Using a cascade of care framework to identify gaps in access to medications for alcohol use disorder in British Columbia, Canada.

BACKGROUND AND AIMS: Despite the significant burden of alcohol use disorder (AUD) and availability of safe and effective medications for AUD (MAUD), population-level estimates of access and engagement in AUD-related care are limited. The aims of this study were to generate a cascade of care for AUD in British Columbia (BC), Canada, and to estimate the impacts of MAUD on health outcomes. DESIGN: This was a retrospective population-based cohort study using linked administrative health data. SETTING: British Columbia, Canada, 2015-2019. PARTICIPANTS: Using a 20% random sample of BC residents, we identified 7231 people with moderate-to-severe alcohol use disorder (PWAUD; overall prevalence = 0.7%). MEASUREMENTS: We developed a six-stage AUD cascade (from diagnosis to ≥6 months retention in MAUD) among PWAUD. We evaluated trends over time and estimated the impacts of access to MAUD on AUD-related hospitalizations, emergency department visits and death. FINDINGS: Between 2015 and 2019, linkage to AUD-related care decreased (from 80.4% to 46.5%). However, rates of MAUD initiation (11.4% to 24.1%) and retention for ≥1 (7.0% to 18.2%), ≥3 (1.2% to 4.3%) or ≥6 months (0.2% to 1.6%) increased significantly. In adjusted analyses, access to MAUD was associated with reduced odds of experiencing any AUD-related adverse outcomes, with longer retention in MAUD showing a trend to greater odds reduction: adjusted odds ratio (95% CI) ranging from 0.59 (0.48-0.71) for MAUD retention <1 month to 0.37 (0.21-0.67) for ≥6 months retention. CONCLUSIONS: Access to medications for alcohol use disorder among people with moderate-to-severe alcohol use disorder in British Colombia, Canada increased between 2015 and 2019; however, initiation and retention remained low. There was a trend between longer retention in medications for alcohol use disorder and greater reductions in the odds of experiencing alcohol use disorder-related adverse outcomes.

The Clinical Epidemiology and 30-Day Outcomes of Emergency Department Patients With Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) is associated with increased mortality and dialysis in hospitalized patients but has been little explored in the emergency department (ED) setting. OBJECTIVE: The objective of this study was to describe the risk factors, prevalence, management, and outcomes in the ED population, and to identify the proportion of AKI patients who were discharged home with no renal-specific follow-up. DESIGN: This is a retrospective cohort study using administrative and laboratory databases. SETTING: Two urban EDs in Vancouver, British Columbia, Canada. PATIENTS: We included all unique ED patients over a 1-week period. METHODS: All patients had their described demographics, comorbidities, medications, laboratory values, and ED treatments collected. AKI was defined pragmatically, based upon accepted guidelines. The cohort was then probabilistically linked to the provincial renal database to ascertain renal replacement (transplant or dialysis) and the provincial vital statistics database to obtain mortality. The primary outcome was the prevalence of AKI; secondary outcomes included (1) the proportion of AKI patients who were discharged home with no renal-specific follow-up and (2) the combined 30-day rate of death or renal replacement among AKI patients. RESULTS: There were 1651 ED unique patients, and 840 had at least one serum creatinine (SCr) obtained. Overall, 90 patients had AKI (10.7% of ED patients with at least one SCr, 95% confidence interval [CI], 8.7%-13.1%; 5.5% of all ED patients, 95% CI, 4.4%-6.7%) with a median age of 74 and 70% male. Of the 31 (34.4%) AKI patients discharged home, 4 (12.9%) had renal-specific follow-up arranged in the ED. Among the 90 AKI patients, 11 died and none required renal replacement at 30 days, for a combined outcome of 12.2% (95% CI, 6.5%-21.2%). LIMITATIONS: Sample sizes may be small. Nearly half of ED patients did not obtain an SCr. Many patients did not have sequential SCr testing, and a modified definition of AKI was used.

MISE EN CONTEXTE: L'insuffisance rénale aiguë (IRA) est associée à une mortalité accrue et à un recours plus fréquent à l'hémodialyse chez les patients hospitalisés. Toutefois, l'IRA a très peu été étudiée dans le cadre du service des urgences. OBJECTIF DE L'ÉTUDE: Dresser le portrait des facteurs de risque, de la prévalence, de la prise en charge et des conséquences de l'IRA au sein d'une population de patients admis aux urgences. Établir la proportion de patients atteints d'IRA qui ont par la suite été renvoyés à la maison sans aucun suivi en néphrologie. MODÈLE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective menée à partir des bases de données administratives et de laboratoire des hôpitaux concernés. CADRE DE L'ÉTUDE: L'étude s'est tenue dans deux services d'urgence de Vancouver (CB) au Canada. PARTICIPANTS: Nous avons inclus tous les patients ayant été admis aux urgences au cours d'une période d'une semaine. MÉTHODOLOGIE: Les données démographiques, les comorbidités, la liste des médicaments prescrits, les résultats de laboratoire et les traitements administrés lors du séjour aux urgences ont été colligés pour chacun des participants. L'IRA a été définie avec pragmatisme, conformément aux lignes directrices acceptées. La cohorte a ensuite été couplée de façon probabiliste à la base de données provinciale sur l'insuffisance rénale afin d'évaluer l'incidence de thérapies de remplacement rénal (dialyse ou greffe) et la base de données statistique provinciale pour obtenir le taux de mortalité. Le critère de jugement principal était la prévalence de l'IRA ; les critères de jugement secondaires incluaient la proportion de patients atteints d'IRA retournés à la maison sans prescription de suivi en santé rénale ainsi que le taux combiné de mortalité ou d'établissement d'une thérapie de remplacement rénal à l'intérieur de 30 jours chez ces mêmes patients. RÉSULTATS: Au total, 1 651 patients se sont présentés aux urgences au cours de la période étudiée. Au moins une mesure de la créatinine sérique (SCr) avait été effectuée pour 840 d'entre eux. Dans l'ensemble, 90 patients souffraient effectivement d'IRA, (10,7% des patients avec au moins une mesure de SCr [IC à 95%: 8,7 à 13,1%] ; 5,5% de tous les patients [IC à 95%: 4,4 à 6,7%]). Il s'agissait de patients majoritairement de sexe masculin (70%) et leur âge médian était de 74 ans. Des 31 patients souffrant d'IRA (34,4%) retournés à la maison, on a prévu un suivi en santé rénale pour seulement quatre (12,9%) d'entre eux pendant leur séjour aux urgences. Parmi les 90 patients souffrant d'IRA, 11 sont décédés et aucun n'a eu besoin d'une thérapie de remplacement de la fonction rénale dans les 30 jours suivant la visite aux urgences, ce qui représente un résultat combiné de 12,2% (IC à 95%: 6,5 à 21,2%). LIMITES DE L'ÉTUDE: Le faible échantillonnage et le fait qu'aucune mesure de la SCr n'ait été effectuée pour près de la moitié des patients ayant séjourné aux urgences. De plus, plusieurs patients pour qui on avait procédé à une mesure de la SCr n'ont pas eu de mesure séquentielle, et une définition modifiée de l'insuffisance rénale a été utilisée pour réaliser l'étude.

Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications.

BACKGROUND: There is little data describing the differences in epinephrine (epi) administration and cardiac complications among older and younger patients with anaphylaxis. METHODS: This retrospective cohort study was conducted at two urban emergency departments (ED) over a 5 year-period, and included adults who met a pre-specified criteria for anaphylaxis. Patients ≥50years of age were defined as "older". Univariate logistic regression was performed to compare the difference in frequency of epi administration between the "older" and "younger" groups. Among those who received epi, the proportion of patients who received doses exceeding the recommended maximum and who had pre-specified cardiovascular complications were compared between the two groups, stratified further by route of administration. RESULTS: Of 2995 allergy-related visits, 492 met criteria for anaphylaxis, including 122 (24.8%) older patients. Older patients were less likely to receive epi injection (36.1% vs. 60.5%). Of those who received epi, older patients were more likely to receive excessive dose of epi (7/44, 15.9% vs 2/225, 0.9%, unadjusted OR 20.7, 95% CI 3.8-211.7). Four (4/44, 9.1%) older patients experienced cardiovascular complications, compared to 1/225 (0.4%) in the younger group (unadjusted OR 22.4, 95% CI 2.1-1129.8). When examining only intra-muscular epinephrine, 1/31 older patients had cardiac complications, compared to 1/186 in the younger group. CONCLUSION: Older patients with anaphylaxis were less likely to receive epi injection. Intramuscular epi appears safe in this population; however, the use of intravenous epi should be avoided in older patients due to the potential of developing serious cardiac complications.

External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP).

OBJECTIVE: The emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP) facilitates low-risk ED chest pain patients early to outpatient investigation. We aimed to validate this rule in a North American population. METHODS: We performed a retrospective validation of the EDACS-ADP using 763 chest pain patients who presented to St Paul's Hospital, Vancouver, Canada, between June 2000 and January 2003. Patients were classified as low risk if they had an EDACS <16, no new ischaemia on ECG and non-elevated serial 0-hour and 2-hour cardiac troponin concentrations. The primary outcome was the number of patients who had a predetermined major adverse cardiac event (MACE) at 30 days after presentation. RESULTS: Of the 763 patients, 317 (41.6%) were classified as low risk by the EDACS-ADP. The sensitivity, specificity, negative predictive value and positive predictive value of the EDACS-ADP for 30-day MACE were 100% (95% CI 94.2% to 100%), 46.4% (95% CI 42.6% to 50.2%), 100% (95% CI 98.5% to 100.0%) and 17.5% (95% CI 14.1% to 21.3%), respectively. CONCLUSIONS: This study validated the EDACS-ADP in a novel context and supports its safe use in a North American population. It confirms that EDACS-ADP can facilitate progression to early outpatient investigation in up to 40% of ED chest pain patients within 2 hours.

Potential Candidates for a Structured Canadian ECPR Program for Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Extracorporeal cardiopulmonary resuscitation (ECPR), while resource-intensive, may improve outcomes in selected patients with refractory out-of-hospital cardiac arrest (OHCA). We sought to identify patients who fulfilled a set of ECPR criteria in order to estimate: (1) the proportion of patients with refractory cardiac arrest who may have benefited from ECPR; and (2) the outcomes achieved with conventional resuscitation. METHODS: We performed a secondary analysis from a 52-month prospective registry of consecutive adult non-traumatic OHCA cases from a single urban Canadian health region serving one million patients. We developed a hypothetical ECPR-eligible cohort including adult patients <60 years of age with a witnessed OHCA, and either bystander CPR or EMS arrival within five minutes. The primary outcome was the proportion of ECPR-eligible patients who had refractory cardiac arrest, defined as termination of resuscitation pre-hospital or in the ED. The secondary outcome was the proportion of EPCR-eligible patients who survived to hospital discharge. RESULTS: Of 1,644 EMS-treated OHCA, 168 (10.2%) fulfilled our ECPR criteria. Overall, 54/1644 (3.3%; 95% CI 2.4%-4.1%) who were ECPR-eligible had refractory cardiac arrest. Of ECPR-eligible patients, 114/168 (68%, 95% CI 61%-75%) survived to hospital admission, and 70/168 (42%; 95% CI 34-49%) survived to hospital discharge. CONCLUSION: In our region, approximately 10% of EMS-treated cases of OHCA fulfilled our ECPR criteria, and approximately one-third of these (an average of 12 patients per year) were refractory to conventional resuscitation. The integration of an ECPR program into an existing high-performing system of care may have a small but clinically important effect on patient outcomes.

Speed and accuracy of text-messaging emergency department electrocardiograms from a small community hospital to a provincial referral center.

BACKGROUND: Currently, transmission of electrocardiograms (EKGs) from a small emergency department (ED) to specialists at referral hospitals can be a time-consuming and laborious process. We investigate whether text messaging by use of short message service (SMS) of EKGs from a small hospital to consultants at a large hospital is rapid and accurate. METHODS: This study involved a one-month prospective evaluation of consecutive EKGs recorded in a small community ED. Investigators obtained de-identified photographs of each EKG via a mobile phone camera. Each EKG picture, along with a brief patient clinical history, was sent via SMS to on-call emergency physicians located at a large referral care site. All images were evaluated solely on a mobile phone. The primary outcome was the proportion of SMS that were received within two minutes of being sent. As a secondary outcome, the intra-rater evaluation of the initial EKG and the SMS EKG image were compared on 13 standardized features. The tertiary outcome was cost of text messaging. RESULTS: A total of 298 patients (14.6%) had 409 EKGs performed and a total of 926 SMS were sent. 921 SMS (99.5%, 95% confidence interval (CI) 98.7-99.8%) arrived within two minutes with a median transmission time of nine seconds (interquartile range (IQR) 3-32 s). Between the gold standard original EKG, and the interpretation of the texted image, six out of 409 (1.5%, 95% CI 0.6-3.3%) had any differences recorded, across all 13 categories. Overall, the study cost 4.1 cents per texted image. CONCLUSIONS: Systematic text messaging of ED EKGs from a small community hospital to a referral center is a rapid, accurate, portable, and inexpensive method of data transfer. This may be a safe and effective strategy to communicate vital patient information.

There Are Sex Differences in the Demographics and Risk Profiles of Emergency Department (ED) Patients With Atrial Fibrillation and Flutter, but no Apparent Differences in ED Management or Outcomes.

OBJECTIVES: In non-emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. METHODS: Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. RESULTS: A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = -3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. CONCLUSIONS: Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes.

Characteristics and thirty-day outcomes of emergency department patients with elevated creatine kinase.

OBJECTIVES: Rhabdomyolysis, as defined by an elevation in creatine kinase (CK), may lead to hemodialysis and death in emergency department (ED) patients, but the patient characteristics, associated conditions, and 30-day outcomes of patients with CK values over 1,000 U/L have not been described. METHODS: All consecutive ED patients with serum CK values over 1,000 U/L between January 1, 2006, and December 31, 2008, were retrospectively identified from two urban hospitals. Patient characteristics, ED treatment, and ED discharge diagnoses were determined by medical record review. Provincial databases were linked to identify patients who died or were treated with hemodialysis within 30 days. The primary outcome was the combined occurrence of death or need for hemodialysis within 30 days. Secondary outcomes included the incidence of acute kidney injury (AKI) and the proportion of patients with initial estimated glomerular filtration rates (eGFR) > 60 mL/min/1.73 m(2) who died or required hemodialysis. RESULTS: Four-hundred patients were identified, the median age was 50 years (interquartile range [IQR] = 35 to 69 years), and 77% were male, with 35% of patients discharged home from the ED. The most common ED discharge diagnoses were related to recreational drug use, infections, and traumatic or musculoskeletal complaints. Within 30 days, 32 (8.0%, 95% confidence interval [CI] = 5.3% to 11%) experienced primary outcomes, with 18 (4.5%, 95% CI = 2.55% to 6.5%) requiring hemodialysis and 21 deaths (5.3%, 95% CI = 3.1% to 7.4%). AKI occurred in 151 patients (38%, 95% CI = 33% to 43%). Of the 257 patients (64%) with initial eGFRs > 60 mL/min/1.73 m(2) , none required hemodialysis. CONCLUSIONS: In ED patients with initial CK > 1,000 U/L, the incidence of death or hemodialysis was 8% within 30 days. Patients with initial eGFRs > 60 mL/min/1.73 m(2) appear to be at a low risk of these outcomes from rhabdomyolysis.

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain.

OBJECTIVES: Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. METHODS: This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. RESULTS: In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is < 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. CONCLUSION: The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation.

Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis.

STUDY OBJECTIVE: Allergic reactions are common presentations to the emergency department (ED). An unknown proportion of patients will develop biphasic reactions, and patients are often monitored for prolonged periods to manage potential reactions. We seek to determine the incidence of clinically important biphasic reactions. METHODS: Consecutive adult patients presenting to 2 urban EDs with allergic reactions during a 5-year period were identified. Encounters were dichotomized as "anaphylaxis" or "allergic reaction" with an explicit algorithm. A comprehensive chart review was conducted on each index and all subsequent visits to detail patient presentations, comorbidities, ED management, and predefined clinically important biphasic reactions. Regional and provincial databases were linked to identify subsequent ED visits and deaths within a 7-day period. The primary outcome was the proportion of patients with a clinically important biphasic reaction, and the secondary outcome was mortality. RESULTS: Of 428,634 ED visits, 2,819 (0.66%) encounters were reviewed (496 anaphylactic and 2,323 allergic reactions). Overall, 185 patients had at least 1 subsequent visit for allergic symptoms. Five clinically important biphasic reactions were identified (0.18%; 95% confidence interval [CI] 0.07% to 0.44%), with 2 occurring during the ED visit and 3 postdischarge. There were no fatalities (95% CI 0% to 0.17%). In the anaphylaxis and allergic reaction groups, clinically important biphasic reactions occurred in 2 patients (0.40%; 95% CI 0.07% to 1.6%) and 3 patients (0.13%; 95% CI 0.03% to 0.41%), respectively. CONCLUSION: Among ED patients with allergic reactions or anaphylaxis, clinically important biphasic reactions and fatalities are rare. Our data suggest that prolonged routine monitoring of patients whose symptoms have resolved is likely unnecessary for patient safety.

A regional survey to determine factors influencing patient choices in selecting a particular emergency department for care.

OBJECTIVES: Increases in regional emergency department (ED) efficiencies might be obtained by shifting patients to less crowded EDs. The authors sought to determine factors associated with a patient's decision to choose a specific regional ED. Based on prior focus group discussions with volunteers, the hypothesis was that distance to a specific ED and perceived ED wait times would be important. METHODS: A cross-sectional survey was developed using qualitative focus group methodology. The resulting survey was composed of 17 questions relating to patient decisions in choosing a specific ED and was administered in each of six EDs in a single urban Canadian health region at all hours of the day. Ambulatory patients with a Canadian Triage and Acuity Scale (CTAS) level 3 to 5 and aged ≥19 years were surveyed. The primary outcome was the proportion of patients whose main motivation for attending a specific ED was either distance traveled to reach the ED or perceived ED waiting time. Multivariable logistic regression was performed to assess factors influencing both of these reasons. RESULTS: A total of 757 patients were approached and 634 surveys (83.8%) were completed. Distance from the ED (named by 44.0% of respondents as their primary reason) and perceived ED wait times (9.3%) were the main motivations for patients to attend a specific ED. Multivariable analysis of factors associated with choosing distance revealed that ED distance < 10 km (adjusted odds ratio [OR] = 2.20, 95% confidence interval [CI] = 1.45 to 3.33; p = 0.001) and age ≥ 60 years (adjusted OR = 1.58, 95% CI = 1.12 to 2.26; p = 0.04) were significant in choosing a particular ED. Multivariable analysis of factors influencing wait times demonstrated that having a painful complaint (adjusted OR = 1.42, 95% CI = 1.05 to 1.98; p = 0.047) and age < 60 years (OR = 1.47, 95% CI = 1.02 to 2.14; p = 0.049) were significant in choosing a particular ED. CONCLUSIONS: In a multicenter survey of patients from an urban health region, distance to a specific ED and perceived ED wait times were the most important reasons for choosing that ED. Younger patients and those with painful conditions appear to place greater priority on wait times.

Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness.

OBJECTIVES: Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. METHODS: This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. RESULTS: A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. CONCLUSIONS: In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

Thirty-day and 1-year outcomes of emergency department patients with atrial fibrillation and no acute underlying medical cause.

STUDY OBJECTIVE: Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. RESULTS: Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. CONCLUSION: In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients-regardless of treatment approach or conversion to sinus rhythm-were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.

Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.

STUDY OBJECTIVE: Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm. METHODS: This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days. RESULTS: We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing. CONCLUSION: In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.

Emergency department management and 1-year outcomes of patients with atrial flutter.

STUDY OBJECTIVE: Atrial flutter is a common arrhythmia seen in the emergency department (ED), yet there is little research describing its management and outcomes. We analyze the success and safety of treatment of ED patients with atrial flutter. METHODS: This was a retrospective cohort study obtained by searching the ED administrative database of 2 urban hospitals to identify consecutive patients with a primary discharge diagnosis of atrial flutter from April 1, 2006, to January 31, 2009. We linked each patient's unique provincial health number to the provincial vital statistics registry and the regional ED database to identify subsequent deaths and strokes within 1 year. Manual chart review was conducted to confirm rhythms and outcomes and to identify patient comorbidities. Patients were stratified into 5 groups based on initial ED presentation and management approach: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no acute ED arrhythmia-specific treatment. Primary outcome was the combined 1-year rate of stroke or death, and secondary outcomes included the proportion of eligible patients with conversion to normal sinus rhythm in each group and discharged to home. RESULTS: Data from 122 consecutive patients with a primary ED diagnosis of atrial flutter were collected; there were 3 deaths and no strokes (2.5%; 95% confidence interval 0% to 5.1%) in the following year. Patients undergoing electrocardioversion achieved normal sinus rhythm 91% of the time, with 93% discharged home; patients undergoing oral or intravenous antiarrhythmic treatment achieved sinus rhythm 27% of the time, with 60% discharged home. Discharge rates of patients with spontaneous cardioversion, rate control, and no ED treatment were 93%, 58%, and 96%, respectively. CONCLUSION: In this 2-center cohort of ED patients with atrial flutter, patients eligible for rhythm control had a higher success and lower admission rate with electrocardioversion than patients treated with antiarrhythmic medications. Overall, the majority of patients were discharged home. Deaths were typically related to concurrent medical illness rather than atrial flutter.

Safety of assessment of patients with potential ischemic chest pain in an emergency department waiting room: a prospective comparative cohort study.

STUDY OBJECTIVE: Emergency department (ED) crowding has been associated with a variety of adverse outcomes. Current guidelines suggest that patients with potentially ischemic chest pain should undergo rapid assessment and treatment in a monitored setting to optimize the diagnosis of acute coronary syndrome. These patients may be at high risk of incorrect diagnosis and adverse events when their evaluation is delayed because of crowding. To mitigate crowding-related delays, we developed processes that enabled emergency physicians to evaluate potentially sick patients in the waiting room when all nurse-staffed stretchers are occupied. The objective of this study was to investigate the safety of waiting room chest pain evaluation. METHODS: This prospective comparative cohort study was conducted in a busy urban, tertiary care ED. Explicit triage and waiting room evaluation processes were introduced. One thousand one hundred seven patients with chest pain of potential cardiac origin were triaged either to a monitored bed or a waiting room chair, depending on bed availability and triage judgment. After diagnostic evaluation, patients were followed for 30 days to identify the proportion of missed cases of acute coronary syndrome (primary outcome) and other prespecified adverse events. Analysis was based on intention to treat. RESULTS: Eight hundred four patients were triaged to monitored bed and 303 to waiting room evaluation. Initial vital signs were similar, but the waiting room group was younger and had lower rates of some cardiovascular risk factors. The rate of acute coronary syndrome, defined as acute myocardial infarction or objective unstable angina, was 11.7% in the monitored bed group and 7.6% in waiting room patients. There were no missed acute coronary syndrome cases in either the monitored bed group (0%; 95% confidence interval [CI] 0% to 0.4%) or the waiting room group (0%; 95% CI 0% to 1.0%). There were 32 adverse events in the monitored bed group (4.0%; 95% CI 2.6% to 5.3%) and 2 in the waiting room group (0.7%; 95% CI 0% to 1.6%). CONCLUSION: Our organized approach to triage and waiting room evaluation for stable chest pain patients was safe and efficient. Although waiting room evaluation is not ideal, it may be a feasible contingency strategy for periods when ED crowding compromises access to monitored, nurse-staffed ED beds.