, and functional outcome in patients with isolated sternal fracture discharged from the emergency department (ED) compared to patients with other minor thoracic trauma. METHODS: This prospective cohort study was conducted in four university-affiliated Canadian EDs. Patients ages 16 and older discharged from the ED with an isolated minor thoracic injury were included and categorized as isolated sternal fracture, rib fracture, or no fracture. A standardized clinical and radiological follow-up was performed at 7 and 14 days as well as a phone follow-up at 30 and 90 days post-injury. Functional outcome was determined using the Medical Outcome Short-Form Health Survey (SF-12). RESULTS: A total of 969 patients were included, of whom 32 (3.3%) had an isolated sternal fracture, 304 (31.3%) had rib fracture, and 633 (65.3%) had no fracture. Within 14 days, 112 patients presented with a delayed hemothorax: 12.5% of sternal fracture patients, 23% of rib fracture(s) patients, and 6% of minor thoracic injury patients without fracture (p<0.05). At 90 days, 57.1% of patients with sternal fracture had moderate to severe disability compared to 25.4% and 21.2% for both of the other groups, respectively (p<0.001). CONCLUSION: In this prospective study, we found that 12.5% (n=4, p<0.05) of patients with sternal fracture developed a delayed hemothorax, but the clinical significance of this remains questionable. The proportion of patients with sternal fracture who had moderate to severe disability was significantly higher than that of patients with other minor thoracic trauma.

Functional Impact of a Minor Thoracic Injury: An Investigation of Age, Delayed Hemothorax, and Rib Fracture Effects.

OBJECTIVE: To investigate whether minor thoracic injuries (MTIs) relate to subsequent functional limitations. BACKGROUND: Approximately 75% of patients with an MTI are discharged after an emergency department (ED) visit, whereas significant functional limitations can occur in the weeks that follow. METHODS: A 19 months' prospective cohort study with a 90-day follow-up was conducted at 4 university-affiliated EDs. Patients 16 years and older with an MTI were assessed at initial ED visit, 7, 14, 30, and 90 days after injury. Functional outcome was measured using the SF-12 scale. General linear model were used to assess outcome. RESULTS: A total of 482 patients were included, of whom 127 (26.3%) were 65 or older. Overall, 147 patients (30.5%) presented with at least 1 rib fracture and 59 subjects (12.2%) with delayed hemothorax. At 90 days, 22.8% of patients still had severe or moderate disabilities on global physical health score. Patients with solely delayed hemothorax and no rib fracture had the lowest global physical health score (46.4 vs 61.1, P < 0.01, effect size =  -2.60) than patients with simple MTI. Generally, functional limitations also increase with increments of number of rib fracture detected on radiograph. Outcomes were not different among patients 65 years or older when compared to their younger counterparts. CONCLUSIONS: In this prospective study of MTIs, severe to moderate disabilities were present in nearly 1 patient out of 5 at 90 days. The presence of delayed hemothorax and the number of rib fracture were associated with increased functional limitations after a MTI.

Cohort study on the prevalence and risk factors for delayed pulmonary complications in adults following minor blunt thoracic trauma.

OBJECTIVES: The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. METHOD: A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray. OUTCOMES: Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. CONCLUSION: The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Risk factors of significant pain syndrome 90 days after minor thoracic injury: trajectory analysis.

OBJECTIVES: The objective was to identify the risk factors of clinically significant pain at 90 days in patients with minor thoracic injury (MTI) discharged from the emergency department (ED). METHODS: A prospective, multicenter, cohort study was conducted in four Canadian EDs from November 2006 to November 2010. All consecutive patients aged 16 years or older with MTI were eligible at discharge from EDs. They underwent standardized clinical and radiologic evaluations at 1 and 2 weeks, followed by standardized telephone interviews at 30 and 90 days. A pain trajectory model characterized groups of patients with different pain evolutions and ascertained specific risk factors in each group through multivariate analysis. RESULTS: In this cohort of 1,132 patients, 734 were eligible for study inclusion. The authors identified a pain trajectory that characterized 18.2% of the study population experiencing clinically significant pain (>3 of 10) at 90 days after a MTI. Multivariate modeling found two or more rib fractures, smoking, and initial oxygen saturation below 95% to be predictors of this group of patients. CONCLUSIONS: To the authors' knowledge, this is the first prospective study of trajectory modeling to detect risk factors associated with significant pain at 90 days after MTI. These factors may help in planning specific treatment strategies and should be validated in another prospective cohort.

[Cohort study on the prevalence and risk factors of late pulmonary complications in adults following a closed minor chest trauma]. / Étude de cohorte sur la prévalence et les facteurs de risque de complications pulmonaires tardives chez les adultes à la suite d'un traumatisme thoracique mineur fermé.

OBJECTIVES: The objectives of this study are to determine the prevalence, risk factors, and time to onset of delayed hemothorax and pneumothorax in adults who experienced a minor blunt thoracic trauma. METHOD: A prospective cohort of 450 consecutive patients was recruited. Eligible patients had to be over 16 years of age, consulted within 72 hours for a trauma, and available for outpatient follow-up at 2, 7, and 14 days posttrauma. The clinical outcome investigated was the presence of delayed pneumothorax or hemothorax on the follow-up chest x-ray. OUTCOMES: Delayed hemothorax occurred in 11.8% (95% CI 8.8-14.8), and delayed pneumothorax occurred in 0.9% (95% CI 0.2-2.3) of participants. During the 14-day follow-up period, 87.0% of these delayed complications developed in the first week. In the multivariate analysis, the only statistically significant risk factor for delayed complications was the location of fractures on the x-ray of the hemithorax. The adjusted odds ratio was 1.52 (95% CI 0.62-3.73) for the lower ribs (tenth to twelfth rib), 3.11 (95% CI 1.60-6.08) for the midline ribs (sixth to ninth rib), and 5.05 (95% CI 1.80-14.19) for the upper ribs (third to fifth rib) versus patients with no fractures. CONCLUSION: The presence of at least one rib fracture between the third and ninth rib on the x-ray of the hemithorax is a significant risk factor for delayed hemothorax and pneumothorax.

Performance of the Canadian Triage and Acuity Scale for children: a multicenter database study.

STUDY OBJECTIVE: We evaluate the association between triage levels assigned using the Canadian Triage and Acuity Scale and surrogate markers of validity for real-life children triaged in multiple emergency departments (EDs). METHODS: This was a retrospective cohort study evaluating the triage assessment and outcomes of all children presenting to 12 pediatric EDs, all of which are members of the Pediatric Emergency Research Canada group, during a 1-year period (2010 to 2011). Anonymous data were retrieved from the ED computerized databases. The primary outcome measure was the proportion of children hospitalized for each triage level. Other outcomes were ICU admission, proportion of patients who left without being seen by a physician, and length of stay in the ED. Evaluation of all children visiting these EDs during 1 year was expected to provide more than 1,000 patients in each triage category. RESULTS: A total of 550,940 children were included. Pooled data demonstrated hospitalization proportions of 61%, 30%, 10%, 2%, and 0.9% for patients in Canadian Triage and Acuity Scale levels 1, 2, 3, 4, and 5, respectively. There was a strong association between triage level and admission to the ICU, probability of leaving without being seen by a physician, and length of stay. CONCLUSION: The strong association between triage level and multiple markers of severity in 12 Canadian pediatric EDs suggests validity of the Canadian Triage and Acuity Scale for children.

Adherence to calcium channel blocker poisoning treatment recommendations in two Canadian cities.

CONTEXT: No study has documented whether physicians call poison control centres (PCC) for calcium channel blocker (CCB) poisoning or if interventions suggested by the PCC are being applied. OBJECTIVES: This study evaluated the compliance of physicians with the Quebec Poison Control Center's (QPCC) recommendations for the treatment of CCB poisoning. It also assessed the outcomes of these patients. METHODS: This retrospective chart review was conducted with CCB-poisoned adults who were admitted to a hospital in Quebec City or Montreal between January 2004 and November 2007. Using the sequence of interventions, it was determined whether or not the PPC recommendations were adhered to. Level of care provided, morbidity and mortality were reported. The researchers also used the QPCC database to verify if the poison centre was consulted for the care of the patient. RESULTS: A total of 103 cases were identified. 42% (43/103) were classified as compliant (all PCC recommendations were followed) and 58% (60/103) non-compliant group (some or no PCC recommendations followed). The poison control centre (PCC) was contacted for 74% of the total cases (81% of cases in the compliant group and 68% in the non-compliant group). High-dose insulin euglycemia therapy (HIET) was not started when indicated or started at too low dosage in 20 cases. Glucagon was given, even if not indicated, in 14 cases and decontamination was inappropriate in at least 10 cases. For the entire sample, there was an average of 8 days of hospitalization, 47 h of intensive care, 11 h of vasopressor use, a morbidity of 50% and a mortality of 6%. Acute renal failure (35%), metabolic acidosis (25%), acute pulmonary oedema (15%), aspiration pneumonia (15%), rhabdomyolysis (8%), myocardial ischemia (7%), abnormal liver function tests (AST/ALT) (6%), cerebral anoxia (4%) and ileus (3%) were among the most frequent complications. The outcomes in the non-compliant group versus the compliant group showed a mortality of 10% versus 0% (95%CI 0.00-0.20, p-value < 0.0001), a morbidity 67% versus 26% (95%CI 0.17-0.57, p-value < 0.0001) (OR 0.21 unadjusted and 0.64 adjusted, p-value < 0.0001), a median hospital length of stay (LOS) of 5 days versus 1 da y (p-value < 0.0001) (OR of a LOS ≥ 1 day 0.23 unadjusted and 0.39 adjusted, p-value < 0.0001), a median ICU LOS of 34 h versus 0 h (p-value < 0.0001) (OR of a ICU LOS ≥ 1 day 0.16 unadjusted and 0.38 adjusted, p-value < 0.0001) and a median duration of vasopressor of 17 h versus 3 h (p-value 0.0002) (OR of a vasopressor ≥ 1 h 0.15 unadjusted and 0.29 adjusted, p-value < 0.0001). CONCLUSION: In conclusion, the majority of the physicians did not follow PCC recommendations for the treatment of CCB poisoning. Further studies are ongoing as to evaluate the barriers to protocol adherence and to develop evidence based guidelines accompanied by an effective implementation strategy.

Patients with rib fractures do not develop delayed pneumonia: a prospective, multicenter cohort study of minor thoracic injury.

STUDY OBJECTIVE: Patients admitted to emergency departments (EDs) for minor thoracic injuries are possibly at risk of delayed pneumonia. We aimed to evaluate the incidence of delayed pneumonia post-minor thoracic injury and the associated risk factors. METHODS: A prospective, multicenter cohort study was conducted in 4 Canadian EDs, from November 2006 to November 2010. All consecutive patients aged 16 years and older with minor thoracic injury who were discharged from the ED were screened for eligibility. Uniform clinical and radiologic evaluations were performed on the initial ED visit and were repeated at weeks 1 and 2. Relative risk analyses quantified incidence with comparison by age, sex, smoking status, alcohol intoxication, pulmonary comorbidity, ability to cough atelectasis, pain level, and number of rib fractures. RESULTS: Of the 1,057 participants recruited, 347 (32.8%) had at least 1 rib fracture, 87 (8.2%) had asthma, and 36 (3.4%) had chronic obstructive pulmonary disease. Only 6 patients (0.6%; 95% confidence interval 0.24% to 1.17%) developed pneumonia during the follow-up period. The relative risk for patients with preexistent pulmonary disease and radiologically proven rib fractures was 8.6 (P=.045; 95% confidence interval 1.05 to 70.9). Sex, smoking habit, initial atelectasis, ability to cough, and alcohol intoxication were not significantly associated with delayed pneumonia. CONCLUSION: This prospective cohort study of nonhospitalized patients with minor thoracic injuries revealed a low incidence of delayed pneumonia. Nonetheless, our results support tailored follow-up for asthmatic or chronic obstructive pulmonary disease patients with rib fracture.

The Canadian Triage and Acuity Scale for children: a prospective multicenter evaluation.

STUDY OBJECTIVE: The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. METHODS: This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. RESULTS: A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. CONCLUSION: The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.

Comparison of pandemic and seasonal influenza in the pediatric emergency department.

BACKGROUND: Emergency department (ED) presentation of pediatric pandemic H1N1 (pH1N1) infection is not well characterized. Our objective was to describe the clinical manifestations of pH1N1 in the pediatric ED. We also compared these characteristics to seasonal influenza A, and explored risk factors for pH1N1 hospitalization. METHODS: We conducted a retrospective cohort study at a pediatric hospital in Quebec City, Canada. Subjects were ED patients aged 0 to 17 years with laboratory-confirmed pH1N1 (April-July 2009) or seasonal influenza A (June 2006-March 2009). Clinical and laboratory data were analyzed by univariate and multivariate log-binomial regression. RESULTS: A total of 127 pH1N1 cases and 110 seasonal influenza cases were identified. pH1N1 patients were older (9.5 vs. 5.6 years; P < 0.0001) and presented more rapidly (2.8 vs. 3.5 days; P = 0.02). Clinical manifestations were similar, although gastrointestinal findings were less frequent in pH1N1 (relative risk [RR]: 0.49; 95% confidence interval [CI]: 0.37-0.65). Hospitalization risk was similar (RR: 1.12; 95% CI: 0.81-1.55), but hospitalized pH1N1 subjects were more frequently diagnosed with pneumonia (RR: 2.41; 95% CI: 1.16-5.00). In a multivariable model, age <2 years was independently associated with pH1N1 hospitalization (RR: 3.17; 95% CI: 1.78-5.65), whereas the absence of significant comorbidities decreased its risk (RR: 0.51; 95% CI: 0.31-0.85). CONCLUSIONS: After adjustment for age and delay to presentation, clinical manifestations and 21-day outcomes of pediatric pH1N1 were similar to those of seasonal influenza. pH1N1 patients with previously established risk factors for severe seasonal influenza experienced increased hospitalization risk. Our results suggest that pH1N1 clinical diagnosis and management in the pediatric ED can be performed in a manner similar to seasonal influenza.

Prospective assessment of practice pattern variations in the treatment of pediatric gastroenteritis.

OBJECTIVES: We aimed to determine whether significant variations in the use of intravenous rehydration existed among institutions, controlling for clinical variables, and to assess variations in the use of ancillary therapeutic and diagnostic modalities. METHODS: We conducted a prospective cohort study of children 3 to 48 months of age who presented to 11 emergency departments with acute gastroenteritis, using surveys, medical record reviews, and telephone follow-up evaluations. RESULTS: A total of 647 eligible children were enrolled and underwent chart review; 69% (446 of 647 children) participated in the survey, and 89% of survey participants (398 of 446 children) had complete follow-up data. Twenty-three percent (149 of 647 children) received intravenous rehydration (range: 6%-66%; P < .001) and 13% (81 of 647 children) received ondansetron (range: 0%-38%; P < .001). Children who received intravenous rehydration had lower Canadian Triage Acuity Scale scores at presentation (3.1 ± 0.5 vs 3.5 ± 0.5; P < .0001). Regression analysis revealed that the greatest predictor of intravenous rehydration was institution location (odds ratio: 3.0 [95% confidence interval: 1.8-5.0]). Children who received intravenous rehydration at the index visit were more likely to have an unscheduled follow-up health care provider visit (29% vs 19%; P = .05) and to revisit an emergency department (20% vs 9%; P = .002). CONCLUSIONS: In this cohort, intravenous rehydration and ondansetron use varied dramatically. Use of intravenous rehydration at the index visit was significantly associated with the institution providing care and was not associated with a reduction in the need for follow-up care.

Prospective evaluation of two clinical scores for acute asthma in children 18 months to 7 years of age.

OBJECTIVES: The objective was to evaluate the discriminatory ability of two clinical asthma scores, the Preschool Respiratory Assessment Measure (PRAM) and the Pediatric Asthma Severity Score (PASS), during an asthma exacerbation. METHODS: This was a prospective cohort study in an academic pediatric emergency department (ED; 60,000 visits/year) conducted from March 2006 to October 2007. All patients 18 months to 7 years of age who presented for an asthma exacerbation were eligible. The primary outcome was a length of stay (LOS) of >6 hours in the ED or admission to the hospital. Clinical findings and components of the PRAM and the PASS were assessed by a respiratory therapist (RT) at the start of the ED visit and after 90 minutes of treatment. RESULTS: During the study period, 3,845 patients were seen in the ED for an asthma exacerbation. Of these, 291 were approached to participate, and eight refused. Moderate levels of discrimination were found between a LOS of >6 hours and/or admission and PRAM (area under the receiver-operating characteristic curve [AUC] = 0.69, 95% confidence interval [CI] = 0.59 to 0.79) and PASS (AUC = 0.70, 95% CI = 0.60 to 0.80) as calculated at the start of the ED visit. Significant similar correlations were seen between the physician's judgment of severity and PRAM (r = 0.54, 95% CI = 0.42 to 0.65) and PASS (r = 0.55, 95% CI = 0.43 to 0.65). CONCLUSIONS: The PRAM and PASS clinical asthma scores appear to be measures of asthma severity in children with discriminative properties.