Backround-Physicians reverse patients' warfarin anticoagulation with frozen plasma or prothrombin complex concentrate.Our objective was to determine adverse event frequency after urgent reversal with frozen plasma versus the prothrombin complex concentrate Octaplex. Methods and Results-This natural before-after retrospective cohort study in 2 tertiary care emergency departments compared anticoagulation reversal with frozen plasma (September 2006-August 2008 and with Octaplex (September 2008-August 2010, without other system changes. We included adult patients on warfarin with an international normalized ratio ≥1.5 who received frozen plasma or Octaplex. Our primary outcome was serious adverse events (death, ischemic stroke, myocardial infarction, heart failure, venous thromboembolism, or peripheral arterial thromboembolism) within 7 days. Secondary outcomes included time to international normalized ratio reversal, hospital length of stay, and red blood cells transfused within 48 hours. We included 149 patients receiving frozen plasma and 165 receiving Octaplex. The incidence of serious adverse events for the frozen plasma group was 19.5% compared with 9.7% for the Octaplex group (P=0.014; relative risk, 2.0; 95% confidence interval, 1.1-3.5). This remained significant after adjustment for baseline history and reason for treatment (P=0.038; adjusted relative risk, 1.85; 95% confidence interval, 1.03-3.3) in multivariable regression analysis. Median international normalized ratio reversal was 11.8 hours with frozen plasma and 5.7 hours with Octaplex (P<0.0001). Mean red cell transfusion was 3.2 with frozen plasma and 1.4 with Octaplex (P<0.0001). Conclusions-Octaplex Hickey et al Complications From Octaplex Versus FFP 361The objective of this study is to compare the efficacy and safety of frozen plasma with that of Octaplex, the available 4-factor prothrombin complex concentrate, in our emergency departments (EDs) during the study period. Specifically, we examine adverse effects, time to INR reversal, hospital length of stay, and red cell transfusion requirements. Methods Design and SettingThis retrospective cohort study was conducted using health records of patients who were treated with frozen plasma or Octaplex for emergency reversal of warfarin anticoagulation therapy in 2 tertiary EDs at our institution, which see a total of ≈120 000 ED visits per year. We compared patients who received frozen plasma over a 2-year period before the introduction of Octaplex in September 2008 with those who received Octaplex over an equivalent time period after September 2008. The treatments for both groups were given or started in the ED. The dose of Octaplex administered during the study period was governed by the department of Transfusion Medicine. A standard dose of 1500 IU was administered to patients with intracranial hemorrhage, and a dose of 1000 IU was used for all other patients. This study was approved by our institution's research ethics board. Study PopulationWe included patients who were ≥18 years of age, were ...

BackgroundEmergency Department (ED) crowding has been studied for the last 20 years, yet many questions remain about its impact on patient care. In this study, we aimed to determine if ED crowding influenced patient triage destination and intensity of investigation, as well as rates of unscheduled returns to the ED. We focused on patients presenting with chest pain or shortness of breath, triaged as high acuity, and who were subsequently discharged home.MethodsThis pilot study was a health records review of 500 patients presenting to two urban tertiary care EDs with chest pain or shortness of breath, triaged as high acuity and subsequently discharged home. Data extracted included triage time, date, treatment area, time to physician initial assessment, investigations ordered, disposition, and return ED visits within 14 days. We defined ED crowding as ED occupancy greater than 1.5. Data were analyzed using descriptive statistics and the χ2 and Fisher exact tests.ResultsOver half of the patients, 260/500 (52.0%) presented during conditions of ED crowding. More patients were triaged to the non-monitored area of the ED during ED crowding (65/260 (25.0%) vs. 39/240 (16.3%) when not crowded, P = 0.02). During ED crowding, mean time to physician initial assessment was 132.0 minutes in the non-monitored area vs. 99.1 minutes in the monitored area, P <0.0001. When the ED was not crowded, mean time to physician initial assessment was 122.3 minutes in the non-monitored area vs. 67 minutes in the monitored area, P = 0.0003. Patients did not return to the ED more often when triaged during ED crowding: 24/260 (9.3%) vs. 29/240 (12.1%) when ED was not crowded (P = 0.31). Overall, when triaged to the non-monitored area of the ED, 44/396 (11.1%) patients returned, whereas in the monitored area 9/104 (8.7%) patients returned, P = 0.46.ConclusionsED crowding conditions appeared to influence triage destination in our ED leading to longer wait times for high acuity patients. This did not appear to lead to higher rates of return ED visits amongst discharged patients in this cohort. Further research is needed to determine whether these delays lead to adverse patient outcomes.

Background: In 2008-2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality. Methods: This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use. Results: We included a total of 167 and 185 patients in the pre-and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8-17.0; p = 0.006). There was also a higher rate of sepsis protocol use in the postintervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1-65.3; p < 0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission. Interpretation: The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

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There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.

Objectives: We surveyed Canadian emergency physicians to determine how skin and soft tissue infections (SSTIs) are managed and which risk factors were felt to be important in predicting failure with oral antibiotics. Methods: We performed an electronic survey of physician members of the Canadian Association of Emergency Physicians (CAEP) using the modified Dillman method. Results: The survey response rate was 36.9% (n = 391) amongst CAEP members. There was a lack of consensus regarding management of SSTIs. CAEP respondents identified 14 risk factors for predicting treatment failure with oral antibiotics, including hypotension, tachypnea, and patient reported severity of pain >8 of 10. Conclusions: The survey demonstrates significant variability regarding physician management of SSTIs, and we have identified several perceived risk factors for treatment failure with oral antibiotics that should be assessed in future studies.

Objectives: To determine the sensitivity of the venous lactate level at presentation for acute myocardial infarction (AMI) in emergency department (ED) patients with chest pain. Methods: A prospective, double-blind observational study was done in a tertiary care ED. From January to April 2000, all consecutive patients presenting with chest pain were eligible. Lactate level was obtained on arrival and compared with two criterion standards for the diagnosis of AMI: the World Health Organization (WHO) and the Joint European Society of Cardiology/American College of Cardiology Committee (ESC/ACC) classifications. A lactate level greater than 1.50 mmol/L was considered positive. Results: Between January and April 2000, 718 patients were enrolled. By the WHO criteria, 64 patients suffered an AMI, of whom 59 had an elevated lactate level, yielding a sensitivity of 92% (95% CI = 86% to 99%), a specificity of 44% (95% CI = 40% to 48%), and a negative predictive value (NPV) of 98% (95% CI = 97% to 99%). For all patients presenting with more than two hours of chest pain (n=34), the lactate level was elevated. When using the ESC/ACC criteria, 100 patients sustained an AMI, of whom 88 had an elevated lactate level, yielding a sensitivity of 88% (95% CI = 82% to 94%), a specificity of 46% (95% CI = 42% to 50%), and an NPV of 96% (95% CI = 94% to 98%). Conclusions: Venous lactate level at presentation is highly sensitive for the diagnosis of AMI, particularly in patients with more than two hours of chest pain. Given its limitations in specificity and ability to detect creatine kinase-MB-negative/troponin-positive microinfarcts, further research is needed to determine how lactate can complement other cardiac enzymes in risk-stratifying all acute coronary syndromes.