Stacy Ackroyd-Stolarz

Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia.

ABSTRACTThe purpose of this study was to document what proportion of noninstitutionalized users of manually propelled wheelchairs are affected by wheelchair-related accidents caused by tips and falls, determine the nature and severity of the resulting injuries, and, by comparison with an unaffected group, identify factors associated with the risk of such accidents. We administered a postal questionnaire to as many as possible of the estimated 2055 members of the target population in the province of Nova Scotia. Among the 577 appropriate respondents, 57.4% reported they had completely tipped over or fallen from their wheelchairs at least once, and 66.0% reported having partially tipped. Of the falls and tips that were reported, 46.3% were forward in direction, 29.5% backward and 24.2% sideways. Many of the accidents occurred outdoors or on ramps. A total of 292 injuries were reported by 272 (47.1%) respondents. Most of the injuries (84.3%) were minor (e.g., abrasions, contusions, lacerations and sprains). Of the 15.8% of injuries that were serious, the most common were fractures (10.6%) and concussions (2.7%). Factors that appear to be associated with an increased risk of accidents and injuries included younger age, male gender, paraplegia or spina bifida as the reason for wheelchair use, having had a wheelchair prescribed, some wheelchair features (lightweight, camber, adjustable rear-axle positions, a knapsack), daily use of a wheelchair, propelling the chair with both hands, use of the wheelchair for recreation, use of a sideways transfer (without a transfer board) and doing repairs themselves or having them done by the dealer. Factors associated with a decreased risk include multiple sclerosis, stroke or arthritis as the reason for wheelchair use, attendant propulsion and the use of a one-person assist for transfers. The results of this study, that wheelchair-related accidents caused by tips and falls are very common, that serious injuries are not unusual and that there is a pattern of risk factors, should be useful to wheelchair users, clinicians, manufacturers and regulatory bodies.

Out-of-Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure : A Randomized Controlled Trial

STUDY OBJECTIVE Continuous positive airway pressure ventilation (CPAP) in appropriately selected patients with acute respiratory failure has been shown to reduce the need for tracheal intubation in hospital. Despite several case series, the effectiveness of out-of-hospital CPAP has not been rigorously studied. We performed a prospective, randomized, nonblinded, controlled trial to determine whether patients in severe respiratory distress treated with CPAP in the out-of-hospital setting have lower overall tracheal intubation rates than those treated with usual care. METHODS Out-of-hospital patients in severe respiratory distress, with failing respiratory efforts, were eligible for the study. The study was approved under exception to informed consent guidelines. Patients were randomized to receive either usual care, including conventional medications plus oxygen by facemask, bag-valve-mask ventilation, or tracheal intubation, or conventional medications plus out-of-hospital CPAP. The primary outcome was need for tracheal intubation during the out-of-hospital/hospital episode of care. Mortality and length of stay were secondary outcomes of interest. RESULTS In total, 71 patients were enrolled into the study, with 1 patient in each group lost to follow-up after refusing full consent. There were no important differences in baseline physiologic parameters, out-of-hospital scene times, or emergency department diagnosis between groups. In the usual care group, 17 of 34 (50%) patients were intubated versus 7 of 35 (20%) in the CPAP group (unadjusted odds ratio [OR] 0.25; 95% confidence interval [CI] 0.09 to 0.73; adjusted OR 0.16; 95% CI 0.04 to 0.7; number needed to treat 3; 95% CI 2 to 12). Mortality was 12 of 34 (35.3%) in the usual care versus 5 of 35 (14.3%) in the CPAP group (unadjusted OR 0.3; 95% CI 0.09 to 0.99). CONCLUSION Paramedics can be trained to use CPAP for patients in severe respiratory failure. There was an absolute reduction in tracheal intubation rate of 30% and an absolute reduction in mortality of 21% in appropriately selected out-of-hospital patients who received CPAP instead of usual care. Larger, multicenter studies are recommended to confirm this observed benefit seen in this relatively small trial.

Emergency Department Utilization by Older Adults: a Descriptive Study

Background Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. Methods In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. Results We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U; p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ2; p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. Conclusions Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.

Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of ‘pneumonia’ or ‘possible pneumonia’ from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as ‘pneumonia’, ‘possible pneumonia’, ‘non-pneumonia’ and ‘normal’, and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of ‘pneumonia’, 304 (45.3%) RR’s reported ‘pneumonia’ and 82 (12.2%), ‘possible pneumonia’. Of 815 EP diagnoses of ‘pneumonia’ or ‘possible pneumonia’, 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.

Prehospital hypoglycemia: the safety of not transporting treated patients

OBJECTIVES Emergency medical services (EMS) personnel frequently encounter patients who refuse transport after being treated for a hypoglycemic episode. The outcomes of most of these patients are unknown. The purpose of this study was to determine the outcomes of patients treated and not transported for hypoglycemia and identify criteria that could be used to identify patients who did not require transport to hospital. METHODS This was a prospective, observational study involving all adult (>15 years) hypoglycemic patients (blood glucose less than 4 mmol/L by glucometer) attended to by the EMS system in the Halifax Metropolitan area in the province of Nova Scotia during a ten-month interval. RESULTS There were 220 calls for adult patients with hypoglycemia. Of the 75 calls that resulted in transport, there were 17 further hypoglycemic episodes requiring a repeat call for an ambulance (22.7%) and three recurrences (4%). Of the 145 calls that did not result in transport, 40 further episodes of hypoglycemia (27.6%) and three recurrences (2%) were reported. These differences were not statistically significant (p=0.43 and 0.33, respectively). There was also no statistically significant difference in the intervals between hypoglycemic episodes for patients transported (51.1 days +/-65) compared with patients not transported for their previous hypogylcemic episode (40.7 days +/-53.5) (p=0.6). Of the 47 calls entered in the study, there were seven repeat calls for hypoglycemia (15%) and one recurrence (2.1%). The majority of patients did not follow up with their physician. CONCLUSIONS Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

Effects of Rear-Wheel Camber on Wheelchair Stability

OBJECTIVES To evaluate how using a wheelchair with rear-wheel camber (when the bottoms of the wheels are farther apart than the tops) is associated with the risk of instability incidents, and to determine the effect of camber on wheelchair stability. DESIGN, SETTING, PATIENTS Epidemiologic data were analyzed from a sample of 576 users of manually propelled wheelchairs in Nova Scotia. A controlled trial was performed using a representative wheelchair occupied by an anthropomorphic test dummy, altering the camber in 5 degrees increments from -15 degrees to +15 degrees. MAIN OUTCOME MEASURES For the epidemiologic study, univariate and multivariate analyses were used. To measure the static stability, a tilting platform was used according to the guidelines of the International Organization for Standardization. RESULTS Camber users reported significantly more instability incidents; of these incidents, more were in the rear direction (40% vs 27%) and fewer in the lateral direction (17% vs 28%) (p < .01). When controlling for other factors, camber was associated with a 3.91-fold increased risk of sustaining an instability incident (p < .001). With increases in camber angle in the laboratory, lateral and forward stability increased and rear stability decreased (with the wheels unlocked and locked) (p < .001). CONCLUSION Camber use is negatively associated with instability incidents in the lateral direction and positively associated with incidents in the backward direction, probably due in part to the effects of camber on lateral and rear stability.

P REHOSPITAL H YPOGLYCEMIA : T HE S AFETY OF N OT T RANSPORTING T REATED P ATIENTS

Objectives. Emergency medical services (EMS) personnel frequently encounter patients who refuse transport after being treated for a hypoglycemic episode. The outcomes of most of these patients are unknown. The purpose of this study was to determine the outcomes of patients treated and not transported for hypoglycemia and identify criteria that could be used to identify patients who did not require transport to hospital. Methods. This was a prospective, observational study involving all adult (>15 years) hypoglycemic patients (blood glucose less than 4 mmol/L by glucometer) attended to by the EMS system in the Halifax Metropolitan area in the province of Nova Scotia during a ten-month interval. Results. There were 220 calls for adult patients with hypoglycemia. Of the 75 calls that resulted in transport, there were 17 further hypoglycemic episodes requiring a repeat call for an ambulance (22.7%) and three recurrences (4%). Of the 145 calls that did not result in transport, 40 further episodes of hypoglycemia (27.6%) and three recurrences (2%) were reported. These differences were not statistically significant (p = 0.43 and 0.33, respectively). There was also no statistically significant difference in the intervals between hypoglycemic episodes for patients transported (51.1 days ± 65) compared with patients not transported for their previous hypogylcemic episode (40.7 days ± 53.5) (p = 0.6). Of the 47 calls entered in the study, there were seven repeat calls for hypoglycemia (15%) and one recurrence (2.1%). The majority of patients did not follow up with their physician. Conclusions. Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. Admission to hospital is rarely required. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and nontransported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.

Medication-Related Emergency Department Visits and Hospital Admissions in Pediatric Patients: A Qualitative Systematic Review

OBJECTIVE To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Adding loads to occupied wheelchairs : effect on static rear and forward stability

OBJECTIVE To determine the extent to which loads added in different positions affect the static rear and forward stability of an occupied wheelchair. DESIGN Controlled, cross-over study. INTERVENTION Loads from 0 to 10kg (in 1-kg increments) were added to five positions: high rear (HR), low rear (LR, beneath the seat and behind the crossbrace), on the lap (LAP), low anterior (LA, beneath the seat and anterior to the crossbrace), and on the footrests (FR). We also used a computer model to evaluate the relationship between stability and load, with a range of loads (0 to 100kg, in 10-kg increments) beyond the loads that were practical to test empirically. OUTCOME MEASURE On a tilting platform, we measured the static stability (in degrees) of a wheelchair occupied by an anthropomorphic test dummy (ATD). RESULTS The greatest increase in rear stability was with FR loads, changes of 64% and 227% for 10-kg and 100-kg loads, respectively. Only HR loads reduced rear stability, by 32% and 64%. The greatest increase in forward stability was with LR loads, by 13% and 92%. The greatest reduction in forward stability was with FR loads, by 10% and 149%. To minimize the effect of added loads on stability, the LAP and LA positions would be preferred. CONCLUSION Added loads affect wheelchair stability as a function of the load magnitude. The extent and direction of the effect is profoundly influenced by load position.

Intensity of Anticoagulation with Warfarin and Risk of Adverse Events in Patients Presenting to the Emergency Department

Background: The ability of patients receiving warfarin to maintain an international normalized ratio (INR) within the desired therapeutic range is important for both efficacy and risk of adverse events. It is unclear whether the desired INR is maintained in patients receiving warfarin who present to the emergency department (ED) and whether they have a higher rate of adverse events. Objective: To evaluate the intensity of anticoagulation with warfarin and the risk of bleeding and thromboembolic complications in patients in the ED. Methods: A prospective observational study was performed using a convenience sample of patients receiving warfarin and presenting to the ED over an 18-week period. Data were collected using a standardized form that included chief complaint, history of present illness, past medical history, medication history, and allergy status. Information from the physical examination, laboratory results, and other diagnostic tests obtained as part of routine assessment in the ED, was used as necessary. The primary outcome was the proportion of patients whose INR was within, above, or below the desired therapeutic range. Bleeding complications and thromboembolic events were recorded in an attempt to determine the relationship between the intensity of anticoagulation and adverse outcomes. Results: Two hundred one patients were included, with a mean (SD) age of 74.0 (13.2) years; 53.7% were female. Primary indications for warfarin were atrial fibrillation (75.6%) and venous thromboembolic disease (14.9%). A therapeutic INR was observed in 88 patients (43.8%; 95% CI 37.1 to 50.7), while 45 patients (22.4%; 95% CI 17.2 to 26.7) and 68 patients (33.8%; 95% CI 27.6 to 40.6) had subtherapeutic and supratherapeutic INRs, respectively. Overall, there were 28 (18 major and 10 minor) bleeding complications (13.9%; 95% CI 9.8 to 19.4) and 4 thromboembolic events (2.0%; 95% CI 0.6 to 5.2). Among patients with a bleeding complication, 14 (50.0%) had a supratherapeutic INR, while 2 patients who experienced a thromboembolic event (50.0%) had a subtherapeutic INR. Conclusions: The majority of patients receiving warfarin on presentation to the ED had INRs outside the desired therapeutic range. By establishing the impact of warfarin-related adverse events in this population, focused interventions can be established in this setting to address factors that can be targeted to reduce these events.