7 results
LO57: Pain associated with investigations and procedural interventions commonly administered in the emergency department in older adults: a prospective cohort study
- L. Baril, L. Baril, E. Nguyen, L. Santerre, V. Émond, M. Émond, S. Berthelot, É. Mercier
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S28
- Print publication:
- May 2020
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Acute pain is frequent among patients visiting the emergency department (ED). In addition to the acute discomfort, pain has been linked to adverse events and poorest outcomes in older adults. However, pain is frequently overlooked by emergency clinicians, particularly in older adults. Advanced age has been linked to poor recognition and under treatment of pain. The contribution of ED investigations and procedures to the patient's pain is unknown. This study aims to determine the intensity of the pain induced by the investigations and procedures commonly performed in the ED. Methods: In two EDs, a convenience sample of older adults (≥ 65 years old) with at least two investigations or procedures performed during their ED visit were eligible. Patients were excluded if they were hemodynamically unstable, in palliative care or not oriented in time and space. The pain intensity was assessed at bedside by a research assistant for the following investigations or procedures: blood sampling, intravenous catheter, electrocardiogram, X-rays, computed tomography, beside ultrasound, urinary catheter, cervical collar and prehospital immobilization mattress. The predetermined sample size was 50 pain assessment per investigation or procedure. The pain intensity was assessed using a numerous rating scale (NRS) ranging from 0 (no pain) to 10 (most severe pain), for each investigation or procedure received. NRS results are presented using median (med) and interquartile range (IQR) and classified as followed: no pain (0), mild pain (1-3), moderate pain (4-6) and severe pain (7-10). Results: Between June 2018 and December 2019, 494 patients were screened of which 318 were finally included (exclusion: not oriented (n = 113), refusal (n = 27), palliative care (n = 34), other reasons (n = 12)). The mean age of included patients was 77.8 years old (standard deviation = 8.0), 54.4% were female and 78.6% were living in the community. Only 15 patients (4.7%) were known to have cognitive impairment or dementia and 23 patients (7.2%) were on regular or PRN opioid medication at home. The expected sample size of at least 50 pain score assessment per investigation or procedure was obtained for all interventions with the exception of urinary catheter (n = 23) and immobilization mattress (n = 35). For the other investigations or procedures, the number of pain assessment ranged between 51 (cervical collar) and 231 (blood sampling). All investigations and procedures were associated with a median pain score of 0 with the exception of blood sampling (n = 231, med NRS 1 (IQR 0;3)), intravenous catheter (n = 241, med NRS 1 (IQR 0;4)), urinary catheter (n = 23, med NRS 4 (IQR 1;6)), cervical collar (n = 51, med NRS 5 (IQR 0;8)) immobilisation mattress (n = 35, med NRS 3 (IQR 0;8)). Moderate or severe pain (NRS 4-10) was infrequently reported following most investigations or procedures with the exception of urinary catheter (60.8%), cervical collar (54.9%) and immobilization mattress (48.5%). Cervical collar induced severe pain in 41.8% of the patients. Conclusion: Most investigations and procedures commonly administered in the ED to older adults are associated with no pain or low intensity of pain. Severe pain is also infrequently induced by these interventions for most older adults. However, urinary catheter, cervical collar and immobilization mattress are associated with a higher intensity of pain and more than 40% of patients suffering from severe pain following the application of cervical collar. Considering the potential adverse effects of pain and the lack of evidence-based data to support the use of some interventions such as the cervical collar, the decision to use these interventions should be carefully weighted and could include a shared-decision making process. The generalizability of those findings to older adults with cognitive impairment is unknown. Future studies should focus on circumstances in which these procedures are beneficial to the patient to limit the unnecessary pain associated with their use.
PL04: Comparison of the cost and the quality of the care provided to low acuity patients in an emergency department and a walk-in clinic
- S. Berthelot, M. Mallet, D. Simonyan, J. Guertin, L. Moore, C. Boilard, J. Boulet, C. Fortier, P. Olivier, B. Huard, K. Vachon, A. Lesage, É. Lévesque, A. Mokhtari, L. Baril, O. Yip, M. Bouchard, M. Létourneau, A. Pineault, M. Lafrenière, S. Blais
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 21 / Issue S1 / May 2019
- Published online by Cambridge University Press:
- 02 May 2019, p. S6
- Print publication:
- May 2019
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Low acuity patients have been controversially tagged as a source of emergency department (ED) misuse. Authorities for many Canadian health regions have set up policies so these patients preferably present to walk-in clinics (WIC). We compared the cost and quality of the care given to low acuity patients in an academic ED and a WIC of Québec City during fiscal year 2015-16. Methods: We conducted an ambidirectional (prospective and retrospective) cohort study using a time-driven activity-based costing method. This method uses duration of care processes (e.g., triage) to allocate to patient care all direct costs (e.g., personnel, consumables), overheads (e.g., building maintenance) and physician charges. We included consecutive adult patients, ambulatory at all time and discharged from the ED or WIC with a diagnosis of upper respiratory tract infection (URTI), urinary tract infection (UTI) or low back pain. Mean cost [95%CI] per patient per condition was compared between settings after risk-adjustment for age, sex, vital signs, number of regular medications and co-morbidities using generalized log-gamma regression models. Proportions [95%CI] of antibiotic prescription and chest X-Ray use in URTI, compliance with provincial guidelines on use of antibiotics in UTI, and column X-Ray use in low back pain were compared between settings using a Pearson Chi-Square test. Results: A total of 409 patients were included. ED and WIC groups were similar in terms of age, sex and vital signs on presentation, but ED patients had a greater burden of comorbidities. Adjusted mean cost (2016 CAN$) of care was significantly higher in the ED than in the WIC (p < 0.0001) for URTI (78.42[64.85-94.82] vs. 59.43[50.43-70.06]), UTI (78.88[69.53-89.48] vs. 53.29[43.68-65.03]), and low back pain (87.97[68.30-113.32] vs. 61.71[47.90-79.51]). For URTI, antibiotics were more frequently prescribed in the WIC (44.1%[34.3-54.3] vs. 5.8%[1.2-16.0]; p < 0.0001) and chest X-Rays, more frequently used in the ED (26.9%[15.6-41.0] vs. 13.7%[7.7-22.0]; p = 0.05). No significant differences were observed in the compliance with guidelines on use of antibiotics in UTI and in the use of column X-Ray in low back pain. Conclusion: Total cost of care for low acuity patients is lower in walk-in clinics than in EDs. However, our results suggest that quality-of-care issues should be considered in determining the best alternate setting for treating ambulatory emergency patients.
P007: Safety and effectiveness of a care protocol to treat migraine with Propofol in the emergency department
- S. Berthelot, S. Baril, M. Mallet, S. Côté
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S59
- Print publication:
- May 2018
-
- Article
-
- You have access Access
- Export citation
-
Introduction: An evidence-based care protocol to treat migraine with low-dose Propofol was implemented in May 2014 at the emergency department (ED) of the CHUL (Québec city). Given potential side effects of Propofol, we aimed to evaluate the safety and effectiveness of this protocol. Methods: We reviewed charts of all patients aged 16 years and older who received Propofol between May 2014 and August 2017 for a migraine headache with or without aura, as defined in the International Headache Society Classification. The care protocol consisted of: 1) administration of intra-venous Propofol 20 mg each 5 to 10 minutes as needed (maximum of 6 doses); 2) sets of vital signs before and after each dose; and 3) continuous cardiac and saturation monitoring. Our primary outcome measures were the incidence (95%CI) of the following side effects: low arterial pressure (< 90 systolic or < 65 mean), desaturation (SaO2<92%), excessive sedation (scores 3 or 4 on the Pasero scale), and any arrhythmia. We also compared the mean reduction (95%CI) of pain pre- and post-treatment (visual analogous scale VAS 0-10) and the proportion (95%CI) of rescue medication among patients who received Propofol as first-line medication to a matched cohort of patients who had Metoclopramide first. The two cohorts were paired for gender, age, triage priority, and month/year of ED visit. Results: Over the 3-year study period, 45 patients with migraine received Propofol through the care protocol, either as a first-line or a rescue therapy. In this cohort, hypotension, bradycardia (<60/min) and desaturation occurred in 17.8% (8.0-32.1), 13.3% (5.1-26.8) and 6.7% (1.4-18.3) of cases respectively; no excessive sedation was reported. An intervention was undertaken in 4 cases [8.9% (2.5-21.2) 3 iv fluid bolus, 1 supplemental oxygen] to palliate the side effects of Propofol. A statistically significant mean reduction of 3.6 points (2.8-4.4) on the VAS scale was observed in patients treated with Propofol as first-line therapy (n=35). However, patients managed with first-line Metoclopramide (n=100) experienced a significantly higher mean reduction of their VAS score [5.3 (4.6-6.0)] than the Propofol group (p=0.003). The proportion of patients requiring the use of rescue medication was higher among patients first treated with Propofol [77.1% (63.2-91.1) vs. 29.0% (20.1-37.9); p<0.001]. Conclusion: Our care protocol to treat migraine with low doses of Propofol appears to be safe and to cause very few side effects prompting corrective interventions. Continuous (as opposed to intermittent) heart and saturation monitoring is probably not indicated. Given the effectiveness of Propofol compared to Metoclopramide, our care protocol will be used as a second-line therapy.
MP29: Creation of the CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist
- I. G. Stiell, F. Scheuermeyer, A. Vadeboncoeur, P. Angaran, D. Eagles, I. D. Graham, C. Atzema, P. Archambault, T. Tebbenham, K. de Wit, A. D. McRae, W. J. Cheung, M. Deyell, G. Baril, R. Mann, R. Sahsi, S. Upadhye, C. Clement, J. Brinkhurst, C. Chabot, D. Gibbons, A., Skanes
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 20 / Issue S1 / May 2018
- Published online by Cambridge University Press:
- 11 May 2018, p. S51
- Print publication:
- May 2018
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Patients with acute atrial fibrillation or flutter (AAFF) are the most common acute arrhythmia cases requiring care in the ED. Our goal was to adapt the existing Canadian Cardiovascular Society (CCS) AF Management Guidelines into an emergency physician-friendly best practices checklist. Methods: We chose to adapt, for use by emergency physicians, existing high-quality clinical practice guidelines (CPG) previously developed by the CCS using the GRADE system. We used the Canadian CAN-IMPLEMENT© process adapted from the ADAPTE Collaboration. We created an Advisory Committee consisting of 14 academic and community emergency physicians, three cardiologists, one PhD methodologist, and two patients. The Advisory Committee communicated by a two-day face-to-face meeting, teleconferences, and email. The checklist was prepared and revised through a process of feedback and discussions through ten iterations until consensus was achieved. We then circulated the draft checklist for comment to approximately 300 emergency medicine and cardiology colleagues whose written feedback was further incorporated into the final approved version. Results: The final CAEP ED AAFF Guidelines are comprised of two algorithms and four sets of checklists, organized by 1) Assessment and Risk Stratification, 2) Rhythm and Rate Control, 3) Long-term Stroke Prevention with the CHADS-65 Algorithm, and 4) Disposition and Follow-up. The guidelines have been endorsed by CAEP and accepted for publication in the Canadian Journal of Emergency Medicine. During the consensus and feedback processes, we addressed a number of issues and concerns. We highlighted the issue that many unstable patients are actually suffering from underlying medical problems rather than a primary arrhythmia. One controversial recommendation is to consider rate control or transesophageal echocardiography guided cardioversion if the duration of symptoms is 24-48 hours and the patient has two or more CHADS-65 criteria. We emphasize the importance of evaluating long-term stroke risk by use of the CHADS-65 algorithm and encourage ED physicians to prescribe anticoagulants where indicated. Conclusion: We have created the CAEP AAFF Best Practices Checklist which we hope will standardize and improve care of AAFF patients in all EDs across Canada. We believe that most of these patients can be managed rapidly and safely with ED rhythm control, early discharge, and appropriate use of anticoagulants.
P017: A time-driven activity-based costing method to estimate health care costs in the emergency department
- S. Berthelot, M. Mallet, L. Baril, P. Dupont, L. Bissonnette, H. Stelfox, M. Émond, S. Blais, A. Vezo, M. Létourneau, S. Côté, G. Bécotte, M. Lafrenière, L. Moore
-
- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, p. S83
- Print publication:
- May 2017
-
- Article
-
- You have access Access
- Export citation
-
Introduction: Poor physicians’ knowledge of health care costs has been identified as an important barrier to improving efficiency and reducing overuse in care delivery. Moreover, costs of tests and treatments estimated with traditional costing methods have been shown to be imprecise and unreliable. We estimated the cost of frequent care activities in the emergency department (ED) using the time-driven activity-based costing (TDABC) method. Methods: We conducted a TDABC study in the ED of the CHUL, Québec city (77000 visits/year). We estimated the cost of all potential care activities (e.g. triage) provided to adult patients with selected urgent (e.g. pulmonary sepsis) and non urgent (e.g. urinary tract infection) conditions frequently encountered in the ED. Following Lean management principles, process maps were developed by a group of ED care providers for each care activity to identify human resources, supplies and equipment involved, and to estimate the time required to complete each process. Resource unit cost (e.g. cost per minute of a nurse) and overhead rate were calculated using financial information from fiscal year 2015-16. Estimated cost of each care activity (e.g. chest X-ray) including physicians’ charges was calculated by summing overhead allocation and the cost of each process (e.g. disinfection of the X-ray machine) as obtained by multiplying the resource unit cost by the time for process completion. Results: Process maps were developed for 14 conditions and 68 ED care activities. We estimated the costs of activities (CAN$) related to nursing (e.g. urinalysis and culture triage ordering $14.70), clerk tasks (e.g. patient registration $3.40), physicians (e.g. FAST scan $20.90), laboratory testing (e.g. CBC $6.30), diagnostic imaging (e.g. abdominal CT scan $146.50), therapy (e.g. 5 mg of iv morphine $20.40), and resuscitation (rapid sequence intubation with ketamine and succinylcholine $146.40). Overall, emergency physicians’ charges, personnel salaries and overheads accounted for 38%, 22% and 16% of all ED care costs, respectively. Conclusion: Our results represent an important step toward increasing emergency physicians’ awareness on the real cost of their interventions and empowering them to adopt more cost-effective practice patterns.
A new family of salts for lithium Secondary batteries
- D. Baril, S. Brranger, N. Ravet, C. Michot, M. Armand
-
- Journal:
- MRS Online Proceedings Library Archive / Volume 575 / 1999
- Published online by Cambridge University Press:
- 10 February 2011, 123
- Print publication:
- 1999
-
- Article
- Export citation
-
A novel family of salts suitable for lithium battery application was synthesized and characterized. These salts have a large delocalized anion whose charge is spread over a single SO2 and a phenyl ring. Remarkable properties were obtained for the lithium N-(3-trifluoromethyl phenyl) trifluoromethanesulfonamide salt or LiTFPTS. The electrochemical stability window is around 4.0 V and its conductivity in solid poly(ethylene oxide) or PEO is close to the one of the lithium perchlorate salt. Calorimetric analysis also showed that LiTFPTS behaves as a plasticizer since it hinders, to a certain extent, the PEO crystallization when it is used in a solid polymer matrix. Above all, its synthesis is quite straightforward and leads to potentially inexpensive salts as the starting amines are made commercially on a large scale.
Patterns of oestrus, time of LH release and ovulation and effects of time of artificial insemination in Mediterranean buffalo cows
- B. M. Moioli, F. Napolitano, S. Puppo, V. L. Barile, G. M. Terzano, A. Borghese, A. Malfatti, A. Catalano, A. M. Pilla
-
- Journal:
- Animal Science / Volume 66 / Issue 1 / February 1998
- Published online by Cambridge University Press:
- 02 September 2010, pp. 87-91
- Print publication:
- February 1998
-
- Article
- Export citation
-
Thirty-two post-partum Mediterranean river buffalo cows were continuously observed for signs of oestrus from September to December with the aid of two vasectomized bulls. Symptoms of oestrus among female Mediterranean buffaloes are weak, therefore oestrus was assessed based on bull behaviour (following and licking a cow and trying to mount her). Oestrus was divided into three phases based on the bull behaviour assessment. Status of the uterus and ovarian follicles were checked rectally every day for each cow which was detected by a teaser bull to be in oestrus. All cows in oestrus were bred twice by artificial insemination (AI), the first at ovulation and the second (using a different bull) 22 h later.
The average duration of interest shown by the bull towards a cow (from the very first to the last sign of interest) was 68 h and the average length of the three phases was: phase 1 = 21 (s.d. 29) h, phase II = 32 (s.d. 24) h and phase III = 15 (s.d. 15) h. Fifteen buffaloes were bled during oestrus, and LH profiles were determined. No differences were evident among oestruses followed by pregnancy (no. = 18) and the others (no. = 26) for the variables describing behavioural events. Neither intensity of the bull courtship, presence or clarity of mucous discharge, or housing system affected the success of AI. The only differences between pregnant and non-pregnant cows were in the timing between the LH peak and the end of phase II (2·4 v. 14·7 h, P < 0·001), end of phase III (22 v. 40 h, P > 0·05) and ovulation (25 v. 46 h, P < 0·05). Successful pregnancies occurred 34 (s.d. 14) h after the end of phase II. The endocrinology and behavioural patterns of buffalo reproduction need further research to clarify the reasons for non-optimal pregnancy rates after AI.
![](/core/cambridge-core/public/images/lazy-loader.gif)