Michael J. Schull

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

Objective To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events. Design Population based retrospective cohort study using health administrative databases. Setting High volume emergency departments in Ontario, Canada, fiscal years 2003-7. Participants All emergency department patients who were not admitted (seen and discharged; left without being seen). Outcome measures Risk of adverse events (admission to hospital or death within seven days) adjusted for important characteristics of patients, shift, and hospital. Results 13u2009934u2009542 patients were seen and discharged and 617u2009011 left without being seen. The risk of adverse events increased with the mean length of stay of similar patients in the same shift in the emergency department. For mean length of stay ≥6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients). Leaving without being seen was not associated with an increase in adverse events at the level of the patient or by annual rates of the hospital. Conclusions Presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, is associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen are not at higher risk of short term adverse events.

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

STUDY OBJECTIVEnMore 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.nnnMETHODSnWe 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).nnnRESULTSnAmong 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.nnnCONCLUSIONnHalf 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.

Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times

BackgroundInternationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.MethodsPragmatic cluster randomized trial. From 131 weekday shifts (8:00–14:30) during a 26-week period, we randomized 65xa0days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66xa0days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.ResultsThe intervention’s median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19–4:38] during comparator shifts. The intervention’s median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02–2:14]. The intervention’s median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention’s left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43–4:16]) and low acuity patients (1:10 95th% CI: 0:58–1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23–0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.ConclusionsThe intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.Trial registration numberNCT00991471 ClinicalTrials.gov

ED triage of patients with acute myocardial infarction: predictors of low acuity triage

OBJECTIVEnVirtually all emergency department (ED) patients receive an ED triage assessment that determines their priority to be seen by a physician. Previous research found that half of patients who are having an acute myocardial infarction (AMI) are given a low priority triage score, which is associated with delays in electrocardiogram (ECG) acquisition and reperfusion therapy. We sought to determine some of the reasons why ED triage is failing in these patients.nnnMETHODSnWe conducted a retrospective cohort analysis of a population-based cohort of AMI patients admitted to 102 acute care hospitals in Ontario, Canada, from July 2000 to March 2001. We examined 10 potential patient- and hospital-level predictors of low acuity triage: age, sex, number of comorbidities, arrival mode, socioeconomic status, time of day, day of week, ED AMI volume, hospital type, and department use of triage ECGs.nnnRESULTSnMean age of the 3088 patients was 67.5 (SD, 14.0), and 65% were men. In adjusted quantile regression analyses, low acuity triage was independently associated with ED AMI volume (odds ratio [OR], 0.44 at very high volume centers), arrival mode (OR, 0.60 for ambulance arrival), sex (OR, 0.80 for males), age (OR, 1.1 per 10 years of age), and a low number of comorbidities (OR, 0.92 for every cardiac co-morbidity).nnnCONCLUSIONSnLow acuity ED triage of AMI patients may be predicted by several patient- and hospital-level characteristics. Focusing future interventions on these factors may improve ED triage and, subsequently, time to initial ECG and reperfusion, in this patient group.

Prediction of emergent heart failure death by semi-quantitative triage risk stratification.

Objectives Generic triage risk assessments are widely used in the emergency department (ED), but have not been validated for prediction of short-term risk among patients with acute heart failure (HF). Our objective was to evaluate the Canadian Triage Acuity Scale (CTAS) for prediction of early death among HF patients. Methods We included patients presenting with HF to an ED in Ontario from Apr 2003 to Mar 2007. We used the National Ambulatory Care Reporting System and vital statistics databases to examine care and outcomes. Results Among 68,380 patients (76±12 years, 49.4% men), early mortality was stratified with death rates of 9.9%, 1.9%, 0.9%, and 0.5% at 1-day, and 17.2%, 5.9%, 3.8%, and 2.5% at 7-days, for CTAS 1, 2, 3, and 4–5, respectively. Compared to lower acuity (CTAS 4–5) patients, adjusted odds ratios (aOR) for 1-day death were 1.32 (95%CI; 0.93–1.88; pu200a=u200a0.12) for CTAS 3, 2.41 (95%CI; 1.71–3.40; p<0.001) for CTAS 2, and highest for CTAS 1: 9.06 (95%CI; 6.28–13.06; p<0.001). Predictors of triage-critical (CTAS 1) status included oxygen saturation <90% (aOR 5.92, 95%CI; 3.09–11.81; p<0.001), respiratory rate >24 breaths/minute (aOR 1.96, 95%CI; 1.05–3.67; pu200a=u200a0.034), and arrival by paramedic (aOR 3.52, 95%CI; 1.70–8.02; pu200a=u200a0.001). While age/sex-adjusted CTAS score provided good discrimination for ED (c-statisticu200a=u200a0.817) and 1-day (c-statisticu200a=u200a0.724) death, mortality prediction was improved further after accounting for cardiac and non-cardiac co-morbidities (c-statistics 0.882 and 0.810, respectively; both p<0.001). Conclusions A semi-quantitative triage acuity scale assigned at ED presentation and based largely on respiratory factors predicted emergent death among HF patients.

The Pre-Hospital Fibrinolysis Experience in Europe and North America and Implications for Wider Dissemination

OBJECTIVESnThe primary objective of this report was to describe the infrastructures and processes of selected European and North American pre-hospital fibrinolysis (PHL) programs. A secondary objective is to report the outcome data of the PHL programs surveyed.nnnBACKGROUNDnDespite its benefit in reducing mortality in patients with ST-segment elevation myocardial infarction, PHL remained underused in North America. Examination of existing programs may provide insights to help address barriers to the implementation of PHL.nnnMETHODSnThe leading investigators of PHL research projects/national registries were invited to respond to a survey on the organization and outcomes of their affiliated PHL programs.nnnRESULTSnPHL was successfully deployed in a wide range of geographic territories (Europe: France, Sweden, Vienna, England, and Wales; North America: Houston, Edmonton, and Nova Scotia) and was delivered by healthcare professionals of varying expertise. In-hospital major adverse outcomes were rare with mortality of 3% to 6%, reinfarction of 2% to 5%, and stroke of <2%.nnnCONCLUSIONSnCombining formal protocols for PHL for some patients with direct transportation of others to a percutaneous coronary intervention hospital for primary percutaneous coronary intervention would allow for tailored reperfusion therapy for patients with ST-segment elevation myocardial infarction. Insights from a variety of international settings may promote widespread use of PHL and increase timely coronary reperfusion worldwide.

Temporal changes in emergency department triage of patients with acute myocardial infarction and the effect on outcomes

BACKGROUNDnAll patients who present to an emergency department (ED) are triaged. The ED triage score may determine when patients are seen by a physician. Half of patients with acute myocardial infarction (AMI) were given a low priority score in Ontario in 2000/2001. We assessed the appropriateness of ED triage and its association with quality indicators and outcomes in a more recent AMI cohort and compared this with previous findings.nnnMETHODSnWe conducted a retrospective cohort study of a population-based cohort of patients with AMI admitted to 96 hospitals in Ontario, Canada, in 2004/2005. Outcome measures included rate of low-priority ED triage (score of 3, 4, or 5), compared with an earlier cohort (fiscal year 2000) at the same sites, and the adjusted effect of low-priority ED triage on door-to-electrocardiogram, door-to-needle, and door-to-balloon time; hospital length of stay (LOS); and mortality.nnnRESULTSnAmong 6,605 patients with AMI, low-priority triage was less frequent than in the earlier cohort, at 33.3% versus 50.3%. In patients with ST-segment elevation myocardial infarction (STEMI), it was 25.9%, versus 43.8% previously. Between cohorts, the greatest improvement in triage occurred in patients with chest pain, in those seen at higher AMI volume EDs, and in ambulatory patients; patients seen at low AMI volume EDs, those with diabetes, and the elderly showed the least improvement. Being assigned a low-priority triage score was associated with an adjusted increase in median door-to-electrocardiogram and door-to-needle time of 12.2 (P < .001) and 20.7 minutes (P < .001), respectively, longer than in the earlier cohort (4.4 and 15.1 minutes). It was associated with hospital LOS >75th percentile (odds ratio [OR] 1.25, P < .001), and higher 90-day (OR 1.50, P = .02) and 1-year mortality (OR 1.37, P = .05) in patients with STEMI.nnnCONCLUSIONnEmergency department triage of patients with AMI improved substantially over 5 years. For the third of patients with AMI who continue to receive a low priority score, including 25% of patients with STEMI, the associated delays in diagnosis and therapy were greater than previously and were associated with increased hospital LOS and mortality. Given the impact of this initial, cursory assessment, hospital systems should consider monitoring the quality of their ED triage.

The medicine man.

The loud knock at the door woke me from a deep sleep. It wasn’t easy for me to get out of my warm sleeping bag that cold night to answer. It was December 1991, and I was living in a town called Diyana in northern Iraq, working with a medical aid organization following the Persian Gulf War. I shared a room with my driver and translator. He told me that the people shouting and gesturing frantically at the door had a very sick relative who had just been treated at the local hospital, but urgently needed transfer to a larger centre. They had no fuel to get her there, and they begged me to come and see her. Though I doubted I could do much with my stethoscope, I agreed to go. The crowd silently led me down narrow, pitch-black alleyways. We arrived at a small house and entered. The first room was jammed with many people, all agitated to varying degrees. Some were crying, most were silent; a terrible anxiety seemed to fill the air. A man appeared, who was the patient’s son, and he told me he was afraid that his mother was dying. Now, I became anxious as well. The hallways were illuminated by small oil lanterns hanging off the walls, and their dim yellow light did little to push back the shadows. I was led into a small bedroom and found an old woman slumped over on a couch, apparently unconscious, the room filled with several more relatives. They first stared at her intently, and then shifted their gaze to me. The room was stiflingly hot, with several kerosene heaters warming it, and was illuminated by 2 more small lamps. Hardly able to move, I asked most of the people to leave the room, keeping only my translator and the patient’s son with me; then I closed the door. I shook the woman’s arms to try to wake her, without response. Her son told us she had received an injection at the hospital, and had fallen asleep soon after. I examined her pulse, which was strong and regular, and her breath sounds were normal. I asked what had happened. According to her son she had yawned widely, and suddenly felt a pain in her face and had been unable to close her mouth. “That’s it?” I asked. “No pain elsewhere, no other symptoms?” But the history was as simple as that: a dislocated jaw. In the hospital she must have been given a sedative injection, which by now had taken full effect. We sat her up on the couch, and I held her while I opened her lips and saw that her teeth couldn’t close. I slid my thumbs onto her lower teeth and, with a gentle push, reduced her jaw into the joint. Her teeth were now well aligned, her mouth opened and closed easily. I let go and she slumped over again. I turned to the son and announced that his mother was cured! The whole operation since entering the house had taken about 4 minutes. The son beamed, his smile lighting up the room. He ran into the hallway and triumphantly announced that I had cured the old woman, then the mob burst in to see for themselves. Though she remained slumped over and looked identical to the way she had before, they were convinced I had saved her life. I attempted to explain that the problem had been very simple, but to no avail. As I struggled to get out of the house, I had to accept the thanks of every person there, and as each one shook my hand they stared at me in awe; to them I seemed more medicine man than doctor. The next day I went back to see the old woman, and, except for a headache, she was back to normal. She thanked me profusely, and offered me a simple gift in return: she would pray for me. The late-night knocks at my door continued, and I was often asked to see “sick” patients. Usually they had simple problems, and I would send most to the hospital rather than treating them myself, for fear of undermining the local doctors. But I didn’t try too hard to dismiss their unearned trust, since, in Iraq in 1991, there wasn’t much else to believe in.

The role of primary care physician and cardiologist follow-up for low-risk patients with chest pain after emergency department assessment

BACKGROUNDnChest pain is one of the most common reasons for presentation to the emergency department (ED); however, there is a paucity of data evaluating the impact of physician follow-up and subsequent management. To evaluate the impact of physician follow-up for low-risk chest pain patients after ED assessment.nnnMETHODSnWe performed a retrospective observational study of low-risk chest pain patients who were assessed and discharged home from an Ontario ED. Low risk was defined as ≥50 years of age and no diabetes or preexisting cardiovascular disease. Follow-up within 30 days was stratified as (a) no physician, (b) primary care physician (PCP) alone, (c) PCP with cardiologist, and (d) cardiologist alone. The primary outcome was death or myocardial infarction (MI) at 1 year.nnnRESULTSnAmong 216,527 patients, 29% had no-physician, 60% had PCP-alone, 8% had PCP with cardiologist, and 4% had cardiologist-alone follow-up after ED discharge. The mean age of the study cohort was 64.2 years, and 42% of the patients were male. After adjusting for important differences in baseline characteristics between physician follow-up groups, the adjusted hazard ratios for death or MI were 1.07 (95% CI 1.00-1.14) for the PCP group, 0.81 (95% CI 0.72-0.91) for the PCP with cardiologist group, and 0.87 (95% CI 0.74-1.02) for the cardiologist alone group, as compared with patients who had no follow-up.nnnCONCLUSIONnIn this cohort of low-risk patients who presented to an ED with chest pain, follow-up with a PCP and cardiologist was associated with significantly reduced risk of death or MI at 1 year.

Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients.

OBJECTIVEnThe American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time.nnnMETHODSnThis retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time.nnnRESULTSnIn 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%.nnnCONCLUSIONSnHospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.