Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.

We conducted a retrospective cohort study comparing 3 clinicians’ determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.

A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss’ Kappa of 0.30 (0.17–0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).

Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.

Our objective was to examine the performance characteristics of a bladder stimulation technique for urine collection among infants presenting to the emergency department (ED).

This prospective cohort study enrolled a convenience sample of infants aged ≤ 90 days requiring urine testing in the ED. Infants were excluded if critically ill, moderately to severely dehydrated, or having significant feeding issues. Bladder stimulation consisted of finger tapping on the lower abdomen with or without lower back massage while holding the child upright. The primary outcome was successful midstream urine collection within 5 minutes of stimulation. Secondary outcomes included sample contamination, bladder stimulation time for successful urine collection, and perceived patient distress on a 100-mm visual analog scale (VAS).

We enrolled 151 infants and included 147 in the analysis. Median age was 53 days (interquartile range [IQR] 27–68 days). Midstream urine sample collection using bladder stimulation was successful in 78 infants (53.1%; 95% confidence interval [CI] 45–60.9). Thirty-nine samples (50%) were contaminated. Most contaminated samples (n = 31; 79.5%) were reported as “no significant growth” or “growth of 3 or more organisms”. Median bladder stimulation time required for midstream urine collection was 45 seconds (IQR 20–120 seconds). Mean VAS for infant distress was 22 mm (standard deviation 23 mm).

The success rate of this bladder stimulation technique was lower than previously reported. The contamination rate was high, however most contaminated specimens were easily identified and had no clinical impact.

Acquired methemoglobinemia (MetHb) is an uncommon presentation of cyanosis in the pediatric emergency department (ED), making its diagnosis and management a clinical challenge. Through this case series we hope to improve clinician ability to recognize the potential for MetHb in pediatric ED patients and to avoid overlooking this important cause of cyanosis.

This was a case series using a health records review, investigating patients diagnosed with MetHb at our pediatric ED during 2007–2018. We included only cases with methemoglobin saturation ≥5%.

Ten patients were diagnosed with MetHb in our pediatric ED during the study period. Five had an underlying hematologic disease who received a pharmacologic trigger known to induce MetHb as well (four dapsone, one rasburicase). The other five patients were previously healthy, who presented with a clinical picture of hemolytic anemia, all of whom were diagnosed with previously unknown glucose-6-phosphate dehydrogenase (G6PD) deficiency. Two of the patients received methylene blue, and five patients needed packed red blood cells. All of the patients survived the acute MetHb episode.

Acquired MetHb in the pediatric ED is a rare but important cause of cyanosis. Diagnosis and management of acute, acquired MetHb in the ED requires a high level of suspicion, and a background knowledge of the common precipitants and underlying conditions associated with this condition. We hope this case series will help ED physicians to consider MetHb in pediatric patients presenting with cyanosis and persistent hypoxia. Exposure to known precipitants (e.g., medications and foods), particularly in the setting of active treatment for malignancy or with symptoms of hemolytic anemia should further increase suspicion.

Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.

Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.

Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.

The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

Prognosis and disposition among older emergency department (ED) patients with suspected infection remains challenging. Frailty is increasingly recognized as a predictor of poor prognosis among critically ill patients; however, its association with clinical outcomes among older ED patients with suspected infection is unknown.

We conducted a multicenter prospective cohort study at two tertiary care EDs. We included older ED patients (≥75 years) with suspected infection. Frailty at baseline (before index illness) was explicitly measured for all patients by the treating physicians using the Clinical Frailty Scale (CFS). We defined frailty as a CFS 5–8. The primary outcome was 30-day mortality. We used multivariable logistic regression to adjust for known confounders. We also compared the prognostic accuracy of frailty with the Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure Assessment (qSOFA) criteria.

We enrolled 203 patients, of whom 117 (57.6%) were frail. Frail patients were more likely to develop septic shock (adjusted odds ratio [aOR], 1.83; 95% confidence interval [CI], 1.08–2.51) and more likely to die within 30 days of ED presentation (aOR 2.05; 95% CI, 1.02–5.24). Sensitivity for mortality was highest among the CFS (73.1%; 95% CI, 52.2–88.4), compared with SIRS ≥ 2 (65.4%; 95% CI, 44.3–82.8) or qSOFA ≥ 2 (38.4; 95% CI, 20.2–59.4).

Frailty is a highly prevalent prognostic factor that can be used to risk-stratify older ED patients with suspected infection. ED clinicians should consider screening for frailty to optimize disposition in this population.

1) To characterize mild, moderate, and severe fear of falling in older emergency department (ED) patients for minor injuries, and 2) to assess whether fear of falling could predict falls and returns to the ED within 6 months of the initial ED visit.

This study was part of the Canadian Emergency and Trauma Initiative (CETI) prospective cohort (2011–2016). Patients ages ≥ 65, who were independent in their basic daily activities and who were discharged from the ED after consulting for a minor injury, were included. Fear of falling was measured by the Short Falls Efficacy Scale International (SFES-I) in order to stratify fear of falling as mild (SFES-I = 7-8/28), moderate (SFES-I = 9-13/28), or severe (SFES-I = 14-28/28). Many other physical and psychological characteristics where collected. Research assistants conducted follow-up phone interviews at 3 and 6 months’ post-ED visit, in which patients were asked to report returns to the ED.

A total of 2,899 patients were enrolled and 2,009 had complete data at 6 months. Patients with moderate to severe fear of falling were more likely to be of ages ≥ 75, female, frailer with multiple comorbidities, and decreased mobility. Higher baseline fear of falling increased the risk of falling at 3 and 6 months (odds ratio [OR]-moderate-fear of falling: 1.63, p < 0.05, OR-severe-fear of falling 2.37, p < 0.05). Fear of falling positive predictive values for return to the ED or future falls were 7.7% to 17%.

Although a high fear of falling is associated with increased risk of falling within 6 months of a minor injury in older patients, fear of falling considered alone was not shown to be a strong predictor of return to the ED and future falls.

A significant gap exists between people awaiting solid organ transplantation and solid organ donors. The purpose of this study was to determine whether there were missed donors in the emergency department (ED).

We performed a health records and organ donation database review of all patients dying in a large tertiary ED from November 1, 2014 to October 31, 2017 at two campuses with 160,000 visits per year. Demographic and donor suitability data were collected. The primary outcome was missed potential solid organ donors. Missed potential donors were intubated, had a pulse, and had no donation contraindications. The secondary outcome was cases where no notification was made to the organ donation organization at all.

There were 605 deaths in the ED. Patients had a mean age of 71.1 years, 58.3% were male, and 12.4% died of a traumatic cause. There were 10 missed potential donors. Missed potential donors had a mean age of 67.4 years, 70.0% were male, and 20.0% died from trauma. In all 10 cases, patients had withdrawal of life-sustaining therapy for medical futility, and referral for donation occurred after death. Missed ED donors could have increased hospital-wide donation up to 10.6%. No notification was made in 12 (2.0%) cases; however, none of these would have been successful solid organ donors.

The ED is a source of missed organ donors. All potential donors were missed due to referral after withdrawal of life-sustaining therapy. ED physicians should consider the possibility of solid organ donation prior to the withdrawal of life-sustaining therapy.

It is traditionally taught that the location to place an ultrasound probe to detect a pneumothorax with point-of-care ultrasound (POCUS) is the anterior chest, given the theory that air will collect at the least dependent area in the supine patient. There is a wide variety of scanning protocols with varying accuracy and completeness. We sought to assess the optimal area to scan for diagnosing pneumothorax by mapping the location of traumatic pneumothorax on computed tomography (CT).

Patients were selected after a retrospective cohort of adult patients who presented to a regional trauma center with a pneumothorax diagnosed on CT. Data were extracted using a standardized data collection tool, and 20% of charts were reviewed by two reviewers. Predefined zones were used to map the areas of pneumothoraces. Theoretical sensitivity and 95% confidence intervals (CIs) are reported.

A total of 203 traumatic pneumothoraces were reviewed from 2006 to 2016. The majority of the pneumothoraces were found in an area defined by the para-sternal border and the mid-clavicular line from the inferior aspect of the clavicle to the physiologic lung point (liver on the right, heart on the left). The theoretical sensitivity for pneumothorax of scanning this area was 91.6% (95% CI, 86.9–95%).

This study suggests any POCUS scanning protocol for traumatic pneumothorax should include an area from the inferior border of the clavicle at the parasternal border down to the liver or cardiac lung points and then the mid clavicular line down to the liver or cardiac lung points.

Both 1- and 2-hour rapid diagnostic algorithms using high-sensitivity troponin (hs-cTn) have been validated to diagnose acute myocardial infarction (MI), leaving physicians uncertain which algorithm is preferable. The objective of this study was to prospectively evaluate the diagnostic performance of 1- and 2-hour algorithms in clinical practice in a Canadian emergency department (ED).

ED patients with chest pain had high-sensitivity cardiac troponin-T (hs-cTnT) collected on presentation and 1- and 2-hours later at a single academic centre over a 2-year period. The primary outcome was index MI, and the secondary outcome was 30-day major adverse cardiac events (MACE). All outcomes were adjudicated.

We enrolled 608 patients undergoing serial hs-cTnT sampling. Of these, 350 had a valid 1-hour and 550 had a 2-hour hs-cTnT sample. Index MI and 30-day MACE prevalence was ~12% and 14%. Sensitivity of the 1- and 2-hour algorithms was similar for index MI 97.3% (95% CI: 85.8–99.9%) and 100% (95% CI: 91.6–100%) and 30-day MACE: 80.9% (95% CI: 66.7–90.9%) and 83.3% (95% CI: 73.2–90.8%), respectively. Both algorithms accurately identified about 10% of patients as high risk.

Both algorithms were able to classify almost two-thirds of patients as low risk, effectively ruling out MI and conferring a low risk of 30-day MACE for this group, while reliably identifying high-risk patients. While both algorithms had equivalent diagnostic performance, the 2-hour algorithm offers several practical advantages, which may make it preferable to implement. Broad implementation of similar algorithms across Canada can expedite patient disposition and lead to resource savings.