Debra Eagles

International Survey of Emergency Physicians’ Awareness and Use of the Canadian Cervical-Spine Rule and the Canadian Computed Tomography Head Rule

OBJECTIVES The derivation and validation studies for the Canadian Cervical-Spine (C-Spine) Rule (CCR) and the Canadian Computed Tomography (CT) Head Rule (CCHR) have been published in major medical journals. The objectives were to determine: 1) physician awareness and use of these rules in Australasia, Canada, the United Kingdom, and the United States and 2) physician characteristics associated with awareness and use. METHODS A self-administered e-mail and postal survey was sent to members of four national emergency physician (EP) associations using a modified Dillman technique. Results were analyzed using repeated-measures logistic regression models. RESULTS The response rate was 54.8% (1,150/2,100). Reported awareness of the CCR ranged from 97% (Canada) to 65% (United States); for the CCHR it ranged from 86% (Canada) to 31% (United States). Reported use of the CCR ranged from 73% (Canada) to 30% (United States); for the CCHR, it was 57% (Canada) to 12% (United States). Predictors of awareness were country, type of rule, full-time employment, younger age, and teaching hospital (p < 0.05). Significant differences in use of the CCR by country were observed, but not for the CCHR. Teaching hospitals were more likely to use the CCR than nonteaching hospitals, but less likely to use the CCHR. CONCLUSIONS This large international study found notable differences among countries with regard to knowledge and use of the CCR and CCHR. Awareness and use of both rules were highest in Canada and lowest in the United States. While younger physicians, those employed full-time, and those working in teaching hospitals were more likely to be aware of a decision rule, age and employment status were not significant predictors of use. A better understanding of factors related to awareness and use of emergency medicine (EM) decision rules will enhance our understanding of knowledge translation and facilitate strategies to enhance dissemination and implementation of future rules.

Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries

Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.

An international study of emergency physicians' practice for acute headache management and the need for a clinical decision rule

OBJECTIVE Patients with acute headache often undergo computed tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study examined current practice, the perceived need for a clinical decision rule for acute headache and the required sensitivity for such a rule. METHODS We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3-5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neurologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country. RESULTS The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency department (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investigated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%-99%). Approximately 1 in 5 physicians suggested that 100% sensitivity was required. CONCLUSION Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED.

Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals

Study objective Recent‐onset atrial fibrillation and flutter are the most common arrhythmias managed in the emergency department (ED). We evaluate the management and 30‐day outcomes for recent‐onset atrial fibrillation and flutter patients in Canadian EDs, where cardioversion is commonly practiced. Methods We conducted a prospective cohort study in 6 academic hospital EDs and enrolled patients who had atrial fibrillation and flutter onset within 48 hours. Patients were followed for 30 days by health records review and telephone. Adverse events included death, stroke, acute coronary syndrome, heart failure, subsequent admission, or ED electrocardioversion. Results We enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%, atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm 80.1%. Although 10.5% of recent‐onset atrial fibrillation and flutter patients had adverse events within 30 days, there were no related deaths and 1 stroke (0.1%). Adjusted odds ratios for factors associated with adverse event were hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05), history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients who left the ED in sinus rhythm were much less likely to experience an adverse event (P<.001). Conclusion Although most recent‐onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30‐day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe.

Emergency Department Stay Associated Delirium in Older Patients

Background Caring for older patients can be challenging in the Emergency Department (ED). A > 12 hr ED stay could lead to incident episodes of delirium in those patients. The aim of this study was to assess the incidence and impacts of ED-stay associated delirium. Methods A historical cohort of patients who presented to a Canadian ED in 2009 and 2011 was randomly constituted. Included patients were aged ≥ 65 years old, admitted to any hospital ward, non-delirious upon arrival and had at least a 12-hour ED stay. Delirium was detected using a modified chart-based Confusion Assessment Method (CAM) tool. Hospital length of stay (LOS) was log-transformed and linear regression assessed differences between groups. Adjustments were made for age and comorbidity profile. Results 200 records were reviewed, 55.5% were female, median age was 78.9 yrs (SD:7.3). 36(18%) patients experienced ED-stay associated delirium. Nearly 50% of episodes started in the ED and within 36 hours of arrival. Comorbidity profile was similar between the positive CAM group and the negative CAM group. Mean adjusted hospital LOS were 20.5 days and 11.9 days respectively (p<.03). Conclusions 1 older adult out of 5 became delirious after a 12 hr ED stay. Since delirium increases hospital LOS by more than a week, better screening and implementation of preventing measures for delirium could reduce LOS and overcrowding in the ED.

Heart failure and palliative care in the emergency department

Objectives Heart failure is a common ED presentation that is underserved by palliative care services and is associated with significant morbidity and mortality. We sought to evaluate use of palliative care services in patients with heart failure presenting to the ED. The primary outcome studied was palliative care involvement. Secondary outcomes of the study were: (1) 1-year mortality, (2) ED visits, (3) hospital admissions and (4) heart failure clinic involvement. Methods We conducted a health records review of 500 patients with heart failure who presented to two Canadian academic hospital EDs from January to August 2013. Results Patients were of mean age 80.7 years, women (53.2%) and had significant comorbidities. Only 41% of all deceased patients at 1 year had any palliative care involvement. Of those with palliative care, 44 (76%) patients had less than 2 weeks of palliative care involvement prior to death. Compared with those with no palliative care, the 79 (15.8%) patients with palliative care involvement had a higher 1-year mortality rate (70.9% vs 18.8%) and more hospital admissions/year (1.4 vs 0.85) for heart failure. Conclusions We found that few patients with heart failure had palliative care services. Additionally, the majority of those who have palliative care involvement do not meet current recommendations for early palliative care involvement in heart failure. This study suggests that the ED may be an appropriate setting to identify and refer high-risk patients with heart failure who could benefit from earlier palliative care involvement.

Mobility assessments of geriatric emergency department patients: A systematic review.

OBJECTIVES We wished to determine the impact of emergency department (ED) mobility assessments for older patients on hospitalization, return visits, future falls, and frailty. METHODS We searched MEDLINE, Embase, CINAHL, Cochrane Library, PEDro, and OTseeker (September 2016). Two independent reviewers identified studies of patients ≥65 years with ED physical mobility assessments and outcomes of hospitalization, return to ED, falls, and frailty. Language was not restricted. Only clinical trials and observational studies were included. RESULTS We identified 1,365 unique citations. Nine studies (six cohort and three cross-sectional) met full inclusion criteria. Patients (n=2,513) with mean age 75-85 years, admitted to hospital and discharged, underwent these ED evaluations: Timed Up and Go (TUG), Get Up and Go, tandem walk, and a gait assessment. Study quality was moderate to poor. Tandem walk did not predict falls at 90 days. TUG was not associated with return to the ED/hospitalization at 90 days. Get Up and Go was associated with hospital admission but not return to ED visits at 1 or 3 months. Due to clinical heterogeneity in study populations and outcomes, a meta-analysis was not undertaken. CONCLUSIONS Despite multiple guidelines recommending a mobility assessment prior to ED discharge for older patients, we found that such assessments were neither associated with nor predictive of adverse outcomes. Robust research is required to guide clinicians on the utility of physical mobility assessments in older ED patients.

204 Accuracy of Dementia Screening Instruments in Emergency Medicine: A Diagnostic Meta-Analysis

Results: Of the 198 patients in the study population 54% were deceased 30 days after hospital discharge with only 25.7% alive at 15 months. Admitted patients had a mean hospital length of stay of 7 days with 73% requiring intensive care. 40.4% of the patients received a formal palliative care intervention during their hospitalization from either the palliative care consult service (12.1%) or by embedded supportive care nurses (28.3%). Formal palliative care interventions occurred a median of 3 days into hospitalization and often changed the direction of care with 85% of patients downgrading their advanced directive wishes and discharge occurring a median of 1 day after intervention. Few formal palliative care interventions began from the emergency department (9.1%). Interestingly, 47.1% of patients who did not receive any documented goals of care discussions or palliative care interventions were deceased at 15 months post-discharge. Conclusions: Elderly patients from long-term care facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment and improve end-oflife care in this vulnerable population and should be considered early in the hospitalization and where available, be initiated in the emergency department.

Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

OBJECTIVE Although older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores. METHODS This health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted. RESULTS Three hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003). CONCLUSIONS Older patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.