Emergency physicians' attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort.

OBJECTIVES: To determine Canadian emergency physicians' estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment. METHODS: 300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (approximately 2 hour) assessment. RESULTS: Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease. CONCLUSIONS: Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.

The NARC (nonsteroidal anti-inflammatory in renal colic) trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial.

OBJECTIVES: Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity. METHODS: This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18-65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25-50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes. RESULTS: Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%-75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%-83%) achieved successful pain relief at 60 minutes (p value for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p = 0.001). CONCLUSIONS: In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment.

Violence in the emergency department: a survey of health care workers.

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.

Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose.

OBJECTIVE: To determine whether naloxone administered i.v. to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (s.q.). METHODS: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate > or =10 breaths/min, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg i.v. (n = 74) or naloxone 0.8 mg s.q. (n = 122), for respiratory depression of <10 breaths/min. RESULTS: Mean interval from crew arrival to respiratory rate > or =10 breaths/min was 9.3 +/- 4.2 min for the i.v. group vs 9.6 +/- 4.58 min for the s.q. group (95% CI of the difference -1.55, 1.00). Mean duration of bag-valve-mask ventilation was 8.1 +/- 6.0 min for the i.v. group vs 9.1 +/- 4.8 min for the s.q. group. Cost of materials for administering naloxone 0.4 mg i.v. was $12.30/patient, compared with $10.70/patient for naloxone 0.8 mg s.q. CONCLUSION: There was no clinical difference in the time interval to respiratory rate > or =10 breaths/min between naloxone 0.8 mg s.q. and naloxone 0.4 mg i.v. for the out-of-hospital management of patients with suspected opioid overdose. The slower rate of absorption via the s.q. route was offset by the delay in establishing an i.v.

Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?

Previous studies have suggested that most emergency department (ED) patients who leave without being seen by a physician (LWBS) are nonurgent. Our institution developed a fast-track process to reduce length of stay (LOS) for these patients. The present study was conducted to determine the effect of reducing LOS on the number of ED patients who leave without seeing a physician and the acuity of this subset of ED patients. We retrospectively audited, at a tertiary care teaching hospital, the number of LWBS patients and their triage status over two 1-mo periods. These sampling periods corresponded to immediately before and after implementation of five solutions developed by a continuous quality improvement (CQI) process to facilitate patient flow through the triage and fast-track areas of our ED. Before the CQI process was begun, 2.4% of patients (110/4553) left without being seen in a 1-mo study period. Of these, 82 were nonurgent and 28 were urgent. After implementation of the CQI process, 1.1% of patients (51/4514) left without being seen. Of these, 35 were nonurgent and 16 were urgent. There was a significant decrease in the LWBS proportion after the CQI process was implemented. We conclude that (1) reducing LOS is associated with a decrease in the number of ED patients who leave without seeing a physician and (2) many patients who leave without being seen are classified as urgent at presentation.

Mortality and morbidity associated with the distribution of monthly welfare payments.

OBJECTIVE: The impact of major social policy decisions on community health is rarely considered or analyzed. This article describes the association of major community and health resource use in relation to the distribution of monthly welfare payments. METHODS: A descriptive, retrospective study was performed using existing accessible databases in the city of Vancouver, British Columbia (BC), and St. Paul's Hospital, a tertiary care, downtown institution. The mean numbers of admissions or responses per week and per day related to the monthly welfare check issue day in 1993 were collected from the following health agencies: the BC Ambulance Service, the Vancouver Fire Department, the BC Coroner's Office, the Vancouver Detox Center, the Vancouver City Police Jail for public drunkenness, and St. Paul's Hospital ED. RESULTS: Comparison of weekly events for non-payweeks vs the week starting on welfare payday (mean +/- SD) are; St. Paul's ED, 949 +/- 51 vs 993 +/- 81 (p = 0.10); Detox Center observation admissions, 29 +/- 5.6 vs 40 +/- 7.3 (p < 0.001); Vancouver Fire Department medical responses, 453 +/- 44 vs 527 +/- 45 (p < 0.001); BC Ambulance Service responses, 3,338 +/- 101 vs 3,634 +/- 85 (p < 0.001); and coroner-reported deaths, 8.8 +/- 3.0 vs 13.6 +/- 2.6 (p < 0.0001). CONCLUSIONS: As measured in multiple independent databases, there is a significant increase in morbidity and mortality in the week after the distribution of monthly welfare paychecks.

Continuous quality improvement reduces length of stay for fast-track patients in an emergency department.

OBJECTIVE: To demonstrate how continuous quality improvement (CQI) can identify rational and effective means to reduce length of stay for minor illness/injury in an ED. METHODS: A CQI team documented the process of fast-track (FT) patient flow and prioritized the causes of delay. In Phase I, two solutions were implemented. In this Phase II of the study, three changes were implemented, including expansion of the FT area, realignment to provide a full-time FT nurse, and a detailed, stricter triage classification. The outcome was assessed by examining the interval from presentation to release from the ED (length of stay; LOS). Differences were ascertained by analysis variance for consecutive FT patients not requiring radiography, ECG, or blood testing. Intervals from three pre-Phase II intervention 48-hour periods and one post-Phase II intervention 48-hour period were analyzed. RESULTS: Before the Phase I changes, the mean +/- SD LOS was 92 +/- 46 min. After the Phase I changes, the LOS was 67 +/- 31 min. After the Phase II changes, this was reduced to 57 +/- 34 min (p < 0.05). CONCLUSION: The formal application of CQI techniques in the ED can change patient flow and reduce LOS for FT patients.

Use of continuous quality improvement to facilitate patient flow through the triage and fast-track areas of an emergency department.

Application of Continuous Quality Improvement techniques can identify (a) major causes of delay in evaluation and treatment of ambulatory patients in an Emergency Department (ED) and (b) rational solutions to reduce those delays. To confirm this hypothesis, a prospective interventional study was conducted at a tertiary care teaching hospital with 50,000 emergency visits per year. Participants included all patients discharged from the ED in three separate time periods. A formal continuous quality improvement process was used to document the current process of ambulatory care patient flow and prioritize the causes of delay. Solutions were defined and presented to the hospital administration. Two solutions were implemented immediately. The effect of these changes was assessed by comparing the time interval from presentation to discharge from the ED (length of stay) and the time interval from presentation to generation of a chart (chart generation). These differences were compared by analysis of variance on consecutive patients seen in a 48-hour control period and two postintervention 48-hour periods. The interventions that were identified and immediately implemented were the addition of an admission clerk and the reduction of the Fast-Track nurse function to include only patient placement and vital signs. The length of stay for all patients was significantly reduced from a mean of 163 +/- 170 min to 115 +/- 86 and 122 +/- 105 min in two separate postintervention 48-hour samples. The mean length of stay for Fast-Track patients not requiring X-ray, electrocardiogram, or blood tests was 92 +/- 46 min. After the intervention, this was reduced to 73 +/- 46 and 67 +/- 31 min in the same two 48-hour samples. Chart generation times were significantly reduced from a mean of 21 +/- 18 min to 8 +/- 6 min. We conclude that the formal application of Continuous Quality Improvement techniques in the Emergency Department can result in appropriate changes in the process of patient flow, leading to measurable and significant reductions in length of stay for Fast-Track patients.

The new American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care: presented by the Emergency Cardiac Care Subcommittee of the Heart and Stroke Foundation of Canada.

CPR courses (both basic and advanced) continue to evolve. The recent CPR and ECC guidelines by the AHA consolidate the research and vast experience in one document. These guidelines are helpful to lay people and health care professionals who intervene in cases of cardiac arrest. They are also excellent resources for those involved in coordinating ECC systems in the community.

Abdominal compressions during CPR: hemodynamic effects of altering timing and force.

To determine the optimal method of applying abdominal compressions during cardiopulmonary resuscitation (CPR), 3 levels of pressure (25, 50, and 100 torr) were applied to the abdomen a) continuously and b) as 500 msec pulses at 10 different phases during the CPR cycle in 8 anesthetized dogs. Thoracic aortic (Ao) and right atrial (RA) pressures were measured and PAo-PRA was calculated as the coronary perfusion gradient. A pneumatic piston device provided external chest compression (60/min, 120 lbs, for 50% of the cycle) and ventilation (80% O2, 12/min, at 20cm, H2O). Another identical device provided abdominal compression (AC) via an air-filled bladder. High-pressure (100 torr) AC applied for 500 msec commencing 200 msec prior to chest compression demonstrated the best overall profile, raising mean aortic pressure 26 torr (P less than 0.001) and peak coronary perfusion gradient pressure 17 torr (P less than 0.02) from control values during standard CPR of 58 and 41 torr, respectively. We conclude that applying high-pressure, 500-msec pulses of AC 200 msec before chest compressions significantly improves CPR hemodynamics.

A non-linear programming method for optimizing parallel-hole collimator design.

A new method for optimizing the design of multi-aperture parallel-hole collimators for the gamma scintillation camera is presented. The method takes into account the frequency spectrum of a plane source object distribution as well as the energy of the radiation. A frequency dependent statistical figure of merit is calculated and combined with a weighted object distribution frequency spectrum to obtain an objective function which, when maximized, yields the optimum collimator design according to the chosen criteria. The optimization is performed by means of a sequential pattern search technique. The results show a positive correlation between te objective function and an experimental performance index evaluated for existing collimators. The optimal designs obtained by maximizing the objective function, under the assumption of no scatter within the source, exhibit somewhat higher sensitivity and lower resolution than the commercial low energy collimators tested. It is concluded that much of the resolution capability of very high resolution collimators is unused because of the limitation imposed by the intrinsic resolution of the detector assembly.