Isolated Lower Limb Weakness Following Hemorrhagic Stroke: A Case Report.

Isolated limb weakness (monoparesis) has many possible etiologies. Although often assumed to be of a peripheral cause, it can be of central origin. This article describes a case from the Emergency Department of left lower limb weakness in a walk-in male patient on no medications, who had a 50-pack-year smoking history, type II diabetes, and asymptomatic atrial fibrillation. The patient had no history of previous episodes or trauma. His vitals were normal, and his speech and facial function were intact. The patient had full function of his upper limbs, no sensory deficits, and equal reflexes bilaterally. The singular clinical finding was decreased strength in the left leg compared to the right. Imaging revealed a right frontal intraparenchymal hemorrhage, which remained stable throughout his hospital admission. His muscle weakness was significantly improved upon discharge. In general, strokes can present with a variety of symptoms, which increase the risk of misdiagnosis. Monoparesis can be the singular sign of a stroke, and it is more common in the upper than the lower limbs.

Adherence to the Canadian CT Head Rule in a Nova Scotian Emergency and Trauma Center.

Background and aims Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada (CWC), aims to address unnecessary care and tests through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five tests, procedures, and treatments to question within the emergency department setting. The Canadian CT-scan Head Rule (CCHR) has been found to be the most effective clinical decision rule in adults with minor head injuries. This study aimed to better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center in Halifax, Nova Scotia. Materials and methods Our mixed methods design included a narrative literature review, a retrospective chart audit, and a qualitative audit-feedback component with physicians who work in the emergency department (ED). The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Results Analysis of qualitative data is included here, in parallel with in-depth analysis to contextualize findings from the chart audit. A total of 302 charts of patients presenting to the surveyed site were retrospectively reviewed for this study. Of the 37 cases where the CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated as per the CCHR, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusions Our review revealed that the CCHR was adhered in 87.8% of cases at the surveyed ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical to achieving the goal of reducing unnecessary CTs. This work will be presented to the physician group to engage and understand factors that are enablers in the process of ED minor head injury care.

Correction: A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure.

[This corrects the article DOI: 10.7759/cureus.17041.].

A Cognitive Autopsy Approach Towards Explaining Diagnostic Failure.

Diagnostic failure has emerged as one of the most significant threats to patient safety. It is important to understand the antecedents of such failures both for clinicians in practice as well is those in training. A consensus has developed in the literature that the majority of failures are due to individual or system factors or some combination of the two. A major source of variance in individual clinical performance is cognitive and affective biases; however, their role in clinical decision making has been difficult to assess partly because they are difficult to investigate experimentally. A significant drawback has been that experimental manipulations appear to confound the assessment of the context surrounding the diagnostic process itself. We conducted an exercise on selected actual cases of diagnostic errors to explore the effect of biases in the 'real world' emergency medicine (EM) context. Thirty anonymized EM cases were analysed in depth through a process of root cause analysis that included an assessment of error-producing conditions (EPCs), knowledge-based errors, and how clinicians were thinking and deciding during each case. A prominent feature of the exercise was the identification of the occurrence of and interaction between specific cognitive and affective biases, through a process called cognitive autopsy. The cases covered a broad range of diagnoses across a wide variety of disciplines. A total of 24 discrete cognitive and affective biases that contributed to misdiagnosis were identified and their incidence recorded. Five to six biases were detected per case, and observed on 168 occasions across the 30 cases. Thirteen EPCs were identified. Knowledge-based errors were rare, occurring in only five definite instances. The ordinal position in which biases appeared in the diagnostic process was recorded. This experiment provides a baseline for investigating and understanding the critical role that biases play in clinical decision making as well as providing a credible explanation for why diagnoses fail.

The Effectiveness of an Interprofessional Education Course in Teaching the Importance of Choosing Wisely and Resource Stewardship: A Pilot Study.

Objectives Rising health care costs and an increase in unnecessary testing have sparked interest in resource stewardship (RS) and subsequently the Choosing Wisely Canada (CWC) campaign. Currently, all Canadian medical schools have student representatives for CWC; however, the same is not true in other health professions. Interprofessional care learned through interprofessional education (IPE) can lead to better patient outcomes. This study assessed whether an IPE course for health profession students was effective in teaching undergraduate students both interprofessional competencies and CWC principles. Methods An approximately seven-hour-long, four-session course was administered to Dalhousie University health profession students (N= 30). A validated survey for IPE competencies and a general survey about CWC principles were administered to assess the course. Descriptive statistics were used to assess the general CWC views, and paired samples t-tests were employed to compare pre- and post-IPE competencies. Results The full survey was completed by 25 (83%) students. Of these, 52% were female, within five health disciplines, and 13 (52%) had heard of CWC prior. Overall, the students agreed that CWC was important and relevant to their profession. They also reported significant improvements in multiple IPE competencies, including communication, collaboration, roles and responsibilities, patient-/family-centered care, conflict management/resolution, and team function. Conclusion Participants in our pilot Choosing Wisely IPE course valued the importance of the CWC campaign and reported improvement in multiple IPE competencies. This adaptable, simple, and low-cost course may be an effective way to integrate RS teaching across multiple health professions.

Emergency medicine airway leads: a rapid response distributed educational model for emergency department COVID-19 airway management.

With the first case of COVID-19 confirmed in Canada in early 2020, our country joined in the fight against a novel pathogen in a global pandemic. The stress of uncertainty and practice change was most apparent in the emergency department when it came to managing known or suspected COVID-19 patients requiring airway management. Recognizing the need for a coordinated approach, a province wide rapid response distributed model of continuing professional development for airway management was developed utilizing Airway Leads to help prepare front-line medical personnel providing airway management for these patients. Airway Leads worked with local physicians to deliver consistent, high quality airway education across the province during the initial surge of cases. Education included both in person and virtual sessions along with real time ongoing support through provincial guidelines, videos, and other documents. Physician reported "stress level" pre- and post-Airway Lead support declined from a median score of 9 to 7 (on a 10-point Likert Scale).

RéSUMé: Le premier cas de COVID-19 ayant été confirmé au Canada au début de 2020, notre pays s'est joint à la lutte contre un nouveau pathogène dans une pandémie mondiale. Le stress de l'incertitude et du changement de pratique était plus évident au service d'urgence lorsqu'il s'agissait de gérer les patients connus ou soupçonnés de la COVID-19 qui avaient besoin d'une prise en charge des voies respiratoires. Reconnaissant la nécessité d'une approche coordonnée, un modèle de développement professionnel continu distribué à l'échelle de la province pour la gestion des voies aériennes a été élaboré en utilisant les Airway Leads pour aider à préparer le personnel médical de première ligne qui assure la gestion des voies aériennes de ces patients. Airway Leads a travaillé avec les médecins locaux pour dispenser un enseignement cohérent et de haute qualité sur les voies aériennes dans toute la province lors de l'augmentation initiale du nombre de cas. L'éducation comprenait à la fois des sessions en personne et virtuelles ainsi qu'un soutien continu en temps réel par le biais de directives provinciales, de vidéos et d'autres documents. Le "niveau de stress" déclaré par le médecin avant et après l'intervention de Airway Lead a diminué, passant d'un score médian de 9 à 7 (sur une échelle de Likert de 10 points).

Identifying Acuity Level-Based Adult Emergency Department Use Time Trends Across Demographic Characteristics.

Introduction Canadian emergency departments (EDs) are struggling under the weight of increased use by a growing population of elderly patients; those who lack proper housing; and those who lack family physicians to provide primary care. The Canadian Foundation for Healthcare Improvement projected a possible ED service utilization increase in Canada at a rate of 40% over three decades. This calls for local-level information on the time trends to understand demographic and temporal variations in the different geographical locations in the country. This study sought to identify and quantify acuity level-based per capita ED visit annual time trends for the 10-year period of 2006-2015 (by age, gender, and housing status). The aim is to provide detailed information on the time trends for demographically targeted ED planning locally. The lengthy record of data allows examining the changing directions in different time segments. Material and methods Administrative data from the largest emergency department in Halifax (Nova Scotia, Canada) was analyzed. Per capita adult ED visit rates (EDVR) based on Canadian Triage Acuity Scale (CTAS), age, gender, and housing status were analyzed. Trends in the age-gender-based standardized rates using 2011 census city population data were also estimated in order to account for the population increase in the city.  Results No study in Canada has documented the possibility of flattening the escalating ED visit trend by maintaining an annual declining trend in low-acuity-level visits or documented a threshold rate of decline to be maintained. This study observed that the annual linear per capita non-homeless EDVR increment trend (328/year, CI:245-411, per 100,000) for all-acuity-level visits - noted for a ten-year period - would become stable when low-acuity-level CTAS4-5 visit declining trends (427/year, CI:350-503 and 121/year, CI:79-163, per 100,000) - noted for the period of 2012-2015 - were maintained at the same magnitude and direction. Alarming annual emergent (high acuity level of CTAS2) EDVR increase equivalent to 335/year (CI:280-391, per 100,000) was noted for all combined visits, from all age, gender, and housing groups visits. The highest incremental rate noted among above-50-year-olds (521/year, per 100,000, 95% CI:433-608) was neither driven by overall increasing population census numbers nor by increasing aging population numbers. We found statistically similar age-gender standardized rates (294/year, CI: 207-382) for all ED visits and (316/year, CI:261-372) for CTAS2 level visits, when adjusted for annual population increase. Homeless ED visits did not contribute to the overall ED visit incremental trend. The highest annual homeless increment rate was shown for <30-year-old group high acuity CTAS-2 level visits (219/year, CI:193-246, per 100,000).  Conclusion Neither the city population increase nor increased homeless visits contributed to ED visit annual per capita incremental trends in the city of Halifax. The increasing trend was chiefly driven by high-acuity-level visits by >50-year-old patients. Our findings suggest one way to make this escalating ED visit rates stable in the future is by maintaining the declining semi-urgent and non-urgent visit trends at the same rates estimated within the years 2012-2015. These findings highlight the potential directions for ED services planning to keep up with the growing demand for high-acuity-level ED services by the aging population.

Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey.

Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.

Community-acquired pneumonia in North American emergency departments: drug resistance and treatment success with clarithromycin.

BACKGROUND: Limited information on antibiotic resistance of Streptococcus pneumoniae (SP) exists for patients discharged from emergency departments with community-acquired pneumonia. OBJECTIVES: Using a standardized collection process, this study examined sputum microbiology in outpatient community-acquired pneumonia. METHODS: This was a multicenter, prospective cohort study conducted in North American emergency departments between December 2001 and May 2003. Thirty-one emergency departments enrolled patients older than 18 years with a Pneumonia Severity Index of I to III. All patients received oral clarithromycin and were followed up for four weeks. SP resistance to macrolides and penicillin was determined by a central laboratory. RESULTS: Among the 317 cultured sputum samples, 116 (37%; 95% confidence interval [CI] = 32% to 42%) grew an identifiable organism; 74 (23% of cultured cases; 95% CI = 19% to 28%) grew non-SP organisms and 42 grew SP organisms (SP positive; 13% of cultured cases; 95% CI = 10% to 17%). A total of 13 resistant organisms (4% of cultured cases; 95% CI = 2% to 6%) were identified. Resistance to macrolides occurred in nine patients (3% of cultured cases [95% CI = 1% to 5%]; 24% of SP-positive cases [95% CI = 11% to 37%]); and resistance to penicillin occurred in nine patients (3% of all sputum-positive cases [95% CI = 1% to 5%]; 21% of SP-positive cases [95% CI = 9% to 34%]). The four-week cure rates were similar in both groups. CONCLUSIONS: Among outpatients with community-acquired pneumonia, half produced adequate sputum samples and most were culture negative. SP resistance was similar to rates from large national databases, and results were of little (if any) consequence. In low-risk Pneumonia Severity Index cases, sputum cultures should not be collected routinely.

Procedural sedation and analgesia in a Canadian adult tertiary care emergency department: a case series.

OBJECTIVES: To examine the safety of emergency department (ED) procedural sedation and analgesia (PSA) and the patterns of use of pharmacologic agents at a Canadian adult teaching hospital. METHODS: Retrospective analysis of the PSA records of 979 patients, treated between Aug. 1, 2004, and July 31, 2005, with descriptive statistical analysis. This represents an inclusive consecutive case series of all PSAs performed during the study period. RESULTS: Hypotension (systolic blood pressure < or = 85 mm Hg) was documented during PSA in 13 of 979 patients (1.3%; 95% confidence interval [CI] 0.3%-2.3%), and desaturation (SaO2 < or = 90) in 14 of 979 (1.4%; Cl 0.1%-2.7%). No cases of aspiration, endotracheal intubation or death were recorded. The most common medication used was fentanyl (94.0% of cases), followed by propofol (61.2%), midazolam (42.5%) and then ketamine (2.7%). The most frequently used 2-medication combinations were propofol and fentanyl (P/F) followed by midazolam and fentanyl (M/F), used with similar frequencies 58.1% (569/979) and 41.0% (401/979) respectively. There was no significant difference in the incidence of hypotension or desaturation between the P/F and M/F treated groups. In these patients, 9.1% (90/979) of patients received more than 2 different drugs. CONCLUSIONS: Adverse events during ED PSA are rare and of doubtful clinical significance. Propofol/fentanyl and midazolam/fentanyl are used safely, and at similar frequencies for ED PSA in this tertiary hospital case series. The use of ketamine for adult PSA is unusual in our facility.

Utility of follow-up recommendations for patients discharged with community-acquired pneumonia.

INTRODUCTION: The joint Canadian Infectious Diseases Society and Canadian Thoracic Society guidelines for community-acquired pneumonia (CAP) recommend 48-72 hour telephone follow-up of patients discharged from the emergency department (ED). The guidelines provide no evidence supporting this practice, and neither the clinical utility nor the effectiveness of such recommendations has been assessed. Our objective was to assess the utility of a 48-72 hour telephone follow-up protocol for patients discharged from the ED with CAP. METHODS: This was a retrospective chart audit covering a 2-year period (Jan. 3, 1999 to Jan. 3, 2001) after the introduction of a clinical practice guideline (CPG) that included routine 48-72 hour telephone follow-up of patients discharged from the ED with CAP. Eligible patients were identified in the ED database, rates of referral for telephone follow-up were recorded, and 30-day outcomes (death and readmission) for patients referred versus not referred were compared. RESULTS: During the study period, 867 patients were identified as being eligible for the study. The mean age was 55.7 years (range 16-98 yr), and mean pneumonia severity index (PSI) was 68.9 (range 6-187). Despite the CPG, only 148 patients (17.1%) were referred for telephone follow-up. Age, demographics, comorbidity, clinical status and pneumonia severity were similar for referred and non-referred patients. Thirty-day death (2.5%) and readmission rates (3%) were strongly related to PSI score, but did not differ significantly in the 2 comparison groups. CONCLUSION: In this setting, physicians were poorly compliant with a routine telephone follow-up protocol. The likelihood of referral for follow-up did not correlate with pneumonia severity, and follow-up referral did not appear to affect patient outcome. These findings do not support recommendations for routine early follow-up mechanisms beyond those already existing in the community.

Ethics in the trenches: Part 2. Case studies of ethical challenges in emergency medicine.

Unique ethical issues arise in the practice of emergency medicine, and common ethical problems are often more difficult to address in the emergency department than in other medical settings. This article is Part 2 of the Series "Ethics in the Trenches" and it presents and analyses 2 cases--each dealing with an ethical challenge that emergency physicians are likely to encounter. The first case deals with patient refusal of care. When a patient refuses recommended care, the emergency physician must ensure the patient's decision is informed and that the patient comprehends the implications of his or her choice. The second case deals with patient involvement in criminal activities. Emergency physicians often encounter patients who have engaged in illegal activities. Although certain activities must be reported, physicians should be mindful of their responsibility to protect patient privacy and confidentiality.