Eric Grafstein

Revisions to the Canadian Emergency Department Triage and Acuity Scale implementation guidelines

There has been widespread implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) across Canada since it was introduced in 1999. This consensus document, developed by the CTAS National Working Group (NWG) of nurse and physician leaders in emergency department (ED) triage, continues to be viewed as a dynamic document that requires modification over time as experience is gained in its application. This article presents the first major modification to the CTAS.

Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials

Abstract Objective To assess the evidence from controlled trials on the efficacy and tolerability of parenteral metoclopramide for acute migraine in adults. Data sources Cochrane Central Register of Controlled Trials, Medline, Embase, LILACS, CINAHL, conference proceedings, clinical practice guidelines, and other sources. Selection criteria Randomised controlled trials of parenteral metoclopramide for acute migraine in adults. Results We reviewed 596 potentially relevant abstracts and found 13 eligible trials totalling 655 adults. In studies comparing metoclopramide with placebo, metoclopramide was more likely to provide significant reduction in migraine pain (odds ratio 2.84, 95% confidence interval 1.05 to 7.68). Used as the only agent, metoclopramide showed mixed effectiveness when compared with other single agents. Heterogeneity of studies for combination treatment prevented statistical pooling. Treatments that did include metoclopramide were as, or more, effective than comparison treatments for pain, nausea, and relapse outcomes reported in all studies. Conclusions Metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments. Given its non-narcotic and antiemetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments.

Intravenous ondansetron for the control of opioid-induced nausea and vomiting

This randomized, double-masked, placebo-controlled, multicenter trial was conducted in 9 countries to assess the safety and efficacy of 2 doses of intravenous ondansetron (8 and 16 mg) for the control of opioid-induced nausea and vomiting. A total of 2574 nonsurgical patients who presented with pain requiring treatment with an opioid analgesic agent participated in this trial. The most common presenting painful condition was back or neck pain, reported by approximately one third of patients. A total of 520 patients (317 females, 203 males) developed nausea or vomiting after opioid administration and were randomly assigned to receive a single dose of 1 of 3 study treatments: placebo (n = 94), ondansetron 8 mg (n = 215), or ondansetron 16 mg (n = 211). Ondansetron 8 and 16 mg led to complete control of emesis in 134 of 215 patients (62.3%) and 145 of 211 patients (68.7%), respectively. Results with both doses were significantly better than those seen with placebo (43 of 94 patients [45.7%]). Complete control of nausea was achieved in 6.8% of placebo patients, 14.8% of ondansetron 8-mg-treated patients, and 19.4% of ondansetron 16-mg treated patients; only ondansetron 16 mg was significantly better than placebo (P = 0.007). Significantly more patients who received ondansetron 8 mg than patients who received placebo were satisfied/very satisfied with their antiemetic treatment, as assessed by 4 patient-satisfaction questions. Significantly more patients who received ondansetron 16 mg compared with placebo were satisfied/very satisfied on 2 of 4 satisfaction questions. In conclusion, based on the observed incidence of opioid-induced nausea and vomiting in this study, it may be more appropriate to treat symptoms on occurrence rather than administering antiemetic agents prophylactically. The results of this study demonstrate that intravenous ondansetron in doses of 8 or 16 mg is an effective antiemetic agent for the control of opioid-induced nausea and vomiting in nonsurgical patients requiring opioid analgesia for pain.

Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department.

OBJECTIVE We sought to estimate the period prevalence of methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) and evaluate risk factors for MRSA SSTI in an emergency department (ED) population. METHODS We carried out a cohort study with a nested case-control design. Patients presenting to our ED with a wound culture and a discharge diagnosis of SSTI between January 2003 and September 2004 were dichotomized as MRSA positive or negative. Fifty patients with MRSA SSTI matched by calendar time to 100 controls with MRSA-negative SSTI had risk factors assessed using multivariate conditional logistic regression. RESULTS Period prevalence of MRSA SSTI was 54.8% (95% confidence interval [CI] 50.2%-59.4%). The monthly period prevalence increased from 21% in January 2003 to 68% in September 2004 (p < 0.01). Risk factors for MRSA SSTI were injection drug use (IDU) (odds ratio [OR] 4.6, 95% CI 1.4-16.1), previous MRSA infection and colonization (OR 6.4, 95% CI 2.1-19.8), antibiotics in 8 weeks preceding index visit (OR 2.6, 95% CI 1.2-8.1), diabetes mellitus (OR 4.1, 95% CI 1.4-12.1), abscess (OR 5.6, 95% CI 1.8-17.1) and admission to hospital in previous 12 months (OR 2.6, 95% CI 1.1-11.2). CONCLUSION The period prevalence of MRSA SSTI between January 2003 and September 2004 was 54.8% at our institution. There was a marked increase in the monthly period prevalence from the beginning to the end of the study. Risk factors are IDU, previous MRSA infection and colonization, prescriptions for antibiotics in previous 8 weeks and admission to hospital in the preceding 12 months. On the basis of local prevalence and risk factor patterns, emergency physicians should consider MRSA as a causative agent for SSTI.

Important returns on investment: an evaluation of a national research grants competition in emergency medicine.

OBJECTIVE We sought to examine scholarly outcomes of the projects receiving research grants from the Canadian Association of Emergency Physicians (CAEP) during the first 10 years of national funding (i.e., between 1996 and 2005). METHODS We sent email surveys to 62 emergency medicine (EM) researchers who received funding from CAEP. We focused our data collection on grant deliverables and opinions using a 1-7 Likert scale with regard to the value of the award. RESULTS Fifty-eight recipients responded to our survey. Grants were most commonly awarded to residents (21 [36%]), followed by senior (16 [28%]) and junior (13 [22%]) emergency staff. Twenty-six applicants from Ontario and 11 from Quebec received the majority of the grants. Overall, 51 projects were completed at the time of contact and, from these, 39 manuscripts were published or in press. Abstract presentations were more common, with a median of 2 abstracts presented per completed project. Abstract presentations for the completed projects were documented locally (23), nationally (39) and internationally (37). Overall, 19 projects received additional funding. The median amount funded was Can

Speed and accuracy of text-messaging emergency department electrocardiograms from a small community hospital to a provincial referral center

4700 with an interquartile range of

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency

3250-

Canadian Emergency Department Information System (CEDIS) Presenting Complaint List (Version 1.0).

5000. Respondents felt CAEP funding was critical to completing their projects and felt strongly that dedicated EM research funding should be continued to stimulate productivity. CONCLUSION Overall, the CAEP Research Grants Competition has produced impressive results. Despite the small sums available, the grants have been important for ensuring study completion and for securing additional funding. CAEP and similar EM organizations need to develop a more robust funding approach so that larger grant awards and more researchers can be supported on an annual basis.

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

Background Currently, transmission of electrocardiograms (EKGs) from a small emergency department (ED) to specialists at referral hospitals can be a time-consuming and laborious process. We investigate whether text messaging by use of short message service (SMS) of EKGs from a small hospital to consultants at a large hospital is rapid and accurate. Methods This study involved a one-month prospective evaluation of consecutive EKGs recorded in a small community ED. Investigators obtained de-identified photographs of each EKG via a mobile phone camera. Each EKG picture, along with a brief patient clinical history, was sent via SMS to on-call emergency physicians located at a large referral care site. All images were evaluated solely on a mobile phone. The primary outcome was the proportion of SMS that were received within two minutes of being sent. As a secondary outcome, the intra-rater evaluation of the initial EKG and the SMS EKG image were compared on 13 standardized features. The tertiary outcome was cost of text messaging. Results A total of 298 patients (14.6%) had 409 EKGs performed and a total of 926 SMS were sent. 921 SMS (99.5%, 95% confidence interval (CI) 98.7–99.8%) arrived within two minutes with a median transmission time of nine seconds (interquartile range (IQR) 3–32 s). Between the gold standard original EKG, and the interpretation of the texted image, six out of 409 (1.5%, 95% CI 0.6–3.3%) had any differences recorded, across all 13 categories. Overall, the study cost 4.1 cents per texted image. Conclusions Systematic text messaging of ED EKGs from a small community hospital to a referral center is a rapid, accurate, portable, and inexpensive method of data transfer. This may be a safe and effective strategy to communicate vital patient information.

Impact of an Overcapacity Care Protocol on Emergency Department Overcrowding

OBJECTIVES Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay. METHODS We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks. RESULTS The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR 21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The CII measured 26% (95% CI 23-28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations. CONCLUSION The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.