James Ducharme

Reliability of the Canadian Emergency Department Triage and Acuity Scale: Interrater Agreement

STUDY OBJECTIVE To determine the rate of interobserver reliability of the Canadian Emergency Department Triage and Acuity Scale (CTAS). METHODS Ten physicians and 10 nurses were randomly selected to review and assign a triage level on 50 ED case summaries containing presenting complaint, mode of arrival, vital signs, and a verbatim triage note. The rate of agreement within and between groups of raters was determined using kappa statistics. One-way, 2-way analysis of variance (ANOVA) and combined ANOVA were used to quantify reliability coefficients for intraclass and interclass correlations. RESULTS The overall chance-corrected agreement kappa for all observers was.80 (95% confidence interval [CI] .79 to .81), and the probability of agreement between 2 random observers on a random case was.539. For nurses alone, kappa=.84 (95% CI .83 to .85, P = .598), and for doctors alone, kappa= .83 (95% CI .81 to .85, P = .566). The 1-way, 2-way ANOVA and combined ANOVA showed that the reliability coefficients (84%) for both nurses and physicians were similar to the kappa values. A combined ANOVA showed there was a. 2-point difference with physicians assigning a higher triage level. CONCLUSION The high rate of interobserver agreement has important implications for case mix comparisons and suggests that this scale is understood and interpreted in a similar fashion by nurses and physicians.

A prospective blinded study on emergency pain assessment and therapy

A prospective blinded observational study was carried out to document acute pain assessment and management in an academic emergency department. Over a 2-month period, 42 patients with a primary complaint of pain were studied. Physicians and nurses did not document levels of pain or changes in pain during patient stays. Eleven of 42 patients had severe pain upon arrival, 5 of whom received medications, only 1 obtaining good relief. No other patient received medication, although five others received some intervention for their pain. Eleven of 38 patients who were discharged home had severe pain on discharge. Despite minimal pain relief, patient satisfaction with pain management was relatively high. Pain assessment and treatment may be poorer than previous retrospective studies have indicated.

Inter-observer agreement using the Canadian Emergency Department Triage and Acuity Scale

OBJECTIVE To determine the inter-observer agreement on triage assignment by first-time users with diverse training and background using the Canadian Emergency Department Triage and Acuity Scale (CTAS). METHODS Twenty emergency care providers (5 physicians, 5 nurses, 5 Basic Life Support paramedics and 5 Advanced Life Support paramedics) at a large urban teaching hospital participated in the study. Observers used the 5-level CTAS to independently assign triage levels for 42 case scenarios abstracted from actual emergency department patient presentations. Case scenarios consisted of vital signs, mode of arrival, presenting complaint and verbatim triage nursing notes. Participants were not given any specific training on the scale, although a detailed one-page summary was included with each questionnaire. Kappa values with quadratic weights were used to measure agreement for the study group as a whole and for each profession. RESULTS For the 41 case scenarios analyzed, the overall agreement was significant (quadratic-weighted K = 0.77, 95% confidence interval, 0.76-0.78). For all observers, modal agreement within one triage level was 94.9%. Exact modal agreement was 63.4%. Agreement varied by triage level and was highest for Level I (most urgent). A reasonably high level of intra- and inter-professional agreement was also seen. CONCLUSIONS Despite minimal experience with the CTAS, inter-observer agreement among emergency care providers with different backgrounds was significant.

Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED Study.

STUDY OBJECTIVE To compare thiopental, fentanyl, and midazolam for rapid-sequence induction and intubation (RSI). METHODS Eighty-six patients undergoing RSI in the emergency department were randomly assigned in a double-blind fashion to receive either thiopental (5 mg/kg), fentanyl (5 μg/kg), or midazolam (.1 mg/kg) before paralysis was induced. Outcome measures were mortality, speed and ease of intubation, and hemodynamics. RESULTS Of the patients who received thiopental, 93% were in tubated within 2 minutes of paralysis (P=.037), but systolic blood pressure fell an average of 38 mm Hg in this group (P=.045). The midazolam group had a greater number of delayed intubations (31%) and an average heart rate increase of 17 beats/minute (P=.008). Mortality (24% inhospital) was unaffected by drug assignment. In all three groups, patients with pulmonary edema had the greatest decrease in blood pressure during RSI, and patients exposed to multiple attempts at intubation manifested pronounced hypertension. CONCLUSION Fentanyl provided the most neutral hemodynamic profile during RSI, although factors other than choice of sedative can play a more significant role in determining hemodynamic re sponse. Depth of sedation may influence the speed of RSI. [Sivilotti MLA, Ducharme J: Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: The SHRED study. Ann Emerg Med March 1998;31;313-324.].

The influence of triage systems and triage scores on timeliness of ED analgesic administration

OBJECTIVES The aim of the study was to examine the association between triage scoring systems and triage priority scores on time to initial emergency department (ED) analgesic administration. METHODS An observational, multicenter, prospective, cohort study was conducted at 20 US and Canadian EDs. Centers from the United States used the Emergency Severity Index triage system or 1 of 3 unvalidated triage systems. Canadian centers used the Canadian Triage and Acuity Scale. Patients aged 8 years or older who presented to the ED with a chief complaint of moderate to severe pain (>3 on a 10-point numerical rating scale) and who were ultimately discharged home were eligible for study enrollment. Triage score, triage system, pain rating on arrival, and time of initial analgesic administration were recorded. RESULTS Among 842 enrolled subjects, 506 (60%) received an analgesic while in the ED. Lower-acuity patients consistently waited longer for analgesics. On multivariate modeling, presenting pain intensity, total time spent in the ED, white ethnicity, and triage system were associated with time to initial analgesic administration. Emergency departments using the Canadian Triage and Acuity Scale triage system exhibited the lowest rates of analgesic use and displayed longer median times to initial analgesic administration. CONCLUSIONS Although there were some differences between triage systems, all sites and systems demonstrated unacceptably long times to analgesic provision. Many patients with moderate to severe pain received no analgesic during their ED stay. Future studies should examine whether ED overcrowding impacts timeliness of analgesic administration and identify specific strategies to improve pain management practices in this challenging environment.

Canadian association of emergency physicians guidelines for the acute management of migraine headache

The aim of this article is to provide an evidence-based guideline on the management of acute migraine headaches in the Emergency Department setting. After a Medline search that covered 1965 to the present, all randomized controlled trials were reviewed. Recommendations as to the efficacy of abortive anti-migraine medications were based on the Canadian Medical Associations Guideline for Guidelines. Classes of medications that are discussed include: dopamine antagonists, serotonin agonists, opioids, local anesthetics, non-steroidal anti-inflammatory agents, and steroids. The recommendations are limited to discussing the efficacy of specific medications, adverse effects to be expected, as well as associated headache rates after discharge. Specific recommendations as to which medication might offer a superior treatment have not been proposed due to lack of proper comparative trials as well as lack of information on headache and quality of life after discharge from the Emergency Department.

Current pain-control practices and research

Abstract [Afilalo M, Cantees K, Ducharme J: Current pain-control practices and research. Ann Emerg Med April 1996;27:404-407.]

The International Federation for Emergency Medicine framework for quality and safety in the emergency department

All emergency departments (EDs) have an obligation to deliver care that is demonstrably safe and of the highest possible quality. Emergency medicine is a unique and rapidly developing specialty, which forms the hub of the emergency care system and strives to provide a consistent and effective service 24 h a day, 7 days a week. The International Federation of Emergency Medicine, representing more than 70 countries, has prepared a document to define a framework for quality and safety in the ED. Following a consensus conference and with subsequent development, a series of quality indicators have been proposed. These are tabulated in the form of measures designed to answer nine quality questions presented according to the domains of structure, process and outcome. There is an urgent need to improve the evidence base to determine which quality indicators have the potential to successfully improve clinical outcomes, staff and patient experience in a cost-efficient manner—with lessons for implementation.

The safety of infliximab infusions in the community setting.

BACKGROUND Tumour necrosis factor-alpha (TNFalpha) has an important role in the pathogenesis of inflammatory conditions such as rheumatoid arthritis, Crohns disease, ulcerative colitis and psoriasis. Infliximab, a chimeric anti-TNFalpha monoclonal antibody, has been shown to reduce the severity of symptoms or induces remission of active disease. Infusions have generally been limited to the hospital setting due to cost and concerns for patient safety. Studies defining its efficacy and safety have, therefore, originated almost exclusively from hospital settings. OBJECTIVE To evaluate the safety of infliximab in a community clinic environment, across all types of patients. METHODS A retrospective chart review of 3161 patients who received a combined 20,976 infusions at a network of community clinics over 16.5 months was conducted. Adverse drug reaction (ADR) information was retrieved and coded for time of onset, severity and outcome. Only ADRs that occurred during or within the first 24 h of the infusion were included. RESULTS A total of 524 (2.5% of all infusions) acute ADRs in 353 patients (11.2%) were recorded. Most reactions (ie, ADRs) were mild (n=263 [50.2%, 1.3% of all infusions]) or moderate (n=233 [44.5%, 1.1% of all infusions]). Twenty-eight reactions (5.3%, 0.1% of all infusions) were severe. Emergency medical services were called to transport patients to hospital for seven of the severe reactions, of which none required admission. As per pre-established medical directives, adrenaline was administered three times. CONCLUSIONS Infliximab infusions are safe in the community setting. Severe ADRs were rare. None required active physician intervention; nurses were able to treat all reactions by following standardized medical directives.

Clinical guidelines and policies: can they improve emergency department pain management?

James Ducharme he prevalence of pain in patients presenting to Emergency Departments (ED) has been well T documented by both CordelP and Johnston.2 Equally well documented has been the apparent failure to adequately control that pain. In 1990 Selbst found that patients with long bone fractures received little analgesia in the ED3, and Ngai, et al., showed that the under-treatment of pain continued after discharge.4 In a prospective study, Ducharme and Barber found that up to one third of patients presented with severe pain and were often unrelieved at discharge.5 Even though specific patient subgroups appear to be at greater risk, all patients are potential victims of oligoanalgesia the under-treatment of pain.6 Despite an ever increasing volume of research about pain in emergency medicine, dissemination of relevant information with widespread change in practice patterns has not been witnessed. Recent studies continue to aiiirm that pain management in the ED is suboptimal.’ Unlike the development of a clinical pathway (see Table 1 for definitions) or a protocol, both of which focus on specific care for a particular medical condition, altering attitudes toward pain management is much more difficult. While it can be agreed in general that severe pain should be controlled, it is difficult, if not impossible, to establish beforehand what degree of control is optimal for any one patient. Patient selected endpoints such as amount of pain relief or final pain score vary widely from individual to individual. Furthermore, physician (and nurse) disbelief in patient reporting of pain, opiophobia and fear of drug seeking are persistent subjective barriers resistant to objective recommendations. In an effort to achieve a ”pain free” ED, one of the options is to modify clinical practice with the implementation of clinical practice guidelines. Guidelines are best accepted when based on meta-analyses, or other high-quality data* Such research is still lacking in many areas of pain management and will continue to be lacking for the foreseeable future. Implementation of guidelines has been met with considerable resistance by physicians. There are concerns that guidelines may be established as a standard of care, placing physicians at legal risk if guidelines are not rigidly followed.9 These concerns arise because many clinical guidelines lack objective graded evidence, relying on “expert opinion.” Frequently, participants in guideline creation are re-