Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

OBJECTIVES: Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. METHODS: This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. RESULTS: In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. CONCLUSION: There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

Core competencies for emergency medicine clerkships: results of a Canadian consensus initiative.

OBJECTIVES: There is no consensus on what constitutes the core competencies for emergency medicine (EM) clerkship rotations in Canada. Existing EM curricula have been developed through informal consensus and often focus on EM content to be known at the end of training rather than what is an appropriate focus for a time-limited rotation in EM. We sought to define the core competencies for EM clerkship in Canada through consensus among an expert panel of Canadian EM educators. METHODS: We used a modified Delphi method and the CanMEDS 2005 Physician Competency Framework to develop a consensus among expert EM educators from across Canada. RESULTS: Thirty experts from nine different medical schools across Canada participated on the panel. The initial list consisted of 152 competencies organized in the seven domains of the CanMEDS 2005 Physician Competency Framework. After the second round of the Delphi process, the list of competencies was reduced to 62 (59% reduction). A complete list of competencies is provided. CONCLUSION: This study established a national consensus defining the core competencies for EM clerkship in Canada.

Emergency Physician Patterns Related to Anticoagulation of Patients with Recent-Onset Atrial Fibrillation and Flutter.

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.

Use of rate control medication before cardioversion of recent-onset atrial fibrillation or flutter in the emergency department is associated with reduced success rates.

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.

Using a Delphi process to establish consensus on emergency medicine clerkship competencies.

BACKGROUND: Currently, there is no consensus on the core competencies required for emergency medicine (EM) clerkships in Canada. Existing EM curricula have been developed through informal consensus or local efforts. The Delphi process has been used extensively as a means for establishing consensus. AIM: The purpose of this project was to define core competencies for EM clerkships in Canada, to validate a Delphi process in the context of national curriculum development, and to demonstrate the adoption of the CanMEDS physician competency paradigm in the undergraduate medical education realm. METHODS: Using a modified Delphi process, we developed a consensus amongst a panel of expert emergency physicians from across Canada utilizing the CanMEDS 2005 Physician Competency Framework. RESULTS: Thirty experts from nine different medical schools across Canada participated on the panel. The initial list consisted of 152 competencies organized in the seven domains of the CanMEDS 2005 Physician Competency Framework. After the second round of the Delphi process, the list of competencies was reduced to 62 (59% reduction). CONCLUSION: This study demonstrated that a modified Delphi process can result in a strong consensus around a realistic number of core competencies for EM clerkships. We propose that such a method could be used by other medical specialties and health professions to develop rotation-specific core competencies.

Variation in management of recent-onset atrial fibrillation and flutter among academic hospital emergency departments.

STUDY OBJECTIVE: Although recent-onset atrial fibrillation and flutter are common arrhythmias managed in the emergency department (ED), there is insufficient evidence to help physicians choose between 2 competing treatment strategies, rate control and rhythm control. We seek to evaluate variation in ED management practices for recent-onset atrial fibrillation and flutter patients at multiple Canadian sites and to determine whether hospital site was an independent predictor of attempted cardioversion. METHODS: We conducted a cross-sectional survey by health records review on an observational cohort of all eligible adult recent-onset atrial fibrillation and flutter cases, with onset of symptoms less than 48 hours, treated at 8 academic hospital EDs during a 12-month period, and evaluated the variation in practice among sites for important management strategies. RESULTS: Among the 1,068 study patients, 88.3% had atrial fibrillation and 11.7% had atrial flutter. The proportion of cases managed with rhythm control was 59.4% (interhospital range 42% to 85%) and, among these, electrocardioversion was attempted first for 44.2% (range 7% to 69%). There was variation in most management strategies, including use of rate control drugs 54.9% (range 37% to 65%), choice of procainamide as rhythm control drug 62.1% (range 15% to 89%), referral to cardiology in the ED 30.7% (range 16% to 64%), use of heparin 13.7% (range 1% to 29%), and outpatient cardiology referral 43.0% (range 30% to 65%). Adverse events were relatively uncommon and transient for patients undergoing attempts at pharmacologic (13.0%) or electrocardioversion (12.1%). Overall, 83.3% of patients were discharged home from the ED (range 73% to 90%). After controlling for 12 covariates, multivariate logistic regression found that factors independently associated with attempted cardioversion were age (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95 to 0.98), history of electrocardioversion (OR 2.73; 95% CI 1.56 to 4.80), associated heart failure (OR 0.29; 95% CI 0.09 to 0.95), and hospital site (ORs ranged from 0.38 to 3.05). CONCLUSION: We demonstrated a high degree of variation in management approaches for recent-onset atrial fibrillation and flutter patients treated in academic hospital EDs. Individual hospital site, age, previous cardioversion, and associated heart failure were independent predictors for the use of rhythm control.

Simulation-based training in critical resuscitation procedures improves residents' competence.

OBJECTIVE: Residents must become proficient in a variety of procedures. The practice of learning procedural skills on patients has come under ethical scrutiny, giving rise to the concept of simulation-based medical education. Resident training in a simulated environment allows skill acquisition without compromising patient safety. We assessed the impact of a simulation-based procedural skills training course on residents' competence in the performance of critical resuscitation procedures. METHODS: We solicited self-assessments of the knowledge and clinical skills required to perform resuscitation procedures from a cross-sectional multidisciplinary sample of 28 resident study participants. Participants were then exposed to an intensive 8-hour simulation-based training program, and asked to repeat the self-assessment questionnaires on completion of the course, and again 3 months later. We assessed the validity of the self-assessment questionnaire by evaluating participants' skills acquisition through an Objective Structured Clinical Examination station. RESULTS: We found statistically significant improvements in participants' ratings of both knowledge and clinical skills during the 3 self-assessment periods ( p < 0.001). The participants' year of postgraduate training influenced their self assessment of knowledge ( F = 4.91, p< 0.01) and clinical 2,25 skills ( F = 10.89, p< 0.001). At the 3-month follow-up, junior 2,25 level residents showed consistent improvement from their baseline scores, but had regressed from their posttraining measures. Senior-level residents continued to show further increases in their assessments of both clinical skills and knowledge beyond the simulation-based training course. CONCLUSION: Significant improvement in self-assessed theoretical knowledge and procedural skill competence for residents can be achieved through participation in a simulation-based resuscitation course. Gains in perceived competence appear to be stable over time, with senior learners gaining further confidence at the 3-month follow-up. Our findings support the benefits of simulation-based training for residents.

Do elective surgical and medical admissions impact emergency department length of stay measurements?

BACKGROUND: Emergency department access block is a growing problem in emergency departments across Canada. Access block is defined as hospital occupancy >85% causing emergency department overcrowding. Hospital overcrowding leads to prolonged emergency department wait times, and delays in the transfer of admitted patients from the emergency department to inpatient beds. The relationship between elective admissions to hospital and emergency department wait times has not been adequately assessed. We undertook a simple linear regression analysis of the impact of elective admissions to hospital on emergency department length of stay. METHODS: Linear regression analysis of the number of daily elective admissions to adult acute care beds in the Calgary Health Region in the year 2004 and the daily median emergency department length of stay was done to establish the relationship between elective admissions and Emergency Department length of stay. RESULTS: 37,007 patients were admitted to adult acute care beds via the emergency department and 46,020 patients were admitted to adult acute care beds by all other routes. Regression analysis determined that there was no relationship between daily emergency department length of stay and the number of elective admissions per day. CONCLUSION: For the year 2004, in the Calgary Health Region, elective acute care admissions to hospital had no relationship to emergency department length of stay for patients admitted via the emergency department. Further study is required to determine causative factors that prolong Emergency Department length of stay. Emergency departments across Canada continue to struggle with the demands of providing high quality care with diminishing resources.