Publications by authors named "Frank X Scheuermeyer"

64 Publications

Emergency medical services employing intra-arrest transport less frequently for out-of-hospital cardiac arrest have higher survival and favorable neurological outcomes.

Resuscitation 2021 Sep 9;168:27-34. Epub 2021 Sep 9.

Centre for Health Evaluation and Outcome Sciences and the BC Resuscitation Research Collaborative, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, British Columbia, Canada.

Background: There is substantial regional variation in out-of-hospital cardiac arrest (OHCA) survival. We investigated whether regional emergency medical services (EMS) intra-arrest transport (IAT) practices are associated with patient outcomes.

Methods: We performed a secondary analysis of a multi-center North American clinical trial dataset, which enrolled EMS-treated adult OHCA cases from 49 regional population-based clusters. The exposure of interest was regional-level intra-arrest transport (IAT), calculated as the proportion of cases in each cluster transported to hospital prior to return of spontaneous circulation, examined as quartiles and as a continuous variable. Multilevel mixed-effects logistic regression modeling estimated the association between regional IAT with survival to hospital discharge and favorable neurologic status (modified Rankin Scale ≤ 3) at hospital discharge.

Results: Of 26,148 subjects (median age 68 years; 36% female; 23% shockable initial rhythm) 2424 (9.3%), survived to hospital discharge and 1993 (7.6%) had favourable neurological outcomes. Across regional clusters, IAT ranged from 0.84% to 75% (quartiles <6.2%, 6.2-19.6%, 19.6-30.4%, and ≥30.4%). For each quartile, 13.3%, 7.9%, 7.4%, and 4.8% survived, and 10.4%, 7.8%, 7.4%, and 4.8% had favourable neurological status. Regional IAT (per 10% change) was associated with decreased probability of survival (AOR 0.86, 95% CI 0.82-0.91) and favorable neurological outcome (AOR 0.80, 95% CI 0.76-0.85).

Conclusion: Treatment within a region that utilizes IAT less frequently was associated with improved clinical outcomes at hospital discharge. These findings may account for some of the known regional variation in OHCA outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2021.09.004DOI Listing
September 2021

Can plain film radiography improve the emergency department detection of clinically important urinary stones?

Am J Emerg Med 2021 Sep 1;50:449-454. Epub 2021 Sep 1.

Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada.

Objective: Physicians frequently use ultrasound to assess hydronephrosis in patients with suspected renal colic, but ultrasound has limited diagnostic sensitivity and rarely clarifies stone size or location. Consequently, up to 80% of emergency department (ED) renal colic patients undergo confirmatory CT imaging. Our goal was to estimate x-ray sensitivity for urinary stones and determine whether x-ray substantially improves stone detection (sensitivity) compared to hydronephrosis assessment alone.

Methods: We reviewed imaging reports from all renal colic patients who underwent x-ray and CT at four EDs. For each patient, we documented stone size, location and hydronephrosis severity on CT and whether stones were identified on x-ray. We considered moderate and severe hydronephrosis (MS-Hydro) as significant positive findings, then calculated the sensitivity (detection rate) of MS-Hydro and x-ray for large stones ≥5 mm and for stones likely to require intervention (all ureteral stones >7 mm and proximal or middle stones >5 mm). We then tested a diagnostic algorithm adding x-ray to hydronephrosis assessment.

Results: Among 1026 patients with 1527 stones, MS-Hydro sensitivity was 39% for large stones and 60% for interventional stones. X-ray sensitivity was 46% for large stones and 52% for interventional stones. Adding x-ray to hydronephrosis assessment increased sensitivity in all stone categories, specifically from 39% to 68% for large stones (gain = 29%; 95%CI, 23% to 35%) and from 60% to 82% for interventional stones (gain = 22%; 95%CI, 13% to 30%). Because CT and ultrasound show strong agreement for MS-Hydro identification, physicians who depend on ultrasound-based hydronephrosis assessment could achieve similar gains by adding x-ray.

Conclusions: Adding x-ray to hydronephrosis assessment substantially improves diagnostic sensitivity, enabling the detection of nearly 70% of large stones and over 80% of interventional stones. This level of sensitivity may be sufficient to reassure physicians about a renal colic diagnosis without CT imaging for many patients.
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http://dx.doi.org/10.1016/j.ajem.2021.08.074DOI Listing
September 2021

Does early intervention improve outcomes for patients with acute ureteral colic?

CJEM 2021 Sep 18;23(5):679-686. Epub 2021 Jan 18.

Centre for Health Services and Policy Research, School for Population and Public Health, University of British Columbia, Vancouver, BC, Canada.

Objectives: Early surgical intervention is increasingly employed for patients with ureteral colic, but guidelines and current practice are variable. We compared 60-day outcomes for matched patients undergoing early intervention vs. spontaneous passage.

Methods: This multicentre propensity-matched cohort analysis used administrative data and chart review to study all eligible emergency department (ED) patients with confirmed 2.0-9.9 mm ureteral stones. Those having planned stone intervention within 5 days comprised the intervention cohort. Controls attempting spontaneous passage were matched to intervention patients based on age, sex, stone width, stone location, hydronephrosis, ED site, ambulance arrival and acuity level. The primary outcome was treatment failure, defined as rescue intervention or hospitalization within 60 days, using a time to event analysis. Secondary outcome was ED revisit rate.

Results: Among 1154 matched patients, early intervention did not reduce the risk of treatment failure (adjusted hazard ratio 0.94; P = 0.61). By 60 days, 21.8% of patients in both groups experienced the composite primary outcome (difference 0.0%; 95% confidence interval - 4.8 to 4.8%). Intervention patients required more hospitalizations (20.1% vs. 12.8%; difference 7.3%; 95% CI 3.0-11.5%) and ED revisits (36.1% vs. 25.5%; difference 10.6%; 95% CI 5.3-15.9%), but (insignificantly) fewer rescue interventions (18.9% vs. 21.3%; difference - 2.4%; 95% CI - 7.0 to 2.2%).

Conclusions: In matched patients with 2.0-9.9 mm ureteral stones, early intervention was associated with similar rates of treatment failure but greater patient morbidity, evidenced by hospitalizations and emergency revisits. Physicians should adopt a selective approach to interventional referral and consider that spontaneous passage probably provides better outcomes for many low-risk patients.
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http://dx.doi.org/10.1007/s43678-020-00016-4DOI Listing
September 2021

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial.

Ann Emerg Med 2021 Aug 2. Epub 2021 Aug 2.

Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.

Study Objective: We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation.

Methods: We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events.

Results: Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]).

Conclusion: In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.
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http://dx.doi.org/10.1016/j.annemergmed.2021.05.023DOI Listing
August 2021

Impact of Atrial Fibrillation Case Volume in the Emergency Department on Early and Late Outcomes of Patients With New Atrial Fibrillation.

Ann Emerg Med 2021 08;78(2):242-252

Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, Canada; Division of General Internal Medicine, University of Alberta, Edmonton, Canada.

Study Objective: To define the association between atrial fibrillation case volume in the emergency department and death or all-cause hospitalization at 30 days and 1 year in patients with new atrial fibrillation. Secondary objectives examined repeat ED visits and the management of atrial fibrillation within 90 days.

Methods: We identified all adults presenting to an ED in Alberta, Canada, with a new primary diagnosis of atrial fibrillation/flutter between 2009 and 2015 using International Classification of Diseases, 10th Revision code I48. Volume was classified in tertiles weighted by annual ED number of atrial fibrillation cases. The association between volume and outcomes was evaluated using generalized linear mixed models, adjusting for prognostically important covariates as fixed effects and ED as a random effect to account for potential clustering within EDs.

Results: The tertiles consisted of 4 high, 9 medium, and 68 low atrial fibrillation volume EDs, with 4,217, 4,193, and 4,112 patients, respectively. Volume was not independently associated with the primary outcome or individual components. However, medium- and high-volume EDs had fewer repeat ED visits at 30 days (respective adjusted odds ratio [aOR] 0.75 [95% confidence interval {CI} 0.66 to 0.87] and 0.64 [0.52 to 0.79]) and 1 year (respective aOR 0.77 [95% CI 0.67 to 0.90] and 0.71 [0.56 to 0.90]). Fewer patients were admitted from medium- (37.1%) and high- (32.0%) compared with low-volume (39.5%) EDs. Patients attending medium- and high-volume EDs were more likely to be cardioverted (aOR 3.28 [95% CI 1.94 to 5.53] and 3.81 [1.39 to 10.48] for medium- and high-volume EDs, respectively).

Conclusion: Treatment in higher volume EDs was associated with significantly lower admission rates and repeat ED visits but no difference in survival.
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http://dx.doi.org/10.1016/j.annemergmed.2021.03.014DOI Listing
August 2021

Experiences of people with opioid use disorder during the COVID-19 pandemic: A qualitative study.

PLoS One 2021 29;16(7):e0255396. Epub 2021 Jul 29.

Department of Emergency Medicine, St Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.

Aim: To capture pandemic experiences of people with opioid use disorder (OUD) to better inform the programs that serve them.

Design: We designed, conducted, and analyzed semi-structured qualitative interviews using grounded theory. We conducted interviews until theme saturation was reached and we iteratively developed a codebook of emerging themes. Individuals with lived experience of substance use provided feedback at all steps of the study.

Setting: We conducted phone or in-person interviews in compliance with physical distancing and public health regulations in outdoor Vancouver parks or well-ventilated indoor spaces between June to September 2020.

Participants: Using purposive sampling, we recruited participants (n = 19) who were individuals with OUD enrolled in an intensive community outreach program, had visited one of two emergency departments, were over 18, lived within catchment, and were not already receiving opioid agonist therapy.

Measurements: We audio-recorded interviews, which were later transcribed verbatim and checked for accuracy while removing all identifiers. Interviews explored participants' knowledge of COVID-19 and related safety measures, changes to drug use and healthcare services, and community impacts of COVID-19.

Results: One third of participants were women, approximately two thirds had stable housing, and ages ranged between 23 and 59 years old. Participants were knowledgeable on COVID-19 public health measures. Some participants noted that fear decreased social connection and reluctance to help reverse overdoses; others expressed pride in community cohesion during crisis. Several participants mentioned decreased access to housing, harm reduction, and medical care services. Several participants reported using drugs alone more frequently, consuming different or fewer drugs because of supply shortages, or using more drugs to replace lost activities.

Conclusion: COVID-19 had profound effects on the social lives, access to services, and risk-taking behaviour of people with opioid use disorder. Pandemic public health measures must include risk mitigation strategies to maintain access to critical opioid-related services.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255396PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320992PMC
August 2021

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

CJEM 2021 Sep 25;23(5):687-695. Epub 2021 Jul 25.

Faculty of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure.

Methods: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group.

Results: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk.

Conclusions: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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http://dx.doi.org/10.1007/s43678-021-00168-xDOI Listing
September 2021

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

CJEM 2021 Sep 25;23(5):687-695. Epub 2021 Jul 25.

Faculty of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure.

Methods: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group.

Results: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk.

Conclusions: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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http://dx.doi.org/10.1007/s43678-021-00168-xDOI Listing
September 2021

Hydronephrosis severity clarifies prognosis and guides management for emergency department patients with acute ureteral colic.

CJEM 2021 Sep 25;23(5):687-695. Epub 2021 Jul 25.

Faculty of Medicine, University of Calgary, Calgary, AB, Canada.

Objective: In emergency department patients with ureteral colic, the prognostic value of hydronephrosis is unclear. Our goal was to determine whether hydronephrosis can differentiate low-risk patients appropriate for trial of spontaneous passage from those with clinically important stones likely to experience passage failure.

Methods: We used administrative data and structured chart review to evaluate a consecutive cohort of patients with ureteral stones who had a CT at nine Canadian hospitals in two cities. We used CT, the gold standard for stone imaging, to assess hydronephrosis and stone size. We described classification accuracy of hydronephrosis severity for detecting large (≥ 5 mm) stones. In patients attempting spontaneous passage we used hierarchical Bayesian regression to determine the association of hydronephrosis with passage failure, defined by the need for rescue intervention within 60 days. To illustrate prognostic utility, we reported pre-test probability of passage failure among all eligible patients (without hydronephrosis guidance) to post-test probability of passage failure in each hydronephrosis group.

Results: Of 3251 patients, 70% male and mean age 51, 38% had a large stone, including 23%, 29%, 53% and 72% with absent, mild, moderate and severe hydronephrosis. Passage failure rates were 15%, 20%, 28% and 43% in the respective hydronephrosis categories, and 23% overall. "Absent or mild" hydronephrosis identified a large subset of patients (64%) with low passage failure rates. Moderate hydronephrosis predicted slightly higher, and severe hydronephrosis substantially higher passage failure risk.

Conclusions: Absent and mild hydronephrosis identify low-risk patients unlikely to experience passage failure, who may be appropriate for trial of spontaneous passage without CT imaging. Moderate hydronephrosis is weakly associated with larger stones but not with significantly greater passage failure. Severe hydronephrosis is an important finding that warrants definitive imaging and referral. Differentiating "moderate-severe" from "absent-mild" hydronephrosis provides risk stratification value. More granular hydronephrosis grading is not prognostically helpful.
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http://dx.doi.org/10.1007/s43678-021-00168-xDOI Listing
September 2021

Converting emergency physician management of patients with atrial fibrillation or flutter.

CJEM 2021 May 6;23(3):267-268. Epub 2021 May 6.

Division of Emergency Medicine and Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1007/s43678-021-00128-5DOI Listing
May 2021

Just the facts: Atrial fibrillation or flutter in patients who are candidates for rate control.

CJEM 2021 Jul 25;23(4):437-440. Epub 2021 Mar 25.

Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.

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http://dx.doi.org/10.1007/s43678-021-00116-9DOI Listing
July 2021

Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis.

CMAJ Open 2021 Jan-Mar;9(1):E242-E251. Epub 2021 Mar 17.

Department of Emergency Medicine (Moe, Purssell), Vancouver General Hospital; British Columbia Centre for Disease Control (Moe, Chong, Zhao, Slaunwhite); Department of Emergency Medicine (Scheuermeyer), St. Paul's Hospital; British Columbia Drug and Poison Information Centre (Purssell); Department of Emergency Medicine (Moe, Scheuermeyer, Purssell), The University of British Columbia, Vancouver, BC.

Background: Visits to the emergency department are critical opportunities to engage individuals after an overdose. We sought to estimate and compare the 12-month mortality between persons with visits to the emergency department related to opioid overdose and those with non-overdose-related visits.

Methods: We conducted a retrospective cohort study using the Provincial Overdose Cohort, which contains data for patients in British Columbia who had an opioid-related overdose between 2015 and 2017, along with a 20% random sample of BC residents for comparison. We examined all nonfatal visits to the emergency department between Jan. 1, 2015, and Dec. 31, 2016, among persons aged 14 to 74 years and compared the 12-month mortality between those with overdose-related visits and those with non-overdose-related visits. We estimated the hazard ratio for death, with adjustment for age, sex, comorbidity and disposition (discharged or left against medical advice).

Results: We included 3593 persons with overdose-related visits and 216 453 with non-overdose-related visits to the emergency department. Those with overdose-related visits were younger, were predominantly male and had more mental health conditions. The 12-month crude mortality probability was 5.4% (95% confidence interval [CI] 4.7%-6.2%) in this group and 1.7% (95% CI 1.6%-1.8%) among those with non-overdose-related visits. After adjustment, for persons who were discharged, the 12-month mortality hazard was 3.5 (95% CI 3.0-4.2) times higher among those with overdose-related visits than those with non-overdose-related visits. For persons who left against medical advice, the mortality hazard was 7.1 (95% CI 4.0-12.5) times higher among those with opioid overdose.

Interpretation: Among persons with overdose-related visits to the emergency department, 12-month mortality was higher than among those with non-overdose-related visits. Overdose-related visits should prompt urgent evidence-based interventions (e.g., take-home naloxone kits, buprenorphine-naloxone induction) to prevent future deaths.
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http://dx.doi.org/10.9778/cmajo.20200169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096380PMC
July 2021

Decrease in emergency medical services utilization during early stages of the COVID-19 pandemic in British Columbia.

CJEM 2021 03 20;23(2):237-241. Epub 2021 Jan 20.

Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC, Canada.

Objective: To date in the COVID-19 pandemic, there has been a decrease in patients accessing emergency health services, (EHS) but research has been conducted in areas with a very high incidence of COVID-19. In an area with a low COVID-19 incidence, we estimate changes in EHS use.

Methods: We compared EHS encounters in British Columbia from March 15 (the date of school and business closures) to May 15, 2020, when compared to the same period in 2019. We categorized EHS encounters into 18 presenting complaints and prespecified critical care complaints including major trauma, cardiac arrest, stroke, and ST-elevation myocardial infarction. We analyzed by descriptive methods.

Results: Comparing 2019 to 2020, total EHS encounters decreased from 83,925 (incidence rate 834 per 100,000 person-months) to 71,611 (incidence rate 701 per 100,000 person-months) for a decrease of 133 per 100,000 person-months (95% CI 126-141). The top 18 codes had a significant decrease in every category except respiratory and anxiety. Encounters for critically ill patients decreased significantly overall from 3019 to 2753 (incidence rate difference 3.1 per 100,000 person-months, 95% CI 1.6-4.5), including stroke, trauma, and STEMI, but the incidence of OHCA appeared stable.

Conclusion: In a single province with a low incidence of COVID-19, there was a 15% reduction in overall EHS use and a 9% reduction in critical illness. EHS planners will need to match patient need with available resources.
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http://dx.doi.org/10.1007/s43678-020-00062-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816052PMC
March 2021

Elderly Woman With Cough, Fever, and Dyspnea.

Ann Emerg Med 2021 01 15;77(1):e64-e65. Epub 2020 Jul 15.

Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1016/j.annemergmed.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362810PMC
January 2021

Comparing mortality and healthcare utilization in the year following a paramedic-attended non-fatal overdose among people who were and were not transported to hospital: A prospective cohort study using linked administrative health data.

Drug Alcohol Depend 2021 01 25;218:108381. Epub 2020 Oct 25.

Faculty of Medicine, University of British Columbia, 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada; Providence Health Care, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.

Background: As the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose.

Methods: Using a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event.

Results: In this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days.

Conclusions: Transport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20-59 and people without chronic conditions.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108381DOI Listing
January 2021

Woman With Neck Pain.

Ann Emerg Med 2020 10;76(4):e65-e66

Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1016/j.annemergmed.2020.04.007DOI Listing
October 2020

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.

Ann Emerg Med 2020 12 28;76(6):774-781. Epub 2020 Jul 28.

Department of Emergency Medicine, Rockyview Hospital and the University of Calgary, Calgary, Alberta, Canada.

Study Objective: Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes.

Methods: From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients.

Results: Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%).

Conclusion: In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.
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http://dx.doi.org/10.1016/j.annemergmed.2020.05.029DOI Listing
December 2020

Which Patients Should Have Early Surgical Intervention for Acute Ureteral Colic?

J Urol 2021 Jan 27;205(1):152-158. Epub 2020 Jul 27.

Departments of Emergency Medicine and Community Health Sciences, University of Calgary Cumming School of Medicine, Foothills Medical Centre, Calgary, Alberta, Canada.

Purpose: Early surgical intervention is an attractive option for acute ureteral colic but existing evidence does not clarify which patients benefit. We compared treatment failure rates in patients receiving early intervention and patients offered spontaneous passage to identify subgroups that benefit from early intervention.

Materials And Methods: We used administrative data and structured chart review to study consecutive patients attending 9 emergency departments in 2 Canadian provinces with confirmed 2.0 to 9.9 mm ureteral stones. We described patient, stone and treatment characteristics, and performed multivariable regression to identify factors associated with treatment failure, defined as intervention or hospitalization within 60 days. Our secondary outcome was emergency department revisit rate.

Results: Overall 1,168 of 3,081 patients underwent early intervention. Those with stones smaller than 5 mm experienced more treatment failures (31.5% vs 9.9%, difference 21.6%, 95% CI 16.9 to 21.2) and emergency department revisits (38.5% vs 19.7%, difference 18.8%, 95% CI 13.8 to 23.8) with early intervention than with spontaneous passage. Patients with stones 7.0 mm or larger experienced fewer treatment failures (34.7% vs 58.6%, risk difference 23.9%, 95% CI 11.3 to 36.6) and similar emergency department revisit rates with early intervention. Patients with 5.0 to 6.9 mm stones had fewer treatment failures with intervention (37.4% vs 55.5%, risk difference 18.1%, 95% CI 7.1 to 28.9) if stones were in the proximal or middle ureter.

Conclusions: Early intervention improves outcomes for patients with large (greater than 7 mm) ureteral stones or 5 to 7 mm proximal or mid ureteral stones. Early intervention may increase morbidity for patients with stones smaller than 5 mm. These findings could help inform future guidelines.
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http://dx.doi.org/10.1097/JU.0000000000001318DOI Listing
January 2021

Diagnosis of pulmonary embolism with D-dimer adjusted to clinical probability.

CJEM 2020 11;22(6):774-775

Department of Emergency Medicine, University of British Columbia, Vancouver, BC.

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http://dx.doi.org/10.1017/cem.2020.428DOI Listing
November 2020

Woman With Abdominal Pain.

Ann Emerg Med 2020 01;75(1):e7-e8

Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1016/j.annemergmed.2019.07.005DOI Listing
January 2020

Decision aid for early identification of acute underlying illness in emergency department patients with atrial fibrillation or flutter.

CJEM 2020 05;22(3):301-308

Department of Emergency Medicine, Vanderbilt University Medical Center and the University of Tennessee, Nashville, Tennessee.

Background: Emergency department (ED) patients with atrial fibrillation or flutter (AFF) with underlying occult condition such as sepsis or heart failure, and who are managed with rate or rhythm control, have poor prognoses. Such conditions may not be easy to identify early in the ED evaluation when critical treatment decisions are made. We sought to develop a simple decision aid to quickly identify undifferentiated ED AFF patients who are at high risk of acute underlying illness.

Methods: We collected consecutive ED patients with electrocardiogram-proven AFF over a 1-year period and performed a chart review to ascertain demographics, comorbidities, and investigations. The primary outcome was having an acute underlying illness according to prespecified criteria. We used logistic regression to identify factors associated with the primary outcome, and developed criteria to identify those with an underlying illness at presentation.

Results: Of 1,083 consecutive undifferentiated ED AFF patients, 400 (36.9%) had an acute underlying illness; they were older with more comorbidities. Modeling demonstrated that three predictors (ambulance arrival; chief complaint of chest pain, dyspnea, or weakness; CHA2DS2-VASc score greater than 2) identified 93% of patients with acute underlying illness (95% confidence interval [CI], 91-96%) with 54% (95% CI, 50-58%) specificity. The decision aid missed 28 patients; (7.0%) simple blood tests and chest radiography identified all within an hour of presentation.

Conclusions: In ED patients with undifferentiated AFF, this simple predictive model rapidly differentiates patients at risk of acute underlying illness, who will likely merit investigations before AFF-specific therapy.
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http://dx.doi.org/10.1017/cem.2019.454DOI Listing
May 2020

Impact of cardiology follow-up care on treatment and outcomes of patients with new atrial fibrillation discharged from the emergency department.

Europace 2020 05;22(5):695-703

Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, AB, Canada.

Aims: The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality.

Methods And Results: Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55-0.93], strokes (aHR 0.60, 95% CI 0.37-0.96), or major bleeds (aHR 0.69, 95% CI 0.53-0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care.

Conclusion: Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.
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http://dx.doi.org/10.1093/europace/euz302DOI Listing
May 2020

Is buddy taping as effective as plaster immobilization to manage adult boxer's fractures?

CJEM 2020 03;22(2):161-162

Department of Emergency Medicine, University of British Columbia, Vancouver, BC.

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http://dx.doi.org/10.1017/cem.2019.445DOI Listing
March 2020

A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation.

Acad Emerg Med 2019 09 19;26(9):969-981. Epub 2019 Aug 19.

Department of Emergency Medicine, University of Alberta Hospital and the University of Alberta, Edmonton, AB, Canada.

Background: Emergency department (ED) patients with uncomplicated atrial fibrillation (AF) of less than 48 hours may be safely managed with rhythm control. Although both chemical-first and electrical-first strategies have been advocated, there are no comparative effectiveness data to guide clinicians.

Methods: At six urban Canadian centers, ED patients ages 18 to 75 with uncomplicated symptomatic AF of less than 48 hours and CHADS score of 0 or 1 were randomized using concealed allocation in a 1:1 ratio to one of the following strategies: 1) chemical cardioversion with procainamide infusion, followed by electrical countershock if unsuccessful; or 2) electrical cardioversion, followed by procainamide infusion if unsuccessful. The primary outcome was the proportion of patients discharged within 4 hours of arrival. Secondary outcomes included ED length-of-stay (LOS); prespecified ED-based adverse events; and 30-day ED revisits, hospitalizations, strokes, deaths, and quality of life (QoL).

Results: Eighty-four patients were analyzed: 41 in the chemical-first group and 43 in the electrical-first group. Groups were balanced in terms of age, sex, vital signs, and CHADS scores. All patients were discharged home, with 83 (99%) in sinus rhythm. In the chemical-first group, 13 of 41 patients (32%) were discharged within 4 hours compared to 29 of 43 patients (67%) in the electrical-first group (p = 0.001). In the chemical-first group, the median ED LOS was 5.1 hours (interquartile range [IQR] = 3.5 to 5.9 hours) compared to 3.5 hours (IQR = 2.4 to 4.6 hours) in the electrical-first group, for a median difference of 1.2 hours (95% confidence interval = 0.4 to 2.0 hours, p < 0.001). No patients experienced stroke or death. All other outcomes, including adverse events, ED revisits, and QoL, were similar.

Conclusion: In uncomplicated ED AF patients managed with rhythm control, chemical-first and electrical-first strategies both appear to be successful and well tolerated; however, an electrical-first strategy results in a significantly shorter ED LOS.
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http://dx.doi.org/10.1111/acem.13669DOI Listing
September 2019

The Association of the Average Epinephrine Dosing Interval and Survival With Favorable Neurologic Status at Hospital Discharge in Out-of-Hospital Cardiac Arrest.

Ann Emerg Med 2019 12 24;74(6):797-806. Epub 2019 Jun 24.

Department of Emergency Medicine, University of British Columbia, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, and St. Paul's Hospital, Vancouver, British Columbia, Canada.

Study Objective: For patients with out-of-hospital cardiac arrest, the recommended dosing interval of epinephrine is 3 to 5 minutes, but this recommendation is based on expert opinion without data to guide optimal management. We seek to evaluate the association between the average epinephrine dosing interval and patient outcomes.

Methods: In a secondary analysis of the Resuscitation Outcomes Consortium continuous chest compression trial, we identified consecutive patients treated with greater than or equal to 2 doses of epinephrine. We defined average epinephrine dosing interval as resuscitation duration after the first dose of epinephrine divided by the total administered epinephrine, and categorized the dosing interval in minutes as less than 3, 3 to less than 4, 4 to less than 5, and greater than or equal to 5. We fit a logistic regression model to estimate the association of the average epinephrine dosing interval category with survival with favorable neurologic status (modified Rankin Scale score ≤3) at hospital discharge.

Results: We included 15,909 patients (median age 68 years [interquartile range 56 to 80 years], 35% women, 13% public location, 46% bystander cardiopulmonary resuscitation, and 19% initial shockable rhythm). The median epinephrine dosing interval was 4.3 minutes (interquartile range 3.5 to 5.3 minutes). Survival with favorable neurologic status occurred in 4.7% of patients. Compared with the reference dosing interval of less than 3 minutes, longer epinephrine dosing intervals were associated with lower survival with favorable neurologic status: dosing interval 3 to less than 4 minutes, adjusted odds ratio 0.44 (95% confidence interval 0.32 to 0.60); 4 to less than 5 minutes, adjusted odds ratio 0.26 (95% confidence interval 0.18 to 0.36); and greater than or equal to 5 minutes, adjusted odds ratio 0.21 (95% confidence interval 0.15 to 0.30).

Conclusion: In this out-of-hospital cardiac arrest series, a shorter average epinephrine dosing interval was associated with improved survival with favorable neurologic status.
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http://dx.doi.org/10.1016/j.annemergmed.2019.04.031DOI Listing
December 2019

Man With Bilateral Heel Pain.

Ann Emerg Med 2019 05;73(5):542-544

Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.

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http://dx.doi.org/10.1016/j.annemergmed.2018.11.038DOI Listing
May 2019

Active management of atrial fibrillation or flutter in emergency department patients with renal impairment is associated with a higher risk of adverse events and treatment failure.

CJEM 2019 05 6;21(3):352-360. Epub 2019 Feb 6.

§Department of Emergency Medicine,Rockyview Hospital and the University of Calgary,Calgary,AB.

Objective: Atrial fibrillation or flutter (AFF) patients with renal impairment have poor long-term prognosis, but their emergency department (ED) management has not been described. We investigated the association of renal impairment upon outcomes after rate or rhythm control (RRC) including ED-based adverse events (AE) and treatment failure.

Methods: This cohort study used an electrocardiogram database from two urban centres to identify consecutive AFF patients and reviewed charts to obtain comorbidities, ED management, including RRC, prespecified AE, and treatment failure. Patients were dichotomized into a normal estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2) or impaired renal function ("low eGFR"). Primary and secondary outcomes were prespecified AEs and treatment failure, respectively. We calculated 1) adjusted excess AE risk for patients with decreased renal function receiving RRC; and 2) adjusted odds ratio of RRC treatment failure.

Results: Of 1,112 consecutive ED AFF patients, 412 (37.0%) had a low eGFR. Crude AE rates for RRC were 27/238 (11.3%) for patients with normal renal function and 26/103 (25.2%) for patients with low eGFR. For patients with low eGFR receiving RRC, adjusted excess AE risk was 13.7%. (95% CI 1.7 to 25.1%). For patients with low eGFR, adjusted odds ratio for RRC failure was 3.07. (95% CI 1.74 to 5.43) CONCLUSIONS: In this cohort of ED AFF patients receiving RRC, those with low eGFR had significantly increased adjusted excess risk of AE compared with patients with normal renal function. Odds of treatment failure were also significantly increased.
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http://dx.doi.org/10.1017/cem.2018.475DOI Listing
May 2019
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