The HEARTRISK6 Scale: Predicting Short-Term Serious Outcomes in Emergency Department Acute Heart Failure Patients.

Background: Acute heart failure (AHF) is a common emergency department (ED) presentation that may have poor outcomes but often does not require hospital admission. There is little evidence to guide dispositional decisions.

Objectives: The authors sought to create a risk score for predicting short-term serious outcomes (SSO) in patients with AHF.

Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program.

The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives.

Door-To-Triage Time in a Canadian Tertiary-Care Center.

Background: The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional.

Objective: We sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada.

Methods: Data were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool.

Study Objective: The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS.

Methods: This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes.

Prospective Validation of the Emergency Heart Failure Mortality Risk Grade for Acute Heart Failure.

Background: Improved risk stratification of acute heart failure in the emergency department may inform physicians' decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality.

Methods: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals.

Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis.

Background: We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions.

Methods: Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED.

Differential survival for men and women from out-of-hospital cardiac arrest varies by age: results from the OPALS study.

Background: The effect of sex on survival in out-of-hospital cardiac arrest (OHCA) is controversial. Some studies report more favorable outcomes in women, while others suggest the opposite, citing disparities in care. Whether sex predicts differential age-specific survival is still uncertain.

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice.

Objective: To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE).

Methods: An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs.

The relationship between out-of-hospital airway management and outcome among trauma patients with Glasgow Coma Scale Scores of 8 or less.

Background: Airway management remains a fundamental component of optimal care of the severely injured patient, with endotracheal intubation representing the definitive strategy for airway control. However, multiple studies document an association between out-of-hospital intubation and increased mortality for severe traumatic brain injury.

Objectives: To explore the relationship between out-of-hospital intubation attempts and outcome among trauma patients with Glasgow Coma Scale (GCS) scores ≤ 8 across sites participating in the Resuscitation Outcomes Consortium (ROC).

A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments.

Background: The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments.

Methods: We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites.

The impact of delays to admission from the emergency department on inpatient outcomes.

Background: We sought to determine the impact of delays to admission from the Emergency Department (ED) on inpatient length of stay (LOS), and IP cost.

Methods: We conducted a retrospective analysis of 13,460 adult (>or= 18 yrs) ED visits between April 1 2006 and March 30 2007 at a tertiary care teaching hospital with two ED sites in which the mode of disposition was admission to ICU, surgery or inpatient wards. We defined ED Admission Delay as ED time to decision to admit > 12 hours.

Survival after application of automatic external defibrillators before arrival of the emergency medical system: evaluation in the resuscitation outcomes consortium population of 21 million.

Objectives: The purpose of this study was to assess the effectiveness of contemporary automatic external defibrillator (AED) use.

Background: In the PAD (Public Access Defibrillation) trial, survival was doubled by focused training of lay volunteers to use an AED in high-risk public settings.

Methods: We performed a population-based cohort study of persons with nontraumatic out-of-hospital cardiac arrest before emergency medical system (EMS) arrival at Resuscitation Outcomes Consortium (ROC) sites between December 2005 and May 2007.

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.

Objective: To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments.

Design: Matched pair cluster randomised trial.

Setting: University and community emergency departments in Canada.

Physician workload and the Canadian Emergency Department Triage and Acuity Scale: the Predictors of Workload in the Emergency Room (POWER) Study.

Introduction: The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a 5-level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). To determine emergency physician (EP) workload and staffing needs, many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level. The purpose of our study was to describe the distribution of EP time by activity during a shift in order to estimate the amount of time required by an EP to assess and treat patients in each triage category and to determine the variability in the distribution of CTAS scoring between hospital sites.

Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers.

Study Objective: To identify any association between out-of-hospital transport interval and survival to hospital discharge in victims of out-of-hospital cardiac arrest.

Methods: Data from the Ontario Prehospital Advanced Life Support Study (January 1, 1991, to December 31, 2002), an Utstein-compliant registry of out-of-hospital cardiac arrest patients from 21 communities, were analyzed. Logistic regression identified factors that were independently associated with survival in consecutive adult, nontraumatic, out-of-hospital cardiac arrest patients and in the subgroup with return of spontaneous circulation.

Comparison of the Cerebral Performance Category score and the Health Utilities Index for survivors of cardiac arrest.

Study Objective: The Cerebral Performance Category score is an easy to use but unvalidated measure of functional outcome after cardiac arrest. We evaluate the comparability of results from the Cerebral Performance Category scale versus those of the validated but more complex Health Utilities Index scale for health-related quality of life.

Methods: This prospective substudy of the Ontario Prehospital Advanced Life Support (OPALS) Study included adult out-of-hospital cardiac arrest patients treated in 20 cities.

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.

Context: Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists.

The University of Michigan Student Health Physics Society's Radiation and Health Physics World Wide Web Site.

The University of Michigan Student Health Physics Society's (UMSHPS) Radiation and Health Physics World Wide Web Site is an informative database of radiation and health physics related topics. With over 1,000 visitors each day, the UMSHPS web site provides professionals and the general public with a valuable resource for information and research. Users of this site can either search for information by topic or submit questions directly to the qualified members the national Health Physics Society.

Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments.

Study Objective: We evaluate the accuracy, reliability, and potential impact of the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria for cervical spine radiography, when applied in Canadian emergency departments (EDs).

Methods: The Canadian C-Spine Rule derivation study was a prospective cohort study conducted in 10 Canadian EDs that recruited alert and stable adult trauma patients. Physicians completed a 20-item data form for each patient and performed interobserver assessments when feasible.

The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.

Background: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance.

Methods: We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition.

Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis.

Background: Several diagnostic strategies using ultrasound imaging, measurement of D-dimer, and assessment of clinical probability of disease have proved safe in patients with suspected deep-vein thrombosis, but they have not been compared in randomized trials.

Methods: Outpatients presenting with suspected lower-extremity deep-vein thrombosis were potentially eligible. Using a clinical model, physicians evaluated the patients and categorized them as likely or unlikely to have deep-vein thrombosis.

The Canadian C-spine rule performs better than unstructured physician judgment.

Study Objectives: We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule.

Methods: This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck.

Outpatient oral prednisone after emergency treatment of chronic obstructive pulmonary disease.

Background: In this randomized, double-blind, placebo-controlled trial, we studied the effectiveness of prednisone in reducing the risk of relapse after outpatient exacerbations of chronic obstructive pulmonary disease (COPD).

Methods: We enrolled 147 patients who were being discharged from the emergency department after an exacerbation of COPD and randomly assigned them to 10 days of treatment with 40 mg of oral prednisone once daily or identical-appearing placebo. All patients received oral antibiotics for 10 days, plus inhaled bronchodilators.

Transport refusal by hypoglycemic patients after on-scene intravenous dextrose.

Objectives: Administration of intravenous (IV) dextrose to hypoglycemic patients is delegated to advanced care paramedics in Ontario. Following a quality assurance review, which revealed that 47% of patients refused transport after receiving IV dextrose, the authors studied whether such patients seek additional medical care in the three days following the initial refusal.

Methods: Sequential ambulance call reports for on-scene treatments of hypoglycemia were examined, and a standardized telephone survey of the patients was conducted.