The most common reason for LWBS is impatience during peak ED periods. Many of these patients seek medical care within one week. Complications occurred rarely; however, "high-risk" patients who leave without being seen do experience adverse health outcomes. Further research is required to examine ways to reduce LWBS cases.

The most common reason for LWBS is impatience during peak ED periods. Many of these patients seek medical care within one week. Complications occurred rarely; however, "high-risk" patients who leave without being seen do experience adverse health outcomes. Further research is required to examine ways to reduce LWBS cases.

Objective: Consultation is a common and important aspect of emergency department (ED) care. We prospectively examined the consultation rates, the admission rates of consulted patients, the emergency physician (EP) disposition prediction of consulted patients and the difficult consultations rates in 2 tertiary care hospitals. Methods: Attending EPs recorded consultations during 5 randomly selected shifts over an 8-week period using standardized forms. Subsequent computer outcome data were extracted for each patient encounter, as well as demographic data from the ED during days in which there was a study shift. Results: During 105 clinical shifts, 1930 patients were managed by 21 EPs (median 17 patients per shift; interquartile range 14-23). Overall, at least 1 consultation was requested in 38% of patients. More than one-half of the patients (54.3%) who received a consultation were admitted to the hospital. Consultation proportions were similar between males and females (51% v. 49%, p = 0.03). Consultations occurred more frequently for patients who were older, had higher acuity presentations, arrived during daytime hours or arrived by ambulance. The proportion of agreement between the EP's and consultant's opinion on the need for admission was 89% (κ = 0.77, 95% confidence interval 0.72-0.83). Overall, 92% of patents received 1 consultation. Six percent of the consultations were perceived as "difficult" by the EPs (defined as the EP's subjective impression of difficulties with consultation times, accessibility and availability of consultants, and the interaction with consultants or disposition issues). Conclusion: Consultation is a common process in the ED. It often results in admission and is predictable based on simple patient factors. Because of perceived difficulty with consultations, strategies to improve the EP consultation process in the ED seem warranted. RÉSUMÉObjectif : La consultation est un aspect courant et important des soins prodigués à l'urgence. Nous avons étudié prospectivement, dans deux centres de soins tertiaires, les taux de consultation, les taux d'admission des patients vus en consultation, les prédictions du médecin d'urgence quant à l'issue des patients vus en consultation ainsi que les taux de difficulté des consultations. Méthodes : Les médecins d'urgence traitants ont consigné, sur des formulaires normalisés, les consultations réalisées pendant cinq quarts de travail choisis au hasard sur une période de huit semaines. Subséquemment, des données informatiques des résultats ont été extraites pour chaque ORIGINAL RESEARCH • RECHERCHE ORIGINALE EM ADVANCES

THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCESStroke prevention clinics (SPCs) are a relatively recent and evolving phenomenon in the delivery of specialized health care. Patients can be seen very early after a cerebrovascular event and stated targets for risk assessment such as hypertension, hyperlipidemia, smoking, atrial fibrillation, and internal carotid artery stenosis can be made. In addition, appropriate medical and surgical interventions such as antiplatelet or anticoagulation treatment, blood pressure management, cholesterol lowering agents, and carotid endarterectomy can be initiated for secondary prevention. 1.2 Little is known about the referral patterns to SPCs ABSTRACT: Objective: To evaluate the referral patterns of patients to a stroke prevention clinic (SPC) and to test the adequacy of prereferral diagnosis and management of modifiable risk factors for stroke. Methods: We collected prospective data on consecutive patients referred to the SPC at University of Alberta Hospital in Edmonton, Alberta, Canada. Outcome measures included: alternate diagnoses to stroke or transient ischemic attack (TIA), uncontrolled or undiagnosed hypertension, hyperlipidemia and diabetes, therapies, and investigations leading to carotid endarterectomy. Results: Two thousand and eleven patients were referred to SPC. Nearly 25% of the referrals originated from the emergency room and the rest from general physicians. Of the referrals, 68.7% were confirmed as TIA or stroke at the SPC. Among 1381 patients with TIA or stroke, 736 had history of hypertension. Uncontrolled hypertension was found in 265 patients (36.0% of those with hypertension: 95% CI: 32.5-39.5) while undiagnosed hypertension was found in 103 (15.9% of those without hypertension: 95%CI: 13.14-18.79). History of hyperlipidemia was present in 451 patients (32.6%) and 356 (78.9%: 95% CI: 75.2-82.69) of these patients were not at target for secondary prevention. Among 930 patients without history of hyperlipidemia, 739 (79.5%: 95% CI: 76.8-82.1) were diagnosed with hyperlipidemia through the SPC. Fasting blood glucose levels above 7.1 mmol/L in patients with and without history of diabetes were 221 (79.2%: 95% CI: 74.5-83.9) and 66 (6%: 95%CI: 4.6-7.4) respectively. Conclusions: Management of risk factors for stroke needs improvement. SPCs should consider actively managing the classical modifiable risk factors of stroke. RÉSUMÉ: L'impact d'une clinique de prévention de l'accident vasculaire cérébral sur le diagnostic des facteurs de risque modifiables de l'accident vasculaire cérébral. Objectif: Évaluer le profil d'orientation de patients vers une clinique de prévention le l'accident vasculaire cérébral (CPAVC) et la pertinence du diagnostic et de la prise en charge des facteurs de risque modifiables de l'accident vasculaire cérébral (AVC). Méthodes:Nous avons recueilli des données prospectives sur des patients consécutifs référés à la CPAVC du University of Alberta Hospital à Edmonton, Alberta, Canada. Nous avons évalué les résultats suivants: les diagnostics a...

Introduction: Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital. Methods: Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview. Results: Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of β-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52). Conclusion:This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

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Patients suffering from a transient ischemic attack (TIA) or stroke need urgent evaluation of their internal carotid arteries because the future risk of stroke and stroke recurrence, in these patients, is dependent on the degree of carotid artery disease. 1 Various non-invasive imaging techniques are used for evaluation of carotid disease, including Doppler Ultrasound (DUS), magnetic resonance angiography and computed tomography angiography 2,3 . Despite improvements in non-invasive imaging technology, conventional cerebral angiography currently remains the gold standard 4 for evaluating the degree of carotid stenosis and to assess the suitability for carotid endarterectomy (CEA). Cerebral angiography however is invasive, expensive ABSTRACT: Introduction: Doppler ultrasound (DUS) is used as a screening tool to assess internal carotid artery (ICA) disease. Recent reports suggest that the DUS may be inaccurate in over 28% of patients. We sought to evaluate the accuracy of DUS, when performed in a dedicated stroke prevention clinic (SPC). Methods: We retrospectively reviewed the charts of patients who had a DUS performed in our SPC, followed by conventional cerebral angiography. Three groups of patients were defined. Group 1 had DUS measured ICA stenosis of >50%; Group II had a DUS measured ICA stenosis of <50%; Group III had complete ICA occlusion on DUS. Results: Sixtyseven patients (69 arteries) were included in the study. There were 45 patients in Group I and based on the findings of cerebral angiography, carotid endarterectomy was considered inappropriate in only one patient. -a misclassification rate of 2.2% (95%CI: 0 -6.5%). Group II consisted of 19 patients and on cerebral angiography, none of these patients had a stenosis of >50% -a misclassification rate of 0%. Group III consisted of five patients in whom DUS showed complete ICA occlusion. The angiogram confirmed the occlusion in all five patients -a misclassification rate of 0%. Overall, misclassification rate was 1.45% (95% CI: 0 -4.3%). Conclusions: Doppler ultrasound when performed in a stroke prevention clinic (SPC), has a high accuracy in measuring ICA stenosis of >50%. Doppler ultrasound is reliable in detecting complete ICA occlusion and finally DUS is a reliable screening tool to rule out clinically significant ICA stenosis.

Aims:To assess if patients follow-up with discharge advice after psychiatric assessment and discharge from Emergency Department (ED).Method:All patients with psychiatric complaint who presented at three ED's in Edmonton, Alberta, Canada were identified via ED Information System (EDIS). Patients presenting complaint were entered onto the EDIS by Triage Nurse along with demographic information. All charts were reviewed and clinical data was obtained. Patients who were assessed by Psychiatry and discharged home were contacted via telephone to determine if they followed-up with discharge advice of psychiatry team.Results:A total of 1420 patients have been identified during April and May 2008.Chart review has been completed. Data entry and follow-up is in progress. Preliminary data of 250 patients is presented here. 55% were male. Mean age 37 years (SD 12). 47% presented voluntarily. Psychiatry was consulted for 53% of patients. The presenting complaint was “Suicidal Ideation” in 29% and “Bizarre behaviour” in 24%. Primary diagnoses for those seen by Psychiatry were mood disorder (30%) and psychotic disorder (26%). Out of those seen by Psychiatry 36% were admitted. 44% of those admitted by psychiatry were diagnosed with psychotic disorder followed by mood disorder in 31%. The patients who were discharged home by Psychiatry were advised to follow up with their family doctor 7%, psychiatrist 15%, outpatient psychiatry services 16% and addiction services 16%.Conclusion:This is the first report of outcome of discharge advice and will help in developing and planning community follow-up system for psychiatric patients.