5 results
LO20: The characteristics, clinical course and disposition of long-term care patients treated by paramedics during an emergency call: Exploring the potential impact of community paramedicine
- S. Leduc, G. Wells, V. Thiruganasambandamoorthy, Z. Cantor, P. Kelly, M. Rietschlin, C. Vaillancourt
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S14
- Print publication:
- May 2020
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Introduction: An increasing number of Canadian paramedic services are creating Community Paramedic programs targeting treatment of long-term care (LTC) patients on-site. We explored the characteristics, clinical course and disposition of LTC patients cared for by paramedics during an emergency call, and the possible impact of Community Paramedic programs. Methods: We completed a health records review of paramedic call reports and emergency department (ED) records between April 1, 2016 and March 31, 2017. We utilized paramedic dispatch data to identify emergency calls originating from LTC centers resulting in transport to one of the two EDs of the Ottawa Hospital. We excluded patients with absent vital signs, a Canadian Triage and Acuity Scale (CTAS) score of 1, and whose transfer to hospital were deferrable or scheduled. We stratified remaining cases by month and selected cases using a random number generator to meet our apriori sample size. We collected data using a piloted standardized form. We used descriptive statistics and categorized patients into groups based on the ED care received and if the treatment received fit into current paramedic medical directives. Results: Characteristics of the 381 included patients were mean age 82.5 years, 58.5% female, 59.7% hypertension, 52.6% dementia and 52.1% cardiovascular disease. On arrival at hospital, 57.7% of patients waited in offload delay for a median time of 45 minutes (IQR 33.5-78.0). We could identify 4 groups: 1) Patients requiring no treatment or diagnostics in the ED (7.9%); 2) Patients receiving ED treatment within current paramedic medical directives and no diagnostics (3.2%); 3) Patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and 4) patients requiring admission (34.1%). Most patients were discharged from the ED (65.6%), and 1.1% died. The main ED diagnoses were infection (18.6%) and musculoskeletal injury (17.9%). Of the patients that required ED care but were discharged, 64.1% required x-rays, 42.1% CT, and 3.4% ultrasound. ED care included intravenous fluids (35.7%), medication (67.5%), antibiotics (29.4%), non-opioid analgesics (29.4%) and opioids (20.7%). Overall, 11.1% of patients didn't need management beyond current paramedic capabilities. Conclusion: Many LTC patients could receive care by paramedics on-site within current medical directives and avoid a transfer to the ED. This group could potentially grow using Community Paramedics with an expanded scope of practice.
LO15: Paramedic and allied health professional interventions at long-term care facilities to reduce emergency department visits: systematic review
- S. Leduc, Z. Cantor, P. Kelly, V. Thiruganasambandamoorthy, G. Wells, C. Vaillancourt
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S12
- Print publication:
- May 2020
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Introduction: Emergency department (ED) crowding, long waits for care, and paramedic offload delay are of increasing concern. Older adults living in long-term care (LTC) are more likely to utilize the ED and are vulnerable to adverse events. We sought to identify existing programs that seek to avoid ED visits from LTC facilities where allied health professionals are the primary providers of the intervention and, to evaluate their efficacy and safety. Methods: We completed this systematic review based on a protocol we published apriori and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. Two investigators independently selected studies and extracted data using a piloted standardized form and evaluated the risk of bias of included studies. We report a narrative synthesis grouped by intervention categories. Results: We reviewed 11,176 abstracts and included 22 studies. Most studies were observational and few assessed patient safety. We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Of the 13 studies that reported ED visits, all (100%) reported a decrease, and of the 16/17 that reported hospitalization, 94.1% reported a decrease. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. When measured, studies reported decreased hospital length of stay, more time spent with patients by allied health professionals and cost savings. Conclusion: We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. Many identified programs focused on improved primary care for patients. Interventions addressing acute care issues such as those provided by community paramedics, patient preferences, and quality of life indicators all deserve more study.
P126: Utilization and outcomes of children presenting to an emergency department by ambulance
- Z. Cantor, M. Aglipay, A. Plint
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S110
- Print publication:
- May 2020
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Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into two groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with the method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 (6.5%) arrived by ambulance, while 64,556 (93.5) self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0%), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance were 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were neurological (22.5%), respiratory (22.7%), and orthopaedic (11.3%). Among self-presenting patients, the top three were general/minor (20.4%), respiratory (16.4%), and gastrointestinal (14.3%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that paramedics have sufficient training to ensure adequate skills to manage critically ill children. Given the low proportion but higher severity of illness of pediatric transports, further research and consideration must be given to how best to enable paramedics in the management of children.
P016: Utilization and outcomes of children presenting to an emergency department by ambulance
- Z. Cantor, M. Aglipay, A. Plint
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, pp. S68-S69
- Print publication:
- May 2019
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Introduction: Children account for a low proportion of paramedic transports. Evidence suggests that many pediatric transports are of low acuity, but there are few studies comparing these patients to those that self-present to the ED. Our primary objective was to determine if illness severity was associated with presentation by ambulance among pediatric patients. Methods: We undertook a single centre, retrospective cohort study at a tertiary care pediatric centre. All patients presenting to the ED in 2015 by any route other than air ambulance were eligible. Patients were divided into 2 groups based on the route of presentation – ambulance or self-presentation. The primary outcome was disposition decision; the secondary outcome was CTAS level. To determine whether patient discharge disposition or CTAS was associated with method of arrival, we conducted generalized estimating equations (GEE) to account for correlation within patients with multiple ED visits. Results: Of the 69,092 visits, 69,034 were eligible and analyzed. Of those, 4478 arrived by ambulance, while 64,556 self-presented. Those arriving by ambulance had a median age of 10 years [IQR: 2-5 years] vs. 4 years [IQR: 1.75-10 years] in the self-presenting group, and were 52.6% male (vs. 52.8%). Two percent of the ambulance cohort were admitted to the ICU (vs. 0.2%), and 16.6% were admitted to the ward (vs. 5%). Patients presenting by ambulance had higher CTAS scores – 5.3% CTAS 1 (vs. 0.3%), 16.4% CTAS 2 (vs. 7.0% ), 61.2% CTAS 3 (vs. 45.8%), and 17.1% CTAS 4-5 (vs. 46.9%). The odds of arriving by ambulance were 10.2 x higher for patients admitted to the ICU (OR = 10.2, 95%CI: 7.9 to 13.3) vs. those discharged home. The odds of arriving by ambulance was 64.2 x (OR = 64.2, 95% CI: 48.6 to 84.7) higher for patients CTAS 1 patients vs. CTAS 5 patients. The top 3 complaints among ambulance patients were respiratory (22.7%), orthopedic (14.7%), and general/minor (10.3%). Among self-presenting patients, the top three were general/minor (22.5%), respiratory (18.0%), and gastrointestinal (15.7%). Conclusion: Children presenting to the ED via ambulance are at higher risk for admission to the ward and critical care unit. It is important that EMS staff responsible for transporting children be well trained in managing critically ill children. Given the low proportion of pediatric transports, consideration must be given to how best to train EMS services in managing these children.
LO25: How safe are our pediatric emergency departments? A multicentre, prospective cohort study
- A. Plint, L. Calder, Z. Cantor, M. Aglipay, A.S. Stang, A.S. Newton, S. Gouin, K. Boutis, G. Joubert, Q. Doan, A. Dixon, R. Porter, S. Sawyer, M. Bhatt, K. Farion, T. Crawford, D. Dalgleish, D.W. Johnson, T. Klassen, N. Barrowman, for Pediatric Emergency Research Canada
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, p. S36
- Print publication:
- May 2017
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Introduction: Data regarding adverse events (AEs) (unintended harm to the patient from health care provided) among children seen in the emergency department (ED) are scarce despite the high risk setting and population. The objective of our study was to estimate the risk and type of AEs, and their preventability and severity, among children treated in pediatric EDs. Methods: Our prospective cohort study enrolled children <18 years of age presenting for care during 21 randomized 8 hr-shifts at 9 pediatric EDs from Nov 2014 to October 2015. Exclusion criteria included unavailability for follow-up or insurmountable language barrier. RAs collected demographic, medical history, ED course, and systems level data. At day 7, 14, and 21 a RA administered a structured telephone interview to all patients to identify flagged outcomes (e.g. repeat ED visits, worsening/new symptoms, etc). A validated trigger tool was used to screen admitted patients’ health records. For any patients with a flagged outcome or trigger, 3 ED physicians independently determined if an AE occurred. Primary outcome was the proportion of patients with an AE related to ED care within 3 weeks of their ED visit. Results: We enrolled 6377 (72.0%) of 8855 eligible patients; 545 (8.5%) were lost to follow-up. Median age was 4.4 years (range 3 months to 17.9 yrs). Eight hundred and seventy seven (13.8%) were triaged as CTAS 1 or 2, 2638 (41.4%) as CTAS 3, and 2839 (44.7%) as CTAS 4 or 5. Top entrance complaints were fever (11.2%) and cough (8.8%). Flagged outcomes/triggers were identified for 2047 (32.1%) patients. While 252 (4.0%) patients suffered at least one AE within 3 weeks of ED visit, 163 (2.6%) suffered an AE related to ED care. In total, patients suffered 286 AEs, most (67.9%) being preventable. The most common AE types were management issues (32.5%) and procedural complications (21.9%). The need for a medical intervention (33.9%) and another ED visit (33.9%) were the most frequent clinical consequences. In univariate analysis, older age, chronic conditions, hospital admission, initial location in high acuity area of the ED, having >1 ED MD or a consultant involved in care, (all p<0.001) and longer length of stay (p<0.01) were associated with AEs. Conclusion: While our multicentre study found a lower risk of AEs among pediatric ED patients than reported among pediatric inpatients and adult ED patients, a high proportion of these AEs were preventable.