Catherine Varner

Methicillin-resistant Staphylococcus aureus colonization among health care workers in a downtown emergency department in Toronto, Ontario

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) acquired in the community, otherwise known as community-acquired MRSA, has emerged rapidly in recent years. Colonization with MRSA has been associated with an increased risk of symptomatic and serious infections and, in some settings, health care workers (HCWs) exhibit a higher prevalence of MRSA colonization. OBJECTIVE To determine MRSA colonization in emergency department (ED) HCWs in the setting of a moderate prevalence of MRSA in skin and soft tissue infections. METHODS The present study was conducted at a downtown ED in Toronto, Ontario. ED HCWs completed a brief questionnaire and swabs were taken from one anterior nare, one axilla and any open wounds (if present). Swabs were processed using standard laboratory techniques. RESULTS None of the 89 staff (registered nurses [n=55], physicians [n=15], other [n=19]) were MRSA positive and 25 (28.1%) were colonized with methicillin-susceptible S aureus. CONCLUSIONS Contrary to common belief among HCWs and previous studies documenting MRSA colonization of HCWs, MRSA colonization of this particular Canadian ED HCW cohort was very low and similar to that of the local population.

Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study

BACKGROUND Emergency physicians provide primary care to patients and often prescribe opioids for acutely painful self-limiting conditions. The objective of this study was to describe patterns of opioid prescribing by emergency physicians and family physicians and to explore the relation between setting of initiation of opioid treatment and adverse events over the subsequent 2 years. METHODS This was a population-based cohort study using administrative data from Ontario. Opioid-naive patients aged 15-64 years who received an opioid prescription for noncancer pain from an emergency or family physician between Apr. 1, 2008, and Mar. 31, 2012 were eligible for inclusion. RESULTS A total of 34 713 and 45 952 patients were initiated on an opioid by an emergency physicians and family physicians, respectively. Both emergency and family physicians most commonly prescribed codeine-containing products (58.9% and 79.6% of prescriptions, respectively); however, emergency physicians were twice as likely as family physicians to prescribe higher-potency opioids (morphine, oxycodone, hydromorphone, fentanyl, meperidine) (both combination and single-agent preparations) (40.6% v. 19.9%, ∆ = 20.7, 95% confidence interval [CI] 20.0-21.3). Compared to patients in the family physician group, those in the emergency physician group received significantly higher daily dosages, a higher proportion were initiated on a daily dosage of 100 mg of morphine equivalents (MEQs) or more, and had a hospital admission for opioid toxicity within 2 years (0.5% v. 0.3%, ∆ = 0.2%, 95% CI 0.1%-0.3%). A higher proportion of patients in the family physician group than in the emergency physician group had dosage escalation beyond 199 mg MEQs within 2 years (0.7% v. 0.1%, ∆ = 0.6%, 95% CI 0.5%-0.7%). INTERPRETATION Codeine was the most common opioid prescribed by emergency and family physicians. Compared to patients prescribed opioids by family physicians, those prescribed opioids by emergency physicians received higher initial daily dosages and had an increased likelihood of opioid toxicity.

Ibuprofen + acetaminophen did not differ from opioids + acetaminophen for reducing acute extremity pain at 2 h

Question In patients who present to the emergency department (ED), how do different oral analgesics, combined with acetaminophen, compare for reducing acute extremity pain? Methods Design Randomized controlled trial (RCT). ClinicalTrials.gov NCT02455518. Allocation Concealed.* Blinding Blinded* (patients and clinicians). Follow-up period 2 hours. Setting 2 EDs in New York, USA. Patients 416 adults 21 to 64 years of age (mean age 37 y, 52% men, mean pain score 8.7 on an 11-point numerical rating scale [NRS]) who presented to the ED for management of acute extremity pain and required radiologic imaging. Exclusion criteria were presence of a chronic condition that required frequent pain management or that could affect metabolism of a study drug, pregnancy or breastfeeding, history of peptic ulcer disease or adverse reaction to any study medication, current use of a drug that could interact with a study drug, use of ibuprofen or acetaminophen in the past 8 hours or opioids in the past 24 hours, or any past use of methadone or illicit narcotics. Intervention 3 identical capsules containing a total of ibuprofen, 400 mg, plus acetaminophen, 1000 mg (n =104); oxycodone, 5 mg, plus acetaminophen, 325 mg (n =104); hydrocodone, 5 mg, plus acetaminophen, 300 mg (n =104); or codeine, 30 mg, plus acetaminophen, 300 mg (n =104). Outcomes Change in pain (NRS) at 2 hours. Secondary outcomes included change in pain at 1 hour and use of rescue analgesics. 400 patients provided 80% power to detect a 1.3-point difference (minimum clinically important difference) in change in the NRS score (2-sided =0.05). Patient follow-up 98% (intention-to-treat analysis). Main results 62% of patients had sprains or strains, 21% had extremity fractures, 9% had muscle pain, 4% had contusions, and 3% had other diagnoses. Analysis of variance showed no difference across all groups in change in pain at 2 hours (P =0.053) or at 1 hour (P =0.13). Comparisons of pairs of treatments showed that no treatment differed from another at 2 hours (Table) or at 1 hour. Groups did not differ for the proportion of patients who received rescue analgesics (P =0.42). Conclusion In patients who present to the emergency department with acute extremity pain, ibuprofen plus acetaminophen did not differ from opioid-plus-acetaminophen combinations for reducing pain at 2 hours. Drug combinations for acute extremity pain in adults presenting to the emergency department Interventions Comparators Between-group difference in mean change in NRS pain score at 2 h (99.2% CI) Ibuprofen + acetaminophen Oxycodone + acetaminophen 0.1 (1.0 to 0.8) Hydrocodone + acetaminophen 0.8 (0.2 to 1.7) Codeine + acetaminophen 0.4 (0.6 to 1.3) Oxycodone + acetaminophen Hydrocodone + acetaminophen 0.9 (0.1 to 1.8) Codeine + acetaminophen 0.5 (0.4 to 1.4) Hydrocodone + acetaminophen Codeine + acetaminophen 0.4 (1.3 to 0.6) NRS = numerical rating scale; CI defined in Glossary. Drug doses described in text. Score range 0 (no pain) to 10 (worst possible pain). Positive between-group difference favors the intervention. Minimal clinically important difference =1.3. Pairwise calculations use a Bonferroni adjustment for multiple comparisons. Commentary ED providers who treat acute pain do so despite a paucity of data of the comparable efficacy of opioid and nonopioid analgesics (1). The RCT by Chang and colleagues of patients presenting to the ED with acute extremity pain found no statistically significant or clinically important differences in pain reduction at 2 hours after a single dose of ibuprofen plus acetaminophen compared with any of 3 opioid-plus-acetaminophen combinations. The trial has several limitations. First, it did not assess adverse events, which is problematic because provider and patient analgesic choices should balance an understanding of the potential benefits and risks. Second, follow-up was only 2 hours. Third, the trial may have been underpowered for the post hoc subgroup analysis of outcomes in patients with severe pain. Moreover, the minimal clinically important difference of 1.3 on the NRS may not be an adequate reduction for patients with severe pain compared with patients with mild-to-moderate pain. Despite its shortcomings, in an era of opioid misuse and abuse, the trial provides timely initial evidence that the nonopioid combination of acetaminophen plus ibuprofen provides similar 2-hour pain reductions as opioid analgesia for patients in the ED with acute extremity pain. Additional RCTs are needed to determine the relative efficacies of pharmacologic and nonpharmacologic analgesic therapies beyond initial ED management, assess the efficacy of analgesics in such populations as the elderly, and compare adverse effects of commonly prescribed analgesics to guide meaningful shared decision making (2, 3).

Clinical impact of extending after-hours radiology coverage for emergency department computed tomography imaging

Background Academic emergency departments (EDs) are often reliant on preliminary interpretation by radiology residents for after-hours computed tomography (CT) images. Identifying residents’ errors in diagnostic interpretation and ensuring appropriate contact with affected patients are areas of continuing concern. Objective The Mount Sinai Hospital ED and Medical Imaging Department in Toronto, Canada sought to examine the clinical impact of extending reporting hours of senior attending radiologists for ED patients undergoing CT imaging. Methods All evening CT studies were read by the on-call sub-specialist staff radiologist before 10 pm; while studies done after 10 pm were read by 8 am, permitting review of final reports by the ordering ED physician. A retrospective review of radiology and ED metrics was performed on ED patients undergoing CT imaging 12 weeks before and 12 weeks after implementation of the extended reading hours. Results In the 12 weeks prior to implementation of extended senior attending radiologist coverage, 871 CT scans were performed as compared to 944 CT scans after implementation. Time from performance of CT scan to obtaining a dictated report decreased from 10.4 hours to 2.8 hours (P<0.001), and time from performance of CT scan to report verification by the radiologist decreased from 29.7 hours to 9.4 hours (P<0.001). There were no statistically significant changes in ED length of stay, rates of admission, or rates of consultation. However, there was a significant reduction in (median) time taken for ED physicians to resolve discrepant reports in the radiology information system queue (20.7 hours versus 13.3 hours, P<0.001). Conclusion The extension of reporting hours reduced the time for ED physicians to review discrepant reports, while balancing educational needs of residents. This project has been considered a success by stakeholders and has now been implemented on a permanent basis.