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OBJECTIVE: There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias. METHODS: This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED. RESULTS: A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion. CONCLUSION: This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care. [ABSTRACT FROM AUTHOR]

A mentor is a person who takes a special interest in the professional development of a junior colleague and provides guidance and support. Mentoring can be beneficial for students, residents, junior colleagues and researchers and can be very rewarding for the physician who provides this guidance. Although mentoring is a well recognized topic in academic medicine, relatively little has been written about mentoring in emergency medicine (EM). Consequently, we conducted a literature review on mentoring in EM and present our findings in this paper. We discuss different models of mentoring, factors that foster the development of strong mentor ship programs, the responsibilities of mentors and mentees, and issues specific to mentorship of female, minority and research physicians. We also present several case scenarios as a basis for recommendations for teachers and learners in EM. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography. METHODS: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6 month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as 'normal,' 'abnormal not requiring intervention' and 'abnormal requiring intervention,' based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with kappa statistics), univariate analyses and recursive partitioning. RESULTS: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of con gestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The kappa statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). CONCLUSION: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The general objective of this study was to explore the challenges of establishing an out of hospital cardiac arrest (OOHCA) surveillance program in Canada. More specifically, we attempted to determine the organizational structure of the delivery of emergency medical services (EMS) in Canada, describe the cardiac arrest data collection infrastructure in each province and determine which OOHCA variables are being collected. METHODS: We conducted a national survey of 82 independent EMS health authorities in Canada. Methodology experts devel oped the survey and distribution using a modified Dillman tech nique. We distributed 67 surveys electronically (84%) and the rest by regular mail. We weighted each survey response by the popu lation of the catchment area represented by the responding health authority (2004 census). Descriptive statistics are reported. RESULTS: We received 60 completed surveys, representing a 73% response rate. The responding health authorities' catchment areas represented 80% of the Canadian population (territories excluded). Our survey results highlight a lack of common OOHCA data definitions used among health authorities, sporadic use of data quality assurance procedures, rare linkages to in hospital survival outcomes and potential confidentiality issues. Other chal lenges raised by respondents included determining warehousing location and finding financial resources for a national OOHCA registry. CONCLUSION: Results from this survey demonstrate that, although it is challenging, it is possible to collect OOHCA data and access in hospital survival outcomes. Collaborative efforts with the Resuscitation Outcomes Consortium and other potential provin cial partners should be explored. [ABSTRACT FROM AUTHOR]

Objective: Patients with acute headache often undergo computed tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study examined current practice, the perceived need for a clinical decision rule for acute headache and the required sensitivity for such a rule. Methods: We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3--5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neurologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country. Results: The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency department (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investigated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%--99%). Approximately 1 in 5 physicians suggested that 100% sensitivity was required. Conclusion: Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Information gaps, defined as previously collected information that is not available to the treating physician, have implications for patient safety and system efficiency. For patients transferred to an emergency department (ED) from a nursing home or seniors residence, we determined the frequency and type of clinically important information gaps and the impact of a regional transfer form. METHODS: During a 6-month period, we studied consecutive patients who were identified through the National Ambulatory Care Reporting System database. Patients were over 60 years of age, lived in a nursing home or seniors residence, and arrived by ambulance to a tertiary care ED. We abstracted data from original transfer and ED records using a structured data collection tool. We measured the frequency of prespecified information gaps, which we defined as the failure to communicate information usually required by an emergency physician (EP). We also determined the use of the standardized patient transfer form that is used in Ontario and its impact on the rate of information gaps that occur in our community. RESULTS: We studied 457 transfers for 384 patients. Baseline dementia was present in 34.1% of patients. Important information gaps occurred in 85.5% (95% confidence interval [CI] 82.0%-88.0%) of cases. Specific information gaps along with their relative frequency included the following: the reason for transfer (12.9%), the baseline cognitive function and communication ability (36.5%), vital signs (37.6%), advanced directives (46.4%), medication (20.4%), activities of daily living (53.0%) and mobility (47.7%). A standardized transfer form was used in 42.7% of transfers. When the form was used, information gaps were present in 74.9% of transfers compared with 93.5% of the transfers when the form was not used (p < 0.001). descriptors of the patient's chief complaint were frequently absent (81.0% for head injury [any information about loss of consciousness], 42.4% for abdominal pain and 47.1% for chest pain [any information on location, severity and duration]). CONCLUSION: Information gaps occur commonly when elderly patients are transferred from a nursing home or seniors residence to the ED. A standardized transfer form was associated with a limited reduction in the prevalence of information gaps; even when the form was used, a large percentage of the transfers were missing information. We also determined that the lack of descriptive detail regarding the presenting problem was common. We believe this represents a previously unidentified information gap in the literature about nursing home transfers. Future research should focus on the clinical impact of information gaps. System improvements should focus on educational and regulatory interventions, as well as adjustments to the transfer form. [ABSTRACT FROM AUTHOR]

OBJECTIVE: A full understanding of an injury event and the mechanical forces involved should be important for predicting specific anatomical patterns of injury. Yet, information on the mechanism of injury is often overlooked as a predictor for specific anatomical injury in clinical decision-making. We measured the relationship between mechanism of injury and risk for cervical spine fracture. METHODS: Our case-control study is a secondary analysis of data collected from the Canadian C-Spine Rule (CCR) study. Data were collected from 1996 to 2002 and included patients presenting to the emergency departments of 9 tertiary care centres after sustaining acute blunt trauma to the head or neck. Cases are defined as patients who were categorized in the CCR study with a clinically important cervical spine fracture. Controls had no radiologic evidence of cervical spine injury. Bivariate and multivariate unconditional logistic regression models were used. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Among the 17,208 patients in the CCR study, 320 (2%)received a diagnosis of a cervical spine fracture. Axial loads, falls, diving incidents and nontraffic motorized vehicle collisions (e.g., collisions involving snowmobiles or all-terrain vehicles) were injury mechanisms that were significantly related to a higher risk of fracture. For motor vehicle collisions, the risk of cervical spine injury increased with the posted speed, being involved in a head-on collision or a rollover, or not wearing a seat belt (p < 0.05). The occurrence of cervical spine fracture was negligible in simple rear-end collisions (1 in 3694 cases; OR 0.015, 95% CI 0.002-0.104]). CONCLUSION: Our study quantitatively demonstrates the relationship between specific mechanisms of injury and the risk of a cervical spine fracture. A full understanding of the injury mechanism would assist providers of emergency health care in assessing risk for injury in trauma patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting. METHODS: We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 x 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form. RESULTS: Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively. CONCLUSION: Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Cardiopulmonary resuscitation (CPR) is a crucial yet weak link in the chain of survival for out-of-hospital cardiac arrest. We sought to understand the determinants of bystander CPR and the factors associated with successful training. METHODS: For this systematic review, we searched 11 electronic databases, 1 trial registry and 9 scientific websites. We performed hand searches and contacted 6 content experts. We reviewed without restriction all communications pertaining to who should learn CPR, what should be taught, when to repeat training, where to give CPR instructions and why people lack the motivation to learn and perform CPR. We used standardized forms to review papers for inclusion, quality and data extraction. We grouped publications by category and classified recommendations using a standardized classification system that was based on level of evidence. RESULTS: We reviewed 2409 articles and selected 411 for complete evaluation. We included 252 of the 411 papers in this systematic review. Differences in their study design precluded a meta-analysis. We classified 22 recommendations; those with the highest scores were 1) 9-1-1 dispatch- assisted CPR instructions, 2) teaching CPR to family members of cardiac patients, 3) Braslow's self-training video, 4) maximizing time spent using manikins and 5) teaching the concepts of ambiguity and diffusion of responsibility. Recommendations not supported by evidence include mass training events, pulse taking prior to CPR by laymen and CPR using chest compressions alone. CONCLUSION: We evaluated and classified the potential impact of interventions that have been proposed to improve bystander CPR rates. Our results may help communities design interventions to improve their bystander CPR rates. [ABSTRACT FROM AUTHOR]

Objectives: There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS. Methods: This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children <16 years of age who were attended by EMS during a 6-month period were enrolled. Data were extracted from ambulance call reports and hospital charts, and analyzed using descriptive statistics.Results: During the study period there were 1377 pediatric EMS calls. Mean age was 8.2 years (standard deviation 5.4), and the most common diagnoses were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The ambulance return code was Urgent in 7%, Prompt in 57%, Deferrable in 8% and Not Transported in 28%. Fifty-six percent received either an Advanced Life Support or Basic Life Support prehospital intervention. Common procedures included cardiac monitoring (20.0%), oxygen administration (19.8%), blood glucose monitoring (16.3%), spine board (12.2%), limb immobilization (11.1%) and cervical collar (10.0%). Uncommon procedures included administering medications intravenously (IV) (1.4%), bag-valve-mask ventilation (0.3%) and endotracheal intubation (0.1%). Seventy-eight percent of attempted IV lines were successful. Only 9.0% of EMS-transported children were admitted to hospital, and 2.2% were admitted to the intensive care unit.Conclusions: This first study of Canadian pediatric prehospital interventions shows a high rate of non-transport, and a low rate of Urgent transports and hospital admissions for children. Very few children receive prehospital airway management, ventilation or IV medications; consequently EMS personnel have little opportunity to maintain these pediatric skills in the field. [ABSTRACT FROM AUTHOR]

Objectives: There is no set of prospectively validated criteria to identify the emergency department (ED) patients with renal colic who are most likely to eventually have to undergo an intervention. This study prospectively assessed predictors of intervention in this patient population.Methods: This prospective cohort study included adult patients with renal colic who presented to 2 tertiary care hospital EDs. Patients had an 18-variable data form completed by an emergency physician and a radiological study to confirm urolithiasis. After discharge, patients were followed at 1 and 4 weeks to assess for intervention. The outcome criteria included the patient having had at least 1 of the following procedures performed: extracorporeal shockwave lithotripsy (ESWL), ureteroscopy, percutaneous nephrostomy or open surgery. Data were analyzed using appropriate univariate techniques, and those variables associated with intervention were combined using logistic regression analysis.Results: Over an 8-month period, 245 patients with confirmed urolithiasis were followed; 20% (95% confidence interval [CI] 15%-25%) eventually had a procedure to remove their calculi. Three variables were significantly correlated with having a procedure: i) size of calculus >/= 6 mm (odds ratio [OR] 10.7, 95% CI 4.6-24.8), ii) location of calculus above mid-ureter (OR 6.9, 95% CI 3.0-15.9), and iii) Visual Analogue Scale score for pain at discharge from the ED >/= 2 cm (OR 2.6, 95% CI 1.0-6.8). The area under receiver operating characteristic curve was 0.77 (95% C I 0.70-0.84) (p < 0.001). If all variables were present there was a 90% probability of the patient having an intervention performed within 4 weeks of discharge from the ED. Conversely, if none of the variables were present there was only a 4% probability of an intervention. Overall, the model had a sensitivity of 92% (95% CI 89%-96%) and a specificity of 63% (95% CI 57%-69%).Conclusions: This study has identified variables that could potentially be used to identify those renal colic patients who require an intervention after ED evaluation. Future studies will prospectively validate this model. [ABSTRACT FROM AUTHOR]