For many patients with addiction and other substance problems, the emergency department (ED) is the sole provider of medical care. This study sought to determine the prevalence and characteristics of substance-related medical problems in ED patients, as defined by documentation in the medical record. We also sought to compare the ED resource use (length of ED stay and number of revisits) of patients with and without substance problems.

Trained evaluators using explicit criteria reviewed all ED charts during a 6-week period at a Canadian tertiary care teaching centre. Data was collected on demographics, documentation of problematic substance use and whether the ED visit was due to substance problems. Using a computerized database, we determined how many patients with and without substance problems had 1 or more subsequent ED visits during the 1-year period from Sept. 1, 2002, to Aug. 31, 2003.

Of 6064 visits made by 5194 patients, 6026 visits (99.4%) representing 5188 patients (99.9%) were captured for review. Of those visits, 674 (11.2%, 95% confidence interval [CI] 10.4%–12.0%), made by 600 patients, had documentation of problematic substance use and 521 visits (8.6%, 95% CI 7.9%–9.4%) by 469 patients were caused by substance problems. The mean age of patients with a visit due to a substance problem was 39.2 years, compared with 48.5 years for those with other visits (p < 0.001). The admission rate for substance-related visits was 25.3%, compared with 17.6% for other visits (p < 0.001). For discharged patients, the median length of the ED visit owing to substance-related problems lasted 232 minutes (IQR [interquartile range] 267 min), compared with 164 minutes (IQR 167 min) for other visits (p < 0.001). In 1 year of follow-up, 161 of 600 patients (26.8%) with a substance problem made 466 revisits (mean 0.78 revisits/patient), compared with 975 of 4588 patients (21.3%) without a substance problem who made a total of 2150 revisits (mean 0.47 revisits/patient, p < 0.001).

Substance problems contribute significantly to ED visits, hospital admissions and duration of ED stay at a tertiary centre. It is likely that our methodology underestimates the scope of the problem and that a universal screening program would find a higher prevalence. The magnitude of this problem supports the need for an interdisciplinary identification and intervention program for ED patients with substance-related issues.

Many trauma patients undergo advanced diagnostic imaging before being transferred to a regional trauma centre, but this step can delay definitive care. This study compared the length-of-stay at the primary hospital between patients who underwent CT scans and those who did not.

This was a medical record review of all consecutive trauma cases transferred to a regional trauma centre servicing 2.2 million people during a 2-year period. Two trained abstractors, blind to each other's results, collected data independently.

Of 249 cases, 79 (31%) underwent a CT scan before being transferred. There was no significant difference in the Injury Severity Score between the 2 groups (p = 0.16), yet the CT group remained at the primary hospital approximately 90 minutes longer before transfer (p < 0.001).

A significant proportion of trauma patients transferred to a regional trauma centre undergo CT scanning at the primary hospital. These patients experience an increased length-of-stay of 90 minutes, on average, before transfer. This appears to be a common practice that does not appear to contribute to definitive trauma management.

For a variety of reasons, many emergency department (ED) visits are classified as less- or nonurgent (Canadian Triage and Acuity Scale [CTAS] level IV and V). A recent survey in a tertiary care ED identified some of these reasons. The purpose of our study was to determine if these same reasons applied to patients presenting with problems triaged at a similar level at a low-volume rural ED.

A 9-question survey tool was administered to 141 CTAS level IV and V patients who attended the South Huron Hospital ED, in Exeter, Ontario, over a 2-week period in December 2006.

Of the 141 eligible patients, 137 (97.2%) completed the study. One hundred and twenty-two patients (89.1%) reported having a family physician (FP) and 53 (38.7%) had already seen an FP before presenting to the ED. Just over one-half of all patients (51.1%) had their problem for more than 48 hours, and 42 (30.7%) stated that they were referred to the ED for care. Fifty-three (38.7%) of the respondents felt they needed treatment as soon as possible. Many patients reported coming to the ED because: 1) their FP office was closed (21.9%); 2) they could not get a timely appointment (16.8%); or 3) the walk-in clinic was closed (24.8%). Only 6 patients (4.4%) specifically stated that they came to the ED because they had no FP. One-third of patients attended the ED because they believed it offered specialized services.

In this rural setting, most less- or nonurgent ED patients had an FP yet they went to the ED because they did not have access to primary care, because they perceived their problem to be urgent or because they were referred for or sought specific services.

Acute myocardial infarction (AMI) remains a major cause of death and β-blockers are known to reduce long-term mortality in post-AMI patients. We sought to determine whether patients receiving β-blockers acutely (within 72 h) following AMI had a lower mortality rate at 6 weeks than patients receiving placebo.

We conducted a systematic review of randomized controlled clinical trials that assessed 6-week mortality and compared β-blockers with placebo in patients randomized within the first 72 hours following AMI. We searched these databases: MEDLINE (1966–2006), EMBASE (1980–2007), Cochrane Central Register of Controlled Trials, Health Star (1966–2007), Cochrane Database for Systematic Reviews, ACP Journal Club (1991–2007), Database of Abstracts of Reviews of Effect (< 1st quarter 2007) and Conference Papers Index (1984–2007). Two blinded reviewers extracted the data and rated study quality using the Jadad score and the adequacy of allocation concealment score, which was adopted by the Cochrane group. We calculated pooled odds ratios (ORs) using a random effect model and performed sensitivity analyses to explore the stability of the overall treatment effect.

We included 18 studies (13 were rated high-quality) with 74 643 enrolled participants and had 5095 deaths. Compared with placebo, adding β-blockers to other interventions within 72 hours after AMI did not result in a statistically significant reduction in 6-week mortality (OR 0.95, 95% confidence interval [CI] 0.90–1.01). When restricted to high quality studies, the OR for 6-week mortality reduction was 0.96 (95% CI 0.91–1.02). We found similar results including studies that enrolled patients within 24 hours after AMI. However, a subgroup analysis that excluded high-risk patients with Killip class III and above showed that β-blockers resulted in a significant reduction in short-term mortality (OR 0.93, 95% CI 0.88–0.99).

Acute intervention with β-blockers does not result in a statistically significant short-term survival benefit following AMI but may be beneficial for low-risk (Killip class I) patients.