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Objective The General Internal Medicine ( GIM) Care Transformation Initiative implemented at one of four teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the emergency department ( ED) is unclear. Methods Controlled before-after study of ED length of stay ( LOS) and crowding metrics for the intervention site ( n = 108,951 visits) compared to the three other teaching hospitals (controls, n = 300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics. Results The GIM Care Transformation was associated with an additional 2.8-hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3-hour decline (from 30.6 hours to 21.3 hours) seen in the three control EDs for GIM patients who were hospitalized (p < 0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p < 0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p < 0.001) at the intervention hospital pre versus post (p = 0.04 for the 15-minute additional reduction, p < 0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences. Conclusion Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics. [ABSTRACT FROM AUTHOR]

Objectives High users of emergency department ( ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility. Methods We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year). Results Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without. Conclusions Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group. [ABSTRACT FROM AUTHOR]

Objectives Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes. Methods This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [ MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering. Results There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non- MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters. Conclusions Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence. [ABSTRACT FROM AUTHOR]

Background: Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. Objectives: The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. Methods: This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. Results: Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. Conclusions: Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury. [ABSTRACT FROM AUTHOR]

Objectives Emergency department ( ED) crowding results from the need to see high volumes of patients of variable acuity within a limited physical space. ED crowding has been associated with poor patient outcomes and increased mortality. The authors evaluated whether ED crowding is also associated with reduced hand hygiene compliance among health care workers. Methods A trained observer measured hand hygiene compliance using standardized definitions for 22 months in the 40-bed ED of a 475-bed academic hospital in Toronto, Ontario, Canada. ED crowding measures, including mean daily patient volumes, time to initial physician assessment, and daily nursing hours, were obtained from hospital administrative and human resource databases. Known predictors of hand hygiene compliance, including the indication for hand hygiene and the health care workers' professions, were also measured. Hand hygiene data, measured during 20-minute observation sessions, were linked to aggregate daily results for each crowding metric. Crowding metrics and known predictors of hand hygiene compliance were then included in a multivariate model if associated with hand hygiene compliance at a p-value of <0.20. Results Hand hygiene compliance was 29% (325 of 1,116 opportunities). Alcohol-based hand rinse was used 66% of the time. Nurses accounted for 68% of hand hygiene opportunities and physicians for 18%, with the remaining 14% attributed to nonphysician, nonnurse health care workers. The most common indications for hand hygiene were hand hygiene prior to (35%) and hand hygiene following (52%) contact with the patient or his or her environment. In multivariate analysis, time to physician assessment > 1.5 hours was associated with lower compliance (odds ratio [ OR] = 0.67, 95% confidence interval [ CI] = 0.51 to 0.89). Additionally, compliance was lower for nonnurse, nonphysician health care workers ( OR = 0.51, 95% CI = 0.33 to 0.79) and higher for hand hygiene performed after contact with the patients or his/her environment, compared to hand hygiene performed before contact with the patient or his/her environment ( OR = 2.0, 95% CI = 1.5 to 2.7). Daily patient volumes and nursing hours were not associated with hand hygiene compliance. Conclusions ED hand hygiene compliance was low. Increased time to physician assessment was associated with reduced compliance, suggesting an association between crowding and compliance. Strategies that minimize ED crowding may improve ED hand hygiene compliance. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives Atrial fibrillation and flutter ( AFF) are the most common arrhythmias seen in the outpatient setting, and they affect more than 300,000 adult Canadians. The aims of this study were to examine temporal and geographic trends in emergency department ( ED) presentations made by adults (age ≥ 35 years) for AFF in Alberta, Canada, from 1999 to 2011. Statistical disease cluster detection techniques were used to identify geographic areas with higher numbers of individuals presenting with AFF and higher numbers of ED presentations for AFF than expected by chance alone. Geographic clusters of individuals with stroke or heart failure follow-up within 365 days of ED presentations for AFF were also identified. Methods All ED presentations for AFF made by individuals aged ≥35 years were extracted from Alberta's Ambulatory Care Classification System. The Alberta Health Care Insurance Plan provided population counts and demographics for the patients presenting (age, sex, year, geographic unit). The Physician Claims File provided non- ED physician claims data after a patient's ED presentation. Statistical analyses included numerical and graphical summaries, directly standardized rates, and statistical disease cluster detection tests. Results During 12 years, there were 63,395 ED presentations for AFF made by 32,101 individuals. Standardized rates remained relatively stable over time, at about two per 1,000 for individuals presenting to the ED for AFF and about three per 1,000 for ED presentations for AFF. The northern and southeastern parts of the province were identified as clusters of individuals presenting for AFF, and ED presentations for AFF, and several of the areas demonstrated clusters in multiple years. Further, several of the geographic clusters were also identified as potential clusters for stroke or heart failure within 365 days after the ED presentations for AFF. Conclusions This population-based study spanned 12 fiscal years and showed variations in the number of people presenting to EDs for AFF and the number of ED presentations for AFF over geography. The potential clusters identified may represent geographic areas with higher disease severity or a lower availability of non- ED health services. The clusters are not all likely to have occurred by chance, and further investigation and intervention could occur to reduce ED presentations for AFF. [ABSTRACT FROM AUTHOR]

Objectives The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments ( EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Methods Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Results Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Conclusions Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM). Methods: Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients < 18 years of age in an ED. Results: In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p < 0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p = 0.001). American physicians administer larger IV fluid bolus volumes (p < 0.001) and over shorter time periods (p = 0.001) and repeat the fluid boluses more frequently (p < 0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%). Conclusions: The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States. [ABSTRACT FROM AUTHOR]

The objectives were to explore the tolerance of pediatric emergency medicine (PEM) physicians for risk in choosing when to perform procedural sedation and analgesia (PSA) and to describe adherence to preprocedural fasting guidelines and factors affecting the physicians' decisions. A survey of Canadian PEM physicians who perform PSA was conducted. Respondents were asked about their PSA practices. Risk tolerance was assessed using an economics-based stated preference elicitation method called a discrete choice experiment (DCE). Using a hypothetical clinical situation of a healthy child needing PSA, three fasting scenarios (ingestion of full meal < 2 hours ago, full meal between 2 and 4 hours ago, liquids less than 1 hour ago) were created. For each fasting scenario, 16-choice questions with varying numeric risks of major and minor adverse events were presented and respondents were asked whether they would administer PSA now or wait for guidelines to be met. In this exploratory study, choice data were analyzed using multivariate regression analysis, and preliminary inferential statistics are presented. A total of 114 (63.6%) completed surveys were returned. Respondents were 54% male, were in practice for a median of 6-10 years, and reported following fasting guidelines 53% of the time. Most had institutional fasting policies (70%), used ketamine (in 78% of PSA by 95% of users), and identified patient variables (prolonged pain, parental concern) as more important than environmental variables (patient flow, use of resources) in deciding when to administer PSA. Both major and minor risks of adverse events affected the choice of whether to do immediate PSA or wait until fasting guidelines were met. A 0.1-percentage-point increase in the probability of a major adverse event reduced physician likelihood of performing immediate PSA before meeting fasting guidelines by 17.6 percentage points. In comparison, a 10-percentage-point increase in the probability of a minor adverse event reduced physician likelihood of performing immediate PSA by 17.2%. Respondents were less likely to perform PSA immediately if a child had a full meal < 2 hours ago versus 2-4 hours ago or liquids < 1 hour ago. Sex, highest level of postgraduate training, frequency of performing PSA, and experience with a prior adverse event did not affect the choice to do immediate PSA. Years in practice affected the decision, with those in practice for 6-10 years more likely to perform immediate PSA than those in practice for shorter or longer. Those who reported having an institutional fasting policy were less likely to perform immediate PSA. These results suggest that fasting guidelines are not strictly adhered to in Canadian pediatric emergency departments (EDs) currently, and there is some willingness of physicians to change their sedation practice in light of evidence from hypothetical surveillance data about risks. On the other hand, some physicians suggest that they will follow guidelines regardless of how low the estimated risk is from surveillance data. An understanding of how physicians respond to evidence about small risks and how the information is best understood by this population is interesting for knowledge translation if evidence-based practice guidelines for procedural sedation in the ED are developed in the future. ACADEMIC EMERGENCY MEDICINE 2010; 17:1207-1215 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]