Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

The association of extreme environmental heat with incidence and outcomes of out-of-hospital cardiac arrest in British Columbia: A time series analysis.

Background: The impact of extreme heat on out-of-hospital cardiac arrest (OHCA) incidence and outcomes is under-studied. We investigated OHCA incidence and outcomes over increasing temperatures. Methods: We included non-traumatic EMS (Emergency Medical Services)-assessed OHCAs in British Columbia during the warm seasons of 2020-2021. We fit a time-series quasi-Poisson generalized linear model to estimate the association between temperature and incidence of both EMS-assessed, EMS-treated, and EMS-untreated OHCAs. Second, we employed a logistic regression model to estimate the association between "heatwave" periods (defined as a daily mean temperature > 99th percentile for ≥ 2 consecutive days, plus 3 lag days) with survival and favourable neurological outcomes (cerebral performance category ≤ 2) at hospital discharge. Results: Of 5478 EMS-assessed OHCAs, 2833 were EMS-treated. OHCA incidence increased with increasing temperatures, especially exceeding a daily mean temperature of 25 °C Compared to the median daily mean temperature (16.9 °C), the risk of EMS-assessed (relative risk [RR] 3.7; 95%CI 3.0-4.6), EMS-treated (RR 2.9; 95%CI 2.2-3.9), and EMS-untreated (RR 4.3; 95%CI 3.2-5.7) OHCA incidence were higher during days with a temperature over the 99th percentile. Of EMS-treated OHCAs, during the heatwave (n = 179) and non-heatwave (n = 2654) periods, 4 (2.2%) and 270 (10%) survived and 4 (2.2%) and 241 (9.2%) had favourable neurological outcomes, respectively. Heatwave period OHCAs had decreased odds of survival (adjusted OR 0.28; 95%CI 0.10-0.79) and favourable neurological outcome (adjusted OR 0.31; 95%CI 0.11-0.89) at hospital discharge, compared to other periods. Conclusion: Extreme heat was associated with a higher incidence of OHCA, and lower odds of survival and favourable neurological status at hospital discharge.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Risk factors associated with 1-week revisit among emergency department patients with alcohol withdrawal.

BACKGROUND: Approximately one-quarter of emergency department (ED) visits for alcohol withdrawal result in unscheduled 1-week ED return visits, but it is unclear what patient and clinical factors may impact this outcome METHODS: From January 1, 2015, to December 31, 2018, at three urban EDs in Vancouver, Canada, we studied patients who were discharged with a primary or secondary diagnosis of alcohol withdrawal. We performed a structured chart review to ascertain patient characteristics, ED treatments, and the outcome of an ED return within 1 week of discharge. We used univariable and multivariable Bayesian binomial regression to identify characteristics associated with being in the upper quartile of 1-week ED revisits. RESULTS: We collected 935 ED visits among 593 unique patients. Median age was 45 years (interquartile range 34 to 55 years) and 71% were male. The risk of a 1-week ED revisit was 15.0% (IQR 12.3; 19.5%). After adjustment, factors independently associated with a high risk for return included any prior ED visit within 30 days, no fixed address, initial blood alcohol level > 45 mmol/L, and initial Clinical Institute Withdrawal Assessment-alcohol revised score > 23. These factors explained 41% of the overall variance in revisits. CONCLUSION: Among discharged ED patients with alcohol withdrawal, we describe high-risk patient characteristics associated with 1-week ED revisits, and these findings may assist clinicians to facilitate appropriate discharge planning with access to integrated follow-up support.

RéSUMé: CONTEXTE: Environ un quart des visites aux urgences pour sevrage alcoolique se traduit par un retour non programmé aux urgences pendant une semaine, mais les facteurs cliniques et relatifs aux patients qui peuvent avoir une incidence sur ce résultat ne sont pas clairs. MéTHODES: Du 1er janvier 2015 au 31 décembre 2018, dans trois urgences urbaines de Vancouver, au Canada, nous avons étudié les patients qui sont sortis avec un diagnostic primaire ou secondaire de sevrage alcoolique. Nous avons procédé à une analyse structurée des dossiers afin de déterminer les caractéristiques des patients, les traitements aux urgences et l'issue d'un retour aux urgences dans la semaine suivant la sortie. Nous avons utilisé une régression binomiale bayésienne univariable et multivariable pour identifier les caractéristiques associées au fait d'être dans le quartile supérieur des visites aux urgences à une semaine. RéSULTATS: Nous avons recueilli 935 visites aux urgences parmi 593 patients uniques. L'âge médian était de 45 ans (intervalle interquartile de 34 à 55 ans) et 71 % étaient des hommes. Le risque d'une nouvelle visite aux urgences à une semaine était de 15,0% (IQR 12,3 ; 19,5%). Après ajustement, les facteurs indépendamment associés à un risque élevé de retour comprenaient toute visite antérieure à l'urgence dans les 30 jours, aucune adresse fixe, le taux d'alcoolémie initial > 45 mmol/L, et l'évaluation initiale du sevrage de l'Institut clinique ­ cote d'alcoolémie révisée > 23. Ces facteurs expliquaient 41 % de la variance globale des visites. CONCLUSIONS: Parmi les patients sortants des urgences en sevrage alcoolique, nous décrivons les caractéristiques des patients à haut risque associés à la réadmission aux urgences après une semaine de sevrage alcoolique. Ces résultats peuvent aider les cliniciens à planifier de manière appropriée la sortie de l'hôpital et à accéder à un suivi intégré.

What is the risk of returning to the emergency department within 30 days for patients diagnosed with substance-induced psychosis?

OBJECTIVES: The primary objective of this study was to measure the risk of return Emergency Department (ED) visits in patients presenting to the ED with a diagnosis of substance-induced psychosis. Secondary objectives included: (1) describing the characteristics of patients returning within 30 days to the ED with substance-induced psychosis, and (2) identifying risk factors associated with such ED return. METHODS: At two urban sites from January 1, 2018 to December 31, 2019, we included consecutive patients presenting to the ED with substance-induced psychosis defined by their ED discharge diagnosis of psychosis and clinical evidence of substance use. We described ED resources utilized by this patient population including ED time and disposition then subsequently described return visits within 30 days and characteristics among those patients who returned. RESULTS: We identified 611 unique patients presenting with substance-induced psychosis, with 813 total ED visits. The median age was 35 years (IQR 28-45), 71.4% (n = 436) were male, and 44.8% (n = 274) were homeless. The median ED length of stay was 619 min (IQR 313-898), and 48.4% (n = 296) were admitted to hospital. Forty percent of patients (n = 237) returned to the ED within 30 days of the index substance-induced psychosis visit, 116 (18.9%) returning more than once. Of these return visits, 74 (31.2%) were for recurrent substance-induced psychosis. Younger age, female gender, no opioid use, and no prior history of bipolar disorder were identified as common characteristics among those returning to the ED with substance-induced psychosis. CONCLUSIONS: In ED patients with substance-induced psychosis, nearly half of all patients were admitted to hospital, 40% had a 30 days return ED visit, and one-third of those were for substance-induced psychosis. We identified clinically relevant factors common to those returning with recurrent substance-induced psychosis.

RéSUMé: OBJECTIFS: L'objectif principal de cette étude était de mesurer le risque de retour aux urgences chez les patients se présentant aux urgences avec un diagnostic de psychose induite par une substance. Les objectifs secondaires comprenaient : 1) décrire les caractéristiques des patients qui retournent aux urgences dans les 30 jours avec une psychose induite par la substance, et 2) déterminer les facteurs de risque associés à ce retour aux urgences. MéTHODES: Dans deux sites urbains, du 1er janvier 2018 au 31 décembre 2019, nous avons inclus des patients consécutifs se présentant aux urgences avec une psychose induite par une substance, définie par leur diagnostic de psychose à la sortie des urgences et des preuves cliniques de consommation de substances. Nous avons décrit les ressources des urgences utilisées par cette population de patients, notamment le temps passé aux urgences et les dispositions prises, puis nous avons décrit les visites de retour dans les 30 jours et les caractéristiques des patients qui sont revenus. RéSULTATS: Nous avons identifié 611 patients uniques présentant une psychose induite par une substance, avec un total de 813 visites aux urgences. L'âge médian était de 35 ans (IQR 28-45), 71,4 % (n = 436) étaient des hommes et 44,8 % (n = 274) étaient sans domicile fixe. La durée médiane du séjour aux urgences était de 619 minutes (IQR 313-898), et 48,4 % (n = 296) ont été hospitalisés. Quarante pour cent des patients (n = 237) sont retournés aux urgences dans les 30 jours suivant la visite de référence pour une psychose due à une substance, 116 (18,9 %) y étant retournés plus d'une fois. Parmi ces visites de retour, 74 (31,2 %) concernaient une psychose récurrente induite par une substance. Un âge plus jeune, le sexe féminin, l'absence de consommation d'opioïdes et d'antécédents de troubles bipolaires ont été identifiés comme des caractéristiques communes chez les personnes revenant aux urgences pour une psychose induite par une substance. CONCLUSIONS: Chez les patients des urgences souffrant de psychose due à une substance, près de la moitié des patients ont été hospitalisés, 40 % sont revenus aux urgences dans les 30 jours, dont un tiers pour une psychose due à une substance. Nous avons identifié des facteurs cliniquement pertinents communs à ceux qui reviennent avec une psychose récurrente induite par une substance.

One-year mortality of emergency department patients with substance-induced psychosis.

OBJECTIVES: Psychosis is a well established complication of non-prescription drug use. We sought to measure the 1-year mortality of emergency department patients with substance-induced psychosis (SIP). METHODS: This study was a multi-centre, retrospective electronic medical records review of patients presenting to the ED with substance-induced psychosis (SIP). We interrogated the hospital ED database from Jan 1, 2018 and Jan 1, 2019 to identify consecutive patients. All patients were followed for one year from index visit, and classified as alive/dead at that time. Patients were included in the study if they met the following criteria: 1) ED discharge diagnosis of psychosis NOS and a positive urine drugs of abuse screen (UDAS) or the patient verbally endorsed drug use, or 2) Mental disorder due to drug use and "disorganized thought", "bizarre behavior" or "delusional behavior" documented in the chart and one or more of the following criteria: a) arrival with police, b) mental health certification, c) physical restraints, d) chemical restraints. We excluded patients who were not British Columbia residents, since we were unable to ascertain if they were alive or dead at 1 year from their index ED visit. Primary statistical analysis was logistic regression for risk of death in 1 year, based on plausible risk factors, selected a priori. RESULTS: We identified 813 presentations for SIP (620 unique patients). The median age of the entire cohort was 35 years (IQR 28-44), and 69.5% (n = 565) were male. Thirty five patients (4.3%; 95% CI 3.2-5.9) had died one year after their initial presentation to the ED for SIP. Separate multivariable logistic regression analyses, controlling for age, demonstrated schizophrenia (OR 4.2, 95% CI 1.8-11.1) significantly associated with increased 1-year mortality. CONCLUSIONS: In our study of patients presenting to the ED with SIP, the 1-year mortality was 4.3%. Controlling for age, schizophrenia was a notable risk factor for increased 1-year mortality.

Exploring how to enhance care and pathways between the emergency department and integrated youth services for young people with mental health and substance use concerns.

BACKGROUND: Integrated youth services (IYS) provide multidisciplinary care (including mental, physical, and social) prioritizing the needs of young people and their families. Despite a significant rise in emergency department (ED) visits by young Canadians with mental health and substance use (MHSU) concerns over the last decade, there remains a profound disconnect between EDs and MHSU integrated youth services. The first objective of this study was to better understand the assessment, treatment, and referral of young people (ages 12-24 years) presenting to the ED with MHSU concerns. The second objective was to explore how to improve the transition from the ED to IYS for young people with MHSU concerns. METHODS: We conducted semi-structured one-on-one video and phone interviews with stakeholders in British Columbia, Canada in the summer of 2020. Snowball sampling was utilized, and participants (n = 26) were reached, including ED physicians (n = 6), social workers (n = 4), nurses (n = 2), an occupational therapist (n = 1); a counselor (n = 1); staff/leadership in IYS organizations (n = 4); mental health/family workers (n = 3); peer support workers (n = 2), and parents (n = 3). A thematic analysis (TA) was conducted using a deductive and inductive approach conceptually guided by the Social Ecological Model. RESULTS: We identified three overarching themes, and factors to consider at all levels of the Social Ecological Model. At the interpersonal level inadequate communication between ED staff and young people affected overall care and contributed to negative experiences. At the organizational level, we identified considerations for assessments and the ED and the hospital (wait times, staffing issues, and the physical space). At the community level, the environment of IYS and other community services were important including wait times and hours of operation. Policy level factors identified include inadequate communication between services (e.g., different charting systems and documentation). CONCLUSIONS: This study provides insight into important long-term systemic issues and more immediate factors that need to be addressed to improve the delivery of care for young people with MHSU challenges. This research supports intervention development and implementation in the ED for young people with MHSU concerns.

Temporal trends of suicide-related non-traumatic out-of-hospital cardiac arrest characteristics and outcomes with the COVID-19 pandemic.

Background: Jurisdictions have reported COVID-19-related increases in the incidence and mortality of non-traumatic out-of-hospital cardiac arrest (OHCA). We hypothesized that changes in suicide incidence during the COVID-19 pandemic may have contributed to these changes. We investigated whether the COVID-19 pandemic was associated with changes in the: (1) incidence of suicide-related OHCA, and (2) characteristics and outcomes of such cases. Methods: We used the provincial British Columbia Cardiac Arrest Registry, including non-traumatic emergency medical system (EMS)-assessed OHCA, to compare suicide-related OHCA (defined as clear self-harm or a priori communication of intent) one-year prior to, and one year after, the start of the COVID-19 pandemic (March 15, 2020). We calculated differences in incidence (with 95% CI), overall and within subgroups of mechanism (hanging, suffocation, poisoning, or unclear mechanism), and in case characteristics and hospital-discharge favourable neurological outcomes (CPC 1-2). Results: Of 13,785 EMS-assessed OHCA, we included 274/6430 (4.3%) pre-pandemic and 221/7355 (3.0%) pandemic-period suicide-related cases. The median age was 43 years (IQR 30-57), 157 (32%) were female, and 7 (1.4%) survived with favourable neurological status. Suicide-related OHCA incidence decreased from 5.4 pre-pandemic to 4.3 per 100 000 person-years (-1.1, 95% CI -2.0 to -0.28). Hanging-related OHCA incidence also decreased. Patient characteristics and hospital discharge outcomes between periods were similar. Conclusion: Suicide-related OHCA incidence decreased with the COVID-19 pandemic and we did not detect changes in patient characteristics or outcomes, suggesting that suicide is not a contributor to increases in COVID-related OHCA incidence or mortality. Overall suicide-related OHCA outcomes in both time periods were poor.

Social determinants of health and depression in adults presenting to the emergency department: Implications for family medicine.

OBJECTIVE: To estimate the extent to which social determinants of health (SDH) predict levels of depression in adults presenting to the emergency department (ED) with an acute mental health crisis. DESIGN: Secondary data analysis. SETTING: St Paul's Hospital, an urban tertiary care hospital in Vancouver, BC. PARTICIPANTS: Patients 19 years and older presenting to the ED with an acute mental health crisis. MAIN OUTCOME MEASURES: Responses to demographic questionnaires focused on SDH and to measures of self-perceived health and depression. Relationships between depression and SDH were described using t tests and χ 2 tests. The extent to which SDH variables predicted depression scores, as measured by the Patient Health Questionnaire-9 (PHQ-9), was determined using linear regression. RESULTS: The primary study had 202 participants. Data for the 156 (77%) participants who completed the PHQ-9 were assessed in this secondary analysis. In this sample, 60% of participants identified as men, 37% as women, and 4% as other. The mean (SD) age was 39.1 (13.8) years, with most participants identifying as white (65%) or Indigenous (18%). Thirty-seven percent had a high school diploma or less education, and 72% reported being unemployed. Identifying as a woman, lack of access to clean drinking water, poor food security, feeling unsafe, little structured use of time, lack of a sense of community, and dissatisfaction with housing significantly predicted higher depression scores. Overall, 59% of respondents met the criteria for moderately severe or severe depression (PHQ-9 score ≥ 15), with 37% of those reporting thoughts of suicide nearly every day for the past 2 weeks. CONCLUSION: This study demonstrates the importance of screening for both depression and SDH in the ED. Because the ED often does not have the capacity to address appropriate levels of follow-up for this population, this study has important implications for primary care. Developing a clear pathway of follow-up support for people with depression and SDH risk factors will be critical to optimize patient outcomes, promote patient safety, enhance patient satisfaction, and optimize the use of resources between the ED and primary care.

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial.

STUDY OBJECTIVE: We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. METHODS: We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. RESULTS: Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). CONCLUSION: In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.

What are Canadian emergency physicians' attitudes and self-perceived competence toward patients who present with suicidal ideation?

INTRODUCTION: Suicide is the 9th leading cause of death in Canada, and a common reason for patients to present to Canadian emergency departments (ED). Little knowledge exists around Canadian emergency physicians (EPs) attitudes toward and understanding of individuals with suicidal ideation. METHODS: We developed a web-based survey on suicide knowledge, which was pilot tested by two EPs and one psychiatrist for clarity and content. The survey was distributed via email to attending physician members of the Canadian Association of Emergency Physicians. Data were described using counts, means, medians and interquartile ranges. The Understanding of Suicidal Patients (USP) Scale is an 11-point questionnaire to assess healthcare providers' attitudes toward individuals with suicidal ideation. Other questions pertaining to suicidal ideation, self-perceptions on ability to treat suicidal patients, and personal experiences with suicide were asked in Likert format. RESULTS: One hundred eighty-eight Canadian EPs responded to the survey (15% response rate), with a median age of 49 (IQR 39-55), academic practice reported by 55% of respondents, and 65% of respondents identified as male. The mean USP score was 21.8 (95% CI 21.1-22.5), which indicates a generally positive attitude and willingness to provide care for suicidal patients. Only 17% of respondents had participated in specific training for treatment of suicidal patients in the last five years, while the majority of respondents estimate treating 5-15 patients with suicidal ideation a month. Sixty four percent of respondents indicated they had the skills to screen patients for suicidal ideation, but less than one-third felt they could create a personalized safety plan for patients. CONCLUSIONS: Respondents have a generally positive attitude toward treating individuals with suicidal ideation. Respondents scored highly on the USP scale that measured willingness to provide care for and empathize with suicidal patients. Respondents felt they had the skills to adequately screen patients for suicidal ideation. Key gaps in knowledge were identified suggesting improved residency and ongoing medical education opportunities are needed to better improve care for this vulnerable population.

RéSUMé: INTRODUCTION: Le suicide est la 9e principale cause de décès au Canada et une raison courante pour laquelle les patients se présentent aux services d'urgence (SU) canadiens. Il existe peu de connaissances sur les attitudes et la compréhension des médecins d'urgence canadiens à l'égard des personnes ayant des idées suicidaires. MéTHODES: Nous avons développé une enquête en ligne sur la connaissance du suicide, qui a été testée par deux médecins d'urgence et un psychiatre pour en vérifier la clarté et le contenu. Le sondage a été distribué par courriel aux médecins traitants membres de l'Association canadienne des médecins d'urgence. Les données ont été décrites à l'aide de chiffres, de moyennes, de médianes et d'intervalles interquartiles. L'échelle de compréhension des patients suicidaires (USP) est un questionnaire en 11 points visant à évaluer l'attitude des prestataires de soins de santé envers les personnes ayant des idées suicidaires. D'autres questions portant sur les idées suicidaires, les perceptions de soi sur la capacité de traiter les patients suicidaires et les expériences personnelles de suicide ont été posées en format Likert. RéSULTATS: Cent quatre-vingt-huit médecins d'urgence canadiens ont répondu à l'enquête (taux de réponse de 15 %), avec un âge médian de 49 ans (IQR 39-55), une pratique universitaire déclarée par 55 % des répondants, et 65 % des répondants se sont identifiés comme des hommes. Le score USP moyen était de 21,8 (IC à 95 % 21,1-22,5), ce qui indique une attitude généralement positive et une volonté de fournir des soins aux patients suicidaires. Seuls 17 % des répondants ont participé à une formation spécifique pour le traitement des patients suicidaires au cours des cinq dernières années, tandis que la majorité des répondants estiment traiter 5 à 15 patients ayant des idées suicidaires par mois. Soixante-quatre pour cent des répondants ont indiqué qu'ils possédaient les compétences nécessaires pour dépister les idées suicidaires chez les patients, mais moins d'un tiers estimaient qu'ils pouvaient créer un plan de sécurité personnalisé pour les patients. CONCLUSIONS: Les répondants ont une attitude généralement positive à l'égard du traitement des personnes ayant des idées suicidaires. Les répondants ont obtenu un score élevé sur l'échelle USP qui mesurait la volonté de fournir des soins et de l'empathie envers les patients suicidaires. Les répondants estimaient avoir les compétences nécessaires pour dépister adéquatement les idées suicidaires chez les patients. Des lacunes importantes dans les connaissances ont été identifiées, ce qui suggère que de meilleures possibilités de formation en résidence et de formation médicale continue sont nécessaires pour améliorer les soins offerts à cette population vulnérable.

Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department.

INTRODUCTION: Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding. METHODS AND ANALYSIS: This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule. ETHICS AND DISSEMINATION: The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media. TRIAL REGISTRATION NUMBER: NCT03745755.

Physician choices in pulmonary embolism testing.

BACKGROUND: Evidence-based guidelines advise excluding pulmonary embolism (PE) diagnosis using d-dimer in patients with a lower probability of PE. Emergency physicians frequently order computed tomography (CT) pulmonary angiography without d-dimer testing or when d-dimer is negative, which exposes patients to more risk than benefit. Our objective was to develop a conceptual framework explaining emergency physicians' test choices for PE. METHODS: We conducted a qualitative study using in-depth interviews of emergency physicians in Canada. A nonmedical researcher conducted in-person interviews. Participants described how they would test simulated patients with symptoms of possible PE, answered a knowledge test and were interviewed on barriers to using evidence-based PE tests. RESULTS: We interviewed 63 emergency physicians from 9 hospitals in 5 cities, across 3 provinces. We identified 8 domains: anxiety with PE, barriers to using the evidence (time, knowledge and patient), divergent views on evidence-based PE testing, inherent Wells score problems, the drive to obtain CT rather than to diagnose PE, gestalt estimation artificially inflating PE probability, subjective reasoning and cognitive biases supporting deviation from evidence-based tests and use of evidence-based testing to rule out PE in patients who are very unlikely to have PE. Choices for PE testing were influenced by the disease, environment, test qualities, physician and probability of PE. INTERPRETATION: Analysis of structured interviews with emergency physicians provided a conceptual framework to explain how these physicians use tests for suspected PE. The data suggest 8 domains to address when implementing an evidence-based protocol to investigate PE.

Lorazepam Versus Diazepam in the Management of Emergency Department Patients With Alcohol Withdrawal.

STUDY OBJECTIVE: Alcohol withdrawal is a common emergency department (ED) presentation. Although benzodiazepines reduce symptoms of withdrawal, there is little ED-based evidence to assist clinicians in selecting appropriate pharmacotherapy. We compare lorazepam with diazepam for the management of alcohol withdrawal to assess 1-week ED and hospital-related outcomes. METHODS: From January 1, 2015, to December 31, 2018, at 3 urban EDs in Vancouver, Canada, we studied patients with a discharge diagnosis of alcohol withdrawal. We excluded individuals presenting with a seizure or an acute concurrent illness. We performed a structured chart review to ascertain demographics, ED treatments, and outcomes. Patients were stratified according to initial management with lorazepam versus diazepam. The primary outcome was hospital admission, and secondary outcomes included in-ED seizures and 1-week return visits for discharged patients. RESULTS: Of 1,055 patients who presented with acute alcohol withdrawal, 898 were treated with benzodiazepines. Median age was 47 years (interquartile range 37 to 56 years) and 73% were men. Baseline characteristics were similar in the 2 groups. Overall, 69 of 394 patients (17.5%) receiving lorazepam were admitted to the hospital compared with 94 of 504 patients receiving diazepam (18.7%), a difference of 1.2% (95% confidence interval -4.2% to 6.3%). Seven patients (0.7%; 95% confidence interval 0.3% to 1.4%) had an in-ED seizure, but all seizures occurred before receipt of benzodiazepines. Among patients discharged home, 1-week return visits occurred for 78 of 325 (24.0%) who received lorazepam and 94 of 410 (23.2%) who received diazepam, a difference of 0.8% (95% confidence interval -5.3% to 7.1%). CONCLUSION: In our sample of ED patients with acute alcohol withdrawal, patients receiving lorazepam had an admission rate similar to that of those receiving diazepam. The few in-ED seizures occurred before medication administration. For discharged patients, the 1-week ED return visit rate of nearly 25% could warrant enhanced follow-up and community support.