Publications by authors named "Ian G Stiell"

260 Publications

RAFF-3 Trial: A Stepped-Wedge Cluster Randomized Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department.

Can J Cardiol 2021 Jul 1. Epub 2021 Jul 1.

Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa.

Background: We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the CAEP AAFF Best Practice Checklist.

Methods: We conducted a stepped-wedge cluster randomized trial at 11 large community and academic hospital EDs, in five Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was the introduction of the CAEP Checklist using a knowledge translation-implementation approach that included behavior change techniques and organization/system level strategies. The primary outcome was length of stay in ED and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed effects regression adjusting for covariates.

Results: Patient visits in the control (N=314) and intervention (N=404) periods were similar with mean age 62.9, 54% male, 71% onset <12 hours, and 86% atrial fibrillation, 14% atrial flutter. We observed a reduction in length of stay of 20.9% (95% CI 5.5 to 33.8%, P=0.01), an increase in use of rhythm control (adjusted odds ratio (OR 4.5, 1.8-11.6; P=0.002), and decrease in use of rate control medications (OR 0.5, 0.2 to 0.9; P=0.02). There was no change in adverse events and no strokes or deaths by 30 days.

Conclusions: The RAFF-3 Trial led to optimized care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities. CLINICALTRIALS.

Gov Identifier: NCT03627143.
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http://dx.doi.org/10.1016/j.cjca.2021.06.016DOI Listing
July 2021

A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter.

CJEM 2021 May 18;23(3):314-324. Epub 2021 Jan 18.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Background: Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only).

Methods: We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm.

Findings: From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths.

Interpretation: This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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http://dx.doi.org/10.1007/s43678-020-00067-7DOI Listing
May 2021

Just the facts: atrial fibrillation or flutter in patients who are candidates for rhythm control.

CJEM 2021 Jul 6;23(4):441-444. Epub 2021 Apr 6.

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

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http://dx.doi.org/10.1007/s43678-021-00120-zDOI Listing
July 2021

Diagnostic Accuracy of Lung Point-Of-Care Ultrasonography for Acute Heart Failure Compared With Chest X-Ray Study Among Dyspneic Older Patients in the Emergency Department.

J Emerg Med 2021 Mar 29. Epub 2021 Mar 29.

Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.

Background: Acute heart failure and exacerbation of chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED).

Objectives: We sought to determine the classification performance of lung point-of-care ultrasound (POCUS) compared with chest x-ray study to identify acute heart failure in an older population.

Methods: We conducted a cohort study with additional health records review between March and September 2017. We included consecutive patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD. The reference standard was discharged diagnosis, ED diagnosis with confirmation by another physician, or diagnosis made by health record reviews. We calculated the classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study, and compared them by exact McNemar test.

Results: There were 81 patients evaluated with lung POCUS, and 67 had acute heart failure. Emergency physicians identified acute heart failure by lung POCUS with sensitivity of 92.5% (95% confidence interval [CI] 83.4-97.5%) and specificity of 85.7% (95% CI 57.2-98.2%). The radiology reading of chest x-ray study had sensitivity of 63.6% (95% CI 50.9-75.1%) and specificity of 92.9% (95% CI 66.1-99.8%). The sensitivity of lung POCUS was significantly higher than that of chest x-ray study (p = 0.0003).

Conclusions: Lung POCUS in a real clinical setting was highly sensitive and specific in identifying acute heart failure, and performed better than chest x-ray in an older population.
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http://dx.doi.org/10.1016/j.jemermed.2021.02.019DOI Listing
March 2021

Evaluating the paramedic application of the prehospital Canadian C-Spine Rule in sport-related injuries.

CJEM 2021 May 15;23(3):356-364. Epub 2021 Mar 15.

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

Objectives: We sought to compare the ability of the prehospital Canadian C-Spine Rule to selectively recommend immobilization in sport-related versus non-sport-related injuries and describe sport-related mechanisms of injury.

Methods: We reviewed data from the prospective paramedic Canadian C-Spine Rule validation and implementation studies in 7 Canadian cities. A trained reviewer further categorized sport-related mechanisms of injury collaboratively with a sport medicine physician using a pilot-tested standardized form. We compared the Canadian C-Spine Rule's recommendation to immobilize sport-related versus non-sport-related patients using Chi-square and relative risk statistics with 95% confidence intervals.

Results: There were 201 sport-related patients among the 5,978 included. Sport-related injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs. 46.8%) than non-sport-related patients. Paramedics did not miss any C-Spine injury when using the Canadian C-Spine Rule. C-Spine injury rates were similar between sport (2/201; 1.0%) and non-sport-injured patients (47/5,777; 0.8%). The Canadian C-Spine Rule recommended immobilization equally between groups (46.4% vs. 42.5%; RR 1.09 95%CI 0.93-1.28), most commonly resulting from a dangerous mechanism among sport-injured (68.7% vs. 54.5%; RR 1.26 95%CI 1.08-1.47). The most common dangerous mechanism responsible for immobilization in sport was axial load.

Conclusion: Although equal proportions of sport and non-sport-related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the Canadian C-Spine Rule to evaluate collegiate or pro athletes assessed by sport medicine physicians. It does support using the Canadian C-Spine Rule as a tool in sport-injured patients assessed by paramedics.
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http://dx.doi.org/10.1007/s43678-021-00086-yDOI Listing
May 2021

Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis.

CJEM 2021 Jul 14;23(4):500-511. Epub 2021 Mar 14.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Background: Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration.

Methods: We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool.

Results: Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS or CHADS-VASc scores; 95% CI 1.25 to 4.04; I = 0%).

Conclusion: Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.
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http://dx.doi.org/10.1007/s43678-021-00103-0DOI Listing
July 2021

Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department.

CJEM 2021 03 4;23(2):169-179. Epub 2021 Jan 4.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Introduction: Acute heart failure patients often have an uncertain or delayed follow-up after discharge from the ED. Our goal was to introduce rapid-access specialty clinics to ensure acute heart failure patients were seen within 7 days, in an effort to reduce admissions and improve follow-up care.

Methods: This prospective cohort study was conducted at two campuses of a large tertiary care hospital. We enrolled acute heart failure patients who presented to the ED with shortness of breath and were later discharged. Following a 12-month before period, we introduced rapid-access acute heart failure clinics staffed by cardiology and internal medicine. We allowed for a 3-month implementation period and then observed outcomes over the subsequent 12-month after period. The primary outcome was hospital admission within 30 days. Secondary outcomes included mortality and actual access to specialty care.

Results: Patients in the before (N = 355) and after periods (N = 374) were similar for age and most characteristics. Segmented autoregression analysis demonstrated there was a pre-existing trend to fewer admissions. Attendance at a specialty clinic increased from 17.8 to 42.1% (P < 0.01) and the median days to the clinic decreased from 13 to 6 days (P < 0.01). 30-days mortality did not change.

Conclusion: Implementation of rapid-access clinics for acute heart failure patients discharged from the ED did not lead to an overall decrease in hospital admissions. It did, however, lead to increased access to specialist care, reduced follow-up times, without an increase in return ED visits or mortality. Widespread use of this rapid-access approach to a specialist can improve care for acute heart failure patients discharged home from the ED.
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http://dx.doi.org/10.1007/s43678-020-00047-xDOI Listing
March 2021

Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study.

Ann Emerg Med 2021 06 19;77(6):561-574. Epub 2021 Feb 19.

Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada.

Study Objective: We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope.

Methods: This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes.

Results: Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses.

Conclusion: Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.
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http://dx.doi.org/10.1016/j.annemergmed.2020.12.012DOI Listing
June 2021

Optimizing collaborative relationships in emergency medicine research.

CJEM 2021 May 18;23(3):291-296. Epub 2021 Feb 18.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Objective: The objective of the Canadian Association of Emergency Physicians (CAEP) 2020 Academic Symposium Panel was to present recommendations for collaboration on (1) writing a grant application; (2) conducting a study; (3) writing an abstract; and (4) writing a manuscript.

Methods: We assembled an expert panel of eight experienced emergency medicine clinician scientists from across Canada. Panel members performed literature searches for each of the four topics. Draft recommendations were developed and refined in an iterative fashion by panel members. We solicited external feedback on the draft recommendations online from identified researchers known to CAEP and in person at the Network of Canadian Emergency Researchers meeting in February 2020. We obtained additional feedback during an online symposium presentation on October 15th, 2020, open to all members of the Canadian Association of Emergency Physicians.

Results: Four sets of recommendations were established for each component including: 14 for writing a grant application including relevant timelines; 23 for conducting a study; 13 for writing an abstract; and 18 for writing a manuscript. Forming a strong team, including patients, appropriate methodologists, content experts and a mix of senior and junior investigators, establishing and following clear timelines, and proactive communications were common themes.

Conclusions: We offer recommendations for research collaboration for (1) writing a grant, (2) conducting a study, (3) writing an abstract, and (4) writing a manuscript. We believe these recommendations will help to improve the science, improve grant success, and improve the impact of the abstracts and manuscripts.
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http://dx.doi.org/10.1007/s43678-020-00080-wDOI Listing
May 2021

Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study.

BMJ 2021 02 4;372:n49. Epub 2021 Feb 4.

Department of Emergency Medicine, Queen's University, Kingston, ON, Canada.

Objective: To validate the previously derived Canadian TIA Score to stratify subsequent stroke risk in a new cohort of emergency department patients with transient ischaemic attack.

Design: Prospective cohort study.

Setting: 13 Canadian emergency departments over five years.

Participants: 7607 consecutively enrolled adult patients attending the emergency department with transient ischaemic attack or minor stroke.

Main Outcome Measures: The primary outcome was subsequent stroke or carotid endarterectomy/carotid artery stenting within seven days. The secondary outcome was subsequent stroke within seven days (with or without carotid endarterectomy/carotid artery stenting). Telephone follow-up used the validated Questionnaire for Verifying Stroke Free Status at seven and 90 days. All outcomes were adjudicated by panels of three stroke experts, blinded to the index emergency department visit.

Results: Of the 7607 patients, 108 (1.4%) had a subsequent stroke within seven days, 83 (1.1%) had carotid endarterectomy/carotid artery stenting within seven days, and nine had both. The Canadian TIA Score stratified the risk of stroke, carotid endarterectomy/carotid artery stenting, or both within seven days as low (risk ≤0.5%; interval likelihood ratio 0.20, 95% confidence interval 0.09 to 0.44), medium (risk 2.3%; interval likelihood ratio 0.94, 0.85 to 1.04), and high (risk 5.9% interval likelihood ratio 2.56, 2.02 to 3.25) more accurately (area under the curve 0.70, 95% confidence interval 0.66 to 0.73) than did the ABCD2 (0.60, 0.55 to 0.64) or ABCD2i (0.64, 0.59 to 0.68). Results were similar for subsequent stroke regardless of carotid endarterectomy/carotid artery stenting within seven days.

Conclusion: The Canadian TIA Score stratifies patients' seven day risk for stroke, with or without carotid endarterectomy/carotid artery stenting, and is now ready for clinical use. Incorporating this validated risk estimate into management plans should improve early decision making at the index emergency visit regarding benefits of hospital admission, timing of investigations, and prioritisation of specialist referral.
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http://dx.doi.org/10.1136/bmj.n49DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859838PMC
February 2021

Emergency physician risk assessment practices prior to prescribing opioids.

CJEM 2021 May 1;23(3):351-355. Epub 2021 Feb 1.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Background: Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported.

Methods: We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important.

Results: The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%).

Conclusion: Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.
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http://dx.doi.org/10.1007/s43678-020-00066-8DOI Listing
May 2021

The impact of an outpatient parenteral antibiotic therapy (OPAT) clinic for adults with cellulitis: an interrupted time series study.

Intern Emerg Med 2021 Jan 30. Epub 2021 Jan 30.

Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.

Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective was to determine whether implementation of an OPAT clinic results in decreased hospitalizations and return ED visits for patients receiving OPAT. We conducted an interrupted time series study involving adults with cellulitis presenting to two EDs and treated with intravenous antibiotics. The intervention was the OPAT clinic, which involved follow up at 48-96 h with an infectious disease physician to determine the need for ongoing intravenous antibiotics (implemented January 1, 2014). The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after initiating OPAT) and adverse peripheral line or antibiotic events. We used an interrupted time series design with segmented regression analysis over one-year pre-intervention and one-year post-intervention. 1666 patients were included. At the end of the study period, there was a non-significant 12% absolute increase in hospital admissions (95% CI - 1.6 to 25.5%; p = 0.084) relative to what would have been expected in the absence of the intervention, but a significant 40.7% absolute reduction in return ED visits (95% CI 25.6-55.9%; p < 0.001). Treatment failure rates were < 2% and adverse events were < 6% in both groups. Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, but did not reduce hospital admission rates. An ED-to-OPAT clinic model is safe, and has a low rate of treatment failures.
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http://dx.doi.org/10.1007/s11739-021-02631-0DOI Listing
January 2021

Emergency department cardioversion of acute atrial fibrillation - Authors' reply.

Lancet 2020 09;396(10255):886

Department of Emergency Medicine and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1Y 4E9, Canada.

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http://dx.doi.org/10.1016/S0140-6736(20)31308-8DOI Listing
September 2020

A special thank you to our authors for their responses to the coronavirus disease pandemic.

CJEM 2020 07;22(4):399

Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB.

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http://dx.doi.org/10.1017/cem.2020.407DOI Listing
July 2020

Intravenous Cetirizine Versus Intravenous Diphenhydramine for the Treatment of Acute Urticaria: A Phase III Randomized Controlled Noninferiority Trial.

Ann Emerg Med 2020 10 9;76(4):489-500. Epub 2020 Jul 9.

TerSera Therapeutics, Deerfield, IL.

Study Objective: Acute urticaria is a frequent presentation in emergency departments (EDs), urgent care centers, and other clinical arenas. Treatment options are limited if diphenhydramine is the only intravenous antihistamine offered because of its short duration of action and well-known adverse effects. We evaluate cetirizine injection, the first second-generation injectable antihistamine, for acute urticaria in this multicenter, randomized, noninferiority, phase 3 clinical trial.

Methods: Adult patients presenting to EDs and urgent care centers with acute urticaria requiring an intravenous antihistamine were randomized to either intravenous cetirizine 10 mg or intravenous diphenhydramine 50 mg. The primary endpoint was the 2-hour pruritus score change from baseline, with time spent in treatment center and rate of return to treatment centers as key secondary endpoints. Frequency of sedation and anticholinergic adverse effects were also recorded.

Results: Among 262 enrolled patients, the 2-hour pruritus score change from baseline for intravenous cetirizine was statistically noninferior to that for intravenous diphenhydramine (-1.6 versus -1.5; 95% confidence interval -0.1 to 0.3), and in favor of cetirizine. Treatment differences also favored cetirizine for mean time spent in treatment center (1.7 versus 2.1 hours; P=.005), return to treatment center (5.5% versus 14.1%; P=.02), lower change from baseline sedation score at 2 hours (0.1 versus 0.5; P=.03), and adverse event rate (3.9% versus 13.3%).

Conclusion: Intravenous cetirizine is an effective alternative to intravenous diphenhydramine for treating acute urticaria, with benefits of less sedation, fewer adverse events, shorter time spent in treatment center, and lower rates of revisit to treatment center.
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http://dx.doi.org/10.1016/j.annemergmed.2020.05.025DOI Listing
October 2020

The impact of increased chest compression fraction on survival for out-of-hospital cardiac arrest patients with a non-shockable initial rhythm.

Resuscitation 2020 09 20;154:93-100. Epub 2020 Jun 20.

Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.

Objective: We evaluated the effect of chest compression fraction (CCF) on survival to hospital discharge and return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients with non-shockable rhythms.

Methods: This is a retrospective analysis (completed in 2016) of a prospective cohort study which included OHCA patients from ten U.S. and Canadian sites (Resuscitation Outcomes Consortium Epistry and PRIMED study (2007-2011)). We included all OHCA victims of presumed cardiac aetiology, not witnessed by emergency medical services (EMS), without automated external defibrillator shock prior to EMS arrival, receiving > 1 min of CPR with CPR process measures available, and initial non-shockable rhythm. We measured CCF using the first 5 min of electronic CPR records.

Results: Demographics of 12,928 adult patients were: mean age 68; male 59.9%; public location 8.5%; bystander witnessed 35.2%; bystander CPR 39.3%; median interval from 911 to defibrillator turned on 10 min:04 s; initial rhythm asystole 64.8%, PEA 26.0%, other non-shockable 9.2%; compression rate 80-120/min (69.1%); median CCF 74%; ROSC 25.6%; survival to hospital discharge 2.4%. Adjusted odds ratio (OR); 95% confidence intervals (95%CI) of survival for each CCF category were: 0-40% (2.00; 1.16, 3.32); 41-60% (0.83; 0.54, 1.24); 61-80% (1.02; 0.77, 1.35); and 81-100% (reference group). Adjusted (OR; 95%CI) of ROSC for each CCF category were: 0-40% (1.02; 0.79, 1.30); 41-60% (0.83; 0.72, 0.95); 61-80% (0.85; 0.77, 0.94); and 81-100% (reference group).

Conclusions: We observed an incremental benefit from higher CCF on the incidence of ROSC, but not survival, among non-shockable OHCA patients with CCF higher than 40%.
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http://dx.doi.org/10.1016/j.resuscitation.2020.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483839PMC
September 2020

Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures.

CJEM 2020 07;22(4):486-493

Department of Emergency Medicine, University of Ottawa, Ottawa, ON.

Background: Opioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.

Methods: We conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016-April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.

Results: We enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1-120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15-36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88-10.35)] had a significantly higher likelihood of opioid prescriptions.

Conclusions: The majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.
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http://dx.doi.org/10.1017/cem.2020.50DOI Listing
July 2020

An environmental scan of emergency medicine research support, training, and infrastructure across Canada.

CJEM 2020 07;22(4):477-485

University of Ottawa, Department of Emergency Medicine, Ottawa, ON; Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON.

Objective: Our study objective was to describe the Canadian emergency medicine (EM) research community landscape prior to the initiation of a nationwide network.

Methods: A two-phase electronic survey was sent to 17 Canadian medical schools. The Phase 1 Environmental Scan was administered to department chairs/hospital EM chiefs, to identify EM physicians conducting clinical or educational research. The Phase 2 Survey was sent to the identified EM researchers to assess four themes: 1) geographic distribution, 2) training/career satisfaction, 3) time/financial compensation, and 4) research facilitators/barriers. Descriptive analyses were conducted, and results were stratified by Canadian regions.

Results: A total of 92 EM researchers were identified in Phase 1; 67 (73%) responded to the Phase 2 Survey. Of those, 42 (63%) reported being clinical researchers, and 19 (45%) had a graduate degree. Three provinces encompassed most of the researchers (n = 35). Of the respondents, 61% had a research degree, 66% felt adequately trained for their research career, 73% had financial support, 83% had access to office spaces, 52% had no mentor during their first years of their career, 69% felt satisfied with their research career, and 82% suggested that they will still be conducting research in 5 years.

Conclusion: EM researchers reported being adequately trained, even though only a little over half had a graduate degree. Only two-thirds had financial support, and mentorship was lacking in one-third of the participants. Not all respondents had a form of infrastructure, but most felt optimistic about their careers. The Canadian EM research environment could be improved to ensure better research capacity.
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http://dx.doi.org/10.1017/cem.2020.18DOI Listing
July 2020

Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial.

JMIR Res Protoc 2020 Jun 1;9(6):e16966. Epub 2020 Jun 1.

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

Background: Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study.

Objective: This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED.

Methods: We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study.

Results: Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario.

Conclusions: We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year).

Trial Registration: ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966.

International Registered Report Identifier (irrid): DERR1-10.2196/16966.
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http://dx.doi.org/10.2196/16966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296410PMC
June 2020

Does -Terminal Pro-B-Type Natriuretic Peptide Improve the Risk Stratification of Emergency Department Patients With Syncope?

Ann Intern Med 2020 05 28;172(10):648-655. Epub 2020 Apr 28.

The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada (M.T.).

Background: Studies have reported that natriuretic peptides provide prognostic information for emergency department (ED) syncope.

Objective: To evaluate whether adding -terminal pro-B-type natriuretic peptide (NT-proBNP) to the Canadian Syncope Risk Score (CSRS) improves prediction of 30-day serious adverse events (SAEs).

Design: Prospective cohort study.

Setting: 6 EDs in 2 Canadian provinces.

Participants: 1452 adult ED patients with syncope.

Intervention: Serum NT-proBNP was measured locally at 1 site and batch processed at a central laboratory from other sites. The concentrations were not available to treating physicians or for adjudication of outcomes.

Measurements: An adjudicated composite outcome of 30-day SAEs, including death and cardiac (arrhythmic and nonarrhythmic) and noncardiac events.

Results: Of 1452 patients enrolled, 152 (10.5% [95% CI, 9.0% to 12.1%]) had 30-day SAEs, 57 (3.9%) of which were identified after the index ED disposition. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them (median, 626.5 ng/L vs. 81 ng/L; < 0.001). Adding NT-proBNP values to the CSRS did not significantly improve prognostication (c-statistic, 0.89 and 0.90;  = 0.12 for difference), regardless of SAE subgroup or whether the SAE was identified after the index ED visit. The net reclassification index shows that NT-proBNP would have correctly reclassified 3% of patients with SAEs at the expense of incorrectly reclassifying 2% of patients without SAEs.

Limitations: Our study was powered to detect a 3% difference in the area under the curve. The heterogeneity of outcomes and robust baseline discrimination by the CSRS will make improvements challenging.

Conclusion: Although serum NT-proBNP concentrations were generally much higher among ED patients with syncope who had a 30-day SAE, this blood test added little new information to the CSRS. Routine use of NT-proBNP for ED syncope prognostication is not recommended.

Primary Funding Source: Physicians' Services Incorporated Foundation, Canadian Institutes of Health Research, and The Ottawa Hospital Academic Medical Organization.
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http://dx.doi.org/10.7326/M19-3515DOI Listing
May 2020

Multicenter Emergency Department Validation of the Canadian Syncope Risk Score.

JAMA Intern Med 2020 05;180(5):737-744

Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, Ontario, Canada.

Importance: The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.

Objective: To validate the Canadian Syncope Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.

Design, Setting, And Participants: This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.

Main Outcomes And Measures: Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.

Results: A total of 3819 patients were included (mean [SD] age 53.9 [22.8] years; 2088 [54.7%] female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.

Conclusions And Relevance: The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
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http://dx.doi.org/10.1001/jamainternmed.2020.0288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7091474PMC
May 2020

Evaluating the impact of point-of-care ultrasonography on patients with suspected acute heart failure or chronic obstructive pulmonary disease exacerbation in the emergency department: A prospective observational study.

CJEM 2020 05;22(3):342-349

Department of Emergency Medicine, University of Ottawa, Ottawa, ON.

Objectives: Acute heart failure and chronic obstructive pulmonary disease (COPD) are sometimes difficult to differentiate in the emergency department (ED). We sought to determine the clinical impact of point-of-care ultrasonography (POCUS) in ED patients with suspected acute heart failure or COPD.

Methods: We conducted a prospectively collected cohort study with health records review with frequency matching at The Ottawa Hospital between March and September 2017. We included patients aged 50 and older with shortness of breath or cough from suspected acute heart failure or COPD. Our primary outcome was ED length of stay. Secondary outcomes were time to disposition decision, time to appropriate treatment, and the incidence of adverse events. We analyzed time-to-event outcomes using Kaplan-Meier analysis and Cox regression analysis with POCUS analyzed as a time-dependent variable, and the incidence of adverse events using logistic regression analyses.

Results: There were 81 patients evaluated with lung POCUS and 243 matched patients who were not. Lung POCUS was not significantly associated with ED length of stay and time to disposition decision; however, patients evaluated with lung POCUS received disease-specific treatment faster compared with the non-POCUS group (adjusted hazard ratio, 1.50 [95% confidence interval, 1.05-2.15], a median time difference of 31 minutes). We found no significant differences in the incidence of adverse events.

Conclusions: In this study, use of lung POCUS resulted in no difference in ED length of stay and time to disposition decision, but was associated with faster administration of disease-specific treatments for elderly patients with suspected acute heart failure or COPD.
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http://dx.doi.org/10.1017/cem.2019.499DOI Listing
May 2020

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.

Lancet 2020 02;395(10221):339-349

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

Background: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion.

Methods: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058.

Findings: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68).

Interpretation: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes.

Funding: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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http://dx.doi.org/10.1016/S0140-6736(19)32994-0DOI Listing
February 2020

Evaluation of the Ottawa 3DY as a screening tool for cognitive impairment in older emergency department patients.

Am J Emerg Med 2020 12 20;38(12):2545-2551. Epub 2019 Dec 20.

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

Objective: This study sought to evaluate the implementation of the Ottawa 3DY Tool, a simple screening instrument for cognitive impairment, by front-line ED clinicians.

Methods: We conducted a prospective cohort study in an academic ED. Patients ≥75 years underwent cognitive screening with the Ottawa 3DY by front-line nurses and physicians. Descriptive statistics were used to describe level of implementation and acceptability of the tool. Sensitivity and specificity was calculated using an Mini-Mental State Exam <25 as the cut-off for cognitive impairment. A weighted kappa was calculated to establish inter-rater agreement.

Results: Cognitive screening was completed in 260/332 eligible patients (78.3%), who were 60% female and had a mean age of 83.7 years. Facilitators to screening: perceived importance and ownership of screening and feasibility of Ottawa 3DY. Barriers to screening were: over confidence in clinical judgement and perceived lack of patient benefit. Ottawa 3DY had a sensitivity of 84.6% (64.3-95.0) and specificity of 54.2% (39.3-68.4) when completed by nurses. When completed by emergency physicians, sensitivity was 78.9% (53.9-93.0) and specificity was 70.0% (45.7-87.2). Inter-rater agreement kappa score was 0.67.

Discussion: This study demonstrated that incorporating the Ottawa 3DY tool into the routine evaluation of older ED patients by front-line ED clinicians is both feasible and effective. With its demonstrated good inter-rater reliability and moderate level of sensitivity and specificity when compared with the much longer MMSE, the routine adoption of this tool may help lead to improved recognition of cognitive impairment and ultimately patient and system outcomes.
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http://dx.doi.org/10.1016/j.ajem.2019.12.036DOI Listing
December 2020

Rate Control Management of Atrial Fibrillation With Rapid Ventricular Response in the Emergency Department.

Can J Cardiol 2020 04 9;36(4):509-517. Epub 2019 Sep 9.

Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Electronic address:

Background: There exists limited evidence on managing atrial fibrillation (AF) with rapid ventricular response in the emergency department. We sought to better understand the burden of disease in patients with AF for whom rhythm control was not successful or not attempted and identify opportunities for improved care.

Methods: We conducted a health records review of consecutive visits of patients with AF at 2 academic emergency departments. We included patients ≥ 18 years with AF, heart rate ≥ 100 beats per minute (bpm), and who were not successfully cardioverted or not attempted cardioversion. Outcomes were: (1) incidence given rate control, (2) management practices, (3) adverse events, (4) compliance with guidelines, and (5) outcomes. We performed descriptive statistics.

Results: We included 665 visits, with mean age ± standard deviation 77.4 ± 12.9, female 51.6%, mean ± standard deviation heart rate 121.6 ± 17.4 bpm, AF status (permanent 53.4%; paroxysmal 29.5%; persistent 17.1%), admitted 61.4%. Of all cases, 147 (22.1%) had primary AF and 518 (77.9%) had a rapid rate secondary to a medical cause (heart failure 12.8%; pneumonia 11.7%; sepsis 8.4%). In 117 with primary AF given rate control, 59.0% had a final rate ≤ 100 bpm and 7.7% suffered adverse events. Suboptimal use of rate control occurred in 47.0% (agent 2.6%; route 27.4%; dosage 9.4%; timing 7.7%). At discharge, 11.5% with CHADS-65 risk factors were still not anticoagulated.

Conclusions: Most patients had a rapid rhythm secondary to a medical cause. There were a concerning number of adverse events related to suboptimal use of rate control. Better awareness of guidelines will ensure safer use of rate control.
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http://dx.doi.org/10.1016/j.cjca.2019.08.040DOI Listing
April 2020

Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: 'The Ottawa Troponin Pathway'.

PLoS One 2020 10;15(1):e0226892. Epub 2020 Jan 10.

Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.

Background: Serial conventional cardiac troponin (cTn) measurements 6-9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway.

Methods: We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L).

Results: 1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8-100%) and 94.6% specificity (95% CI 93.3-95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9-100%) and decreased the specificity to 26.5% (95% CI 24.3-28.7%).

Conclusion: The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226892PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6953858PMC
April 2020

Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule.

Stroke 2020 02 6;51(2):424-430. Epub 2019 Dec 6.

From the Departments of Emergency Medicine (I.G.S., J.J.P.), University of Ottawa, Canada.

Background and Purpose- The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods- We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. Consecutive alert, neurologically intact adults with headache were included. For intervention period, physicians were given a 1-hour lecture, pocket cards, posters were installed, and physicians indicated Ottawa SAH rule criteria when ordering CTs. SAH was defined by blood on CT, xanthochromia in cerebrospinal fluid, or >1×10/L red blood cells in cerebrospinal fluid with aneurysm. Results- We enrolled 3672 patients, 1743 before and 1929 after implementation, including 188 with SAH. Proportions undergoing CT was unchanged (88.0% versus 87.5%; =0.643). Lumbar puncture use decreased (38.9% versus 25.9%; <0.0001). Additional testing following CT (ie, lumbar puncture or CT angiography) decreased (51.3% versus 42.2%; <0.0001). Admissions declined (9.8% versus 7.4%; =0.011). Mean emergency department stay was unchanged (6.3±4.0 versus 6.4±4.2 hours; =0.685). The Ottawa SAH rule was 100% (95% CI, 98.1%-100%) sensitive, and the 6-hour-CT rule was 95.5% (95% CI, 89.8-98.5) sensitive for SAH. The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions- The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.
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http://dx.doi.org/10.1161/STROKEAHA.119.026969DOI Listing
February 2020

Barriers and enablers that influence guideline-based care of geriatric fall patients presenting to the emergency department.

Emerg Med J 2019 Dec 24;36(12):741-747. Epub 2019 Sep 24.

Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.

Background: Geriatric patients commonly present to the ED after a fall. Recent evidence suggests that ED physicians are poorly adherent to published ED-specific geriatric fall guidelines. This study applied a theoretical domains framework (TDF) approach to systematically investigate barriers and enablers in the provision of guideline-based care to ED geriatric fall patients.

Methods: From June to September 2017, semistructured interviews of staff ED physicians practising in Ontario, Canada, were conducted and analysed. An interview guide based on the TDF was used to capture 14 domains influencing provision of guideline-based care. Relevant domains were identified based on frequencies of beliefs, existence of conflicting beliefs and evidence of strong beliefs that would influence provision of guideline-based care.

Results: Eleven interviews were conducted with practising ED physicians. Thirty belief statements were identified across 13 relevant TDF domains (all except ). Prominent themes included lack of knowledge, paucity of evidence, heterogeneous self-perceived skills, perceived increased time and workload, importance of allied health support, inconsistently available allied health workers, lack of positive reinforcement, emotions negatively impacting these clinical encounters and support for memory aids. Overall, ED physicians were supportive of guideline implementation, and believe it will lead to better outcomes for geriatric fall patients.

Conclusion: This study identified important barriers and enablers to provision of guideline-based care in geriatric ED fall patients. Based on these findings, future implementation of guidelines nationally and internationally should focus on improving knowledge and training on guidelines, improving positive reinforcement for guideline-appropriate management, greater allied health support and further research to support guidelines.
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http://dx.doi.org/10.1136/emermed-2018-208260DOI Listing
December 2019

Safe Cardioversion for Patients With Acute-Onset Atrial Fibrillation and Flutter: Practical Concerns and Considerations.

Can J Cardiol 2019 10 13;35(10):1296-1300. Epub 2019 Jun 13.

Division of Cardiology, Western University, London, Ontario, Canada.

In this Viewpoint concerns raised by Canadian emergency physicians regarding recommendations 2 and 6 from the recent Canadian Cardiovascular Society 2018 update for atrial fibrillation are discussed. These recommendations narrow the window for safe cardioversion and suggest 4 weeks of anticoagulation for all patients who undergo urgent cardioversion regardless of their CHADS-65 status. We discuss the implications of Grading of Recommendations, Assessment, Development, and Evaluation weak recommendations on the basis of low-quality evidence.
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http://dx.doi.org/10.1016/j.cjca.2019.06.007DOI Listing
October 2019