Evaluating the paramedic application of the prehospital Canadian C-Spine Rule in sport-related injuries.

OBJECTIVES: We sought to compare the ability of the prehospital Canadian C-Spine Rule to selectively recommend immobilization in sport-related versus non-sport-related injuries and describe sport-related mechanisms of injury. METHODS: We reviewed data from the prospective paramedic Canadian C-Spine Rule validation and implementation studies in 7 Canadian cities. A trained reviewer further categorized sport-related mechanisms of injury collaboratively with a sport medicine physician using a pilot-tested standardized form. We compared the Canadian C-Spine Rule's recommendation to immobilize sport-related versus non-sport-related patients using Chi-square and relative risk statistics with 95% confidence intervals. RESULTS: There were 201 sport-related patients among the 5,978 included. Sport-related injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs. 46.8%) than non-sport-related patients. Paramedics did not miss any C-Spine injury when using the Canadian C-Spine Rule. C-Spine injury rates were similar between sport (2/201; 1.0%) and non-sport-injured patients (47/5,777; 0.8%). The Canadian C-Spine Rule recommended immobilization equally between groups (46.4% vs. 42.5%; RR 1.09 95%CI 0.93-1.28), most commonly resulting from a dangerous mechanism among sport-injured (68.7% vs. 54.5%; RR 1.26 95%CI 1.08-1.47). The most common dangerous mechanism responsible for immobilization in sport was axial load. CONCLUSION: Although equal proportions of sport and non-sport-related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the Canadian C-Spine Rule to evaluate collegiate or pro athletes assessed by sport medicine physicians. It does support using the Canadian C-Spine Rule as a tool in sport-injured patients assessed by paramedics.

RéSUMé: OBJECTIFS: Nous avons cherché à comparer la capacité préhospitalière de la Canadian C-spine Rule à recommander de façon sélective l'immobilisation dans les blessures liées au sport par rapport aux blessures non liées au sport et à décrire les mécanismes des blessures liés au sport. LES MéTHODES: Nous avons examiné les données des études prospectives de validation et de mise en œuvre de la règle canadienne de la colonne vertébrale dans sept villes canadiennes. Un examinateur qualifié a ensuite classé les mécanismes de blessure liés au sport, en collaboration avec un médecin du sport, à l'aide d'un formulaire standardisé testé dans le cadre d'un projet pilote. Nous avons comparé la recommandation de la Canadian C-Spine Rule d'immobiliser les patients liés au sport par rapport aux patients non liés au sport en utilisant les statistiques du chi carré et du risque relatif avec un intervalle de confiance de 95 %. RéSULTATS: Parmi les 5 978 patients inclus il y avait 201 patients liés au sport. Les patients blessés liés au sport étaient plus jeunes (âge moyen 36,2 ans contre 42,4 ans) et plus majoritairement de sexe masculin (60,5 % contre 46,8 %) que les patients non liés au sport. Les ambulanciers paramédicaux n'ont manqué aucune blessure au rachis cervical lorsqu'ils ont utilisé la Canadian C-spine Rule. Les taux de blessures au rachis cervical étaient semblables chez les patients sportifs (2/201 ; 1,0 %) et non sportifs (47/5 777 ; 0,8 %). La Canadian C-spine Rule recommande l'immobilisation de manière égale entre les groupes (46,4 % contre 42,5 % ; RR 1,09 95 % IC 0,93-1,28), le plus souvent en raison d'un mécanisme dangereux chez les sportifs blessés (68,7 % contre 54,5 % ; RR 1,26 95 % IC 1,08-1,47). Le mécanisme dangereux le plus souvent responsable de l'immobilisation dans le sport était la charge axiale. CONCLUSION: Bien que des proportions égales de blessures sportives et non sportives aient été immobilisées, un mécanisme dangereux était le plus souvent responsable de l'immobilisation dans les cas liés au sport. Ces conclusions n'abordent pas l'impact potentiel de l'utilisation de la Canadian C-spine Rule pour évaluer les athlètes collégiaux ou professionnels évalués par les médecins du sport. Elle est favorable à l'utilisation de la Canadian C-spine Rule comme outil pour les patients blessés par le sport et évalués par les ambulanciers.

Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study.

OBJECTIVES: For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events. METHODS: An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition. RESULTS: We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02). CONCLUSIONS: A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.

Clinically important change in the visual analog scale after adequate pain control.

OBJECTIVES: To define the minimum clinically important difference (MCID) for the visual analog scale (VAS) of pain severity by measuring the change in VAS associated with adequate pain control. METHODS: The authors conducted a prospective, observational study. Adult emergency department (ED) patients with acute pain (<72 hours) were eligible. Patients rated their pain severity on a 100-mm VAS on presentation and at discharge. Patients were asked if they would accept any analgesic, then if they would accept a parenteral analgesic before treatment. At discharge, they were asked whether they had received adequate pain control. RESULTS: The authors enrolled 143 patients (mean age, 36 years; 54% female). The mean decrease in VAS was -30.0 mm (95% confidence interval [CI] = -36.4 to -23.6) for the 116 of 143 (81%) patients with adequate pain control at discharge vs. -5.7 (95% CI = -11.2 to -0.3) for the 27 with inadequate pain control (p < 0.001). At discharge, the mean VAS was 31.3 mm for those with adequate pain control vs. 55.1 for those without. Mean VAS for the 114 of 143 patients who would accept any analgesics initially was 64.7 vs. 47.1 for the 29 reporting no analgesic need. Initially, 77 patients would accept parenteral analgesics (mean VAS = 72.5 mm). CONCLUSIONS: A mean reduction in VAS of 30.0 mm represents a clinically important difference in pain severity that corresponds to patients' perception of adequate pain control. Defining MCID based on adequate analgesic control rather than minimal detectable change may be more appropriate for future analgesic trials, when effective treatments for acute pain exist.