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1.
Lancet ; 395(10221): 339-349, 2020 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-32007169

RESUMEN

BACKGROUND: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.


Asunto(s)
Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Cardioversión Eléctrica , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Protocolos Clínicos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven
2.
CMAJ ; 190(48): E1406-E1413, 2018 12 03.
Artículo en Inglés | MEDLINE | ID: mdl-30510045

RESUMEN

BACKGROUND: The Ottawa chronic obstructive pulmonary disease (COPD) Risk Scale (OCRS), which consists of 10 criteria, was previously derived to identify patients in the emergency department with COPD who were at high risk for short-term serious outcomes. We sought to validate, prospectively and explicitly, the OCRS when applied by physicians in the emergency department. METHODS: We conducted this prospective cohort study involving patients in the emergency departments at 6 tertiary care hospitals and enrolled adults with acute exacerbation of COPD from May 2011 to December 2013. Physicians evaluated patients for the OCRS criteria, which were recorded on a data form along with the total risk score. We followed patients for 30 days and the primary outcome, short-term serious outcomes, was defined as any of death, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction (MI) or relapse with hospital admission. RESULTS: We enrolled 1415 patients with a mean age of 70.6 (SD 10.6) years and 50.2% were female. Short-term serious outcomes occurred in 135 (9.5%) cases. Incidence of short-term serious outcomes ranged from 4.6% for a total score of 0 to 100% for a score of 10. Compared with current practice, an OCRS score threshold of greater than 1 would increase sensitivity for short-term serious outcomes from 51.9% to 79.3% and increase admissions from 45.0% to 56.6%. A threshold of greater than 2 would improve sensitivity to 71.9% with 47.9% of patients being admitted. INTERPRETATION: In this clinical validation of a risk-stratification tool for COPD in the emergency department, we found that OCRS showed better sensitivity for short-term serious outcomes compared with current practice. This risk scale can now be used to help emergency department disposition decisions for patients with COPD, which should lead to a decrease in unnecessary admissions and in unsafe discharges.


Asunto(s)
Hospitalización/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Mortalidad , Infarto del Miocardio/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/terapia , Respiración Artificial/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Canadá/epidemiología , Estudios de Cohortes , Progresión de la Enfermedad , Servicio de Urgencia en Hospital , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Ventilación no Invasiva/estadística & datos numéricos , Estudios Prospectivos , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Recurrencia , Reproducibilidad de los Resultados , Medición de Riesgo
3.
Ann Emerg Med ; 72(4): 333-341, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-29729811

RESUMEN

STUDY OBJECTIVE: The Canadian C-Spine Rule has been widely applied by emergency physicians to safely reduce use of cervical spine imaging. Our objective is to evaluate the clinical effect and safety of real-time Canadian C-Spine Rule implementation by emergency department (ED) triage nurses to remove cervical spine immobilization. METHODS: We conducted this multicenter, 2-phase, prospective cohort program at 9 hospital EDs and included alert trauma patients presenting with neck pain or with cervical spine immobilization. During phase 1, ED nurses were trained and then had to demonstrate competence before being certified. During phase 2, certified nurses were empowered by a medical directive to "clear" the cervical spine of patients, allowing them to remove cervical spine immobilization and to triage to a less acute area. The primary outcomes were clinical effect (cervical spine clearance by nurses) and safety (missed clinically important cervical spine injuries). RESULTS: In phase 1, 312 nurses evaluated 3,098 patients. In phase 2, 180 certified nurses enrolled 1,408 patients (mean age 43.1 years, women 52.3%, collision 56.5%, and cervical spine injury 1.1%). In phase 2 and for the 806 immobilized ambulance patients, the primary outcome of immobilization removal by nurses was 41.1% compared with 0% before the program. The primary safety outcome of cervical spine injuries missed by nurses was 0. Time to discharge was reduced by 26.0% (3.4 versus 4.6 hours) for patients who had immobilization removed. In only 1.3% of cases did nurses indicate their discomfort with applying the Canadian C-Spine Rule. CONCLUSION: We clearly demonstrated that ED triage nurses can successfully implement the Canadian C-Spine Rule, leading to more rapid and comfortable management of patients without any threat to patient safety. Widespread adoption of this approach should improve care and comfort for trauma patients, and could decrease length of stay in our very crowded EDs.


Asunto(s)
Servicio de Urgencia en Hospital/normas , Traumatismos Vertebrales/diagnóstico , Triaje , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Canadá , Protocolos Clínicos , Estudios de Cohortes , Técnicas de Apoyo para la Decisión , Femenino , Implementación de Plan de Salud , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Traumatismos Vertebrales/diagnóstico por imagen , Traumatismos Vertebrales/enfermería , Adulto Joven
4.
CJEM ; 20(1): 68-79, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-27927264

RESUMEN

OBJECTIVES: Nurses and respiratory therapists are seldom allowed to use automated external defibrillators (AED) during in-hospital cardiac arrest. This can result in significant time delays before defibrillation occurs and lower survival for cardiac arrest victims. We sought to identify barriers and facilitators to AED use by nurses and respiratory therapists. METHODS: We conducted semi-structured qualitative interviews with a purposeful sample of nurses and respiratory therapists. We developed the interview guide based on the constructs of the theory of planned behaviour, which elicits salient attitudes, social influences, and control beliefs potentially influencing the intent to use an AED. Interviews were recorded, transcribed verbatim, and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging categories and themes, and ranked them by frequency of the number of participants stating the topic. RESULTS: Demographics for the 24 interviewees include mean age 40.5, 79.2% female, 87.5% performed cardiopulmonary resuscitation (CPR), 29.2% defibrillated a patient. Identified attitudes pertained to the timeliness of defibrillation, patient survival, simplicity of AED use, accuracy of rhythm recognition, and harm to self or others. Social influences consisted of physician and hospital administration support of AED use. Control beliefs included training on AED use, policy allowing AED use, familiarity with AED, and task burden during resuscitation. CONCLUSIONS: Most nurses and respiratory therapists intended to use an AED if permitted to do so by a medical directive. Successful implementation would require educational initiatives focusing on safety and efficacy of AEDs, support from physicians and hospital administrators, and additional training on AED use.


Asunto(s)
Reanimación Cardiopulmonar/métodos , Muerte Súbita Cardíaca/prevención & control , Desfibriladores/estadística & datos numéricos , Servicios Médicos de Urgencia/normas , Conocimientos, Actitudes y Práctica en Salud , Competencia Profesional , Investigación Cualitativa , Adulto , Actitud del Personal de Salud , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y Cuestionarios , Adulto Joven
5.
CJEM ; 20(2): 222-229, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-28367768

RESUMEN

OBJECTIVES: Following release by emergency department (ED) for acute heart failure (AHF), returns to ED represent important adverse health outcomes. The objective of this study was to document relapse events and factors associated with return to ED in the 14-day period following release by ED for patients with AHF. METHODS: The primary outcome was the number of return to ED for patients who were release by ED after the initial visit, for any related medical problem within 14 days of this initial ED visit. RESULTS: Return visits to the EDs occurred in 166 (20%) patients. Of all patients who returned to ED within the 14-day period, 77 (47%) were secondarily admitted to the hospital. The following factors were associated with return visits to ED: past medical history of percutaneous coronary intervention or coronary artery bypass graft (aOR=1.51; 95% CIs [1.01-2.24]), current use of antiarrhythmics medications (1.96 [1.05-3.55]), heart rate above 80 /min (1.89 [1.28-2.80]), systolic blood pressure below 140 mm Hg (1.67[1.14-2.47]), oxygen saturation (SaO2) above 96% (1.58 [1.08-2.31]), troponin above the upper reference limit of normal (1.68 [1.15-2.45]), and chest X-ray with pleural effusion (1.52 [1.04-2.23]). CONCLUSIONS: Many heart failure patients (i.e. 1 in 5 patients) are released from the ED and then suffer return to ED. Patients with multiple medical comorbidities, and those with abnormal initial vital signs are at increased risk for return to ED and should be identified.


Asunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Alta del Paciente/tendencias , Readmisión del Paciente/tendencias , Medición de Riesgo/métodos , Enfermedad Aguda , Anciano , Canadá/epidemiología , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Humanos , Incidencia , Tiempo de Internación/tendencias , Masculino , Pronóstico , Estudios Retrospectivos , Factores de Tiempo
6.
Stroke ; 48(3): 624-630, 2017 03.
Artículo en Inglés | MEDLINE | ID: mdl-28213572

RESUMEN

BACKGROUND AND PURPOSE: The Ontario Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP) was revised to allow paramedics to bypass to designated stroke centers if total transport time would be <2 hours and total time from symptom onset <3.5 hours. We sought to evaluate the impact and safety of implementing the Revised ASMRPP. METHODS: We conducted a 12-month implementation study involving prehospital patients presenting with possible stroke symptoms. A total of 1317 basic and advanced life support paramedics, of 9 land services in 10 rural counties and 5 cities, used the Revised ASMRPP to take appropriate patients directly to 6 designated stroke centers. RESULTS: We enrolled 1277 patients with 98.8% paramedic compliance in form completion. Of these, 755 (61.2%) met the redirect criteria and had these characteristics: mean age 72.1 (range 16-101), male 51.1%, mean time scene to hospital 16.7 minutes (range 0-92). Paramedics demonstrated excellent interobserver agreement (κ, 0.94; 95% confidence interval, 0.91-0.96) and 97.9% accuracy in interpretation of the Revised ASMRPP. Prehospital adverse events occurred in 14.7% of patients, but few were life-threatening. Overall, 71.4% of 755 cases had a stroke code activated at the hospital and 23.2% received thrombolysis. For the 189 potential stroke patients picked up in 1 city, the ASMRPP classified thrombolysis administration with sensitivity 100% and specificity 37.3% and a final diagnosis of stroke, with sensitivity 86.1% and specificity 41.9%. CONCLUSIONS: In a large urban-rural area with 9 paramedic services, we demonstrated accurate, safe, and effective implementation of the Revised ASMRPP. These revisions will allow more patients with stroke to benefit from early treatment.


Asunto(s)
Competencia Clínica/normas , Auxiliares de Urgencia/normas , Hospitalización/estadística & datos numéricos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Transporte de Pacientes/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ontario , Factores de Tiempo , Adulto Joven
7.
Ann Emerg Med ; 69(5): 562-571.e2, 2017 May.
Artículo en Inglés | MEDLINE | ID: mdl-28110987

RESUMEN

STUDY OBJECTIVE: Recent-onset atrial fibrillation and flutter are the most common arrhythmias managed in the emergency department (ED). We evaluate the management and 30-day outcomes for recent-onset atrial fibrillation and flutter patients in Canadian EDs, where cardioversion is commonly practiced. METHODS: We conducted a prospective cohort study in 6 academic hospital EDs and enrolled patients who had atrial fibrillation and flutter onset within 48 hours. Patients were followed for 30 days by health records review and telephone. Adverse events included death, stroke, acute coronary syndrome, heart failure, subsequent admission, or ED electrocardioversion. RESULTS: We enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%, atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm 80.1%. Although 10.5% of recent-onset atrial fibrillation and flutter patients had adverse events within 30 days, there were no related deaths and 1 stroke (0.1%). Adjusted odds ratios for factors associated with adverse event were hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05), history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients who left the ED in sinus rhythm were much less likely to experience an adverse event (P<.001). CONCLUSION: Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.


Asunto(s)
Fibrilación Atrial/terapia , Aleteo Atrial/terapia , Servicio de Urgencia en Hospital/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Aleteo Atrial/complicaciones , Canadá , Cardioversión Eléctrica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Resultado del Tratamiento , Adulto Joven
8.
Acad Emerg Med ; 24(3): 316-327, 2017 03.
Artículo en Inglés | MEDLINE | ID: mdl-27976497

RESUMEN

OBJECTIVES: We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS. METHODS: This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days. RESULTS: We enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score > 1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold score > 1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS. CONCLUSION: Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.


Asunto(s)
Técnicas de Apoyo para la Decisión , Insuficiencia Cardíaca/diagnóstico , Hospitalización/estadística & datos numéricos , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Medición de Riesgo , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Sensibilidad y Especificidad
9.
Scand J Trauma Resusc Emerg Med ; 24(1): 132, 2016 Nov 07.
Artículo en Inglés | MEDLINE | ID: mdl-27821147

RESUMEN

BACKGROUND: Heart failure is one of the leading reasons for hospitalization in developed countries. Our goal was to describe the hemodynamic vital signs (heart rate and systolic blood pressure) of patients presenting to the emergency department (ED) with heart failure and to describe the frequency of adverse events for patients presenting with various heart rate and systolic blood pressure values. METHOD: We conducted two prospective cohort studies of heart failure conducted at six Canadian teaching hospital sites and this study was a secondary analysis of these data. The primary outcome was serious adverse events defined as death from any cause within 30 days of the ED visit or any complication following within 14 days of the index ED visit. RESULTS: We included a convenience sample of adults > 50 years of age who presented with acute shortness of breath or new-onset heart failure. In total, 1,638 patients were included in this analysis. Patients with heart rates < 50 % MHR (maximal heart rate) and systolic blood pressure (SBP) > 140 mmHg had the lowest rate of serious adverse events (6 %). patients with heart rates > 75 % MHR had the highest rate of serious adverse events, regardless of the SBP. Among patients with heart rates > 75 % MHR, the proportion of serious adverse events decreased as SBP increased (30 % when SBP < 120 mmHg, 24 % when SBP between 120 and 140 mmHg, and 21 % when SBP > 140 mm Hg). Patients with heart rates < 50 % MHR and with SBP > 140 mm Hg had the lowest rate of admissions to hospital (38 %). CONCLUSIONS: We found a relatively high frequency of serious adverse events among patients who present to the ED with heart failure, particularly among the patients having low systolic blood pressure and high heart rate.


Asunto(s)
Manejo de la Enfermedad , Servicio de Urgencia en Hospital , Insuficiencia Cardíaca/terapia , Hemodinámica/fisiología , Pacientes Internos , Anciano , Canadá/epidemiología , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias
10.
Am J Emerg Med ; 34(11): 2159-2166, 2016 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-27590209

RESUMEN

INTRODUCTION: The first aim of this study was to investigate the characteristics for elderly patients with acute heart failure presenting to the emergency department (ED). The second aim was to determine the characteristics of these elderly patients associated with serious adverse events. METHODS: The population was divided into 2 age groups, <80 and ≥80 years. The primary outcome was the occurrence of a serious adverse event, defined as either death from any cause within 30 days of the index ED visit or any of the following events within 14 days of the index ED visit: admission to a monitored unit, intubation, need for noninvasive ventilation, myocardial infarction, major procedure, or, for patients who were discharged after the initial visit, return to the ED resulting in admission to hospital. RESULTS: This prospective cohort study included 1658 visits. Older patients had a lower heart rate and higher diastolic blood pressure. The older patients were more likely to experience hospital admission (56% vs 46%, P < .001). For patients 80 years or older, 109 (14%) experienced a serious adverse event. In this ≥80-year group, history of heart failure, current medication with antiarrhythmic, acute infarction on the arrival electrocardiography, chest x-ray with pleural effusion, and urea greater than 12 mmol/L were independently associated with short-term serious adverse events. CONCLUSIONS: Elderly patients with heart failure are a high-risk group. Careful assessment of these factors could help physicians identify those patients most at risk for adverse outcomes and, therefore, most in need of hospital admission.


Asunto(s)
Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/fisiopatología , Enfermedad Aguda , Factores de Edad , Anciano , Anciano de 80 o más Años , Antiarrítmicos/uso terapéutico , Presión Sanguínea , Electrocardiografía , Servicio de Urgencia en Hospital , Femenino , Frecuencia Cardíaca , Humanos , Intubación Intratraqueal , Masculino , Infarto del Miocardio/etiología , Infarto del Miocardio/fisiopatología , Ventilación no Invasiva , Admisión del Paciente , Readmisión del Paciente , Derrame Pleural/diagnóstico por imagen , Estudios Prospectivos , Urea/sangre
11.
CJEM ; 18(6): 429-436, 2016 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-27021437

RESUMEN

OBJECTIVES: The Ottawa Heart Failure Risk Scale (OHFRS) and the Ottawa COPD Risk Scale (OCRS) were developed in order to estimate medical risk and to help guide disposition decisions for patients presenting to the ED with acute exacerbations of heart failure (HF) and COPD. We sought to determine physician attitudes towards these two new risk scales and to identify potential barriers to their ED implementation. METHODS: Two self-administered online surveys were distributed to the Canadian Association of Emergency Physicians. The surveys each consisted of 16 questions relating to the OHFRS and OCRS. The primary outcome measures were the overall physician rating of the two risk scales. Secondary outcome measures assessed the likelihood of risk scale implementation into Canadian EDs, as well as the perceived barriers to such implementation. Descriptive statistics were used. RESULTS: For the OHFRS survey, we received responses from 195 emergency physicians (35.7%). Overall, 74.4% approved of the risk scale based on a Likert rating of 4 or 5 and 66.7% believed that the risk scale would be implemented at their hospital. For the OCRS survey, we received responses from 208 emergency physicians (38.1%). Overall, 76.9% approved of the risk scale based on a Likert rating of 4 or 5 and 70.2% believed that the risk scale would be implemented at their hospital. CONCLUSIONS: Canadian emergency physicians are very supportive of the new OHFRS and OCRS. We believe these risk scales will assist physicians with making safe and efficient disposition decisions and improve outcomes for patients suffering from HF and COPD.


Asunto(s)
Actitud del Personal de Salud , Servicio de Urgencia en Hospital/estadística & datos numéricos , Insuficiencia Cardíaca/terapia , Enfermedad Pulmonar Obstructiva Crónica/terapia , Encuestas y Cuestionarios , Canadá , Estudios Transversales , Progresión de la Enfermedad , Medicina de Emergencia/organización & administración , Tratamiento de Urgencia , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Humanos , Incidencia , Masculino , Médicos/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Índice de Severidad de la Enfermedad
12.
Int Emerg Nurs ; 27: 24-30, 2016 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-26796288

RESUMEN

OBJECTIVES: We recently conducted a multicentre implementation study on the use of the Canadian C-Spine Rule (CCR) by emergency department (ED) nurses to clear the c-spine in alert and stable trauma patients (n = 4506). The objective of this study was to conduct a survey of nurses, physicians, and administrators to evaluate their views on the facilitators and barriers to the implementation of the CCR. METHODS: We conducted both a paper-based and an electronic survey of the three different ED hospital staff groups of nine large teaching hospitals in Ontario, including six regional trauma centres. The content of this survey was informed by a qualitative evaluation of the opinions of the study nurses who had participated in the validation study. RESULTS: 57.5% (281/489) ED triage nurses, 50.2% ED physicians, and 82.8% of administrators responded. Nurse responses most often showed support from manager/educators and teamwork between physicians, nurses, and managers as being important facilitators to the use of the CCR. Physician responses most often identified the importance of a nurse leader/champion/educator, and presence of strong physician leaders. Administrator responses indicated the importance of nurse educators/champions, nurse engagement, and educational support. Barriers indicated by all three groups included busy department, lack of physician support, and lack of nursing support. CONCLUSIONS: Bringing about change in clinical practice is complex. Strong leadership, effective communication, and senior physician buy-in appear to be very important. Identification of system-specific barriers and facilitators are important components of successful knowledge translation.


Asunto(s)
Vértebras Cervicales/lesiones , Adhesión a Directriz/normas , Inmovilización/métodos , Adulto , Actitud del Personal de Salud , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/normas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermeras y Enfermeros/psicología , Enfermeras y Enfermeros/normas , Ontario , Triaje/métodos , Recursos Humanos
13.
Implement Sci ; 9: 88, 2014 Aug 07.
Artículo en Inglés | MEDLINE | ID: mdl-25099167

RESUMEN

BACKGROUND: Clinical decision rules (CDRs) can be an effective tool for knowledge translation in emergency medicine, but their implementation is often a challenge. This study examined whether the Theory of Planned Behaviour (TPB) could help explain the inconsistent results between the successful Canadian C-Spine Rule (CCR) implementation study and unsuccessful Canadian CT Head Rule (CCHR) implementation study. Both rules are aimed at improving the accuracy and efficiency of emergency department radiography use in clinical contexts that exhibit enormous inefficiency at the present time. The rules were prospectively derived and validated using the same methodology demonstrating high sensitivity and reliability. The rules subsequently underwent parallel implementations at 12 Canadian hospitals, yet only the CCR was observed to significantly reduce radiography ordering rates, while the CCHR failed to have any significant impact at all. The drastically different results are unlikely to be the result of differences in implementation strategies or the decision rules. METHODS: Physicians at the 12 participating Canadian hospitals were randomized to CCR or CCHR TPB surveys that were administered during the baseline phases of the implementation studies, before any intervention had taken place. The collected baseline survey data were linked to concurrent baseline physician and patient-specific imaging data, and subsequently analyzed using mixed effects linear and logistic models. RESULTS: A total of 223 of the 378 eligible physicians randomized to a TPB survey completed their assigned baseline survey (CCR: 122 of 181; CCHR: 101 of 197). Attitudes were significantly associated with intention in both settings (CCR: ß = 0.40; CCHR: ß = 0.30), as were subjective norms (CCR: ß = 0.26; CCHR: ß = 0.73). Intention was significantly associated with actual image ordering for CCR (OR = 1.79), but not CCHR. CONCLUSIONS: The TPB can be used to better understand processes underlying use of CDRs. TPB constructs were significantly associated with intention to perform both imaging behaviours, but intention was only associated with actual behaviour for CCR, suggesting that constructs outside of the TPB framework may need to be considered when seeking to understand use of CDRs.


Asunto(s)
Técnicas de Apoyo para la Decisión , Diagnóstico por Imagen/normas , Servicio de Urgencia en Hospital , Adulto , Canadá , Recolección de Datos , Diagnóstico por Imagen/psicología , Diagnóstico por Imagen/estadística & datos numéricos , Difusión de Innovaciones , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Humanos , Masculino , Modelos Psicológicos , Pautas de la Práctica en Medicina/estadística & datos numéricos
14.
CMAJ ; 186(6): E193-204, 2014 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-24549125

RESUMEN

BACKGROUND: To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events. METHODS: We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission. RESULTS: We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%. INTERPRETATION: In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.


Asunto(s)
Progresión de la Enfermedad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/terapia , Distribución por Edad , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Canadá , Causas de Muerte , Estudios de Cohortes , Toma de Decisiones , Tratamiento de Urgencia/efectos adversos , Tratamiento de Urgencia/métodos , Femenino , Estudios de Seguimiento , Hospitales de Enseñanza , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Alta del Paciente/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Medición de Riesgo , Distribución por Sexo , Análisis de Supervivencia
15.
Acad Emerg Med ; 20(1): 17-26, 2013 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-23570474

RESUMEN

OBJECTIVES: There are no validated guidelines to guide physicians with difficult disposition decisions for emergency department (ED) patients with heart failure (HF). The authors sought to develop a risk scoring system to identify HF patients at high risk for serious adverse events (SAEs). METHODS: This was a prospective cohort study at six large Canadian EDS that enrolled adult patients who presented with acute decompensated HF. Each patient was assessed for standardized clinical and laboratory variables as well as for SAEs defined as death, intubation, admission to a monitored unit, or relapse requiring admission. Adjusted odds ratios for predictors of SAEs were calculated by stepwise logistic regression. RESULTS: In 559 visits, 38.1% resulted in patient admission. Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with good calibration between observed and expected probabilities. Internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. A threshold of 1, 2, or 3 total scores for admission would be associated with sensitivities of 95.2, 80.6, or 64.5%, respectively, all better than current practice. CONCLUSIONS: Many HF patients are discharged home from the ED and then suffer SAEs or death. The authors have developed an accurate risk scoring system that could ultimately be used to stratify the risk of poor outcomes and to enable rational and safe disposition decisions.


Asunto(s)
Causas de Muerte , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/efectos adversos , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/terapia , Alta del Paciente/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Estudios de Cohortes , Progresión de la Enfermedad , Medicina de Emergencia/normas , Medicina de Emergencia/tendencias , Tratamiento de Urgencia/métodos , Femenino , Insuficiencia Cardíaca/diagnóstico , Mortalidad Hospitalaria/tendencias , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Oportunidad Relativa , Admisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Factores de Tiempo
16.
J Atr Fibrillation ; 5(6): 645, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-28496821

RESUMEN

Guidelines strongly recommend long-term anticoagulation with warfarin for patients with newly recognized AF who have high embolic risk by virtue of a CHADS2 (Congestive Heart Failure, Hypertension, Age >65, Diabetes, History of Stroke) score ≥ 2. The goal of this study was to determine patterns of emergency department-initiated anticoagulation among eligible patients discharged from Canadian centers with an episode of recent-onset atrial fibrillation and flutter (RAFF) and determine if decision-making is driven by the CHADS2 score or other factors. This was accomplished by examining health records using uniform case identification and data abstraction as well as centralized quality control; it was conducted in 8 Canadian university emergency departments over a 12-month period. Eligible patients for this analysis demonstrated RAFF requiring emergency management, were not already taking warfarin and were not admitted to hospital. Univariate analyses were conducted using T-test or Chi-square to select factors associated with anticoagulation initiation at a significance level of p < 0.15 and multiple logistic regression was employed to evaluate independent predictors after adjustment for confounders. Among 633 eligible patients, only 21 out of 120 patients (18%) with a CHADS2 score ≥ 2 received anticoagulation and among 70 patients who were given anticoagulation only 21 (30%) had a CHADS2 score ≥ 2. Independent predictors of anticoagulation included age by 10-year strata: (OR = 1.7; 95% CI 1.3 - 2.1), heparin use in the anticoagulation (OR = 9.6; 95% CI 4.9 - 18.9), a new prescription for metoprolol (OR = 9.6; 95% CI 4.9 - 18.9) and being referred to cardiology for follow-up (OR = 5.6; 95% CI 2.6 - 12.0). CHADS2 ≥ 2 doubled the likelihood of being prescribed anticoagulation (OR= 2.0; 95% CI 1.5 - 3.5) but was not an independent predictor. It was thus determined that patients discharged from the emergency department in this study were not prescribed anticoagulation in keeping with current recommendations. This practice gap merits further investigation and may benefit from educational efforts or enhanced support for anticoagulation use from the emergency department.

17.
Acad Emerg Med ; 19(11): 1255-60, 2012 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-23167856

RESUMEN

OBJECTIVES: This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia). METHODS: The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP; United States-500), College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics. RESULTS: Response rates were as follows: overall, 40.5%; Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%; and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41%; p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78%; p < 0.0001). CONCLUSIONS: There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.


Asunto(s)
Fibrilación Atrial/terapia , Medicina de Emergencia/normas , Servicio de Urgencia en Hospital , Pautas de la Práctica en Medicina/tendencias , Adulto , Antiarrítmicos/uso terapéutico , Anticoagulantes/uso terapéutico , Fibrilación Atrial/diagnóstico , Australasia , Canadá , Distribución de Chi-Cuadrado , Sedación Consciente/métodos , Cardioversión Eléctrica/estadística & datos numéricos , Medicina de Emergencia/tendencias , Femenino , Encuestas de Atención de la Salud , Frecuencia Cardíaca , Humanos , Cooperación Internacional , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Tasa de Supervivencia , Resultado del Tratamiento , Reino Unido , Estados Unidos
18.
CJEM ; 14(3): 169-77, 2012 May.
Artículo en Inglés | MEDLINE | ID: mdl-22575297

RESUMEN

OBJECTIVE: It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion. METHODS: This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion. RESULTS: A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2 score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74). CONCLUSION: We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.


Asunto(s)
Antiarrítmicos/efectos adversos , Fibrilación Atrial/tratamiento farmacológico , Aleteo Atrial/tratamiento farmacológico , Cardioversión Eléctrica/métodos , Premedicación/efectos adversos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amiodarona/efectos adversos , Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Aleteo Atrial/terapia , Canadá , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Procainamida/efectos adversos , Procainamida/uso terapéutico , Propafenona/efectos adversos , Propafenona/uso terapéutico , Estudios Retrospectivos , Resultado del Tratamiento
19.
Acad Emerg Med ; 19(1): 2-10, 2012 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-22251188

RESUMEN

OBJECTIVES: This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with "clinically important" brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15. METHODS: This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of "any traumatic intracranial injury" on CT. Secondary outcomes included "clinically important brain injury" on CT and need for neurosurgical intervention. RESULTS: Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had "clinically important" brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For "clinically important" brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention. CONCLUSIONS: In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.


Asunto(s)
Traumatismos Craneocerebrales/diagnóstico por imagen , Sistemas de Apoyo a Decisiones Clínicas , Tomografía Computarizada por Rayos X/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Traumatismos Craneocerebrales/cirugía , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Centros Traumatológicos , Estados Unidos
20.
N Engl J Med ; 365(9): 798-806, 2011 Sep 01.
Artículo en Inglés | MEDLINE | ID: mdl-21879897

RESUMEN

BACKGROUND: The impedance threshold device (ITD) is designed to enhance venous return and cardiac output during cardiopulmonary resuscitation (CPR) by increasing the degree of negative intrathoracic pressure. Previous studies have suggested that the use of an ITD during CPR may improve survival rates after cardiac arrest. METHODS: We compared the use of an active ITD with that of a sham ITD in patients with out-of-hospital cardiac arrest who underwent standard CPR at 10 sites in the United States and Canada. Patients, investigators, study coordinators, and all care providers were unaware of the treatment assignments. The primary outcome was survival to hospital discharge with satisfactory function (i.e., a score of ≤3 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating greater disability). RESULTS: Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (risk difference adjusted for sequential monitoring, -0.1 percentage points; 95% confidence interval, -1.1 to 0.8; P=0.71). There were also no significant differences in the secondary outcomes, including rates of return of spontaneous circulation on arrival at the emergency department, survival to hospital admission, and survival to hospital discharge. CONCLUSIONS: Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).


Asunto(s)
Reanimación Cardiopulmonar/instrumentación , Paro Cardíaco Extrahospitalario/terapia , Anciano , Servicios Médicos de Urgencia , Femenino , Humanos , Masculino , Paro Cardíaco Extrahospitalario/mortalidad , Resultado del Tratamiento
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