Erin Weldon

To Transmit or Not to Transmit: How Good Are Emergency Medical Personnel in Detecting STEMI in Patients With Chest Pain?

BACKGROUND There is growing use of prehospital electrocardiograms (ECGs) in establishing early diagnosis of ST segment myocardial infarction (STEMI) to facilitate early reperfusion. This study aimed to determine the predictive value of prehospital ECGs interpreted by nonphysician emergency medical services (EMS) in chest pain presentations. METHODS In our city of 658,700 people, EMS/paramedics received 21 hours of instruction on STEMI management, ECG acquisition, and interpretation. Suspected STEMI ECGs were wirelessly transmitted to and discussed with a physician for possible therapy. ECGs deemed negative for STEMI by EMS were not transmitted; patients were transported to the closest hospital without prehospital physician involvement. RESULTS From July 21, 2008 to July 21, 2010, there were 5426 chest pain calls to EMS, 380 were suspected STEMI cases. The remaining ECGs were deemed negative for STEMI by EMS. To audit the nontransmitted ECGs we analyzed 323 consecutive patients over 2 selected months (January and June 2010) for comparison. Of nontransmitted cases there was 1 missed and 2 STEMIs that developed subsequently. Based on 380 transmitted and 323 nontransmitted cases, the sensitivity and specificity of EMS detecting STEMI were 99.6% and 67.6%, respectively. The positive and negative predictive values for STEMI were 59.5% and 99.7%, respectively. CONCLUSIONS Our findings demonstrate nonphysician EMS interpretation of STEMI on prehospital ECG has excellent sensitivity and high negative predictive value. This finding supports the use of prehospital ECGs interpreted by EMS to help identify and facilitate treatment of STEMI. These results may have broad implications on staffing models for first responder/EMS units.

Cardiac Outcomes Through Digital Evaluation (CODE) STEMI Project: Prehospital Digitally-Assisted Reperfusion Strategies

BACKGROUND Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times. METHODS In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physicians hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room. RESULTS From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%. CONCLUSIONS Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.

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.

Characteristics of evidence-based medicine training in Royal College of Physicians and Surgeons of Canada emergency medicine residencies - a national survey of program directors

BackgroundRecent surveys suggest few emergency medicine (EM) training programs have formal evidence-based medicine (EBM) or journal club curricula. Our primary objective was to describe the methods of EBM training in Royal College of Physicians and Surgeons of Canada (RCPSC) EM residencies. Secondary objectives were to explore attitudes regarding current educational practices including e-learning, investigate barriers to journal club and EBM education, and assess the desire for national collaboration.MethodsA 16-question survey containing binary, open-ended, and 5-pt Likert scale questions was distributed to the 14 RCPSC-EM program directors. Proportions of respondents (%), median, and IQR are reported.ResultsThe response rate was 93% (13/14). Most programs (85%) had established EBM curricula. Curricula content was delivered most frequently via journal club, with 62% of programs having 10 or more sessions annually. Less than half of journal clubs (46%) were led consistently by EBM experts. Four programs did not use a critical appraisal tool in their sessions (31%). Additional teaching formats included didactic and small group sessions, self-directed e-learning, EBM workshops, and library tutorials. 54% of programs operated educational websites with EBM resources. Program directors attributed highest importance to two core goals in EBM training curricula: critical appraisal of medical literature, and application of literature to patient care (85% rating 5 - “most importance”, respectively). Podcasts, blogs, and online journal clubs were valued for EBM teaching roles including creating exposure to literature (4, IQR 1.5) and linking literature to clinical practice experience (4, IQR 1.5) (1-no merit, 5-strong merit). Five of thirteen respondents rated lack of expert leadership and trained faculty educators as potential limitations to EBM education. The majority of respondents supported the creation of a national unified EBM educational resource (4, IQR 1) (1-no support, 5- strongly support).ConclusionsRCPSC-EM programs have established EBM teaching curricula and deliver content most frequently via journal club. A lack of EBM expert educators may limit content delivery at certain sites. Program directors supported the nationalization of EBM educational resources. A growing usage of electronic resources may represent an avenue to link national EBM educational expertise, facilitating future collaborative educational efforts.

Pleural Disease in the Emergency Department

Emergency department presentations of pleural-based diseases are common, with severity ranging from mild to life threatening. The acute assessment, diagnosis, and treatment of pleural disease are critical as urgent invasive maneuvers such as thoracocentesis and thoracostomy may be indicated. The emergency physician must have a systematic approach to these conditions that allows for rapid recognition, diagnosis, and definitive management. This article focuses on nontraumatic pleural disease, including diagnostic and treatment considerations of pleural effusion, empyema, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pediatric pneumothorax, spontaneous hemothorax, and spontaneous tension pneumothorax.

Bottleneck detection for improvement of Emergency Department efficiency

Purpose – The purpose of this paper is to introduce a method of the bottleneck detection for Emergency Department (ED) improvement using benchmarking and design of experiments (DOE) in simulation model. Design/methodology/approach – Four procedures of treatments are used to represent ED activities of the patient flow. Simulation modeling is applied as a cost-effective tool to analyze the ED operation. Benchmarking provides the achievable goal for the improvement. DOE speeds up the process of bottleneck search. Findings – It is identified that the long waiting time is accumulated by previous arrival patients waiting for treatment in the ED. Comparing the processing time of each treatment procedure with the benchmark reveals that increasing the treatment time mainly happens in treatment in progress and emergency room holding (ERH) procedures. It also indicates that the to be admitted time caused by the transfer delay is a common case. Research limitations/implications – The current research is conducted in ...

STEMI Stymie: Metastatic Cancer and Cardiac Tamponade Presenting as Inferior STEMI

The combination of chest pain and isolated ST-segment elevation on an ECG immediately suggests the diagnosis of myocardial infarction. However, given the potential for complications associated with reperfusion strategies, clinicians must maintain a high index of suspicion for ST-segment elevation myocardial infarction mimics, including pericardial disease, in their assessment of these patients. Here we report a case that illustrates a rare presentation in which a patient with isolated inferior ST-segment elevation and acute chest pain suggestive of ST-segment elevation myocardial infarction was ultimately diagnosed with cardiac tamponade as the first presentation of an occult malignancy. This case supports the rationale for the use of bedside ultrasonography as a diagnostic modality to include in the evaluation of select cardiac patients and all pulseless electrical activity arrest patients in the emergency department.

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.

Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain

Abstract In the treatment of acute coronary syndromes, reduction of sympathetic stress and catecholamine release is an important therapeutic goal. One method used to achieve this goal is pain reduction through the systemic administration of analgesia. Historically, morphine has been the analgesic of choice in ischemic cardiac pain. This randomized double-blind controlled trial seeks to prove the utility of fentanyl as an alternate first-line analgesic for ischemic-type chest pain in the prehospital setting. Successive patients who were treated for suspected ischemic chest pain in the emergency medical services system were considered eligible. Once chest pain was confirmed, patients received oxygen, aspirin, and nitroglycerin therapy. If the ischemic-type chest pain continued the patient was randomized in a double-blinded fashion to treatment with either morphine or fentanyl. Pain scale scores, necessity for additional dosing, and rate of adverse events between the groups were assessed every 5 minutes and were compared using t-testing, Fishers Exact test, or Analysis of Variance (ANOVA) where appropriate. The primary outcome of the study was incidence of hypotension and the secondary outcome was pain reduction as measured by the visual analog score and numeric rating score. A total of 207 patients were randomized with 187 patients included in the final analysis. Of the 187 patients, 99 were in the morphine group and 88 in the fentanyl group. No statistically significant difference between the two groups with respect to hypotension was found (morphine 5.1% vs. fentanyl 0%, p = 0.06). Baseline characteristics, necessity for additional dosing, and other adverse events between the two groups were not statistically different. There were no significant differences between the changes in visual analog scores and numeric rating scale scores for pain between the two groups (p = 0.16 and p = 0.15, respectively). This study supports that fentanyl and morphine are comparable in providing analgesia for ischemic-type chest pain. Fentanyl appears to be a safe and effective alternative to morphine for the management of chest pain in the prehospital setting.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

Background Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV). Methods Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients. Results The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians. Conclusions PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.