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1.
Can Respir J ; 17(1): 25-30, 2010.
Artigo em Inglês | MEDLINE | ID: mdl-20186368

RESUMO

BACKGROUND: Asthma exacerbations constitute one of the most common causes of emergency department (ED) attendance in most developed countries. While severe asthma often requires hospitalization, variability in admission practices has been observed. OBJECTIVE: To describe the factors associated with admission to Canadian hospitals for acute asthma after ED treatment. METHODS: Subjects 18 to 55 years of age treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview (n=695) and telephone interview two weeks later. RESULTS: The median age of the patients was 30 years, and the majority were women (62.8%). The admission rate was 13.1% (95% CI 10.7% to 15.8%). Admitted patients were older, more often receiving oral or inhaled corticosteroids at presentation, and more frequently receiving systemic corticosteroids and magnesium sulphate in the ED. Similar proportions received beta-2 agonists and/or ipratropium bromide within 1 h of arrival. On multivariable analyses, factors associated with admission included age, previous admission in the past two years, more than eight beta-2 agonist puffs in the past 24 h, a Canadian Triage and Acuity Score of 1 to 2, a respiratory rate of greater than 22 breaths/min and an oxygen saturation of less than 95%. CONCLUSION: The admission rate for acute asthma from these Canadian EDs was lower than reported in other North American studies. The present study provides insight into practical factors associated with admission for acute asthma and highlights the importance of history and asthma severity markers on ED decision making. Further efforts to standardize ED management and expedite admission decision-making appear warranted.


Assuntos
Asma/terapia , Admissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença
2.
Emerg Med J ; 26(4): 278-82, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19307390

RESUMO

INTRODUCTION: Emergency department (ED) physicians face frequent decisions on whether to admit patients with congestive heart failure (CHF) or acute exacerbation of chronic obstructive pulmonary disease (COPD). This feasibility study evaluated the potential of a structured 3-minute walk test as a clinical decision tool for admission and correlated its performance with poor clinical outcomes. It also aimed to gather evidence and directions for the design of a multicentre study to derive clinical guidelines. METHODS: In this prospective cohort study, a convenience sample was enrolled of 40 adult patients who presented to a tertiary care ED with CHF, COPD, or stable chest pain and were being considered for discharge. Patients walked at their own pace and their dyspnoea, respiratory rate, heart rate and oxygen saturation were recorded each minute for 4 minutes. The primary outcome was "poor clinical outcome" defined as admission to hospital, the need for biphasic positive airway pressure, the need for intubation, relapse, or death. RESULTS: 85.0% successfully completed the test and 30.0% had poor clinical outcomes. Of those with poor clinical outcomes, 41.7% were unable to complete the test compared with only 3.6% of those with good clinical outcomes (p<0.01). Significant differences were noted in the dyspnoea (p = 0.04) and respiratory rate (p = 0.03) as well as oxygen saturation measurements at 3 minutes. CONCLUSIONS: The 3-minute walk test is a non-resource intensive, simple procedure with applicability in most ED for discharge decisions in patients with cardiopulmonary conditions. Multicentre studies are being planned to validate these findings and establish guidelines for admission and discharge of patients with CHF or acute exacerbation of COPD.


Assuntos
Dispneia/diagnóstico , Serviço Hospitalar de Emergência , Teste de Esforço/métodos , Idoso , Idoso de 80 Anos ou mais , Técnicas de Apoio para a Decisão , Dispneia/etiologia , Métodos Epidemiológicos , Feminino , Insuficiência Cardíaca/complicações , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Alta do Paciente , Seleção de Pacientes , Prognóstico , Doença Pulmonar Obstrutiva Crônica/complicações
3.
Resuscitation ; 79(3): 417-23, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-18951678

RESUMO

OBJECTIVES: While lower socioeconomic status is associated with lower level of education and increased incidence of cardiovascular diseases, the impact of socioeconomic status on out-of-hospital cardiac arrest outcomes is unclear. We used residential property values as a proxy for socioeconomic status to determine if there was an association with: (1) bystander CPR rates and (2) survival to hospital discharge for out-of-hospital cardiac arrest. METHODS: We performed a secondary data analysis of cardiac arrest cases prospectively collected as part of the Ontario Prehospital Advanced Life Support study, conducted in 20 cities with ALS and BLS-D paramedics. We measured patient and system characteristics for cardiac arrests of cardiac origin, not witnessed by EMS, occurring in a single residential dwelling. We obtained property values from the Municipal Property Assessment Corporation. Analyses included descriptive statistics with 95% CIs and stepwise logistic regression. RESULTS: Three thousand six hundred cardiac arrest cases met our inclusion criteria between 1 January 1995 and 31 December 1999. Patient characteristics were: mean age 69.2, male 67.8%, witnessed 44.7%, bystander CPR 13.2%, VF/VT 33.8%, time to vehicle stop 5:36min:s, return of spontaneous circulation 12.7%, and survival 2.7%. Median property value was $184,000 (range $25,500-2,494,000). For each $100,000 increment in property value, the likelihood of receiving bystander CPR increased (OR=1.07; 95% CI 1.01-1.14; p=0.03) and survival decreased (OR=0.77; 95% CI 0.61-0.97; p=0.03). CONCLUSIONS: This is the largest study showing an association between socioeconomic status and survival, and the first study showing an association with bystander CPR. Our findings suggest targeting CPR training among lower socioeconomic groups.


Assuntos
Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca/mortalidade , Idoso , Feminino , Humanos , Masculino , Ontário/epidemiologia , Fatores Socioeconômicos , Taxa de Sobrevida
4.
JAMA ; 286(15): 1841-8, 2001 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-11597285

RESUMO

CONTEXT: High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients. OBJECTIVE: To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients. DESIGN: Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments. SETTING: Ten EDs in large Canadian community and university hospitals. PATIENTS: Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15. MAIN OUTCOME MEASURE: Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the kappa coefficient, logistic regression analysis, and chi(2) recursive partitioning techniques. RESULTS: Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age >/=65 years, dangerous mechanism, or paresthesias in extremities)? (2) is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and (3) is the patient able to actively rotate neck 45 degrees to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%. CONCLUSION: We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography.


Assuntos
Traumatismos Craniocerebrais/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Serviços Médicos de Emergência/normas , Lesões do Pescoço/diagnóstico por imagem , Traumatologia/normas , Ferimentos não Penetrantes/diagnóstico por imagem , Adulto , Idoso , Canadá , Vértebras Cervicais/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Estudos Prospectivos , Radiografia/normas , Análise de Regressão , Medição de Risco , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X
5.
Can J Surg ; 44(4): 267-74, 2001 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-11504260

RESUMO

OBJECTIVE: To determine clinicians' accuracy and reliability for the clinical diagnosis of unstable meniscus tears in patients with symptomatic osteoarthritis of the knee. DESIGN: A prospective cohort study. SETTING: A single tertiary care centre. PATIENTS: One hundred and fifty-two patients with symptomatic osteoarthritis of the knee refractory to conservative medical treatment were selected for prospective evaluation of arthroscopic debridement. INTERVENTION: Arthroscopic debridement of the knee, including meniscal tear and chondral flap resection, without abrasion arthroplasty. OUTCOME MEASURES: A standardized assessment protocol was administered to each patient by 2 independent observers. Arthroscopic determination of unstable meniscal tears was recorded by 1 observer who reviewed a video recording and was blinded to preoperative data. Those variables that had the highest interobserver agreement and the strongest association with meniscal tear by univariate methods were entered into logistic regression to model the best prediction of resectable tears. RESULTS: There were 92 meniscal tears (77 medial, 15 lateral). Interobserver agreement between clinical fellows and treating surgeons was poor to fair (kappa < 0.4) for all clinical variables except radiographic measures, which were good. Fellows and surgeons predicted unstable meniscal tear preoperatively with equivalent accuracy of 60%. Logistic regression modelling revealed that a history of swelling and a ballottable effusion were negative predictors. A positive McMurray test was the only positive predictor of unstable meniscal tear. "Mechanical" symptoms were not reliable predictors in this prospective study. The model was 69% accurate for all patients and 76% for those with advanced medial compartment osteoarthritis defined by a joint space height of 2 mm or less. CONCLUSIONS: This study underscored the difficulty in using clinical variables to predict unstable medial meniscal tears in patients with pre-existing osteoarthritis of the knee. The lack of interobserver agreement must be overcome to ensure that the findings can be generalized to other physician observers.


Assuntos
Osteoartrite do Joelho/complicações , Lesões do Menisco Tibial , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Estudos Prospectivos , Reprodutibilidade dos Testes
6.
Ann Emerg Med ; 38(3): 317-22, 2001 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-11524653

RESUMO

Prospective validation on a new set of patients is an essential test of a new decision rule. However, many clinical decision rules are not prospectively assessed to determine their accuracy, reliability, clinical sensibility, or potential impact on practice. This validation process is important because many statistically derived rules or guidelines do not perform well when tested in a new population. The methodologic standards for a validation study are similar to those described in the article on phase I for derivation studies in the August 2001 issue of Annals of Emergency Medicine. The goal of phase II is to prospectively assess the accuracy, reliability, and acceptability of the decision rule in a new set of patients with minor head injury. This will determine the clinical utility of the rule and is essential if such a rule is to be widely adopted into clinical practice.


Assuntos
Traumatismos Craniocerebrais/economia , Política de Saúde/economia , Programas Nacionais de Saúde/economia , Tomografia Computadorizada por Raios X/economia , Canadá , Ensaios Clínicos Fase II como Assunto , Estudos de Coortes , Controle de Custos , Traumatismos Craniocerebrais/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Pesquisa sobre Serviços de Saúde , Humanos , Estudos Prospectivos , Reprodutibilidade dos Testes
7.
Ann Emerg Med ; 38(2): 160-9, 2001 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-11468612

RESUMO

Head injuries are among the most common types of trauma seen in North American emergency departments, with an estimated 1 million cases seen annually. "Minor" head injury (sometimes known as "mild") is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, that is, with a Glasgow Coma Scale score of 13 to 15. Although most patients with minor head injury can be discharged without sequelae after a period of observation, in a small proportion, their neurologic condition deteriorates and requires neurosurgical intervention for intracranial hematoma. The objective of the Canadian CT Head Rule Study is to develop an accurate and reliable decision rule for the use of computed tomography (CT) in patients with minor head injury. Such a decision rule would allow physicians to be more selective in their use of CT without compromising care of patients with minor head injury. This paper describes in detail the rationale, objectives, and methodology for Phase I of the study in which the decision rule was derived. [Stiell IG, Lesiuk H, Wells GA, McKnight RD, Brison R, Clement C, Eisenhauer MA, Greenberg GH, MacPhail I, Reardon M, Worthington J, Verbeek R, Rowe B, Cass D, Dreyer J, Holroyd B, Morrison L, Schull M, Laupacis A, for the Canadian CT Head and C-Spine Study Group. The Canadian CT Head Rule Study for patients with minor head injury: rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med. August 2001;38:160-169.]


Assuntos
Traumatismos Craniocerebrais/diagnóstico por imagem , Técnicas de Apoio para a Decisão , Tomografia Computadorizada por Raios X , Adolescente , Adulto , Idoso , Canadá/epidemiologia , Traumatismos Craniocerebrais/epidemiologia , Interpretação Estatística de Dados , Serviço Hospitalar de Emergência/estatística & dados numéricos , Escala de Coma de Glasgow , Humanos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sensibilidade e Especificidade
8.
Lancet ; 358(9276): 105-9, 2001 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-11463411

RESUMO

BACKGROUND: Survival rates for cardiac arrest patients, both in and out of hospital, are poor. Results of a previous study suggest better outcomes for patients treated with vasopressin than for those given epinephrine, in the out-of-hospital setting. Our aim was to compare the effectiveness and safety of these drugs for the treatment of in-patient cardiac arrest. METHODS: We did a triple-blind randomised trial in the emergency departments, critical care units, and wards of three Canadian teaching hospitals. We assigned adults who had cardiac arrest and required drug therapy to receive one dose of vasopressin 40 U or epinephrine 1 mg intravenously, as the initial vasopressor. Patients who failed to respond to the study intervention were given epinephrine as a rescue medication. The primary outcomes were survival to hospital discharge, survival to 1 h, and neurological function. Preplanned subgroup assessments included patients with myocardial ischaemia or infarction, initial cardiac rhythm, and age. FINDINGS: We assigned 104 patients to vasopressin and 96 to epinephrine. For patients receiving vasopressin or epinephrine survival did not differ for hospital discharge (12 [12%] vs 13 [14%], respectively; p50.67; 95% CI for absolute increase in survival 211.8% to 7.8%) or for 1 h survival (40 [39%] vs 34 [35%]; p50.66; 210.9% to 17.0%); survivors had closely similar median mini-mental state examination scores (36 [range 19-38] vs 35 [20-40]; p50.75) and median cerebral performance category scores (1 vs 1). INTERPRETATION: We failed to detect any survival advantage for vasopressin over epinephrine. We cannot recommend the routine use of vasopressin for inhospital cardiac arrest patients, and disagree with American Heart Association guidelines, which recommend vasopressin as alternative therapy for cardiac arrest.


Assuntos
Epinefrina/uso terapêutico , Parada Cardíaca/tratamento farmacológico , Hospitalização , Ressuscitação/métodos , Vasopressinas/uso terapêutico , Idoso , Arritmias Cardíacas/etiologia , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Método Duplo-Cego , Feminino , Parada Cardíaca/complicações , Parada Cardíaca/mortalidade , Humanos , Hipertensão/etiologia , Infarto/etiologia , Masculino , Entrevista Psiquiátrica Padronizada , Mesentério/irrigação sanguínea , Pessoa de Meia-Idade , Ontário/epidemiologia , Segurança , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
9.
Ann Emerg Med ; 37(6): 602-8, 2001 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-11385328

RESUMO

STUDY OBJECTIVE: There is little evidence that cardiopulmonary resuscitation (CPR) alone may lead to the resuscitation of cardiac arrest victims with other than respiratory causes (eg, pediatric arrest, drowning, drug overdose). The objective of this study was to identify out-of-hospital cardiac arrest survivors resuscitated without defibrillation or advanced cardiac life support. METHODS: This observational cohort included all adult survivors of out-of-hospital cardiac arrest of a cardiac cause from phases I and II of the Ontario Prehospital Advanced Life Support Study. During the study period, the system provided a basic life support/defibrillation level of care but no advanced life support. CPR-only patients were patients determined to be without vital signs by EMS personnel who regained a palpable pulse in the field with precordial thump or CPR only and then were admitted alive to the hospital. Six members of a 7-member expert review panel had to rate the patient as either probably or definitely having an out-of-hospital cardiac arrest, and a rhythm strip consistent with a cardiac arrest rhythm had to be present to be considered a patient. Criteria considered were witness status, citizen or first responder CPR, CPR duration, arrest rhythm and rate, and performance of precordial thump. RESULTS: From January 1, 1991, to June 30, 1997, 9,667 patients with out-of-hospital cardiac arrest were treated. The overall survival rate to hospital discharge was 4.6%. There were 97 apparent CPR-only patients admitted to the hospital. Application of the inclusion criteria yielded 24 CPR-only patients who had true out-of-hospital cardiac arrest and 73 patients judged not to have cardiac arrest. Of the 24 true CPR-only patients admitted to the hospital, 15 patients were discharged alive, 10 patients were witnessed by bystanders, and 7 patients were witnessed by EMS personnel. The initial arrest rhythm was pulseless electrical activity in 9 patients, asystole in 12 patients, and ventricular tachycardia in 3 patients. One patient with ventricular tachycardia converted to sinus tachycardia with a single precordial thump. CONCLUSION: CPR-only survivors of true out-of-hospital cardiac arrest do exist; some victims of out-of-hospital cardiac arrest of primary cardiac cause can survive after provision of out-of-hospital basic life support care only. However, many patients found to be pulseless by means of out-of-hospital evaluation likely did not have a true cardiac arrest. This has implications for the survival rates of most, if not all, previous cardiac arrest reports. Survival rates from cardiac arrest may actually be lower if one excludes survivors who never had a true arrest. The absence of vital signs by out-of-hospital assessment alone is not adequate to include patients in research reports or quality evaluations for cardiac arrest.


Assuntos
Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Pesquisa sobre Serviços de Saúde/métodos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Sobreviventes/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/normas , Estudos de Coortes , Cardioversão Elétrica , Eletrocardiografia , Serviços Médicos de Emergência/normas , Feminino , Pesquisa sobre Serviços de Saúde/normas , Parada Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Palpação , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
10.
Ann Emerg Med ; 37(6): 657-63, 2001 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-11385338

RESUMO

Development of methodologically acceptable outcomes models for emergency medical services (EMS) is long overdue. In this article, the Emergency Medical Services Outcomes Project proposes a conceptual framework that will provide a foundation for future EMS outcomes research. The "Episode of Care Model" and the "Out-of-Hospital Unit of Service Model" are presented. The Episode of Care Model is useful in conditions in which interventions and outcomes, especially survival and major physiologic dysfunction, are linked in a time-dependent manner. Conditions such as severe trauma, anaphylaxis, airway obstruction, respiratory arrest, and nontraumatic cardiac arrest are amenable to this methodology. The Out-of-Hospital Unit of Service Model is essentially a subunit of the Episode of Care Model. It is valuable for evaluating conditions that have minimal-to-moderate therapeutic time dependency. This model should be used when studying outcomes limited to the out-of-hospital interval. An example of this is pain management for injuries sustained in motor vehicle crashes. These models can be applied to a wide spectrum of conditions and interventions. With the scrutiny of health care expenditures ever increasing, the identification of clinical interventions that objectively improve patient outcome takes on growing importance. Therefore, the development, dissemination, and use of meaningful methodologies for EMS outcomes research is key to the future of EMS system development and maintenance.


Assuntos
Serviços Médicos de Emergência/organização & administração , Cuidado Periódico , Pesquisa sobre Serviços de Saúde/organização & administração , Modelos Organizacionais , Avaliação de Resultados em Cuidados de Saúde/organização & administração , Desenvolvimento de Programas/métodos , Projetos de Pesquisa/normas , Assistência ao Convalescente/organização & administração , Prioridades em Saúde , Humanos , Morbidade , Risco Ajustado/organização & administração , Análise de Sobrevida , Fatores de Tempo , Estados Unidos/epidemiologia
11.
Lancet ; 357(9266): 1391-6, 2001 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-11356436

RESUMO

BACKGROUND: There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries. METHODS: We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT. FINDINGS: The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT. INTERPRETATION: We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.


Assuntos
Lesões Encefálicas/diagnóstico , Traumatismos Craniocerebrais/diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/etiologia , Canadá , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/etiologia , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X
12.
Ann Emerg Med ; 37(3): 259-66, 2001 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-11223761

RESUMO

STUDY OBJECTIVES: We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision rules in general. METHODS: We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these rules, and attitudes toward clinical decision rules in general. RESULTS: A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of all physicians, those from the United States held the least positive attitudes toward decision rules. CONCLUSION: This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision rules. Striking differences were apparent among countries with regard to knowledge and use of decision rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such rules in the emergency department.


Assuntos
Traumatismos do Tornozelo/diagnóstico por imagem , Atitude do Pessoal de Saúde , Conscientização , Sistemas de Apoio a Decisões Clínicas , Difusão de Inovações , Traumatismos do Joelho/diagnóstico por imagem , Editoração , Adulto , Canadá , Procedimentos Clínicos , Comparação Transcultural , Coleta de Dados , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estados Unidos
13.
CJEM ; 3(3): 186-92, 2001 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17610782

RESUMO

OBJECTIVES: Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system. METHODS: This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival. RESULTS: From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call response interval (CRI)

14.
Acad Emerg Med ; 7(9): 980-7, 2000 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-11043991

RESUMO

UNLABELLED: To the authors' knowledge, no outcome-based, randomized clinical trial of the safety of opioid analgesics in acute abdominal pain exists. OBJECTIVES: 1) To assess the feasibility of a randomized clinical trial of opioid safety by estimating the adverse outcome rate among patients with abdominal pain severe enough to necessitate opioid analgesics. 2) To explore the association of opioid administration with adverse outcomes in acute abdominal pain. METHODS: The authors conducted a prospective observational study of emergency department (ED) abdominal pain patients, and followed them by telephone at three weeks to determine whether an adverse outcome occurred (defined as obstruction, perforation, ischemia, hemorrhage, peritonitis, sepsis, or death). A logistic regression of factors predicting adverse outcome was performed. RESULTS: Adverse outcomes occurred in 67 of 860 abdominal pain patients (7.8%, 95% CI = 6.1% to 9.8%), and 252 of 860 (29%) received opioids. The adverse outcome rate was 12.7% (95% CI = 9.0% to 17.0%) among patients who received opioids. Variables predictive of adverse outcome in logistic regression included: ED diagnosis of adverse outcome (OR 12.4), age (OR 1.6 per decade), fever (OR 4.6), received opioids (OR 2.1), pain duration (OR 1.5 per day), and leukocytosis (OR 2.0). CONCLUSIONS: A clinical trial would need to randomize more than 1,500 patients to establish the equivalent adverse outcome rates of opioids and placebo: the sample size of all existing studies combined is insufficient to make such a conclusion. Although opioids were associated with a higher adverse outcome rate in this logistic regression, the authors believe this may be due to confounding by pain severity. They emphasize that the study's design precludes conclusion of a causal link. No change in clinical practice is warranted. A randomized clinical trial of sufficient size to definitively resolve this issue is needed.


Assuntos
Dor Abdominal/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Dor Abdominal/complicações , Doença Aguda , Adulto , Analgésicos Opioides/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Modelos Logísticos , Masculino , Estudos Prospectivos , Resultado do Tratamento
15.
Acad Emerg Med ; 7(7): 739-44, 2000 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-10917321

RESUMO

OBJECTIVES: To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself. METHODS: A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression. RESULTS: One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan. CONCLUSIONS: Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.


Assuntos
Traumatismos Craniocerebrais/diagnóstico por imagem , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adolescente , Análise de Variância , Canadá , Criança , Pré-Escolar , Estudos de Coortes , Intervalos de Confiança , Traumatismos Craniocerebrais/diagnóstico , Medicina de Emergência/estatística & dados numéricos , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Probabilidade , Estudos Retrospectivos , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X/métodos
16.
JAMA ; 284(1): 79-84, 2000 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-10872017

RESUMO

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84


Assuntos
Técnicas de Apoio para a Decisão , Medicina Baseada em Evidências , Publicações Periódicas como Assunto , Custos de Cuidados de Saúde , Satisfação do Paciente , Qualidade da Assistência à Saúde , Reprodutibilidade dos Testes
17.
Ann Emerg Med ; 35(2): 138-46, 2000 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-10650231

RESUMO

STUDY OBJECTIVE: The Utstein guidelines recommend that emergency medical services (EMS)-witnessed cardiac arrests be considered separately from other out-of-hospital cardiac arrest cases. The objective of this study was to assess EMS-witnessed cardiac arrest and to determine predictors of survival in this group. METHODS: This prospective cohort included all adults with an EMS-witnessed cardiac arrest in the 21 communities of the Ontario Prehospital Advanced Life Support (OPALS) study. Systems provided a basic life support with defibrillation (BLS-D) level of care. Case and survival definitions followed the Utstein style. Descriptive and univariate methods (chi(2) and t test) were used to characterize EMS-witnessed cardiac arrest. Multivariate logistic regression was undertaken to assess predictors of survival to hospital discharge. RESULTS: From January 1, 1991, to December 31, 1996, there were 9,072 cardiac arrest cases in the study communities. Of these, 610 (6.7%) were EMS-witnessed. The majority had preexisting cardiac or respiratory disease (81.5%) and experienced prodromal symptoms before EMS personnel arrived (91.4%). An initial rhythm of pulseless electrical activity was present in 50.1% of the patients, ventricular fibrillation/ventricular tachycardia in 34.2%, and asystole in 15.7%. Survival to discharge was 12.6%. Multivariate analysis identified the following as independent predictors of survival (odds ratio with 95% confidence intervals [CIs]): nitroglycerin use before EMS arrival: 2.3 (95% CI 1.2 to 4.5), prodromal symptoms of chest pain: 2.5 (95% CI 1.4 to 4.5) or dyspnea: 0.5 (95% CI 0.3 to 1.0), and unconsciousness on EMS arrival: 0.5 (95% CI 0.2 to 0.9). Patients with chest pain were more likely than dyspneic patients to experience ventricular fibrillation/ventricular tachycardia (62% versus 17%, P<.0001), and were 5 times more likely to survive (30.6% versus 6.3%, P<.0001). CONCLUSION: EMS-witnessed cases are clearly an important subset of out-of-hospital cardiac arrest and are characterized by 2 distinct symptom groups: chest pain and dyspnea. These symptoms are important predictors of survival and may also help determine underlying mechanisms before patient collapse. A later phase of the OPALS study will prospectively evaluate the impact of out-of-hospital advanced life support on the survival of victims of EMS-witnessed cardiac arrest.


Assuntos
Auxiliares de Emergência , Parada Cardíaca/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Ambulâncias , Estudos de Coortes , Intervalos de Confiança , Cardioversão Elétrica , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Nitroglicerina/uso terapêutico , Razão de Chances , Prognóstico , Estudos Prospectivos , Ressuscitação , Fatores de Risco , Análise de Sobrevida , Taquicardia Ventricular/mortalidade , Fatores de Tempo , Inconsciência , Vasodilatadores/uso terapêutico , Fibrilação Ventricular/mortalidade
20.
Resuscitation ; 41(3): 249-56, 1999 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-10507710

RESUMO

Active compression decompression resuscitation (ACD-CPR) has been developed as an alternative to standard cardiopulmonary resuscitation (S-CPR). To determine the effect of ACD-CPR on survival and neurologic outcome in patients with out-of-hospital cardiac arrest, this combined analysis involved individual patient data from 2866 patients from seven separate randomized prospective prehospital studies who had received ACD-CPR or S-CPR after out-of-hospital cardiac arrest in seven international sites. Significant improvement in 1-h survival (odds ratio (OR) = 0.83; confidence interval (CI): 0.695-0.99; P < 0.05) was found with ACD-CPR (n = 1410) versus S-CPR (n = 1456). The odds ratio for hospital discharge after ACD-CPR was similar (OR = 0.82; CI: 0.609-1.107, P = NS), but this finding was not statistically significant. Using the chi2-test for trend, there was a significant improvement in overall survival with ACD-CPR (P < 0.05) versus S-CPR. This improvement was largely due to the influence of results from one study site. Neurological outcome and complication rates were comparable between groups. Further study is needed to determine which emergency medical services systems may benefit from out-of-hospital use of ACD-CPR.


Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Massagem Cardíaca/métodos , Idoso , Serviços Médicos de Emergência/métodos , Estudos de Avaliação como Assunto , Feminino , Massagem Cardíaca/mortalidade , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Sensibilidade e Especificidade , Estatística como Assunto , Análise de Sobrevida , Taxa de Sobrevida
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