The consequences of minor trauma involving a head injury (MT-HI) in independent older adults are largely unknown. This study assessed the impact of a head injury on the functional outcomes six months post-injury in older adults who sustained a minor trauma.

This multicenter prospective cohort study in eight sites included patients who were aged 65 years or older, previously independent, presenting to the emergency department (ED) for a minor trauma, and discharged within 48 hours. To assess the functional decline, we used a validated test: the Older Americans’ Resources and Services Scale. The cognitive function of study patients was also evaluated. Finally, we explored the influence of a concomitant injury on the functional decline in the MT-HI group.

All 926 eligible patients were included in the analyses: 344 MT-HI patients and 582 minor trauma without head injury. After six months, the functional decline was similar in both groups: 10.8% and 11.9%, respectively (RR=0.79 [95% CI: 0.55–1.14]). The proportion of patients with mild cognitive disabilities was also similar: 21.7% and 22.8%, respectively (RR=0.91 [95% CI: 0.71–1.18]). Furthermore, for the group of patients with a MT-HI, the functional outcome was not statistically different with or without the presence of a co-injury (RR=1.35 [95% CI: 0.71–2.59]).

This study did not demonstrate that the occurrence of a MT-HI is associated with a worse functional or cognitive prognosis than other minor injuries without a head injury in an elderly population, six months after injury.

Children with suspected appendicitis are at risk for suboptimal pain management. We sought to describe pain management patterns for suspected appendicitis across Canadian pediatric emergency departments (PEDs).

A retrospective medical record review was undertaken at 12 Canadian PEDs. Children ages 3 to 17 years who were admitted to the hospital in February or October 2010 with suspected appendicitis were included. Patients were excluded if partially assessed or treated at another hospital. Data were abstracted using a study-specific, standardized electronic data extraction tool. The primary outcome was the proportion of children who received analgesia while in the emergency department (ED). Secondary outcomes included the proportion of children receiving intravenous (IV) morphine and the timing of analgesic provision.

A total of 619 health records were abstracted; mean (SD) patient age was 11.4 (3.5) years. Sixty-one percent (381/616) of patients received analgesia in the ED; 42.8% (264/616) received IV morphine. Other analgesic agents provided included oral acetaminophen (23.5% [145/616]) and oral ibuprofen (5.8% [36/616]). The median (IQR) initial dose of IV morphine was 0.06 (0.04, 0.09) mg/kg. The median (IQR) time from triage to the initial dose of analgesia was 196 (101, 309.5) minutes. Forty-three percent (117/269) of children receiving analgesia received the initial dose following surgical consultation; 43.7% (121/277) received their first analgesic after abdominal ultrasound was performed.

Suboptimal and delayed analgesia remains a significant issue for children with suspected appendicitis in Canadian PEDs. This suggests a role for multidimensional knowledge translation interventions and care protocols to improve timely access to analgesia.

To determine how often the Ambulance Call Record (ACR) was available to emergency department (ED) physicians and whether it contained information that changed the ED management of patients.

This was a prospective cohort study of adult patients transported to one of two tertiary care centre EDs. Physicians completed a data collection form for each patient regarding ACR availability and the perceived value of the ACR. This study began shortly after the implementation of a new electronic ACR (eACR) handover process (Round 1). To control for any confounding factors related to this new eACR handover process, the study was repeated 6 months after its implementation (Round 2).

Total of 869 forms were collected: 545 in Round 1, and 324 in Round 2. The ACR was available at first physician assessment for 82 (15.7%) patients in Round 1, and 76 (24.4%) patients in Round 2 (Δ8.7%, 95% CI: 3.1%, 14.5%). The ACR was available at some point during patients’ ED stay for 154 (28.9%) patients in Round 1, compared to 111 (34.5%) patients in Round 2 (Δ5.6%, 95% CI: 0.0%, 12.1%). When the ACR was available for a patient (n=265), physicians believed that information in the ACR changed their treatment plan in 76 (28.8%) cases.

Physicians who review the ACR believe that the ACR contains relevant information that may influence patient management; however, physicians commonly manage patients without reviewing the ACR.

Three are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED.

A retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution.

Over the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED.

This assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

To develop consensus recommendations for training future clinician educators (CEs) in emergency medicine (EM).

A panel of EM education leaders was assembled from across Canada and met regularly by teleconference over the course of 1 year. Recommendations for CE training were drafted based on the panel’s experience, a literature review, and a survey of current and past EM education leaders in Canada. Feedback was sought from attendees at the Canadian Association of Emergency Physicians (CAEP) annual academic symposium. Recommendations were distributed to the society’s Academic Section for further feedback and updated by a consensus of the expert panel.

Recommendations were categorized for one of three audiences: 1) Future CEs; 2) Academic departments and divisions (AD&D) that support training to fulfill their education leadership goals; and 3) The CAEP Academic Section. Advanced medical education training is recommended for any emergency physician or resident who pursues an education leadership role. Individuals should seek out mentorship in making decisions about career opportunities and training options. AD&D should regularly perform a needs assessment of their future CE needs and identify and encourage potential individuals who fulfill education leadership roles. AD&D should develop training opportunities at their institution, provide support to complete this training, and advocate for the recognition of education scholarship in their institutional promotions process. The CAEP Academic Section should support mentorship of future CEs on a national scale.

These recommendations serve as a framework for training and supporting the next generation of Canadian EM medical educators.

Because abnormal vital signs indicate the potential for clinical deterioration, it is logical to make emergency physicians immediately aware of those patients who present with abnormal vital signs.

To determine if a clinical triggers program in the emergency department (ED) setting that utilized predetermined abnormal vital signs to activate a rapid assessment by an emergency physician-led multidisciplinary team had a measurable effect on inpatient hospital metrics.

The study design was a retrospective pre and post intervention study. The intervention was the implementation of an ED clinical “triggers” program. Abnormal vital sign criteria that warranted a trigger response included: heart rate <40 beats/minute or>130 beats/minutes, respiratory rate <8 breaths/minute or>30 breaths/minute, systolic blood pressure <90 mm Hg, or oxygen saturation <90% on room air. The primary outcome investigated was the median days admitted with secondary outcomes of median days in special care unit, in-hospital 30-day mortality and proportion of patients who required an upgrade in inpatient care level.

There was no difference in median days admitted for inpatient care (3.8 v. 4.0 days, p=0.21) or median days spent in a special care unit (5.0 v. 5.6 days, p=0.42) between the groups. There was no difference in the percentage of in-hospital patient deaths (6.0% v. 5.6%, p=0.66) or frequency of upgrade in level of care within 24 hours (4.9% v. 4.0%, p=0.52).

In our study, the implementation of an ED clinical triggers program did not result in a significant change in measured inpatient outcomes.

Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data.

Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used.

Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs.

Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.

Choosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians’ (CAEP) top five list of recommendations, and the process undertaken to generate them.

The CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus.

The top five CAEP CWC recommendations are: 1) Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.

The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

Frostbite is a common yet challenging injury to both diagnose and treat. McCauley’s frostbite treatment protocol consists of 12 treatments that might well represent the standard of care. However, its effectiveness in preventing operative intervention has yet to be examined. Our objectives were to characterize frostbite injuries in Eastern Ontario, identify risk factors for deep injuries, and assess the protocol’s efficacy in preventing operative outcomes.

This cohort study examined patients with frostbite over ten years at a tertiary care hospital. Demographics and predisposing factors were recorded. Frostbite severity was categorized into superficial or deep. Treatments were recorded, including adherence to protocol and operative outcome.

Of the 265 frostbite patients identified, deep frostbite accounted for 56 (21.1%, 95% CI: 16.2–26.1%), of whom 20 (35.7%) had an operative outcome. Amputation occurred in 16 (28.6%) of deep injuries and debridement in 5 (8.9%). Risk factors for deep frostbite were older age (p =0.002), smoking (p <0.001), male sex (p =0.056) and alcohol abuse (p =0.056). None of the patients with deep frostbite had all 12 treatments performed. Adherence to protocol ranged from 0.0% to 48.2% per treatment. The rate of operative intervention was 7.7% in patients with deep frostbite who did not have any McCauley’s frostbite treatments and ranged from 0.0% to 100.0% per treatment in those who did receive treatments.

The frostbite protocol was not regularly followed and therefore its efficacy in preventing operative intervention could not be determined. Further, none of the individual treatments in the protocol were associated with preventing operative intervention. We recommend that future research focus on identifying effective individual treatments.

Assess the feasibility of a study evaluating one dose of oral ondansetron to decrease post-concussion symptoms at one week and one month following concussion in children aged 8 to 17 years old.

This was a pilot study for a randomized, triple-blind controlled trial of one dose of either ondansetron or placebo performed in a tertiary care pediatric emergency department. Participants were children aged 8 to 17 years who sustained a concussion in the previous 24 hours and visited a single emergency department. The outcome of interest was an increase from pre-concussion baseline of at least 3 symptoms from the Post-Concussion Symptom Inventory, measured at one week and at one month following concussion. The primary outcome was to determine the proportion of children who completed the assessment at one week following the intervention. Secondary outcome was the proportion of children who completed the assessment at one month following the intervention. All children, care givers, and those assessing the outcomes were blinded to the group assignment.

Of the 218 children presenting with a concussion during the study period, we screened 108 and found 36/108 (33%) eligible to participate and 16/108 (14.8%) agreed to participate. All enrolled patients were compliant with the intervention and follow-up.

In our study population, approximately one-third of the screened concussion patients were eligible to participate and approximately one half of those eligible agreed to participate. Our study found that most enrolled patients preferred electronic follow-up; the noncompliance rate was minimal.

We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics.

We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method.

The survey response rate was 36.9% (n=391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10.

The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.

Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival for refractory out-of-hospital cardiac arrest (OHCA). We developed a prehospital, emergency department (ED), and hospital-based clinical and educational protocol to improve the key variable of time-to-ECPR (TTE).

In a single urban health region we involved key prehospital, clinical, and administrative stakeholders over a 2-year period, to develop a regional ECPR program with destination to a single urban tertiary care hospital. We developed clear and reproducible inclusion criteria and processes, including measures of program efficiency. We conducted seminars and teaching modules to paramedics and hospital-based clinicians including monthly simulator sessions, and performed detailed reviews of each treated case in the form of report cards. In this before-and-after study we compared patients with ECPR attempted prior to, and after, protocol implementation. The primary outcome was TTE, defined as the time of initial professional CPR to establishment of extracorporeal circulation. We compared the median TTE for patients in the two groups using the Wilcoxon signed rank test.

Four patients were identified prior to the protocol and managed in an ad hoc basis; for nine patients the protocol was utilized. Overall favourable neurological outcomes among ECPR-treated patients were 27%. The median TTE was 136 minutes (IQR 98 - 196) in the pre-protocol group, and 60 minutes (IQR 49 - 81) minutes in the protocol group (p=0.0165).

An organized clinical and educational protocol to initiate ECPR for patients with OHCA is feasible and significantly reduces the key benchmark of time-to-ECPR flows.

Geriatric patients represent a large and complex subgroup seen in emergency departments (EDs). Competencies in geriatric emergency medicine (EM) training have been established. Our objectives were to examine Canadian postgraduate year (PGY)-5 EM residents’ comfort with the geriatric EM competency domains, assess whether Canadian EM residents become more comfortable through residency, and determine whether geriatric educational exposures are correlated with resident comfort with geriatric EM.

A national, cross-sectional study of PGY-1 and PGY-5 Royal College EM residents was conducted to determine their comfort in geriatric EM clinical competency domains. Residents reported their level of comfort in satisfying each competency domain using a seven-point Likert scale. Residents were also asked about the location of their medical education as well as the type and number of different geriatric exposures that they had received to date.

Of the 141 eligible residents from across Canada, 77% (109) consented to participate. None of the PGY-1 EM residents and 34% (14) of PGY-5 EM residents reported that they were comfortable with all eight geriatric EM competency domains. PGY-5 EM residents were significantly more comfortable than PGY-1 EM residents. Residents reported a highly variable range of geriatric educational exposures obtained during training. No relationship was found between resident-reported comfort and the nature or number of geriatric exposures that they had received.

Current Royal College EM residency training in Canada may not be adequately preparing graduates to be comfortable with defined competencies for the care of older ED patients.

Intravenous lipid emulsion (ILE) has been used increasingly over the last decade for a range of drug overdoses. Although the use of ILE in local anesthetic toxicity (LAST) is well established, the hemodynamic effectiveness of ILE in non-LAST poisonings is still unclear. Thus, the primary objective of this study was to examine a cohort of poisoned patients in whom ILE was administered.

Consecutive patients were identified by calls to a regional poison center from May 1, 2012 to May 30, 2014. Patients were enrolled if they ingested a drug, developed hemodynamic instability, failed conventional treatment, and received ILE therapy. Data were collected by medical record review. The primary outcome was the change in mean arterial pressure (MAP) in the first hour after ILE administration. Secondary outcomes included survival, length of stay, and the effect of drug class on patient outcome.

Thirty-six patients were enrolled. Agents ingested included calcium channel blockers and beta blockers (10/36, 27.8%), tricyclic antidepressants (5/36, 13.9%), bupropion (3/36, 8.3%), and antiepileptic agents (1/36, 2.8%). Seventeen patients (47.2%) ingested multiple agents. Twenty-five patients survived (69.0%). Overall, MAP increased by 13.79 mm Hg (95% CI 1.43–26.15); this did not meet our a priori definition of clinical significance.

Our study did not find a clinically important improvement in MAP after ILE administration. Until future research is done to more definitively study its efficacy, ILE should remain a potential treatment option for hemodynamically unstable overdose patients only after conventional therapy has failed.

Optic nerve sheath diameter (ONSD) measured on a head computed tomography (CT) has been suggested as a potential prognostic factor for poor neurological outcome after cardiac arrest. We performed a single centre retrospective cohort analysis to further investigate this relationship.

All patients >18 years of age admitted to St. Paul’s Hospital in Vancouver, Canada who survived a cardiac arrest and had a CT scan of the head within 48 hours were included in the analysis.

A total of 72 patients met inclusion criteria for the study; 54 (75.0%) of the patients had a poor neurological outcome, whereas 18 (25.0%) patients were discharged from the hospital with a good outcome. A CT head was obtained for patients in the good outcome group in a mean time of 9.3 hours (SD 10.0) compared to 10.2 hours (SD 11.2) for the poor outcome group (p=0.75). There was no difference in average ONSD observed between the two outcome groups (6.66 mm SD 0.78 v. 6.60 mm SD 0.82, p=0.77). Multiple logistic regression failed to show any association between ONSD and neurological outcome when adjusted for all other covariates (OR 1.32 95% CI 0.40-4.34, p=0.65). Setting an ONSD threshold of >8 mm (OR 2.32, 95% CI 0.14-39.40, p=0.55) or >7 mm (OR 0.28, 95% CI 0.03-2.77, p=0.28) also failed to show any association on neurological outcome.

There was no observed difference in ONSD between those with a good neurological outcome and those with a poor outcome. ONSD was not an independent predictor of poor neurological outcome.

The emergency department (ED) left-without-being-seen (LWBS) rate is a performance indicator, although there is limited knowledge about why people leave, or whether they seek alternate care. We studied characteristics of ED LWBS patients to determine factors associated with LWBS.

We collected demographic data on LWBS patients at two urban hospitals. Sequential LWBS patients were contacted and surveyed using a standardized telephone survey. A matched group of patients who did not leave were also surveyed. Data were analysed using the Fisher exact test, chi-square test, and student t-test.

The LWBS group (n=1508) and control group (n=1504) were matched for sex, triage category, recorded wait times, employment and education, and having a family physician. LWBS patients were younger, more likely to present in the evening or at night, and lived closer to the hospital. A long wait time was the most cited reason for leaving (79%); concern about medical condition was the most common reason for staying (96%). Top responses for improved likelihood of waiting were shorter wait times (LWBS, 66%; control, 31%) and more information on wait times (41%; 23%). A majority in both groups felt that their condition was a true emergency (63%; 72%). LWBS patients were more likely to seek further health care (63% v. 28%; p<0.001) and sooner (median time 1 day v. 2-4 days; p=0.002). Among patients who felt that their condition was not a true emergency, the top reason for ED attendance was the inability to see their family doctor (62% in both groups).

LWBS patients had similar opinions, experiences, and expectations as control patients. The main reason for LWBS was waiting longer than expected. LWBS patients were more likely to seek further health care, and did so sooner. Patients wait because of concern about their health problem. Shorter wait times and improved communication may reduce the LWBS rate.

The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED.

This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment.

The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%.

We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events.