13 results
P017: Chart audit of patients with no fixed address presenting to the emergency department to identify areas to improve care
- S. Todorovich, D. Giffin, M. Columbus
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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. S70
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- May 2020
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Background: Homelessness is a growing Canada-wide concern. Those with no fixed address have increased rates of emergency department (ED) utilization and increased healthcare spending compared to the general population, with higher rates of acute and chronic illnesses, as well as all-cause mortality. EDs are uniquely situated to act as an access point to the network of available community services, however referral rates from the ED is uncertain. To date, there has been no data collected on London, Ontario's homeless population, their health burden, and their utilization patterns of the ED. Aim Statement: The primary objective of this study is to describe ED visits for adult patients with no fixed address in London, Ontario to assess for potential areas to improve care. Measures & Design: This is a retrospective chart review, of patients with no fixed address visiting London, Ontario Emergency Departments in 2018. ED visits were identified and pulled using either a diagnosis of “homeless”, a lack of postal code, or a postal code for a known shelter. Cases included based on postal code were manually reviewed to determine whether the patient had a resident address with the same postal code. Evaluation/Results: From this search, 4,294 visits were identified for 1237 unique patients. The median visits per person was 1 (IQR 1-2), with 388 patients having 3 or more visits, and the max being 138 visits. The median age was 38 (IQR 28-52), with 73% male. Ground ambulance was used for 46% of visits. 28% of visits were CTAS 1&2 and 5% were CTAS 5. Police facilitated visits in 401 cases. Top 3 discharge diagnosis categories were mental health (19%), infection (18%), drug misuse (17%). Discussion/Impact: Several errors were identified with our search strategy suggesting the current system of capturing homelessness in the EPR is not accurate, leading to an underestimation of the problem and limiting our ability to describe this population. The Ministry of Health mandates homelessness be applied as a tertiary discharge diagnosis during coding of the patient visit if possible. However, use of this code is inconsistent leading to large-scale omission of visits and an underrepresentation of pediatric cases. Systemic steps should be taken to improve identification of these patients moving forward.
LO53: Emergency department visits for hyperglycemia: through the eyes of the patient
- J. Yan, D. Azzam, S. Liu, T. Spaic, M. Columbus, K. Van Aarsen, L. Shepherd
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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. S26
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- May 2020
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Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.
MP53: Management of cutaneous abscesses in the emergency department: a survey of Canadian practice patterns
- B. Rostas, D. Pringle, M. Columbus, J. Yan
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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, p. S61
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- May 2019
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Introduction: The treatment of cutaneous abscesses in the Emergency Department (ED) is common. While most sources describe only incision and drainage (I&D) followed by healing through secondary intention, recent literature suggests that primary repair following I&D results in similar rates of healing as well as treatment failures when compared to standard care in the ED. The primary goal of this research project was to describe the variability in practice with respect to self-reported management of abscesses among Canadian ED physicians and explore potential reluctance in adopting primary repair as a management strategy. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 9-question survey probed the willingness of physicians to perform primary closure of abscess in the ED as well as factors that dissuade them from performing this type of closure. The primary outcome was the quantification of practice variability among ED physicians with respect to abscess closure in the ED. The data was presented with simple descriptive statistics. Results: 217 surveys were completed out of 1145 eligible physicians. Physicians working at academic centres comprised 53% of responses, with 47% coming from community centres. Over half of responses were from physicians in practice at least ten years (65.9%). The overwhelming majority of physicians indicated that they manage abscesses following I&D by secondary closure (96.3%). The two main concerns dissuading respondents from performing primary closure of abscesses included risk of treatment failure (47.8%) and the procedure not being considered standard of care (36.7%). Despite these concerns, 67.3% of physicians indicated a willingness to perform primary closure if further evidence supported its use. These physicians were most likely to consider primary closure at the head and neck, breast, trunk, and extremities, however, only 1.5% considered primary closure appropriate for perianal or pilonidal abscesses. Conclusion: This study demonstrates that almost all Canadian ED physicians, regardless of experience or practice centre, manage cutaneous abscesses with I&D followed by healing via secondary intention. With increasing evidence supporting the use of primary closure, many physicians may be willing to adopt primary closure as part of the management of cutaneous abscesses in the ED.
P143: A prospective cohort study characterizing 30-day recurrent emergency department visits for hyperglycemia
- J. Yan, D. Azzam, M. Columbus, K. Van Aarsen
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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, p. S116
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- May 2019
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Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.
P020: Post-return of spontaneous circulation care and outcomes a single centre experience
- M. D. Clemente, K. Woolfrey, K. Van Aarsen, M. Columbus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, pp. S63-S64
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- May 2018
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Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. In 2015, the American Heart Association release updated guidelines dictating best practices in post-return of spontaneous circulation (ROSC) care, advocating for more liberal utilization of emergent coronary angiography. We sought to determine if the post-ROSC care at our centre during our study period adhered to the previously published (2010) guidelines. Methods: We performed a retrospective analysis (Sept. 2011 - June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Key variables included rates of post-ROSC emergent angiography, survival to hospital discharge and survival to hospital discharge with favourable neurologic outcome (modified Rankin score 2). Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. Of those who achieved sustained ROSC, median age was 65 years (IQR=21.75), 66.8% were male. ECG interpretation data was available on 214 patients, of whom 56 had definite STEMI, and 135 had definite absence of STEMI. 37/56 (66.1%) definite STEMI patients received coronary angiography within 24 hours of presentation, as per AHA guidelines. 58/262 (22.1%) post-ROSC patients overall received coronary angiography within 24 hours of presentation to the ED. Of those 58 patients who received emergent angiography, 38 (65.5%) underwent percutaneous coronary intervention (PCI). No patients received fibrinolysis. Of post-ROSC patients who received emergent coronary angiography, 40/58 (69.0%) survived to hospital discharge and 37/58 (63.8%) survived with good neurologic outcome. In comparison, 55/204 (27.0%) who did not receive emergent angiography survived to hospital discharge and 18.8% survived with good neurologic outcome. Conclusion: Only 22.1% of patients with OHCA, and only 66.1% with ECG-proven STEMI underwent emergent coronary angiography post-ROSC. Further investigation into causes for delay or the withholding of emergent angiography is necessary.
P021: Outcomes of out of hospital cardiac arrest in London, Ontario
- M. D. Clemente, K. Woolfrey, K. Van Aarsen, M. Columbus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S64
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- May 2018
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Introduction: Out of hospital cardiac arrest (OHCA) continues to carry a very high mortality rate, with approximately 10% surviving to hospital discharge. We sought to determine if outcomes from out of hospital cardiac arrest (OHCA) at our centre were consistent with recently published North American outcomes data from the Resuscitation Outcomes Consortium (ROC). Methods: We performed a retrospective analysis (Sept 2011 June 2015) of the Resuscitation Outcomes Consortium (ROC) database, which contains pre-hospital, in-hospital and outcomes data on adult, EMS-treated, non-traumatic OHCA. Patients under 18 years, with missing age data or with obvious non-cardiac causes of arrest were excluded. Results: During the study period, there were a total of 997 OHCA; 86 met exclusion criteria. Of the 911 remaining patients, 557 (61.1%) were transported to a local ED. 92 (35.1%) were receiving ongoing CPR at the time of their presentation to the ED. Of those transported to the ED, 262 (47.0%) achieved sustained ROSC, defined as survival to ED discharge. A total of 95 patients survived to hospital discharge (36.3% of patients who achieved sustained ROSC, 17.1% of those who were transported to the ED, and 10.4% of the all OHCA). Of those who survived to hospital discharge who had neurologic outcome data, 90.5% had a modified Rankin score of 2. Initial presenting rhythm with EMS was ventricular fibrillation or pulseless ventricular tachycardia in 233 patients. Of these, 212 (91.0%) were transported to the ED, 134 (57.5%) achieved sustained ROSC, and 71 (30.5%) survived to hospital discharge. 54/60 (90.0%) of those with a documented neurologic exam had a favourable neurologic outcome. Initial presenting rhythm with EMS was PEA or asystole in 636 patients. Of these, 320 (50.3%) were transported to the ED, 115 (18.1%) achieved sustained ROSC, and 17 (2.7%) survived to hospital discharge. 9/10 (90%) of those with a documented neurologic exam had a favourable neurologic outcome. 358 of the arrests were witnessed. Of these, 274 (76.5%) were transported to the ED, 150 (41.9%) achieved sustained ROSC, and 51 (15.9%) survived to hospital discharge. 47/53 (88.7%) of those with a documented neurologic exam had a favourable neurologic outcome. Conclusion: Outcomes from out of hospital cardiac arrest in London, Ontario are comparable to other sites across North America.
LO34: Does utilization of an intubation safety checklist reduce dangerous omissions during simulated resuscitation scenarios?
- C. Forristal, K. Hayman, N. Smith, S. Mal, M. Columbus, N. Farooki, S. McLeod, K. Van Aarsen, D. Ouellette
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, pp. S18-S19
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- May 2018
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Introduction: One of the most high-risk tasks regularly performed by emergency medicine (EM) physicians is airway management. Many studies identify an increase in adverse events associated with airway management outside of the operating theatre. Errors of omission are the single most common human error type. To address this risk, the checklist is becoming a common pre-intubation tool. Simulation is a safe setting in which to study the implementation of a new airway checklist. The purpose of this study was to determine if a novel airway checklist decreases practitioners rates of omission of important tasks during simulated resuscitation scenarios. Methods: This was a dual-centre, randomized controlled trial of a novel airway checklist utilized by EM practitioners in a simulated environment. The 29-item peri-intubation checklist was derived by experienced EM practitioners following a review of airway checklists in published and gray literature. Participants were EM residents or EM physicians who work more than 20 hours/month in an emergency department. Volunteers were recruited from two academic health centres to complete three simulated scenarios (two requiring intubation, one cricothyroidotomy), and were randomized to either regular care or checklist use. A minimum of two assessors documented the number of omitted tasks deemed important in airway management and the time until definitive airway management. Discrepancies between assessors were resolved by single-assessor video review. Results: Fifty-four EM practitioners participated. There was no significant difference in baseline characteristics between the two study groups. The average percentage of omitted tasks over the three scenarios was 45.7% in the control group (n=25) and 13.5% in the checklist group (n=29) an absolute difference of 32.2% (95% CI: 27.8%, 36.6%). Time to intubation (normally distributed) was significantly longer in the checklist group for the first two scenarios (mean difference 114.10s, 95% CI: 48.21s, 179.98s and 76.34s, 95% CI:31.35s ,121.33s), but there was no statistical difference in the third scenario where cricothyroidotomy was required (mean difference 33.75s, 95% CI: -28.14s, 95.65s). Conclusion: In a simulated setting, use of an airway checklist significantly decreased the omission rate of important airway management tasks, however it increased the time to definitive airway management. Further study is required to determine if these findings are consistent in a clinical setting and how they impact the rate of adverse events.
LO43: Perceptions of airway checklists and the utility of simulation in their implementation emergency medicine practitioner perspectives
- C. Forristal, K. Hayman, N. Smith, S. Mal, M. Columbus, N. Farooki, S. McLeod, K. Van Aarsen, D. Ouellette
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, pp. S21-S22
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- May 2018
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Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.
P048: Profiling the burdens of working nights. Traditional 8-hour nights vs staggered 6-hour casino shifts in an academic emergency department
- A.X. Dong, M. Columbus, R. Arntfield, D. Thompson, M. Peddle
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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. S94
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- May 2017
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Introduction: Emergency physicians (EP) often work at undesirable hours. In response to deleterious effects on quality of life for EPs, traditional 2300-0700 night shifts have been replaced at some centres with staggered 6-hour casino shifts (22:00-04:00 and 04:00-10:00). Though purported to allow for better sleep and recovery patterns, no evidence exists to support the benefits on sleep or quality of life that is used to justify a casino shift model. Using a before and after survey model, this study examines the impact of overhauling night work from a traditional 8-hour shift to casino shifts on the quality of life and job satisfaction of EPs working in an academic emergency department (ED). Methods: In 2010, an initial online, 37-item survey, was sent to all EPs working in the ED, just prior to the transition to casino shifts. 6 years following the transition, a slightly modified 37-item survey was again distributed to all current EPs working at that same centre. Participants rated their level of agreement on a 7-point Likert scale regarding questions related to night work. Results from the two surveys were compared. Results: 43 2010- and 47 2016-surveys were completed. In 2016, recovery to baseline function after a single early shift (22:00-04:00) was most common after 1 day at 52.4%, and after multiple early shifts was ≥2 days at 66.7%. Recovery after a single late shift (04:00-10:00) was most common at 1 day at 54.8%, and after multiple late shifts was ≥2 days at 59.5%. This was in contrast to 2010, when 55.8% recovered from a single traditional night shift after 1 day, and 95.3% required ≥2 days to recover from multiple traditional night shifts. In relation to casino shifts, 40.5% of respondents stated that night shifts are the greatest drawback of their job, compared to 79.1% previously. A minority of respondents felt that teaching (36.5%), diagnostic test interpretation (23.2%), and quality of handover (33.5%) were inferior on early and late night shifts compared to other shifts (74.4%, 58.1%, and 60.5% for traditional night shifts respectively).95.0% of respondents preferred casino over traditional night shifts. Conclusion: There were self-reported improvements in all domains following the implementation of casino shifts.
P039: What are the frequencies of interventions performed by paramedics during seizure calls?
- D. Eby, J. Robson, M. Columbus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S91
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- May 2016
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Introduction: Paramedics frequently attend out-of-hospital seizure patients. They administer oxygen, check blood glucose levels and if within scope of practice, start IVs and administer benzodiazepines. Little is know about how frequently these procedures are performed. The objective of this study was to determine the frequency of procedures performed by paramedics (Advanced Care (ACP), Primary Care IV (PCP-IV) and Primary Care non-IV (PCP)) attending seizure patients in a regional paramedic base hospital program. Methods: Retrospective analysis of a secondary database of ambulance call reports (ACRs) (January 01-December 31, 2014). All 2854 ACRs with paramedic determined primary / final problem codes of “seizure” were identified from total calls performed by 8 municipal paramedic services (MPSs), covering an urban and rural population of 1.4 million. MPSs used iMedic electronic ACRs. A 10% sample, generated using a random number table, was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Findings were summarized using descriptive statistics. Results: 285 calls were analyzed; (adult 72.7%, paediatric (age <18) 27.3%). Paramedics witnessed seizures in 8.1% of all calls they attended; (paediatric 7.8%). The blood sugar was checked in 87.9% of adult calls; (ACP 88.7%, PCP-IV 89%, PCP 77.8%) and in 70.5% of paediatric calls; (ACP 72.0%, PCP-IV 63.3%, PCP 70.5%). Oxygen was administered in 80.7% of adult calls; (ACP 85.9%, PCP-IV 78.0%, PCP 80.7%) and 83.3% of paediatric calls; (ACP 92.0%, PCP-IV 80.1%, PCP 82.4%). IVs were started by paramedics (if in scope of practice) in 28.0% of adult calls; (ACP 47.9%, PCP-IV 16.1%) and 6.6% of paediatric calls; (ACP 8.0%, PCP-IV 5.6%) Midazolam was administered in 10.4% of ACP attended calls and in 91.0% of the calls were they witnessed seizures. Transport occurred in 93.2% of adult calls and 100% of paediatric calls. Conclusion: ACPs were more likely to perform procedures on seizure patients than PCPs or PC-IVs. Children were much less likely to have procedures performed on them - blood sugar checks, and IV starts - but more likely receive oxygen and be transported. These findings have training implications.
P038: How frequently is hypoglycemia found in ambulance calls for “seizure”?
- D. Eby, J. Robson, M. Columbus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S91
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- May 2016
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Introduction: Paramedics often attend seizure patients in the pre-hospital setting. Received wisdom is that hypoglycemia is frequently present during a seizure or is a ‘cause’ of seizures. Recent literature disputes this. The purpose of this study was to determine the frequency of hypoglycemia in patients identified as having “seizure” listed as the primary or final problem code in Ambulance Call Reports from a large regional paramedic base hospital program. Methods: Retrospective analysis of a database of ambulance call reports (ACRs) from January 01-December 31, 2014. All 2854 ACRs with paramedic determined primary or final problem codes of “seizure” were identified from a database of all calls performed by 8 municipal paramedic services covering a total urban and rural population of 1.4 million. Municipal paramedic services used iMedic electronic ACRs. A 10% sample generated by a random number table was analyzed. ACRs were manually searched and data extracted onto spreadsheets. Results were described using frequencies and summary statistics. Results: A total of 285 call were analyzed. 207 (72.6%) calls were adults and 78 (27.4%) were paediatric (age <18). Seizures were witnessed by paramedics in 23/285 (8.1%) calls; adults 17/207 (8.2%), paediatric 6/78 (7.7%). A blood sugar was determined in 237/285 (83.2%) of all calls; adults 182/207 (87.9%), paediatric 55/78 (70.5%). In calls were paramedics witnessed a seizure a blood sugar was determined 17/21 (80.9%) of the time; adults 13/17 (76.5%), paediatric 6/6 (100%) Hypoglycemia (BS < 4.0 mm/L) was found in only 1 case - 1/237 (0.4%); adults 0/ 207 (0%), paediatric 1/78 (1.3%). The child was age 1, had a GCS 13, and the blood sugar was 3.9 mm/L. Conclusion: Hypoglycemia was rarely found in patients who had a seizure and were attended to by paramedics in the pre-hospital setting. The routine determination of blood sugars in all patients who have had a seizure prior to paramedic arrival should be reconsidered.
MP030: Problems in paramedic-physician telecommunication
- D. Eby, J. Robson, M. Columbus
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S76
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- May 2016
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Introduction: Clear paramedic-physician telecommunications (patches) are critical in systems utilizing on-line medical control. In systems using extensive medical directives individual paramedics patch infrequently. Investigations of specific problem calls indicated that communication problems were more common than believed. Existing literature on this topic is sparse. This project is a quality assurance exercise undertaken to understand the extent and nature of problems in paramedic-physician telecommunications Methods: Retrospective analysis of anonymized transcriptions made from MP3 audio files recorded as part of normal operating procedures by the Central Ambulance Communication Centre during January-March 2014. All calls where telecommunication occurred between paramedics from 4 ambulance services and base hospital physicians providing on-line medical oversight during ambulance calls were included. Transcripts were read multiple times and data extracted onto spreadsheets for frequency analysis. Further thematic framework analysis of emergent themes was done. Results: All 42 patches were transcribed and used for analysis. 36 (85.7%) were for termination of resuscitation orders, 4 (9.5%) were for advice, and 2 (4.8%) were for orders not covered by medical directives. Communication problems were identified in 40 (95.2%) patches. Most had multiple problems. These included disconnections (23.8%), difficulty hearing one another (40.5%) - indicated by phrases such as “sorry?” “what?”, “I can’t hear you” - or caused by individuals interrupting each other (83.3%), and talking simultaneously (47.6%). Signaling the end of “talk turns” - such as “10-4” or “over” - was never used. Instead, terms like “yah” and “OK” were used. When communication went awry, time was spent trying to repair the mis/poor communication. This led to repeating information or attempting to ‘sell’ the case by providing information unnecessary for decision making - such as during a request for termination of resuscitation, “there is vomit on the floor”. Conclusion: Paramedic-physician telecommunication problems were extremely common. They involved technical (mechanical problems) and human factors (disorganized radio ‘technique’). The high incidence of telecommunication problems identified is concerning. Critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Further study of these issues is warranted.
Estimating fermentative amino acid catabolism in the small intestine of growing pigs1
- D. A. Columbus, J. P. Cant, C. F. M. de Lange
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Fermentative catabolism (FAAC) of dietary and endogenous amino acids (AA) in the small intestine contributes to loss of AA available for protein synthesis and body maintenance functions in pigs. A continuous isotope infusion study was performed to determine whole body urea flux, urea recycling and FAAC in the small intestine of ileal-cannulated growing pigs fed a control diet (CON, 18.6% CP; n=6), a high fibre diet with 12% added pectin (HF, 17.7% CP; n=4) or a low-protein diet (LP, 13.4% CP; n=6). 15N-ammonium chloride and 13C-urea were infused intragastrically and intravenously, respectively, for 4 days. Recovery of ammonia at the distal ileum was increased by feeding additional fibre when compared with the CON (P<0.05) but was not affected by dietary protein (0.24, 0.39 and 0.14 mmol nitrogen/kg BW/day for CON, HF and LP, respectively; P<0.05). Lowering protein intake reduced urea flux (25.3, 25.7 and 10.3 mmol nitrogen/kg BW/day; P<0.01), urinary urea excretion (14.4, 15.0 and 6.2 mmol N/kg BW/day; P<0.001) and urea recycling (12.1, 11.3 and 3.23 mmol nitrogen/kg BW/day; P<0.01) compared with CON. There was a rapid reduction in 15N-ammonia enrichment in digesta along the small intestine suggesting rapid absorption of ammonia before the distal ileum and lack of uniformity of enrichment in the digesta ammonia pool. A two-pool model was developed to determine possible value ranges for nitrogen flux in the small intestine assuming rapid absorption of ammonia. Maximum estimated FAAC based on this model was significantly lower when dietary protein content was decreased (32.9, 33.4 and 17.4 mmol nitrogen/kg BW/day; P<0.001). There was no impact of dietary fibre on estimates of small intestine nitrogen flux (P>0.05) compared with CON. The two-pool model developed in the present study allows for estimation of FAAC but still has limitations. Quantifying FAAC in the small intestine of pigs, as well as other non-ruminants and humans, offers a number of challenges but warrants further investigation.