Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.

A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).

Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.

Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.

This study assessed the use and clinical yield of diagnostic imaging (radiography, computed tomography, and medical resonance imaging) ordered to assist in the diagnosis of acute neck injuries presenting to emergency departments (EDs) in Kingston, Ontario, from 2002–2003 to 2009–2010.

Acute neck injury cases were identified using records from the Kingston sites of the Canadian National Ambulatory Care Reporting System. Use of radiography was analyzed over time and related to proportions of cases diagnosed with clinically significant cervical spine injuries.

A total of 4,712 neck injury cases were identified. Proportions of cases referred for diagnostic imaging to the neck varied significantly over time, from 30.4% in 2002–2003 to 37.6% in 2009–2010 (ptrend = 0.02). The percentage of total cases that were positive for clinically significant cervical spine injury (“clinical yield”) also varied from a low of 5.8% in 2005–2006 to 9.2% in 2008–2009 (ptrend = 0.04), although the clinical yield of neck-imaged cases did not increase across the study years (ptrend = 0.23). Increased clinical yield was not observed in association with higher neck imaging rates whether that yield was expressed as a percentage of total cases positive for clinically significant injury (p = 0.29) or as a percentage of neck-imaged cases that were positive (p = 0.77).

We observed increases in the use of diagnostic images over time, reflecting a need to reinforce an existing clinical decision rule for cervical spine radiography. Temporal increases in the clinical yield for total cases may suggest a changing case mix or more judicious use of advanced types of diagnostic imaging.

The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7% for women in the United States. Tamsulosin, an α-antagonist, has been used as therapy to facilitate the expulsion of lithiasis. Whether it is a good treatment for distal lithiasis remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of tamsulosin on the passage of distal ureterolithiasis.

A systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central. Trial eligibility was evaluated by two investigators. All randomized controlled trials (RCTs) comparing tamsulosin to standard therapy or placebo for the treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with renal colic confirmed by radiographic imaging were included. Data extraction was conducted in duplicate. Primary outcome was the expulsion rate, and secondary outcomes were the mean time for ureterolithiasis expulsion, analgesic requirements, and side effects. Mantel-Haenszel random effect models were used, and heterogeneity was assessed using I2 statistics. Data were presented with relative risks (RRs).

The search strategy identified 685 articles, of which 22 studies were included. Combined results suggested a benefit for the expulsion of ureterolithiasis (≥ 10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95% CI 1.31–1.71], I2 = 70%). A decrease in the average time of expulsion of the ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI −4.23, −2.44], I2 = 67%).

Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis (≤ 10 mm).

Drowning is a major public health concern, yet little is known about the characteristics of drowning patients. The objectives of this study were to describe the demographic and clinical characteristics of out-of-hospital cardiac arrest (OHCA) attributed to drowning in Ontario and to compare the characteristics of OHCA attributed to drowning to those of presumed cardiac etiology.

A retrospective, observational study was carried out of consecutive OHCA patients of drowning etiology in Ontario between August 2006 and July 2011. Bivariate analysis was used to evaluate differences between drowning and presumed cardiac etiologies.

A total of 31,763 OHCA patients were identified, and 132 (0.42%) were attributed to drowning. Emergency medical services treated 98 patients, whereas the remaining 34 met the criteria for legislative death. Overall, 5.1% of drowning patients survived to hospital discharge. When compared to patients of presumed cardiac etiology, drowning patients were younger and their arrest was more likely to be unwitnessed, present with a nonshockable initial rhythm, occur in a public location, and receive bystander cardiopulmonary resuscitation (CPR). A nonsignificant trend was noted for drowning cases to more frequently have a public access AED applied. There were no significant differences in the gender ratio or paramedic response times. Drowning patients were more likely to be transported to hospital but had a trend to be less likely to arrive with a return of spontaneous circulation. They were also more likely to be admitted to hospital but had no difference in survival to hospital discharge.

Significant differences exist between OHCA of drowning and presumed cardiac etiologies. Most drownings are unwitnessed, occur in public locations, and present with nonshockable initial rhythms, suggesting that treatment should focus on bystander CPR. Future initiatives should focus on strategies to improve supervision in targeted locations and greater emphasis on bystander-initiated CPR, both of which may reduce drowning mortality.

Cognitive forcing strategies (CFS)may reduce error arising from cognitive biases. This is the first experimental test to determine the effect of CFS training in medical students.

Students were allocated to CFS training or control during a 4-week emergency medicine rotation (n = 191). At the end of the rotation examination, students were tested using computer-based cases. Application of CFS could enable reduction of diagnostic error, as evidenced by identifying multiple correct diagnoses for the two cases prone to search satisficing bias (SSB) and uncommon diagnoses for the two cases prone to availability bias (AB). Two “false positive” cases were included to test for possible “oversearching.”

There were 145 students in the intervention and 46 in the control group. For the SSB cases, 52% of students with CFS training and 48% in the control group initiated a search for the second diagnosis (χ2 = 0.13, df = 1, p = 0.91). More than half (54%) correctly identified the second diagnosis in the CFS group, and 48% identified it in the control group. The difference was not significant (χ2 = 2.25, df = 1, p = 0.13). For the second diagnosis in the false positive cases, 64% of the CFS group and 77% of the control group incorrectly identified it. There were no significant differences between groups (χ2 = 2.38, df = 1, p = 0.12). In the AB cases, only 45% in each group identified the uncommon correct diagnosis (χ2 = 0.001, df = 1, p = 0.98).

The educational interventions suggested by experts in clinical reasoning and employed in our study to teach CFS failed to show any reduction in diagnostic error by novices.

Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs)without inpatient admission is notwell known.

Patients without a diagnosis of acute coronary syndrome discharged fromtwo EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-not-resuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year.

Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1–5.0, p < 0.001) and both of its components (p < 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3–3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2–3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6–2.9, p 5 0.5) after adjustment.

A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.

Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative Ddimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges.

We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed.

ED visits were investigated for suspected VTE in the pre- and postintervention periods (n 5 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%).

In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low–pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.