Exploring Stroke Outcomes Following a Door-to-Needle Quality Improvement Project.

BACKGROUND: Although stroke rates in Canada are expected to increase dramatically over the next decade, time-driven hyperacute stroke care with thrombolysis increases the likelihood of a good clinical outcome. Following a period of suboptimal performance results for stroke care, our tertiary care center undertook a door-to-needle (DTN) quality improvement initiative. The purpose of our study was to determine if the resulting improved median DTN times and greater proportion of patients treated within 60 minutes of arrival at our emergency department were associated with improved clinical outcomes. METHODS: Guided by the Donabedian quality framework, we retrospectively reviewed charts of consecutive patients (n = 324) who received thrombolysis pre- and post-quality improvement initiative. Data on patient characteristics, and process and outcome measures were collected. Primary study outcomes included mortality, adverse events, discharge location, and independence at discharge. Data analysis compared proportions with Chi Square and means using the two-tailed t-test and a 0.05 level of significance. RESULTS: Median DTN times and the percentage of cases with a DTN ≤60 minutes improved significantly post-intervention (p < 0.001). In-hospital mortality decreased (p = 0.013), and the proportion of favorable versus unfavorable discharge locations improved (p = 0.005). Mortality rates for all study patients with DTN ≤60 versus >60 minutes were also significantly lower (p = 0.044) post-intervention. CONCLUSIONS: Our quality improvement initiative resulted in timelier care and positively influenced clinical outcomes. This study highlights the need for ongoing, innovative investment strategies to ensure timely hyperacute stroke care and optimal patient outcomes.

Patterns of emergency department utilization by patients on chronic dialysis: A population-based study.

IMPORTANCE: Patients on dialysis are often elderly and frail, with multiple comorbid conditions, and are heavy users of Emergency Department (ED) services. However, objective data on the frequency and pattern of ED utilization by dialysis patients are sparse. Such data could identify periods of highest risk for ED visits and inform health systems interventions to mitigate these risks and improve outcomes. OBJECTIVE: To describe the pattern and frequency of presentation to ER by dialysis patients. DESIGN: Retrospective cohort study using administrative data collected over ten years (2000-2009) in the Province of Manitoba, Canada. SETTING: Patients presenting to any of 9 ED's in Winnipeg and Brandon Manitoba. These departments serve >90% of the population of Manitoba, Canada (population 1.2 million). PARTICIPANTS: All patients presenting to an ED in any of 9 emergency departments in Manitoba, Canada. EXPOSURE: Dialysis status. MAIN OUTCOMES: Presentation to the ED. RESULTS: Over 2.1 million ED visits by more than 1.2 million non-dialysis patients and 17,782 ED visits by 3257 dialysis patients were included. Dialysis patients presented 8.5 times more frequently to the ED than the general population (age and sex adjusted, p<0.001). For dialysis patients, ED utilization was significantly higher following the long interdialytic interval (33.6% higher Mondays and 19.5% higher Tuesdays vs. other days of the week, p<0.001) and was 10-fold higher in the 7 days before and after the initiation of dialysis. CONCLUSION AND RELEVANCE: The heavy use of ED services by dialysis patients spikes upward following the long interdialytic interval and also in the week before and after dialysis initiation. The relative risks associated with these vulnerable periods were much higher than those reported for clinical patient characteristics. We propose that intrinsic gaps in the structure of care delivery (e.g. 3 times a week dialysis, imperfect surveillance and clinical monitoring of patients with low GFR) may be the fundamental drivers of this periodicity. Strategies to mitigate this excess health risk are needed.

Prehospital Application of the Canadian Triage and Acuity Scale by Emergency Medical Services.

OBJECTIVES: Triage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice. METHODS: Variables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTAS arrival ) score was compared to the initial nursing CTAS score (CTAS initial ) and the final nursing CTAS score (CTAS final ) incuding nursing overrides. Interrater reliability between ED CTAS initial and EMS CTAS arrival scores was assessed. Interrater reliability between ED CTAS final and EMS CTAS arrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated. RESULTS: Our primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTAS arrival and ED CTAS initial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTAS arrival ) score and the final ED triage CTAS score (CTAS final ) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466). CONCLUSIONS: Interrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.

Predictors of Emergency Department Use by Persons with Inflammatory Bowel Diseases: A Population-based Study.

BACKGROUND: To describe the patterns and predictors of emergency department (ED) attendance and post-ED hospitalization by persons with inflammatory bowel disease (IBD). METHODS: We linked the University of Manitoba IBD Epidemiology Database with the Emergency Department Information System of the Winnipeg Regional Health Authority to determine the rates of presentation to the ED by persons with IBD from January 01, 2009 to March 31, 2012. Incident cases were diagnosed during the study period and all others were considered prevalent cases. Multivariate logistic regression was used to determine predictors of attendance in the ED and for hospitalization within 2 days of ED attendance. RESULTS: The study population included 300 incident and 3394 prevalent IBD cases, of whom 76% and 49%, respectively, attended the ED at least once during the study period. Incident cases with Crohn's disease or with a history of opioid use were more likely to attend the ED. Those who had seen a gastroenterologist within the year before diagnosis were less likely to visit the ED. Among prevalent cases, higher comorbidity, opioid or corticosteroid use, and recent hospital admission were predictive of ED attendance and those who saw only 1 physician in the preceding year had lower ED attendance. Presenting to the ED with a primary gastrointestinal complaint was the strongest predictor of subsequent hospital admission. CONCLUSIONS: ED attendance by both incident and prevalent cases of IBD is high. Identified predictors of ED attendance and post-ED hospitalization could guide the optimization of outpatient IBD care to limit ED attendance and potentially post-ED hospitalization.

Development of an Emergency Department Violence Intervention Program for Youth: An Integrated Knowledge Translation Approach.

BACKGROUND: Violent interpersonal injury is a common presentation to emergency departments (EDs) and is increasingly being treated as a preventable condition. Given the complexity of the issue, it is key to ensure interventions are feasible and acceptable within the communities that are affected by violence. Our team consists of ED staff, community members who work with youth affected by violence, people who were affected by violence in their youth, and researchers. OBJECTIVES: We describe how an integrated knowledge translation (KT) process was used to develop an ED violence intervention program (EDVIP) for youth affected by violence. METHODS: We used the Canadian Institutes of Health Research Guidelines for integrated KT (iKT) to develop an EDVIP. Specifically, we report the Knowledge to Action process which involves both knowledge creation and an action cycle. RESULTS: Our team determined the research question, the research approach, assessed feasibility and determined outcomes for our study. Using the iKT approach facilitated initiation of a funded trial that is now active. CONCLUSIONS: This paper highlights the benefit of including community experts at the beginning of and throughout the research process.

Wraparound care for youth injured by violence: study protocol for a pilot randomised control trial.

INTRODUCTION: Injury by violence is the fourth cause of death and the leading reason for a youth to visit an emergency department (ED) in Canada. In Winnipeg, 20% of youth who visit an ED with an injury due to violence have a second visit for a subsequent violent injury within 1 year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. METHODS AND ANALYSIS: This protocol describes a wraparound care model delivered by a support worker with lived experience with violence, supported by social workers and links to multiple community partners. Support workers will be on call 24 h a day, 7 days a week in order to start the intervention in the ED and take advantage of the 'teachable moment'. The protocol is of a pilot randomised control trial to assess the feasibility of a randomised control trial designed to assess efficacy. For the pilot trial, we will assess recruitment, treatment fidelity, participant adherence and safety. The intervention arm will receive wraparound care initiated at the time of their visit for injury due to violence. The control arm will receive standard care. We will use an adapted preconsent randomisation methodology. This intervention has been developed using an integrated knowledge translation approach. DISCUSSION: Interventions delivered in the ED for youth injured by violence require an approach that is appropriate for the unique situation the youth are in. ETHICS: The University of Manitoba Health Research Ethics Board (HS 16445 (Cohort study) and HS 16444 (WrapAround Care study) granted ethical approval. TRIAL REGISTRATION NUMBER: NCT01895738.

Frequent users of an inner-city emergency department.

BACKGROUND: Within the emergency department (ED) patient population there is a subset of patients who make frequent visits. This chart review sought to characterize this population and identify strategies to reduce frequent ED visits. METHODS: Frequent use at an urban tertiary care centre was defined as 15 or more visits over 1 year. The details of each visit-demographics, entrance complaint, discharge diagnosis, arrival method, Canadian Triage and Acuity Scale (CTAS) score, and length of stay-were analyzed and compared to data from the entire ED population for the same period. RESULTS: Ninety-two patients generated 2,390 ED visits (of 25,523 patients and 44,204 visits). This population was predominantly male (66%) and middle-aged (median 42 years), with no fixed address (27.2%). Patients arrived by ambulance in 59.3% of visits with less acute CTAS scores than the general population. Substance use accounted for 26.9% of entrance complaints. Increased lengths of stay were associated with female gender and abnormal vital signs, whereas shorter stays were associated with no fixed address and substance use (. < 0.05). Admissions were lower than the general population, and women were twice as likely as men to be admitted (. < 0.05). Patients left without being seen in 15.8% of visits. CONCLUSIONS: High-frequency ED users are more likely to be male, younger, and marginally housed and to present secondary to substance use. Although admissions among this population are low, the costs associated with these presentations are high. Interventions designed to decrease visits and improve the health of this population appear warranted.

Application of Lean principles to improve early cardiac care in the emergency department.

OBJECTIVE: To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED). METHODS: Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study. RESULTS: The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p < 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p  =  0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (p values < 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources. CONCLUSIONS: The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.

"Google flu trends" and emergency department triage data predicted the 2009 pandemic H1N1 waves in Manitoba.

OBJECTIVES: We assessed the performance of syndromic indicators based on Google Flu Trends (GFT) and emergency department (ED) data for the early detection and monitoring of the 2009 H1N1 pandemic waves in Manitoba. METHODS: Time-series curves for the weekly counts of laboratory-confirmed H1N1 cases in Manitoba during the 2009 pandemic were plotted against the three syndromic indicators: 1) GFT data, based on flu-related Internet search queries, 2) weekly count of all ED visits triaged as influenza-like illness (ED ILI volume), and 3) percentage of all ED visits that were triaged as an ILI (ED ILI percent). A linear regression model was fitted separately for each indicator and correlations with weekly virologic data were calculated for different lag periods for each pandemic wave. RESULTS: All three indicators peaked 1-2 weeks earlier than the epidemic curve of laboratory-confirmed cases. For GFT data, the best-fitting model had about a 2-week lag period in relation to the epidemic curve. Similarly, the best-fitting models for both ED indicators were observed for a time lag of 1-2 weeks. All three indicators performed better as predictors of the virologic time trends during the second wave as compared to the first. There was strong congruence between the time series of the GFT and both the ED ILI volume and the ED ILI percent indicators. CONCLUSION: During an influenza season characterized by high levels of disease activity, GFT and ED indicators provided a good indication of weekly counts of laboratory-confirmed influenza cases in Manitoba 1-2 weeks in advance.

Load Balancing at Emergency Departments using 'Crowdinforming'.

BACKGROUND: Emergency Department (ED) overcrowding is an important healthcare issue facing increasing public and regulatory scrutiny in Canada and around the world. Many approaches to alleviate excessive waiting times and lengths of stay have been studied. In theory, optimal ED patient flow may be assisted via balancing patient loads between EDs (in essence spreading patients more evenly throughout this system). This investigation utilizes simulation to explore "Crowdinforming" as a basis for a process control strategy aimed to balance patient loads between six EDs within a mid-sized Canadian city. METHODS: Anonymous patient visit data comprising 120,000 ED patient visits over six months to six ED facilities were obtained from the region's Emergency Department Information System (EDIS) to (1) determine trends in ED visits and interactions between parameters; (2) to develop a process control strategy integrating crowdinforming; and, (3) apply and evaluate the model in a simulated environment to explore the potential impact on patient self-redirection and load balancing between EDs. RESULTS: As in reality, the data available and subsequent model demonstrated that there are many factors that impact ED patient flow. Initial results suggest that for this particular data set used, ED arrival rates were the most useful metric for ED 'busyness' in a process control strategy, and that Emergency Department performance may benefit from load balancing efforts. CONCLUSIONS: The simulation supports the use of crowdinforming as a potential tool when used in a process control strategy to balance the patient loads between EDs. The work also revealed that the value of several parameters intuitively expected to be meaningful metrics of ED 'busyness' was not evident, highlighting the importance of finding parameters meaningful within one's particular data set. The information provided in the crowdinforming model is already available in a local context at some ED sites. The extension to a wider dissemination of information via an Internet web service accessible by smart phones is readily achievable and not a technological obstacle. Similarly, the system could be extended to help direct patients by including future estimates or predictions in the crowdinformed data. The contribution of the simulation is to allow for effective policy evaluation to better inform the public of ED 'busyness' as part of their decision making process in attending an emergency department. In effect, this is a means of providing additional decision support insights garnered from a simulation, prior to a real world implementation.

Patients presenting to the emergency department: the use of other health care services and reasons for presentation.

OBJECTIVE: Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation. METHODS: Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option. RESULTS: Of the 1,389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED. CONCLUSION: Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.

Reviewer agreement trends from four years of electronic submissions of conference abstract.

BACKGROUND: The purpose of this study was to determine the inter-rater agreement between reviewers on the quality of abstract submissions to an annual national scientific meeting (Canadian Association of Emergency Physicians; CAEP) to identify factors associated with low agreement. METHODS: All abstracts were submitted using an on-line system and assessed by three volunteer CAEP reviewers blinded to the abstracts' source. Reviewers used an on-line form specific for each type of study design to score abstracts based on nine criteria, each contributing from two to six points toward the total (maximum 24). The final score was determined to be the mean of the three reviewers' scores using Intraclass Correlation Coefficient (ICC). RESULTS: 495 Abstracts were received electronically during the four-year period, 2001-2004, increasing from 94 abstracts in 2001 to 165 in 2004. The mean score for submitted abstracts over the four years was 14.4 (95% CI: 14.1-14.6). While there was no significant difference between mean total scores over the four years (p = 0.23), the ICC increased from fair (0.36; 95% CI: 0.24-0.49) to moderate (0.59; 95% CI: 0.50-0.68). Reviewers agreed less on individual criteria than on the total score in general, and less on subjective than objective criteria. CONCLUSION: The correlation between reviewers' total scores suggests general recognition of "high quality" and "low quality" abstracts. Criteria based on the presence/absence of objective methodological parameters (i.e., blinding in a controlled clinical trial) resulted in higher inter-rater agreement than the more subjective and opinion-based criteria. In future abstract competitions, defining criteria more objectively so that reviewers can base their responses on empirical evidence may lead to increased consistency of scoring and, presumably, increased fairness to submitters.