Clare L. Atzema

Emergency Department Triage of Acute Myocardial Infarction Patients and the Effect on Outcomes

STUDY OBJECTIVE More than half of all acute myocardial infarction patients still do not meet benchmark reperfusion times, and the triage assessment that all patients receive when they arrive at an emergency department (ED) is a hospital-level process that has not been studied as a potential contributor to delays. Our objective was to examine the triage of acute myocardial infarction patients (ST-elevation and non-ST elevation myocardial infarction) and determine whether it is associated with subsequent delays in acute myocardial infarction processes of care. METHODS We conducted a retrospective cohort analysis of a population-based cohort of acute myocardial infarction patients admitted to 102 acute care hospitals in Ontario, Canada, from July 2000 to March 2001. Main outcome measures were the rate of low-acuity triage (defined as a Canadian Triage and Acuity Scale score of III, IV, or V) among acute myocardial infarction patients and its association with delays in time from ED arrival to initial ECG (door-to-ECG time) and to administration of fibrinolysis (door-to-needle time). RESULTS Among 3,088 acute myocardial infarction patients, the rate of low acuity triage was 50.3%. Median door-to-ECG and door-to-needle time was 12.0 and 40.0 minutes, respectively. In adjusted quantile regression analyses, low-acuity triage was independently associated with a 4.4-minute delay in median door-to-ECG time and a 15.1-minute delay in median door-to-needle time. The adjusted odds of achieving benchmark door-to-ECG and door-to-needle times were 0.54 (95% confidence interval 0.46 to 0.65) and 0.44 (95% confidence interval 0.30 to 0.65), respectively, for acute myocardial infarction patients assigned a low-acuity ED triage score. CONCLUSION Half of acute myocardial infarction patients were given a low acuity triage score when they presented to an ED in Ontario, which was independently associated with substantial delays in ECG acquisition and to reperfusion therapy. The quality of ED triage may be an important factor limiting performance on key measures of quality of acute myocardial infarction care.

A population-based description of atrial fibrillation in the emergency department, 2002 to 2010.

STUDY OBJECTIVE We aimed to describe the demographics, care, and outcomes of patients with atrial fibrillation in the emergency department (ED), as well as temporal changes over time. METHODS In this retrospective cohort study, we used a province-wide database to identify all adult patients who were treated in a nonpediatric ED in the province of Ontario with a primary diagnosis of atrial fibrillation, April 2002 to March 2010. We determined the frequency and rate of ED visits and assessed patient demographics, ED care, and outcomes, both overall and by year. RESULTS During the 8-year study period, 113,786 patients made 143,003 ED visits for atrial fibrillation, accounting for 0.5% of all ED visits. The annual number of ED visits increased from 15,931 to 20,168 (29.4%; 95% confidence interval [CI] 28.7% to 30.1%) between 2002 and 2010, whereas the crude rate increased from 172 per 100,000 to 195 per 100,000 persons. Median age was 72.0 years (Interquartile range 61.0 to 80.0 years) and 50.8% were women, which did not change significantly during the study period. The percentage of index ED visits with a physician billing for cardioversion increased from 6.3% (95% CI 5.9% to 6.7%) to 11.8% (95% CI 11.3% to 12.3%). Although the percentage of patients with a CHADS2 score greater than or equal to 2 increased from 49.3% (95% CI 48.4% to 50.2%) to 53.6% (95% CI 52.9% to 54.4%) and high-acuity ED triage scores increased from 41.1% (95% CI 40.2% to 42.0%) to 62.5% (95% CI 61.7% to 63.2%), hospital admissions decreased from 48.1% (95% CI 47.3% to 49.0%) to 38.4% (95% CI 37.6% to 39.2%). Thirty-day mortality was 3.3% (95% CI 3.2% to 3.4%) and showed a slight downward trend during the study period (P=.05), whereas subsequent hospitalizations within 30 days for atrial fibrillation or stroke (2.8%; 95% CI 2.7% to 2.9%) and repeated ED visits (7.3%; 95% CI 7.1% to 7.4%) remained unchanged. CONCLUSION The number of ED visits for atrial fibrillation increased markedly during an 8-year period. Although it appears that slightly higher-risk patients are being treated in the provinces EDs, fewer patients are being admitted to the hospital, and mortality rates have not increased.

The Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Using Big Data to Measure and Improve Cardiovascular Health and Healthcare Services

Background—The CArdiovascular HEalth in Ambulatory care Research Team (CANHEART) is conducting a unique, population-based observational research initiative aimed at measuring and improving cardiovascular health and the quality of ambulatory cardiovascular care provided in Ontario, Canada. A particular focus will be on identifying opportunities to improve the primary and secondary prevention of cardiovascular events in Ontario’s diverse multiethnic population. Methods and Results—A population-based cohort comprising 9.8 million Ontario adults ≥20 years in 2008 was assembled by linking multiple electronic survey, health administrative, clinical, laboratory, drug, and electronic medical record databases using encoded personal identifiers. The cohort includes ≈9.4 million primary prevention patients and ≈400 000 secondary prevention patients. Follow-up on clinical events is achieved through record linkage to comprehensive hospitalization, emergency department, and vital statistics administrative databases. Profiles of cardiovascular health and preventive care will be developed at the health region level, and the cohort will be used to study the causes of regional variation in the incidence of major cardiovascular events and other important research questions. Conclusions—Linkage of multiple databases will enable the CANHEART study cohort to serve as a powerful big data resource for scientific research aimed at improving cardiovascular health and health services delivery. Study findings will be shared with clinicians, policy makers, and the public to facilitate population health interventions and quality improvement initiatives.

Factors Associated With 90-Day Death After Emergency Department Discharge for Atrial Fibrillation

STUDY OBJECTIVE More than 10% of patients treated in the emergency department (ED) for atrial fibrillation die within a year of the visit. We sought to describe the post-ED care of an older population of atrial fibrillation patients who were discharged home from the ED and to assess patient characteristics and processes of care associated with risk of death within 90 days of discharge. METHODS This retrospective cohort analysis included patients aged 65 years or older with a primary ED diagnosis of atrial fibrillation who were treated at all nonpediatric EDs in the province of Ontario, Canada, between April 2007 and March 2010. Only the index emergency visit for each patient was included, and patients admitted to the hospital were excluded. We evaluated the association of postdischarge outpatient care and medications, ED cardioversion, and site volumes of atrial fibrillation patients with adjusted hazard of 90-day death. RESULTS Among 12,772 qualifying index ED visits, there were 417 (3.3%; 95% confidence interval [CI] 3.0% to 3.6%) deaths within 90 days of the visit. Patients with no follow-up care had a significantly increased hazard of death (hazard ratio [HR] 2.27; 95% CI 1.50 to 3.43) relative to those who consulted a family physician, as did patients prescribed a calcium-channel blocker (HR 1.55; 95% CI 1.15 to 2.09) relative to a β-blocker. A filled warfarin prescription was associated with a lower hazard of death (HR 0.70; 95% CI 0.51 to 0.95). Higher site volumes (HR 0.66; 95% CI 0.41 to 1.08), cardioversion (HR 0.69; 95% CI 0.42 to 1.15), and follow-up care by a specialist only (HR 0.75; 95% CI 0.51 to 1.12) were not associated with 90-day mortality. CONCLUSION Among older atrial fibrillation patients discharged from the ED in the province of Ontario, lack of follow-up care had the strongest association with subsequent mortality. If validated, these results suggest that as proportionately more of these patients are discharged from EDs in future, the focus should go beyond ED care itself to the care subsequent to the emergency visit.

Effect of marriage on duration of chest pain associated with acute myocardial infarction before seeking care

Background: Coronary artery disease is the most common cause of death in the Western world, and being married decreases the risk of death from cardiovascular causes. We aimed to determine whether marital status was a predictor of the duration of chest pain endured by patients with acute myocardial infarction before they sought care and whether the patient’s sex modified the effect. Methods: We conducted a retrospective, population-based cohort analysis of patients with acute myocardial infarction admitted to 96 acute care hospitals in Ontario, Canada, from April 2004 to March 2005. We excluded patients who did not experience chest pain. Using multivariable regression analyses, we assessed marital status in relation to delayed presentation to hospital (more than six hours from onset of pain), both overall and stratified by sex. In patients who reported the exact duration of chest pain, we assessed the effect of marital status on the delay in seeking care. Results: Among 4403 eligible patients with acute myocardial infarction, the mean age was 67.3 (standard deviation 13.6) years, and 1486 (33.7%) were women. Almost half (2037 or 46.3%) presented to a hospital within two hours, and 3240 (73.6%) presented within six hours. Overall, 75.3% (2317/3079) of married patients, 67.9% (188/277) of single patients, 68.5% (189/276) of divorced patients and 70.8% (546/771) of widowed patients presented within six hours of the onset of chest pain. Being married was associated with lower odds of delayed presentation (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.30–0.71, p < 0.001) relative to being single. Among men, the OR was 0.35 (95% CI 0.21–0.59, p < 0.001), whereas among women the effect of marital status was not significant (OR 1.36, 95% CI 0.49–3.73, p = 0.55). Interpretation: Among men experiencing acute myocardial infarction with chest pain, being married was associated with significantly earlier presentation for care, a benefit that was not observed for married women. Earlier presentation for medical care appears to be one reason for the observed lower risk of cardiovascular death among married men, relative to their single counterparts.

The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines

The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Program has generated a comprehensive series of documents regarding the management of atrial fibrillation (AF) between 2010 and 2014. The guidelines provide evidence-based consensus management recommendations in a broad range of areas. These guidelines have proven useful in informing clinical practice, but often lack detail in specifications related to practical application, particularly for areas in which the evidence base is limited or conflicting. Based on feedback from the community, the CCS Atrial Fibrillation Guidelines Committee has identified a number of areas that require clarification to address commonly asked practical questions related to guidelines application. In the present article a number of such questions are presented and suggestions about how they can be answered are suggested. Among the issues considered are: (1) What duration of AF is clinically significant? (2) How are the risk factors in the CCS Algorithm for selecting anticoagulation therapy derived and defined? (3) How is valvular heart disease defined and how do different forms of valve disease affect the choice of anticoagulant therapy for AF patients? (4) How should we quantify renal dysfunction and how does it affect therapeutic choices? The response to these questions and the underlying logic are provided, along with an indication of future research needed where no specific approach can presently be recommended based on the literature.

Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo.

We aimed to determine the risk of short‐ and long‐term stroke, as well as accidental injury, in patients discharged from an emergency department who were given a diagnosis of a peripheral vestibular disorder.

Opioid Prescription After Pain Assessment: A Population-Based Cohort of Elderly Patients With Cancer

PURPOSE The purpose of this study was to measure opioid prescription (OP) rates in elderly cancer outpatients around the time of assessment for pain and to evaluate factors associated with receiving OPs for those with severe pain. PATIENTS AND METHODS The cross-sectional cohort includes all patients with cancer in Ontario older than age 65 years who completed a pain assessment as part of a provincial initiative of systematic symptom screening. Patients were assigned to mutually exclusive categories by pain score severity: 0, 1 to 3 (mild), 4 to 6 (moderate), and 7 to 10 (severe). We linked multiple provincial health databases to examine the proportion of patients with an OP within 7 days after or 30 days before the assessment date. We examined factors associated with OPs for patients with pain scores of 7 to 10. RESULTS The proportion of patients with an OP increased as pain score severity increased: 10% of those with no pain, 24% of those with mild pain, 45% of those with moderate pain, and 67% of those with severe pain. More specifically, for those with severe pain, 41% filled an OP within 7 days of assessment for pain, and 26% had an OP from the 30 days before assessment for pain, leaving 33% without an OP. In multivariable analysis, factors associated with OPs are younger age, male sex, comorbid illness, cancer type, and assessment at home. CONCLUSION Despite a generous time window for capturing OPs, the proportion of patients without an OP seems high. Further knowledge translation is required to maximize the impact of the symptom screening initiative in Ontario and to optimize management of cancer-related pain.

Do Patient-Reported Symptoms Predict Emergency Department Visits in Cancer Patients? A Population-Based Analysis

STUDY OBJECTIVE Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System has been routinely used for cancer outpatients. The purpose of this study is to determine the relationship between individual patient symptoms and symptom severity, with the likelihood of an emergency department (ED) visit. METHODS The cohort included all cancer patients in Ontario who completed an Edmonton Symptom Assessment System between January 2007 and March 2009. Using multiple linked provincial health databases, we examined the adjusted association between symptom scores and the likelihood of an ED visit within 7 days of assessment. RESULTS The cohort included 45,118 patients whose first assessment contributed to the study, of whom 3.8% made a subsequent ED visit. A severe well-being score was associated with the highest odds of a subsequent ED visit (adjusted odds ratio [OR] 1.9; 95% confidence interval 1.5 to 2.4). Nausea, drowsiness, and shortness of breath with moderate or severe scores were associated with ED visits (adjusted OR 1.2 to 1.5), whereas pain, tiredness, poor appetite, and well-being had a significant association for mild scores (adjusted OR 1.2, 1.3, 1.2, and 1.3, respectively), moderate scores (adjusted OR 1.3, 1.5, 1.5, and 1.7, respectively), and severe scores (adjusted OR 1.4, 1.7, 1.7, and 1.9, respectively). Anxiety and depression were not associated with ED visits. CONCLUSION Worsening symptoms contribute to emergency visits in cancer patients. Specific symptoms such as pain are obvious management targets, but constitutional symptoms were associated with even higher odds of ED usage and therefore warrant detailed assessment to optimize both patient outcomes and resource use.

The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction

Background Patients with acute myocardial infarction may have worse outcomes if they also have a history of depression. The early management of acute myocardial infarction is known to influence outcomes, and patients with a coexisting history of depression may be treated differently in the emergency department than those without one. Our goal was to determine whether having a charted history of depression was associated with a lower-priority emergency department triage score and worse performance on quality-of-care indices. Methods We conducted a retrospective population-based cohort analysis involving patients with acute myocardial infarction admitted to 96 acute care hospitals in the province of Ontario from April 2004 to March 2005. We calculated the adjusted odds of low-priority triage (Canadian Emergency Department Triage and Acuity Scale score of 3, 4 or 5) for patients with acute myocardial infarction who had a charted history of depression. We compared these odds with those for patients having a charted history of asthma or chronic obstructive pulmonary disease (COPD). Secondary outcome measures were the odds of meeting benchmark door-to-electrocardiogram, door-to-needle and door-to-balloon times. Results Of 6784 patients with acute myocardial infarction, 680 (10.0%) had a past medical history of depression documented in their chart. Of these patients, 39.1% (95% confidence interval [CI] 35.3%–42.9%) were assigned a low-priority triage score, as compared with 32.7% (95% CI 31.5%–33.9%) of those without a charted history of depression. The adjusted odds of receiving a low-priority triage score with a charted history of depression were 1.26 (p = 0.01) versus 0.88 (p = 0.23) with asthma and 1.12 (p = 0.24) with COPD. For patients with a charted history of depression, the median door-to-electrocardiogram time was 20.0 minutes (v. 17.0 min for the rest of the cohort), median door-to-needle time was 53.0 (v. 37.0) minutes, and median door-to-balloon time was 251.0 (v. 110.0) minutes. The adjusted odds of missing the benchmark time with a charted history of depression were 1.39 (p < 0.001) for door-to-electrocardiogram time, 1.62 (p = 0.047) for door-to-needle time and 9.12 (p = 0.019) for door-to-balloon time. Interpretation Patients with acute myocardial infarction who had a charted history of depression were more likely to receive a low-priority emergency department triage score than those with other comorbidities and to have worse associated performance on quality indicators in acute myocardial infarction care.