Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments.

OBJECTIVE: To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample. DESIGN: A prospective observational cohort study was conducted in 3 Canadian hospitals. SETTING: Emergency Department. PATIENTS: Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited. INTERVENTIONS: Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected. MAIN OUTCOME MEASURES: Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge. RESULTS: Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms. CONCLUSION: Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions.

A prospective study of patients with low back pain attending a Canadian emergency department: Why they came and what happened?

Low back pain is a common presentation to emergency departments, but the reasons why people choose to attend the emergency department have not been explored. We aimed to fill this gap with this study to understand why persons with low back pain choose to attend the emergency department. Between July 4, 2017 and October 1, 2018, consecutive patients with a complaint of low back pain presenting to the University of Alberta Hospital emergency department were screened. Those enrolled completed a 13-item questionnaire to assess reasons and expectations related to their presentation. Demographics, acuity and disposition were obtained electronically. Factors associated with admission were examined in a logistic regression model. After screening 812 patients, 209 participants met the study criteria. The most common Canadian Triage and Acuity Scale score was 3 (73.2%). Overall, 37 (17.7%) received at least one consultation, 89.0% of participants were discharged home, 9.6% were admitted and 1.4% were transferred. Participants had a median pain intensity of 8/10 and a median daily functioning of 3/10. When asked, 64.6% attended for pain control while 44.5% stated ease of access. Most participants expected to obtain pain medication (67%) and advice (56%). Few attended because of cost savings (3.8%). After adjustment, only advanced age and ambulance arrival were significantly associated with admission. In conclusion, most low back pain patients came to the emergency department for pain control yet few were admitted and the majority did not receive a consultation. Timely alternatives for management of low back pain in the emergency department appear needed, yet are lacking.

A Prospective Evaluation of the Influence of an Electronic Clinical Practice Guidelines on Concussion Patients' Future Activities and Outcomes.

BACKGROUND: Patients with mild traumatic brain injury or concussion commonly present to the emergency department for assessment; providing patients with information on usual symptoms and their progression may encourage faster recovery. OBJECTIVES: This study aimed to document the role of an electronic clinical practice guideline (eCPG) patient handout on concussion recovery in adult patients discharged from the hospital. METHODS: A prospective cohort study was carried out in 3 Canadian urban emergency departments. Adults (≥17 years of age) with a Glasgow Coma Scale score of 13 to 15 who sustained a concussion were recruited by on-site research assistants. Physician use of a concussion-specific eCPG was documented from physician and patient reports. Patient follow-up calls at 30 and 90 days documented return to work/school activities and patient symptoms. Multivariate analyses were performed using logistic regression methods. RESULTS: Overall, 250 patients were enrolled; the median age was 35 (interquartile range 23-49) and 52% were female. Approximately half (n = 119, 48%) of patients received the eCPG handout, and return to work/school recommendations varied. Symptoms persisted in 60% of patients at 30 days; patients in the eCPG group had fewer symptoms (odds ratio 0.57, 95% confidence interval 0.33-0.99). At 90 days, 40% of patients reported persistent symptoms, with no significant difference between groups. CONCLUSION: An eCPG handout improved patients' short-term outcomes; however, physician use and adherence to guideline recommendations was low. To further facilitate physician compliance and therefore patient recovery, barriers to use of the eCPG handout need to be identified and addressed.

Concussion diagnoses among adults presenting to three Canadian emergency departments: Missed opportunities.

OBJECTIVES: Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population. METHODS: Patients >17years old presenting meeting the World Health Organization's definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi-variable comparisons are reported using chi-square tests, t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. RESULTS: Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty-one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR=0.71; 95% CI: 0.60 to 0.83), presenting to the non-academic centers (Hospital 2: OR=0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR=0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR=0.11; 95% CI: 0.03 to 0.46). CONCLUSION: One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion.

The impact of consultation on length of stay in tertiary care emergency departments.

BACKGROUND: Consultations in the emergency department (ED) are infrequently studied. This study quantifies the contribution of consultations to ED length of stay (LOS) and examines patient and consultation characteristics associated with prolonged ED LOS. METHODS: Prospective cohort study of a convenience sample of shifts by volunteering emergency physicians (EP) at two urban tertiary care Canadian EDs. EPs completed standardised forms on all patients for whom a consultation was requested. Medical chart reviews and secondary analyses of administrative databases were also performed. Factors associated with longer LOS were determined through linear regression modelling. RESULTS: 1180 patients received at least one consultation during study shifts and EPs completed data collection on 841 (71%) of these. Median patient age was 54 years, 53.3% were male, and 2.9% had documented dementia. Admitted patients receiving consultations had a longer overall LOS compared to discharged patients. Median time from triage to consultation request accounted for approximately 28% of the total median LOS in admitted patients compared to 46% for discharged patients. Consultation decision time accounted for 33% and 54% of the LOS for admitted and discharged patients, respectively. Linear regression modelling revealed that advanced age, longer latency between arrival and first consultation request, history of dementia and multiple consultations were significantly associated with longer LOS. Conversely, undergoing procedures while in the ED was associated with a shorter LOS. CONCLUSIONS: Consultation decision time contributes significantly to ED LOS. Further efforts are needed to validate these results in other ED settings and improve this aspect of ED throughput.

Short-term effects of ambient air pollution on stroke: who is most vulnerable?

Several studies have demonstrated positive associations between day-to-day increases in air pollution and stroke. These findings have been inconsistent, and the influence of patient characteristics has been largely ignored. In this study, we investigated the short-term effects of air pollution on stroke using a time-stratified case-crossover design. Data for hospital visits for stroke were extracted from 5927 medical charts of patients who presented to emergency departments between 2003 and 2009 in Edmonton, Canada. Daily concentrations of five air pollutants (NO(2), PM (2.5), CO, O(3), and SO(2)) were obtained from fixed-site monitors. Relative humidity and temperature were obtained from a metrological station operating at the city's airport. Chart data included: disease history, medication use, and smoking status. Conditional logistic regression was used to estimate the odds ratio (OR) of stroke in relation to an increase in the interquartile range for each pollutant. Positive associations were observed between ischemic stroke and air pollution during the 'warm' season (April through September). Specifically, the OR for an increase in 9.4 ppb in the 3-day average of NO(2) was 1.50 (95% CI: 1.12, 2.01). There were no statistically significant associations with any of the other pollutants after adjusting for NO(2) concentrations. Associations with ischemic stroke were stronger for those with a history of stroke (OR=2.31; 95% CI: 1.39, 3.83), heart disease (OR=1.99; 95% CI: 1.20, 3.28), and taking medication for diabetes (OR=2.03; 95% CI: 1.14, 3.59). Temperature was inversely associated with ischemic stroke during the 'warm' season, but no associations were evident with the other stroke subtypes. Air pollution was not associated with hemorrhagic stroke or transient ischemic attacks. The findings suggest that specific patient characteristics modify associations between air pollution and ischemic stroke.