Publications by authors named "Kerstin de Wit"

43 Publications

Reliability of patient-reported outcome measures: Hemorrhage, anticoagulant, antiplatelet medication use.

Res Pract Thromb Haemost 2021 May 26;5(4):e12501. Epub 2021 Mar 26.

Division of Emergency Medicine Department of Medicine McMaster University Hamilton ON Canada.

Background: Most antithrombotic medication users are older adults. Patient-reported outcome measures are commonly used in clinical research on antithrombotic medication, such as the diagnosis of intracranial hemorrhage.

Objectives: To determine the reliability of patient-reported intracranial hemorrhage, anticoagulant and platelet aggregation inhibitor use in the older adult population.

Patients/methods: We conducted a secondary analysis of a prospective, observational cohort study of older adults who presented to the emergency department with a fall. The primary outcome was diagnosis of intracranial bleeding. We compared patient-reported intracranial bleeding to structured chart review with adjudication. We also compared patient-reported use of antiplatelet and anticoagulant medication to physician-reported medication use supplemented with structured chart review. We calculated the diagnostic accuracy of the patient-reported outcomes using our comparators as the reference standard.

Results: Exact agreement for patient-reported intracranial bleeds was 95%, with a Cohen's kappa of 0.30 (95% confidence interval [CI], 0.15-0.45). The sensitivity was 36.7% (95% CI, 20.6%-56.1%) and specificity 97.2% (95% CI, 95.8%-98.1%). For anticoagulant medication use, exact agreement was 87%, Cohen's kappa 0.66 (95% CI, 0.63-0.72), sensitivity 84.0% (95% CI, 79.3%-83.8%), and specificity 87.6% (95% CI, 85.1%-89.7%). For antiplatelet medication use, exact agreement was 77%, Cohen's kappa 0.50 (95% CI, 0.44-0.55), sensitivity 68.7% (95% CI, 64.0%-73.1%), and specificity 81.2% (95% CI, 78.0-83.8%).

Conclusions: Patient-reported outcome and exposure data were unreliable in this study. Our findings have a bearing on future research study design.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/rth2.12501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117814PMC
May 2021

Anticoagulation for newly diagnosed atrial fibrillation and 90-day rates of stroke and bleeding.

CJEM 2021 May 20;23(3):325-329. Epub 2021 Jan 20.

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.

Background: Atrial fibrillation increases the risk of stroke, which can be mitigated by anticoagulant prescription. We evaluated local emergency physician anticoagulation practice for patients discharged from the emergency department with atrial fibrillation, along with 90-day incidence of stroke and major bleeding.

Methods: This was a health record review of patients diagnosed with new onset atrial fibrillation in two emergency departments between 2014 and 2017. We collected data on CHADS65 scores, contraindications to direct oral anticoagulant (DOAC) prescription and initiation of anticoagulation in the ED. Patient charts were reviewed for the diagnosis of stroke, transient ischemic attack (TIA), systemic embolism or major bleeding within 90 days.

Results: We identified 399 patients, median age 68 (IQR 57-79), 213 (53%) male. Only 299/399 patients had an indication for anticoagulation (CHADS65-positive). Of these 299, 27 had a contraindication to or were already prescribed anticoagulation. 45/272 (17%, 95% confidence interval 12-22%) patients eligible for initiation of anticoagulation left the emergency department with a prescription for anticoagulation. During 90-day follow-up, seven patients had stroke or TIA. Four stroke/TIA patients had been eligible to start an anticoagulant but were not started, two left the emergency department with prescriptions for an anticoagulant and one patient had a contraindication to initiating anticoagulation in the emergency department. There were no major bleeding episodes.

Conclusion: Few eligible patients were prescribed anticoagulation and the 90-day stroke rate was high. Physicians should become familiar with the CAEP Acute AF Best Practices Checklist AF which offers guidance on anticoagulation prescription.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43678-020-00054-yDOI Listing
May 2021

Diagnostic Potential of Coagulation-Related Biomarkers for Sepsis in the Emergency Department: Protocol for a Pilot Observational Cohort Study.

Crit Care Explor 2021 Apr 26;3(4):e0414. Epub 2021 Apr 26.

Thrombosis & Atherosclerosis Research Institute (TaARI), Department of Medicine, McMaster University, Hamilton, ON, Canada.

Background: Between 75% and 80% of patients with sepsis arrive in the hospital through the emergency department. Early diagnosis is important to alter patient prognosis, but currently, there is no reliable biomarker. The innate immune response links inflammation and coagulation. Several coagulation -related biomarkers are associated with poor prognosis in the ICU. The role of coagulation biomarkers to aid in early sepsis diagnosis has not previously been investigated. The objective of our study is to determine the individual or combined accuracy of coagulation and inflammation biomarkers with standard biochemical tests to diagnose adult septic patients presenting to the emergency department.

Methods: in the Emergency Department is a prospective, observational cohort study with a target enrolment of 250 suspected septic patients from two Canadian emergency departments. The emergency physicians will enroll patients with suspected sepsis. Blood samples will be collected at two time points (initial presentation and 4 hr following). Patients will be adjudicated into septic, infected, or not infected status in accordance with the Sepsis-3 definitions. Patient demographics, cultures, diagnosis, and biomarkers will be reported using descriptive statistics. Optimal cut off values with sensitivity and specificity for each biomarker will be determined using C-statistics to distinguish between septic and nonseptic patients. Stepwise multiple logistic regression analysis with exclusion of nonsignificant covariates from the final model will be used to establish a panel of biomarkers.

Conclusions: Our protocol describes the processes and methods for a pragmatic observational biomarker study in the emergency department. This study will seek to determine the potential diagnostic importance of early coagulation abnormalities to identify additional tools for sepsis diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCE.0000000000000414DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078466PMC
April 2021

A simplified decision rule to rule out deep vein thrombosis using clinical assessment and D-dimer.

J Thromb Haemost 2021 Apr 8. Epub 2021 Apr 8.

Department of Oncology, McMaster University, Hamilton, ON, Canada.

Background: Current clinical decision rules to exclude deep vein thrombosis (DVT) are underused partly because of their complexity. A simplified rule that can be easily applied would be more appealing to use in clinical practice.

Methods: We used individual patient data from prospective diagnostic studies of patients suspected of DVT to develop a new clinical decision rule. The primary outcome was presence of DVT either at initial testing or during follow-up. DVT was considered safely excluded if the upper 95% confidence interval (CI) of DVT prevalence was <2%.

Results: Four studies and 3368 patients were eligible for this analysis. Overall prevalence of DVT was 17%. In addition to D-dimer, two variables, calf swelling and DVT as the most likely diagnosis, are included in the new rule. Based on these two variables, two clinical pretest probability (CPTP) groups were defined; low (none of the two items present) and high (at least one of the items present). DVT can be safely excluded in patients with low CPTP with a D-dimer <500 ng/mL (prevalence = 0.1%; 95% CI, 0.0-0.8), low CPTP with a D-dimer between 500 ng/ml and 1000 ng/ml (prevalence = 0.3%; 95% CI, 0.0-1.7), and D-dimer <500 ng/ml in patients with high CPTP (prevalence = 0.3%; 95% CI, 0.0-1.0).

Conclusions: The combination of D-dimer and Wells items resulted in a simple clinical decision rule with 3 items. The results suggest that the rule can safely exclude DVT. Prospective validation is required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jth.15337DOI Listing
April 2021

The psychological impact of pulmonary embolism: A mixed-methods study.

Res Pract Thromb Haemost 2021 Feb 28;5(2):301-307. Epub 2021 Jan 28.

Hamilton Health Sciences Hamilton ON Canada.

Background: Patients diagnosed with pulmonary embolism (PE) are reported to experience symptoms of posttraumatic stress disorder (PTSD) and existential anxiety following their diagnosis. They may also experience negative changes in perspective and hypervigilance of PE symptoms.

Objective: The aim of this study was to document the mental and emotional experience associated with PE diagnosis through the lens of PTSD, to better understand the factors involved in psychological distress following receipt of a PE diagnosis.

Patients/methods: This was a mixed-methods study in two parts: (i) measurement of self-reported PTSD symptoms among patients attending thrombosis clinic and (ii) semistructured interviews with patients about their experience of receiving a diagnosis of PE and its psychological aftermath.

Results: Of 72 patients who participated in the survey, two met the criteria for a tentative diagnosis of PTSD. The semistructured interviews with 37 patients suggested that around half of respondents experienced some degree of ongoing psychological distress. Those with psychological distress often recalled painful symptoms, recalled diagnosis delivery as stressful, worried about PE recurrence, and had anxieties about stopping their anticoagulant medication. Few patients reported inclination to seek support from professional mental health services.

Conclusions: We found ongoing and untreated psychological distress among people who were previously diagnosed with PE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/rth2.12484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938621PMC
February 2021

Starting, building and sustaining a program of research in emergency medicine in Canada.

CJEM 2021 May 15;23(3):297-302. Epub 2021 Feb 15.

Schwartz/Reisman Emergency Medicine Institute, Sinai Health and Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.

Objective: To develop pragmatic recommendations for starting, building and sustaining a program of research in emergency medicine (EM) in Canada at sites with limited infrastructure and/or prior research experience.

Methods: At the direction of the Canadian Association of Emergency Physicians (CAEP) academic section, we assembled an expert panel of 10 EM researchers with experience building programs of research. Using a modified Delphi approach, our panel developed initial recommendations for (1) starting, (2) building, and (3) sustaining a program of research in EM. These recommendations were peer-reviewed by emergency physicians and researchers from each of the panelist's home institutions and tested for face and construct validity, as well as ease of comprehension. The recommendations were then iteratively revised based on feedback and suggestions from peer review and amended again after being presented at the 2020 CAEP academic symposium.

Results: Our panel created 15 pragmatic recommendations for those intending to start (formal research training, find mentors, local support, develop a niche, start small), build (funding, build a team, collaborate, publish, expect failure) and sustain (become a mentor, obtain leadership roles, lead national studies, gain influence, prioritize wellness) a program of EM research in centers without an established research culture. Additionally, we suggest four recommendations for department leads aiming to foster a program of research within their departments.

Conclusion: These recommendations serve as guidance for centres wanting to establish a program of research in EM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43678-020-00081-9DOI Listing
May 2021

Predictors of persistent concussion symptoms in adults with acute mild traumatic brain injury presenting to the emergency department.

CJEM 2021 May 8;23(3):365-373. Epub 2021 Feb 8.

Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

Objective: To identify risk factors associated with persistent concussion symptoms in adults presenting to the emergency department (ED) with acute mild traumatic brain injury (TBI).

Methods: This was a secondary analysis of a randomized controlled trial conducted in three Canadian EDs whereby the intervention had no impact on recovery or healthcare utilization outcomes. Adult (18-64 years) patients with a mild TBI sustained within the preceding 48 h were eligible for enrollment. The primary outcome was the presence of persistent concussion symptoms at 30 days, defined as the presence of ≥ 3 symptoms on the Rivermead Post-concussion Symptoms Questionnaire.

Results: Of the 241 patients who completed follow-up, median (IQR) age was 33 (25 to 50) years, and 147 (61.0%) were female. At 30 days, 49 (20.3%) had persistent concussion symptoms. Using multivariable logistic regression, headache at ED presentation (OR: 7.7; 95% CI 1.6 to 37.8), being under the influence of drugs or alcohol at the time of injury (OR: 5.9; 95% CI 1.8 to 19.4), the injury occurring via bike or motor vehicle collision (OR: 2.9; 95% CI 1.3 to 6.0), history of anxiety or depression (OR: 2.4; 95% CI 1.2 to 4.9), and numbness or tingling at ED presentation (OR: 2.4; 95% CI 1.1 to 5.2), were found to be independently associated with persistent concussion symptoms at 30 days.

Conclusions: Five variables were found to be significant predictors of persistent concussion symptoms. Although mild TBI is mostly a self-limited condition, patients with these risk factors should be considered high risk for developing persistent concussion symptoms and flagged for early outpatient follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43678-020-00076-6DOI Listing
May 2021

A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury.

Acad Emerg Med 2021 05 28;28(5):493-501. Epub 2021 Feb 28.

Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada.

Background: There is a paucity of effective management strategies to prevent prolonged symptoms following mild traumatic brain injury (mTBI), and emerging evidence suggesting possible benefits of exercise. The objective of this trial was to determine whether adult patients presenting to the emergency department (ED) with a diagnosis of acute mTBI prescribed light exercise were less likely to develop persistent postconcussion symptoms (PCS).

Methods: This was a randomized controlled trial conducted in three Canadian EDs. Consecutive, adult (18-64 years) ED patients with an mTBI sustained within the preceding 48 hours were eligible for enrollment. The intervention group received discharge instructions prescribing 30 minutes of daily light exercise, and the control group was given standard mTBI instructions advising gradual return to exercise following symptom resolution. The primary outcome was the proportion of patients with PCS at 30 days, defined as the presence of three or more symptoms on the Rivermead Post-concussion Symptoms Questionnaire (RPQ).

Results: A total of 367 patients were enrolled (control group, n = 184; intervention, n = 183). Median age was 32 years and 201 (57.6%) were female. There was no difference in the proportion of patients with PCS at 30 days (control, 13.4% vs intervention, 14.6%; ∆1.2%, 95% confidence interval [CI] = -6.2 to 8.5). There were no differences in median change of RPQ scores, median number of return health care provider visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35; ∆5, 95% CI = 2 to 15).

Conclusion: In this trial of prescribed early light exercise for acute mTBI, there were no differences in recovery or health care utilization outcomes. Results suggest that early light exercise may be encouraged as tolerated at ED discharge following mTBI, but this guidance is not sufficient to prevent PCS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/acem.14215DOI Listing
May 2021

Physician choices in pulmonary embolism testing.

CMAJ 2021 01;193(2):E38-E46

Faculty of Medicine (Zarabi, Varner) and Dalla Lana School of Public Health (Mercuri), University of Toronto, Toronto, Ont.; Faculty of Health Sciences (Chan, Mercuri, Kearon, de Wit), McMaster University, Hamilton, Ont.; Faculty of Medicine (Turcotte, Eagles), University of Ottawa, Ottawa, Ont.; Faculty of Medicine (Grusko), University of Manitoba, Winnipeg, Man.; Faculty of Medicine (Barbic), University of British Columbia, Vancouver, BC; Faculty of Medicine (Bridges), McGill University, Montréal, Que.; Chapel Hill School of Medicine (Houston), University of North Carolina, Chapel Hill, NC

Background: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE.

Methods: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests.

Results: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE.

Interpretation: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cmaj.201639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773048PMC
January 2021

Feasibility of a quality improvement project to increase adherence to evidence-based pulmonary embolism diagnosis in the emergency department.

Pilot Feasibility Stud 2021 Jan 4;7(1). Epub 2021 Jan 4.

Department of Health Research Methods, Evidence, and Impact, Health Information Research Unit (HIRU), Communication Research Laboratory (CRL), McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.

Background: Many evidence-based clinical decision tools are available for the diagnosis of pulmonary embolism (PE). However, these clinical decision tools have had suboptimal uptake in the everyday clinical practice in emergency departments (EDs), despite numerous implementation efforts. We aimed to test the feasibility of a multi-faceted intervention to implement an evidence-based PE diagnosis protocol.

Methods: We conducted an interrupted time series study in three EDs in Ontario, Canada. We enrolled consecutive adult patients accessing the ED with suspected PE from January 1, 2018, to February 28, 2020. Components of the intervention were as follows: clinical leadership endorsement, a new pathway for PE testing, physician education, personalized confidential physician feedback, and collection of patient outcome information. The intervention was implemented in November 2019. We identified six criteria for defining the feasibility outcome: successful implementation of the intervention in at least two of the three sites, capturing data on ≥ 80% of all CTPAs ordered in the EDs, timely access to electronic data, rapid manual data extraction with feedback preparation before the end of the month ≥ 80% of the time, and time required for manual data extraction and feedback preparation ≤ 2 days per week in total.

Results: The intervention was successfully implemented in two out of three sites. A total of 5094 and 899 patients were tested for PE in the period before and after the intervention, respectively. We captured data from 90% of CTPAs ordered in the EDs, and we accessed the required electronic data. The manual data extraction and individual emergency physician audit and feedback were consistently finalized before the end of each month. The time required for manual data extraction and feedback preparation was ≤ 2 days per week (14 h).

Conclusions: We proved the feasibility of implementing an evidence-based PE diagnosis protocol in two EDs. We were not successful implementing the protocol in the third ED.

Registration: The study was not registered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40814-020-00741-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779326PMC
January 2021

Challenging anticoagulation cases: A case of acute pulmonary embolism in a patient with chronic thrombocytopenia.

Thromb Res 2021 02 3;198:83-85. Epub 2020 Dec 3.

Department of Medicine, McMaster University, Hamilton, Canada.

We present a case of acute pulmonary embolism in a patient with myelofibrosis and thrombocytopenia. The patient had a history of portal vein thrombosis and had taken warfarin for the past six years. At the time of his pulmonary embolism diagnosis, his INR was 1.5 and platelet count 58 × 10/L. This article discusses how to balance the risk of thrombosis against the risk of bleeding, and reviews the options for pulmonary embolism treatment including transition to low-molecular-weight heparin, direct oral anticoagulants and/or inferior vena cava filters.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.thromres.2020.11.035DOI Listing
February 2021

Canadian stroke best practice recommendations: , 7th Edition Update 2020.

Int J Stroke 2021 04 11;16(3):321-341. Epub 2020 Nov 11.

Department of Neurology, Universite de Montreal, Montreal, Canada.

Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The () are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1747493020968424DOI Listing
April 2021

Pulmonary embolism prevalence among emergency department cohorts: A systematic review and meta-analysis by country of study.

J Thromb Haemost 2021 01 18;19(1):173-185. Epub 2020 Nov 18.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.

Essentials The threshold to test for pulmonary embolism (PE) might be lower in North America than Europe. We compared the PE prevalence and positive yield of imaging in Europe and North America. More patients tested in Europe are diagnosed with PE, and imaging is more often positive. Our systematic review supports the hypothesis of overtesting for PE in North America. ABSTRACT: Background There is an impression that North American emergency department (ED) patients tested for pulmonary embolism (PE) differ from European ones. Objectives We compared the PE prevalence, frequency of use, and positive yield of imaging among ED patients tested for PE in Europe and North America. Methods We searched for studies reporting consecutive ED patients tested for PE. Two authors screened full texts, performed risk of bias assessment, and data extraction. We conducted a meta-analysis of proportions for each outcome and a multiple meta-regression. Results From 3109 publications, 44 were included in the systematic review. The prevalence of PE in Europe was 23% (95% confidence interval [CI], 21-26) and in North America 8% (95% CI, 6-9). The adjusted mean difference (aMD) in the prevalence of PE in the European compared with North American studies, was 15% (95% CI, 10-20). Computed tomography pulmonary angiography (CTPA) was used in 60% (95% CI, 52%-68) of European and 38% (95% CI, 24-51) of North American patients tested for PE (aMD, 23% [95% CI, 7-39]). The CTPA diagnostic yield was 29% (95% CI, 26-32) in Europe and 13% (95% CI, 9-17) in North America (aMD, 15% [95% CI, 8-21]). Conclusion Compared with North America, European ED studies have a higher prevalence of PE and diagnostic yield from CTPA, despite a higher frequency of CTPA use among patients tested for PE. This supports the hypothesis that those tested for PE in North American EDs have a lower risk of PE compared with Europe.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jth.15124DOI Listing
January 2021

Burnout and depression among Canadian emergency physicians.

Authors:
Kerstin de Wit

CJEM 2020 09;22(5):559-560

Department of Medicine, McMaster University; Emergency Department, Hamilton General Hospital, Hamilton, ON.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/cem.2020.446DOI Listing
September 2020

Canadian emergency physician psychological distress and burnout during the first 10 weeks of COVID-19: A mixed-methods study.

J Am Coll Emerg Physicians Open 2020 Aug 26. Epub 2020 Aug 26.

Department of Medicine McMaster University Hamilton Ontario Canada.

Objectives: The aim of this study was to report burnout time trends and describe the psychological effects of working as a Canadian emergency physician during the first weeks of the coronavirus disease 2019 (COVID-19) pandemic.

Methods: This was a mixed-methods study. Emergency physicians completed a weekly online survey. The primary outcome was physician burnout as measured by the emotional exhaustion and depersonalization items, from the Maslach Burnout Inventory. We captured data on work patterns, aerosolizing procedures, testing and diagnosis of COVID-19. Each week participants entered free text explaining their experiences and well-being.

Results: There were 468 participants who worked in 143 Canadian hospitals. Burnout levels did not significantly change over time (emotional exhaustion = 0.632, depersonalization = 0.155). Three participants were diagnosed with COVID-19. Being tested for COVID-19 (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.1-42.5) and the number of shifts worked (OR 1.3, 95% CI 1.1-1.5 per additional shift) were associated with high emotional exhaustion. Having been tested for COVID-19 (OR 4.3, 95% CI 1.1-17.8) was also associated with high depersonalization. Personal safety, academic and educational work, personal protective equipment, the workforce, patient volumes, work patterns, and work environment had an impact on physician well-being. A new financial reality and contrasting negative and positive experiences affected participants' psychological health.

Conclusion: Emergency physician burnout levels remained stable during the initial 10 weeks of this pandemic. The impact of COVID-19 on the work environment and personal perceptions and fears about the impact on lifestyle have affected physician well-being.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/emp2.12225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461319PMC
August 2020

Hypercoagulability and coronavirus disease 2019-associated hypoxemic respiratory failure: Mechanisms and emerging management paradigms.

J Trauma Acute Care Surg 2020 12;89(6):e177-e181

From the Department of Medicine (C.H.Y.), Division of Emergency Medicine, University of Toronto, Toronto; Thrombosis and Atherosclerosis Research Institute (C.H.Y., J.I.W., N.V., P.C.L., A.F.-R., P.Y.K.), Hamilton; Department of Critical Care (C.H.Y., K.S.), Lakeridge Health Corporation, Oshawa; Department of Medicine (K.d.W., J.I.W., P.C.L., A.F.-R., P.Y.K.), McMaster University, Hamilton, Ontario, Canada; Department of Anesthesiology (J.H.L.), Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina; Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton; and Department of Critical Care Medicine (K.S.), Queen's University, Kingston, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TA.0000000000002938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7687878PMC
December 2020

Predicting hospital admission for older emergency department patients: Insights from machine learning.

Int J Med Inform 2020 08 16;140:104163. Epub 2020 May 16.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Big Data and Geriatric Models of Care (BDG) Cluster, McMaster University, Hamilton, Ontario, Canada.

Background: Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications.

Materials And Methods: We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation.

Results: Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition.

Conclusion: To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijmedinf.2020.104163DOI Listing
August 2020

Diagnosing deep vein thrombosis in cancer patients with suspected symptoms: An individual participant data meta-analysis.

J Thromb Haemost 2020 09 8;18(9):2245-2252. Epub 2020 Jul 8.

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Background: A previous individual participant data (IPD) meta-analysis showed that the Wells rule and D-dimer testing cannot exclude suspected deep vein thrombosis (DVT) in cancer patients.

Objectives: To explore reasons for this reduced diagnostic accuracy and to optimize the diagnostic pathway for cancer patients suspected of DVT.

Patients And Methods: Using IPD from 13 studies in patients with suspected DVT, DVT prevalence and the predictive value of the Wells rule items and D-dimer testing were compared between patients with and without cancer. Next, we developed a prediction model with five variables selected from all available diagnostic predictors.

Results: Among the 10 002 suspected DVT patients, there were 834 patients with cancer. The median prevalence of DVT in these patients with cancer was 37.5% (interquartile range [IQR], 30.8-45.5), whereas it was 15.1% (IQR, 11.5-16.7) in patients without cancer. Diagnostic performance of individual Wells rule items and D-dimer testing was similar across patients with and without cancer, except "immobility" and "history of DVT." The newly developed rule showed a pooled c-statistic 0.80 (95% confidence interval [CI], 0.75-0.83) and good calibration. However, using this model, still only 4.3% (95% CI, 3.0-5.7) of the suspected patients with cancer could be identified with a predicted DVT posttest probability of <2%.

Conclusions: Likely because of the high prevalence of DVT, clinical models followed by D-dimer testing fail to rule out DVT efficiently in cancer patients suspected of DVT. Direct referral for compression ultrasonography appears to be the preferred approach for diagnosis of suspected DVT in cancer patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jth.14900DOI Listing
September 2020

Emerging key laboratory tests for patients with COVID-19.

Clin Biochem 2020 07 30;81:13-14. Epub 2020 Apr 30.

Department of Pathology & Molecular Medicine, McMaster University, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clinbiochem.2020.04.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192114PMC
July 2020

Clinical chemistry tests for patients with COVID-19 - important caveats for interpretation.

Clin Chem Lab Med 2020 06;58(7):1142-1143

Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1515/cclm-2020-0436DOI Listing
June 2020

Diagnosis of Pulmonary Embolism with d-Dimer Testing. Reply.

N Engl J Med 2020 03;382(11):1075

McMaster University, Hamilton, ON, Canada

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMc1917227DOI Listing
March 2020

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study.

J Am Geriatr Soc 2020 05 3;68(5):970-976. Epub 2020 Feb 3.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Objectives: Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling.

Design: Prospective cohort study.

Setting: Three Canadian EDs.

Participants: A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours.

Measurements: Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression.

Results: A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4).

Conclusion: The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16338DOI Listing
May 2020

Reply to Thromboprophylaxis in temporary lower limb immobilization: Extrapolate with care.

J Thromb Haemost 2020 02;18(2):519-520

School of Health and Related Research, The University of Sheffield, Sheffield, UK.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jth.14708DOI Listing
February 2020

Showing Your Thinking: Using Mind Maps to Understand the Gaps Between Experienced Emergency Physicians and Their Students.

AEM Educ Train 2020 Jan 1;4(1):54-63. Epub 2019 Sep 1.

Division of Emergency Medicine Department of Medicine McMaster University Hamilton Ontario Canada.

Background: Clinical teaching faculty rely on schemas for diagnosis. When they attempt to teach medical students, there may be a gap in the interpretation because the students do not have the same schemas. The aim of this analysis was to explore expert thinking processes through mind maps, to help determine the gaps between an expert's mind map of their diagnostic thinking and how students interpret this teaching artifact.

Methods: A novel mind-mapping approach was used to examine how emergency physicians (EPs) explain their clinical reasoning schemas. Nine EPs were shown two different videos of a student interviewing a patient with possible venous thromboembolism. EPs were then asked to explain their diagnostic approach using a mind map, as if they were thinking to a student. Later, another medical student interviewed the EPs to clarify the mind map and revise as needed. A coding framework was generated to determine the discrepancy between the EP-generated mind map and the novice's interpretation.

Results: Every mind map (18 mind maps from nine individuals) contained some discrepancy between the expert's mind and novice's interpretation. From the qualitative analysis of the changes between the originally created mind map and the later revision, the authors developed a conceptual framework describing types of amendments that students might expect teachers to make in their mind maps: 1) substantive amendments, such as incomplete mapping; and 2) clarifications, such as the need to explain background for a mind map element.

Conclusion: Emergency physician teachers tend to make jumps in reasoning, most commonly including incomplete mapping and maps requiring clarifications. Educating EPs on these processes will allow modification of their teaching modalities to better suit learners.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/aet2.10379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6965674PMC
January 2020

Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review.

Injury 2020 Feb 26;51(2):157-163. Epub 2019 Dec 26.

Centre de recherche sur les soins et services de première ligne de l'Université Laval (CERSSPL-UL), Quebec, Quebec, Canada.

Introduction: Seniors who fall are an increasing proportion of the patients who are treated in emergency departments (ED). Falling on level-ground is the most common cause of traumatic intracranial bleeding. We aimed to determine the incidence of intracranial bleeding among all senior patients who present to ED after a fall.

Method: We performed a systematic review. Medline, EMBASE, Cochrane, and Database of Abstracts of Reviews of Effects databases, Google Scholar, bibliographies and conference abstracts were searched for articles relevant to senior ED patients who presented after a ground-level fall. Studies were included if they reported on patients aged 65 or older who had fallen. At least 80% of the population had to have suffered a ground-level fall. There were no language restrictions. We performed a meta-analysis (using the random effects model) to report the pooled incidence of intracranial bleeding within 6 weeks of the fall.

Results: We identified eleven studies (including 11,102 patients) addressing this clinical question. Only three studies were prospective in design. The studies varied in their inclusion criteria, with two requiring evidence of head injury and four requiring the emergency physician to have ordered a head computed tomography (CT). One study excluded patients on therapeutic anticoagulation. Overall, there was a high risk of bias for eight out of eleven studies. The pooled incidence of intracranial bleeding was 5.2% (95% CI 3.2-8.2%). A sensitivity analysis excluding studies with a high risk of bias gave a pooled estimate of 5.1% (95% CI 3.6-7.2%).

Conclusion: We found a lack of high-quality evidence on senior ED patients who have fallen. The available literature suggests there is around a 5% incidence of intracranial bleeding in seniors who present to the ED after a fall.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.injury.2019.12.036DOI Listing
February 2020

Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation.

Health Technol Assess 2019 12;23(63):1-190

Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada.

Background: Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis.

Objectives: To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research.

Data Sources: Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field.

Review Methods: Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services.

Results: Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%.

Limitations: Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling.

Conclusions: Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain.

Future Work: Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis.

Study Registration: This study is registered as PROSPERO CRD42017058688.

Funding: The National Institute for Health Research Health Technology Assessment programme.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3310/hta23630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936165PMC
December 2019

Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules.

Acad Med 2020 08;95(8):1230-1237

K. de Wit is assistant professor, Division of Emergency Medicine, Department of Medicine, and associate professor, Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.

Purpose: Physicians are often asked to integrate clinical decision rules (CDRs) with their own cognitive processes to reach a diagnosis. Clinicians, researchers, and educators must understand these cognitive processes to evaluate and improve the diagnostic process. The authors sought to explore emergency physicians' diagnostic processes and to examine how they integrated CDRs into their reasoning using simulated cases (with chest pain or leg pain).

Method: From August 2015 to July 2016, 16 practicing emergency physicians from 3 teaching hospitals associated with McMaster University, Ontario, Canada, were interviewed via a novel "teach aloud" protocol. Six videos of simulated patients with chest pain, breathlessness, or leg discomfort were used as prompts for the physicians to demonstrate their diagnostic thinking. Using a constructivist grounded theory analysis, 3 investigators independently reviewed the interview transcripts, meeting regularly to discuss identified themes and subthemes until sufficiency was reached.

Results: A model to describe how clinicians integrate their own decision making with CDRs was developed, showing that physicians engage in an iterative diagnostic process that repeatedly refines the differential diagnosis list. The steps in the diagnostic process were: refinement of the differential diagnosis, ordering a hierarchy of risk, the decision to test, choosing the tests, and interpreting test results. Physicians applied CDRs when they had already decided to test.

Conclusions: To date, CDRs assume a static, linear model of clinical decision making. Findings demonstrate that participants engaged in iterative and dynamic decision-making processes that changed throughout their patient encounter, contingent on multiple contextual features. Understanding these processes could inform future development of CDRs and educational strategies around these decision aids.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ACM.0000000000003098DOI Listing
August 2020

Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability.

N Engl J Med 2019 11;381(22):2125-2134

From the Departments of Medicine (C.K., K.W., S. Schulman, F.A.S., S. Sharma, S.M.B.), Health Research Methods, Evidence, and Impact (C.K., S.P., S. Schulman), and Oncology (S.P., L.R.-S., J.A.J.), McMaster University, Hamilton, ON, the Departments of Emergency Medicine (M.A.) and Medicine (A.H.), McGill University, Montreal, the Departments of Anesthesia (F.D.) and Family and Emergency Medicine (J.-F.D.), Sherbrooke University, Sherbrooke, QC, the Department of Medicine, University of Ottawa, Ottawa (G.L.G.), the Departments of Medicine and Epidemiology and Biostatistics, Western University, London, ON (A.L.-L.), and the Department of Medicine, University of Alberta, Edmonton (C.W.) - all in Canada.

Background: Retrospective analyses suggest that pulmonary embolism is ruled out by a d-dimer level of less than 1000 ng per milliliter in patients with a low clinical pretest probability (C-PTP) and by a d-dimer level of less than 500 ng per milliliter in patients with a moderate C-PTP.

Methods: We performed a prospective study in which pulmonary embolism was considered to be ruled out without further testing in outpatients with a low C-PTP and a d-dimer level of less than 1000 ng per milliliter or with a moderate C-PTP and a d-dimer level of less than 500 ng per milliliter. All other patients underwent chest imaging (usually computed tomographic pulmonary angiography). If pulmonary embolism was not diagnosed, patients did not receive anticoagulant therapy. All patients were followed for 3 months to detect venous thromboembolism.

Results: A total of 2017 patients were enrolled and evaluated, of whom 7.4% had pulmonary embolism on initial diagnostic testing. Of the 1325 patients who had a low C-PTP (1285 patients) or moderate C-PTP (40 patients) and a negative d-dimer test (i.e., <1000 or <500 ng per milliliter, respectively), none had venous thromboembolism during follow-up (95% confidence interval [CI], 0.00 to 0.29%). These included 315 patients who had a low C-PTP and a d-dimer level of 500 to 999 ng per milliliter (95% CI, 0.00 to 1.20%). Of all 1863 patients who did not receive a diagnosis of pulmonary embolism initially and did not receive anticoagulant therapy, 1 patient (0.05%; 95% CI, 0.01 to 0.30) had venous thromboembolism. Our diagnostic strategy resulted in the use of chest imaging in 34.3% of patients, whereas a strategy in which pulmonary embolism is considered to be ruled out with a low C-PTP and a d-dimer level of less than 500 ng per milliliter would result in the use of chest imaging in 51.9% (difference, -17.6 percentage points; 95% CI, -19.2 to -15.9).

Conclusions: A combination of a low C-PTP and a d-dimer level of less than 1000 ng per milliliter identified a group of patients at low risk for pulmonary embolism during follow-up. (Funded by the Canadian Institutes of Health Research and others; PEGeD ClinicalTrials.gov number, NCT02483442.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMoa1909159DOI Listing
November 2019