Postthrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling, and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT have been shown to reduce the incidence and severity of PTS. The aim of our study was to investigate practices and perceptions of physicians regarding adjunct therapies to anticoagulation in patients diagnosed with lower extremity DVT.

A national online survey was conducted of Canadian emergency medicine staff physicians and residents (n=471) to investigate their attitudes toward the prescription of ECS post-diagnosis of DVT. A paper survey of patients in a thrombosis clinic (n=58) was also administered to better understand the patient experiences with ECS.

The majority of staff physician (62%) and resident (69%) respondents were unsure of whether ECS were effective in preventing PTS and managing venous symptoms. Only 6% of staff physicians and 7% of residents routinely prescribed ECS for above-knee DVTs. More than 78% of respondents were unsure about the optimal timing of initiation of ECS and duration of therapy. Although all patients noted symptomatic relief with ECS, only 50% were prescribed stockings by an emergency or family doctor, and 69% of those patients wore the stockings on a daily basis. Staff physicians most frequently identified poor fit as the reason for lack of patient compliance, whereas patients most frequently cited cost.

Our findings suggest that there is variability in practice among Canadian emergency medicine physicians and trainees and a need for widespread education regarding the latest evidence of the benefit of ECS after DVT.

Elderly patients often present to the emergency department (ED) with non-specific complaints. Previous studies indicate that such patients are at greater risk for life-threatening illnesses than similarly aged patients with specific complaints. We evaluated the diagnoses and outcomes of elderly patients presenting with non-specific complaints.

Two trained data abstractors independently reviewed all records of patients over 70 years old presenting (to two academic EDs) with non-specific complaints, as defined by the Canadian Emergency Department Information System (CEDIS). Outcomes of interest were ED discharge diagnosis, hospital admission, length of stay, and ED revisit within 30 days.

Of the 743 patients screened for the study, 265 were excluded because they had dizziness, vertigo, or a specific complaint recorded in the triage notes. 419 patients (87.7%) presented with weakness and 59 patients (12.3%) presented with general fatigue or unwellness. The most common diagnoses were urinary tract infection (UTI) (11.3%), transient ischemic attack (TIA) (10.0%), and dehydration (5.6%). There were 11 hospital admissions with median length of stay of five days. Eighty-one (16.9%) patients revisited the ED within 30 days of discharge. Regression analysis indicated that arrival to the ED by ambulance was independently associated with hospital admission.

Our results suggest that elderly patients presenting to the ED with non-specific complaints are not at high risk for life-threatening illnesses. The most common diagnoses are UTI, TIA, and dehydration. Most patients can be discharged safely, although a relatively high proportion revisit the ED within 30 days.

There are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury.

After a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman’s Tailored Design Method.

Of 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks.

A drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.

Given the recent publication of several large trials and systematic reviews, we undertook a study of the current management of bronchiolitis in Canadian pediatric emergency departments (EDs) and explored physicians’ rationale for their treatment decisions. The overarching purpose of this study was to assist in planning a future trial of combined epinephrine and dexamethasone for bronchiolitis.

Physicians in the Pediatric Emergency Research Canada (PERC) database received an 18-item electronic survey. A modified Dillman method was used.

Of the 271 physicians surveyed, 191 (70.1%) responded. The majority (120 of 271; 66.5%) reported ‘‘typically’’ giving a bronchodilator trial in the ED, with respondents almost evenly divided between treatment with salbutamol (n=62) and treatment with epinephrine (n=61). Of those who use salbutamol, 77.4% indicated that they prefer it because it can be prescribed for home use. Of those who use epinephrine, 80.3% indicated that they believe the medical literature supports its benefit over salbutamol. Few participants (2.6%) reported ‘‘always’’ using steroids, whereas the majority (62.8%) reported ‘‘sometimes’’ using them. The most common factor reported to influence steroid use was illness severity (73.3%). The majority (60.5%) reported that if corticosteroids were beneficial in bronchiolitis, they prefered treatment with a single dose in the ED as opposed to a multiday course.

Our results indicate that physicians practicing in Canadian pediatric EDs commonly use bronchodilators to manage bronchiolitis but use corticosteroids less commonly. They appear to be uncomfortable using corticosteroids, particularly longer courses, and have a stated preference for a single dose. Any future trial examining the role of corticosteroids in bronchiolitis should carefully consider the issue of steroid dosage.

Paroxysmal supraventricular tachycardia (SVT) is a common dysrhythmia treated in the prehospital setting. Emergency medical service (EMS) agencies typically require patients treated for SVT to be transported to the hospital. This retrospective cohort study evaluated the impact, paramedic adherence, and patient re-presentation rates of a treat-and-release (T+R) protocol for uncomplicated SVT.

Data were linked from the Alberta Health Services EMS electronic patient care record (EPCR) database for the City of Calgary to the Regional Emergency Department Information System (REDIS). All SVT patients treated by EMS between September 1, 2010, and September 30, 2012, were identified. Databases were queried to identify re-presentations to EMS or an emergency department (ED) within 72 hours of T+R.

There were 229 confirmed SVT patient encounters, including 75 T+R events. Of these 75 T+R events, 10 (13%, 95% confidence interval [CI] [7.4, 23]) led to an EMS re-presentation within 72 hours, and 4 (5%, 95% CI [2.1, 13]) led to an ED. All re-presentations were attributed to a single individual. After excluding 15 records that were incomplete due to limitations in the EPCR platform, 43 of 60 (72%) T+R encounters met all protocol criteria for T+R.

The T+R protocol evaluated in this study applied to a significant proportion of patients presenting to EMS with SVT. Risk of re-presentation following T+R was low, and paramedic protocol adherence was reasonable. T+R appears to be a viable option for uncomplicated SVT in the prehospital setting.

Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one’s peers provides a de facto standard.

A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient- and provider-level factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge.

All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively.

Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

Emergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.

A retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.

From 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.

Better performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.

Fast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.

A daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).

WT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.

Implementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

To determine the sensitivity and specificity of clinical and laboratory signs for the diagnosis of septic arthritis (SA).

This prospective study included all adult patients with suspected SA seen in the emergency department or rheumatology department at the University Hospital, Clermont-Ferrand, France, over a period of 18 months.

In total, 105 patients with suspected SA were included, 38 (36%) presenting with SA (29 [28%] with bacteriologically documented SA). In the univariate analysis, chills (p=0.015), gradual onset (p=0.04), local redness (p=0.01), as well as an entry site for infection (p=0.01) were most often identified in SA. A history of crystal-induced arthritis (p=0.004) was more frequent in non-SA cases. An erythrocyte sedimentation rate (ESR)>50 mm (p=0.005), a C-reactive protein (CRP) level >100 mg/L (p=0.019), and radiological signs suggestive of SA (p=0.001) were more frequent in the SA cases. Synovial fluid appearance: purulent (p<0.001) and clear (p=0.007), synovial white blood cell (WBC) count >50,000/μL (p < 0.001), differentiated between SA and non-SA.

In multivariate analysis, only chills (odds ration [OR]=4.7, 95% confidence interval [CI] 1.3–17.1), a history of crystal-induced arthritis (OR=0.09, 95% CI 0.01–0.9), purulent appearance of the joint fluid (OR=8.4, 95% CI 2.4–28.5), synovial WBC count >50,000/mm3 (OR=6.8, 95% CI 1.3–36), and radiological findings (OR=7.1, 95% CI 13–37.9) remained significant.

No clinical sign or laboratory test (excluding bacteriological test), taken alone, is conclusive for the differentiation between SA and non-SA, but the association of several signs, notably chills, history of crystal-induced arthritis, radiological findings, and the appearance and cellularity of joint fluid may be suggestive.

To determine the influence of early pain relief for patients with suspected appendicitis on the diagnostic performance of surgical residents.

A prospective randomized, double-blind, placebo-controlled trial was conducted for patients with suspected appendicitis. The patients were randomized to receive placebo (normal saline intravenous [IV]) infusions over 5 minutes or the study drug (morphine 5 mg IV). All of the clinical evaluations by surgical residents were performed 30 minutes after administration of the study drug or placebo. After obtaining the clinical probability of appendicitis, as determined by the surgical residents, abdominal computed tomography was performed. The primary objective was to compare the influence of IV morphine on the ability of surgical residents to diagnose appendicitis.

A total of 213 patients with suspected appendicitis were enrolled. Of these patients, 107 patients received morphine, and 106 patients received placebo saline. The negative appendectomy percentages in each group were similar (3.8% in the placebo group and 3.2% in the pain control group, p=0.62). The perforation rates in each group were also similar (18.9% in the placebo group and 14.3% in the pain control group, p=0.75). Receiver operating characteristic analysis revealed that the overall diagnostic accuracy in each group was similar (the area under the curve of the placebo group and the pain control group was 0.63 v. 0.61, respectively, p=0.81).

Early pain control in patients with suspected appendicitis does not affect the diagnostic performance of surgical residents.

Emergency medical services (EMS) programs, which provide an alternative to traditional EMS dispatch or transport to the emergency department (ED), are becoming widely implemented. This scoping review identified and catalogued all outcomes used to measure such alternative EMS programs.

Broad systematized bibliographic and grey literature searches were conducted.

Inclusion criteria were 911 callers/EMS patients, reported on alternatives to traditional EMS dispatch OR traditional EMS transport to the ED, and reported an outcome measure.

The reports were categorized as either alternative to dispatch or to EMS transport, and outcome measures were categorized and described.

The bibliographic search retrieved 13,215 records, of which 34 articles met the inclusion criteria, with an additional 10 added from reference list hand-searching (n=44 included). In the grey literature search, 31 websites were identified, from which four met criteria and were retrieved (n=4 included). Fifteen reports (16 studies) described alternatives to EMS dispatch, and 33 reports described alternatives to EMS transport. The most common outcomes reported in the alternatives to EMS dispatch reports were service utilization and decision accuracy. Twenty-four different specific outcomes were reported. The most common outcomes reported in the alternatives to EMS transport reports were service utilization and safety, and 50 different specific outcomes were reported.

Numerous outcome measures were identified in reports of alternative EMS programs, which were catalogued and described. Researchers and program leaders should achieve consensus on uniform outcome measures, to allow benchmarking and improve comparison across programs.

Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences.

Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema.

Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5–20 mL/kg) and length of time boluses should be administered (20–120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration.

This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

Goal-directed point-of-care ultrasound (PoCUS) protocols have been shown to improve the diagnostic accuracy of the initial clinical assessment of the critically ill patient. The diagnostic impact of the Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) protocol was assessed in simulated emergency medical scenarios.

Following a focused PoCUS training program, the diagnostic accuracy, confidence, and precision of 12 medical learners participating in standardized scenarios were tested using high-fidelity clinical and ultrasound simulators. Participants were assessed during 72 simulated cardiorespiratory scenarios. Differential diagnoses were collected from participants before and after PoCUS in each scenario, and confidence surveys were completed. Data were analysed using R software.

Prior to PoCUS, 45 (62.5%) correct primary diagnoses were made compared with 64 (88.9%) following PoCUS (χ2=14, 1df, p=0.0002). PoCUS was also shown to increase participants’ confidence in their diagnoses. The mean confidence in diagnosis score pre-PoCUS was 52.2 (SD=14.7), whereas post-PoCUS it was 81.7 (SD=9.5). The estimated difference in means (−28.36) was significant (t=−7.71, p<0.0001). Using PoCUS, participants were further able to narrow their differential diagnoses. The median number of diagnoses for each patient pre-PoCUS was 3.5 (interquartile range [IQR]=3.8, 3.0) with a median of 2.3 (IQR=2.9,1.5) diagnoses post-PoCUS. The difference was significant (W=0, p<0.001).

This pilot study suggests that, in medical learners newly competent in PoCUS, the addition of an ACES PoCUS protocol to standard clinical assessment improves diagnostic accuracy, confidence, and precision in simulated cardiorespiratory scenarios. This is consistent with clinical studies and supports the use of ultrasound during medical simulation.

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives.

An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010.

During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population.

Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a “learning organization” and improve both efficacy and safety of first aid care.

By the end of residency training, pediatric emergency medicine (PEM) residents are expected to have developed the confidence and abilities required to manage acutely ill children. Acquisition of competence requires exposure and/or supplemental formal education for critical and noncritical medical clinical presentations. Simulation can provide experiential learning and can improve trainees’ knowledge, skills, and attitudes. The primary objective of this project was to identify the content for a simulation-based national curriculum for PEM training.

We recruited participants for the Delphi study by contacting current PEM program directors and immediate past program directors as well as simulation experts at all of the Canadian PEM fellowship sites. We determined the appropriate core content for the Delphi study by combining the PEM core content requirements of the Royal College of Physicians and Surgeons of Canada (RCPSC) and the American Board of Pediatrics (ABP). Using the Delphi method, we achieved consensus amongst the national group of PEM and simulation experts. The participants completed a three-round Delphi (using a four-point Likert scale).

Response rates for the Delphi were 85% for the first round and 77% for second and third rounds. From the initial 224 topics, 53 were eliminated (scored <2). Eighty-five topics scored between 2 and 3, and 87 scored between 3 and 4. The 48 topics, which were scored between 3.5 and 4.0, were labeled as “key curriculum topics.”

We have iteratively identified a consensus for the content of a national simulation-based curriculum.

To meet a critical and growing need for a standardized approach to emergency point of care ultrasound (PoCUS) worldwide, emergency physicians must be trained to deliver and teach this skill in an accepted and reliable format. Currently, there is no globally recognized, standard PoCUS curriculum that defines the accepted applications, as well as standards for training and practice of PoCUS by specialists and trainees in emergency medicine. To address this deficit, the International Federation for Emergency Medicine (IFEM) convened a sub-committee of international experts in PoCUS to outline a curriculum for training of specialists in emergency PoCUS. This curriculum document represents the consensus of recommendations by this sub-committee. The curriculum is designed to provide a framework for PoCUS education in emergency medicine.

The focus is on the processes required to select core and enhanced applications, as well as the key elements required for the delivery of PoCUS training from introduction through to continuing professional development and skill maintenance. It is designed not to be prescriptive but to assist educators and emergency medicine leadership to advance PoCUS education in emergency medicine no matter the training venue. The content of this curriculum is relevant not just for communities with mature emergency medicine systems but in particular for developing nations or for nations seeking to develop PoCUS training programs within the current educational structure. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational environment, resources and goals of educational programs.

Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism.

This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism.

We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0).

In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.