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Wickham ME, McGrail KM, Law MR, Cragg A, Hohl CM. Validating methods used to identify non-adherence adverse drug events in Canadian administrative health data. Br J Clin Pharmacol 2024; 90:1240-1246. [PMID: 38320955 DOI: 10.1111/bcp.16014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
AIMS Medication non-adherence is a type of adverse drug event that can lead to untreated and exacerbated chronic illness, and that drives healthcare utilization. Research using medication claims data has attempted to identify instances of medication non-adherence using the proportion of days covered or by examining gaps between medication refills. We sought to validate these measures compared to a gold standard diagnosis of non-adherence made in hospital. METHODS This was a retrospective analysis of adverse drug events diagnosed during three prospective cohorts in British Columbia between 2008 and 2015 (n = 976). We linked prospectively identified adverse drug events to medication claims data to examine the sensitivity and specificity of typical non-adherence measures. RESULTS The sensitivity of the non-adherence measures ranged from 22.4% to 37.5%, with a proportion of days covered threshold of 95% performing the best; the non-persistence measures had sensitivities ranging from 10.4% to 58.3%. While a 7-day gap was most sensitive, it classified 61.2% of the sample as non-adherent, whereas only 19.6% were diagnosed as such in hospital. CONCLUSIONS The methods used to identify non-adherence in administrative databases are not accurate when compared to a gold standard diagnosis by healthcare providers. Research that has relied on administrative data to identify non-adherent patients both underestimates the magnitude of the problem and may label patients as non-adherent who were in fact adherent.
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Affiliation(s)
- Maeve E Wickham
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
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Wickham ME, McGrail KM, Law MR, Cragg A, Hohl CM. Validating use of diagnostic codes in Canadian administrative data for identification of adverse drug events. Br J Clin Pharmacol 2024. [PMID: 38604986 DOI: 10.1111/bcp.16067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS While diagnostic codes from administrative health data might be a valuable source to identify adverse drug events (ADEs), their ability to identify unintended harms remains unclear. We validated claims-based diagnosis codes for ADEs based on events identified in a prospective cohort study and assessed whether key attributes predicted their documentation in administrative data. METHODS This was a retrospective analysis of 3 prospective cohorts in British Columbia, from 2008 to 2015 (n = 13 969). We linked prospectively identified ADEs to administrative insurance data to examine the sensitivity and specificity of different diagnostic code schemes. We used logistic regression to assess which key attributes (e.g., type of event, symptoms and culprit medications) were associated with better documentation of ADEs in administrative data. RESULTS Among 1178 diagnosed events, the sensitivity of the diagnostic codes in administrative data ranged from 3.4 to 52.6%, depending on the database and codes used. We found that documentation was worse for certain types of ADEs (dose-related: odds ratio [OR]: 0.32, 95% confidence interval [CI]: 0.15, 0.69; nonadherence events (OR: 0.35, 95% CI: 0.20, 0.62), and better for those experiencing arrhythmias (OR: 4.19, 95% CI: 0.96, 18.28). CONCLUSION ADEs were not well documented in administrative data. Alternative methods should be explored to capture ADEs for health research.
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Affiliation(s)
- Maeve E Wickham
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, Canada
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Rosychuk RJ, Khangura JK, Ortiz SS, Cheng I, Bielska IA, Yan J, Morrison LJ, Hayward J, Grant L, Hohl CM. Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). Emerg Med J 2024; 41:210-217. [PMID: 38365437 DOI: 10.1136/emermed-2023-213277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Unplanned return emergency department (ED) visits can reflect clinical deterioration or unmet need from the original visit. We determined the characteristics and outcomes of patients with COVID-19 who return to the ED for COVID-19-related revisits. METHODS This retrospective observational study used data for all adult patients visiting 47 Canadian EDs with COVID-19 between 1 March 2020 and 31 March 2022. Multivariable logistic regression assessed the characteristics associated with having a no return visit (SV=single visit group) versus at least one return visit (MV=return visit group) after being discharged alive at the first ED visit. RESULTS 39 809 patients with COVID-19 had 44 862 COVID-19-related ED visits: 35 468 patients (89%) had one visit (SV group) and 4341 (11%) returned to the ED (MV group) within 30 days (mean 2.2, SD=0.5 ED visit). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days, 49% returned within 72 hours. In multivariable modelling, a repeat visit was associated with a variety of factors including older age (OR=1.25 per 10 years, 95% CI (1.22 to 1.28)), pregnancy (1.86 (1.46 to 2.36)) and presence of comorbidities (eg, 1.72 (1.40 to 2.10) for cancer, 2.01 (1.52 to 2.66) for obesity, 2.18 (1.42 to 3.36) for organ transplant), current/prior substance use, higher temperature or WHO severe disease (1.41 (1.29 to 1.54)). Return was less likely for females (0.82 (0.77 to 0.88)) and those boosted or fully vaccinated (0.48 (0.34 to 0.70)). CONCLUSIONS Return ED visits by patients with COVID-19 within 30 days were common during the first two pandemic years and were associated with multiple factors, many of which reflect known risk for worse outcomes. Future studies should assess reasons for revisit and opportunities to improve ED care and reduce resource use. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT04702945.
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Affiliation(s)
- Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jaspreet K Khangura
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sylvia S Ortiz
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ivy Cheng
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Division of Emergency/Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Iwona A Bielska
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Institute of Public Health, Jagiellonian University, Krakow, Poland
| | - Justin Yan
- Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Laurie J Morrison
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Montreal, Québec, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Moura CS, Morrison LJ, Hohl CM, Grant L, Pilote L, Neville A, Hau JP, Bernatsky S. Administrative data ICD-10 diagnostic codes identifies most lab-confirmed SARS-CoV-2 admissions but misses many discharged from the Emergency Department. Sci Rep 2024; 14:6008. [PMID: 38472258 PMCID: PMC10933440 DOI: 10.1038/s41598-023-49501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 12/08/2023] [Indexed: 03/14/2024] Open
Abstract
We estimated the operating characteristics of ICD-10 code U07.1, introduced by the World Health Organization in 2020, to identify lab-confirmed SARS-CoV-2. CCEDRRN is a national research registry of adults (March 2020-August 2021) with suspected/confirmed SARS-CoV-2 identified in Canadian emergency departments (EDs) using chart review (symptoms, clinical information, and lab test results including SARS-CoV-2 polymerase chain reaction, PCR results). CCEDRRN data were linked to administrative hospitalization discharge and ED ICD-10 diagnostic codes (accessed centrally via the Canadian Institute for Health Information). We identified ICD-10 diagnostic codes in CCEDRRN participants. We defined lab-confirmed SARS-CoV-2 based on at least one positive PCR in the 0-14 days before the ED presentation and/or during hospitalization (in those admitted from ED). We performed separate analyses for CCEDRRN participants discharged from ED and those hospitalized from the ED. Additional analyses were stratified by province, sex, age, and (for hospitalized patients) timing of the first PCR test. The sensitivity of ICD-10 code U07.1 for a positive SARS-CoV-2 test was 93.6% (95% CI 93.0-94.1%) in those hospitalized from ED and 83.0% (95% CI 82.1-83.9%) in those discharged from the ED. Sensitivity was similar across provinces and demographics, but in each stratified analysis, values were higher in those hospitalized versus those discharged from ED. The ICD-10 diagnostic code for U07.1 within administrative data identified most lab-confirmed SARS-CoV-2 within persons hospitalized from ED, although a significant number of cases discharged from ED were missed. This should be considered when using administrative data for research and public health planning.
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Affiliation(s)
| | - Laurie J Morrison
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Autumn Neville
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeffrey P Hau
- University of British Columbia, Vancouver, BC, Canada
| | - Sasha Bernatsky
- McGill University, Montreal, QC, Canada.
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
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Gossack-Keenan K, Yeom DS, Kanu J, Hau JP, Rosychuk RJ, Clark D, Bola R, Tze C, Niosco C, Emery H, Yeung P, Hohl CM. Heatstroke presentations to urban hospitals during BC's extreme heat event: lessons for the future. CAN J EMERG MED 2024; 26:111-118. [PMID: 38153655 PMCID: PMC10861625 DOI: 10.1007/s43678-023-00622-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/07/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Climate change is leading to more extreme heat events in temperate climates that typically have low levels of preparedness. Our objective was to describe the characteristics, treatments, and outcomes of adults presenting to hospitals with heatstroke during BC's 2021 heat dome. METHODS We conducted a review of consecutive adults presenting to 7 hospitals in BC's Lower Mainland. We screened the triage records of all patients presenting between June 25th and 30th, 2021 for complaints related to heat, and reviewed the full records of those who met heatstroke criteria. Our primary outcome was in-hospital mortality. We used Mann-Whitney U tests and logistic regression to investigate associations between patient and treatment factors and mortality. RESULTS Among 10,247 consecutive presentations to urban hospitals during the extreme heat event, 1.3% (139; 95% confidence intervals [CI] 1.1-1.6%) met criteria for heatstroke. Of heatstroke patients, 129 (90.6%) were triaged into the two highest acuity levels. Patients with heatstroke had a median age of 84.4 years, with 122 (87.8%) living alone, and 101 (84.2%) unable to activate 911 themselves. A minority (< 5, < 3.6%) of patients presented within 48 h of the onset of extreme heat. Most patients (107, 77.0%) required admission, and 11.5% (16) died in hospital. Hypotension on presentation was associated with mortality (odds ratio [OR] 5.3). INTERPRETATION Heatstroke patients were unable to activate 911 themselves, and most presented with a 48-h delay. This delay may represent a critical window of opportunity for pre-hospital and hospital systems to prepare for the influx of high-acuity resource-intensive patients.
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Affiliation(s)
- Kira Gossack-Keenan
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
- Faculty of Medicine, Diamond Health Care Centre, 11th Floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - David Seonguk Yeom
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Josephine Kanu
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | | | - Dylan Clark
- Climate Institute Canada, Vancouver, BC, Canada
| | - Rajan Bola
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Caris Tze
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chris Niosco
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hayley Emery
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Phillip Yeung
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
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Lau EY, Cragg A, Small SS, Butcher K, Hohl CM. Characterizing and Comparing Adverse Drug Events Documented in 2 Spontaneous Reporting Systems in the Lower Mainland of British Columbia, Canada: Retrospective Observational Study. JMIR Hum Factors 2024; 11:e52495. [PMID: 38236629 PMCID: PMC10835584 DOI: 10.2196/52495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Robust adverse drug event (ADE) reporting systems are crucial to monitor and identify drug safety signals, but the quantity and type of ADEs captured may vary by system characteristics. OBJECTIVE We compared ADEs reported in 2 different reporting systems in the same jurisdictions, the Patient Safety and Learning System-Adverse Drug Reaction (PSLS-ADR) and ActionADE, to understand report variation. METHODS This retrospective observational study analyzed reports entered into PSLS-ADR and ActionADE systems between December 1, 2019, and December 31, 2022. We conducted a comprehensive analysis including all events from both reporting systems to examine coverage and usage and understand the types of events captured in both systems. We calculated descriptive statistics for reporting facility type, patient demographics, serious events, and most reported drugs. We conducted a subanalysis focused on adverse drug reactions to enable direct comparisons between systems in terms of the volume and events reported. We stratified results by reporting system. RESULTS We performed the comprehensive analysis on 3248 ADE reports, of which 12.4% (375/3035) were reported in PSLS-ADR and 87.6% (2660/3035) were reported in ActionADE. Distribution of all events and serious events varied slightly between the 2 systems. Iohexol, gadobutrol, and empagliflozin were the most common culprit drugs (173/375, 46.2%) in PSLS-ADR, while hydrochlorothiazide, apixaban, and ramipril (308/2660, 11.6%) were common in ActionADE. We included 2728 reports in the subanalysis of adverse drug reactions, of which 12.9% (353/2728) were reported in PSLS-ADR and 86.4% (2357/2728) were reported in ActionADE. ActionADE captured 4- to 6-fold more comparable events than PSLS-ADR over this study's period. CONCLUSIONS User-friendly and robust reporting systems are vital for pharmacovigilance and patient safety. This study highlights substantial differences in ADE data that were generated by different reporting systems. Understanding system factors that lead to varying reporting patterns can enhance ADE monitoring and should be taken into account when evaluating drug safety signals.
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Affiliation(s)
- Erica Y Lau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Centre, Vancouver, BC, Canada
| | - Amber Cragg
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Centre, Vancouver, BC, Canada
| | - Serena S Small
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Centre, Vancouver, BC, Canada
| | - Katherine Butcher
- Pharmaceutical Science, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
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Cragg A, Small SS, Lau E, Rowe A, Lau A, Butcher K, Hohl CM. Sharing Adverse Drug Event Reports Between Hospitals and Community Pharmacists to Inform Re-dispensing: An Analysis of Reports and Process Outcomes. Drug Saf 2023; 46:1161-1172. [PMID: 37783974 PMCID: PMC10632212 DOI: 10.1007/s40264-023-01348-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Adverse drug events (ADEs) are a leading cause of unplanned hospital visits. We designed ActionADE, an online ADE reporting platform, and integrated it with PharmaNet, British Columbia's (BC's) provincial medication dispensing system, to overcome identified barriers in ADE reporting and communicate ADEs to community pharmacies. Our objectives were to characterise ADEs reported in ActionADE, explore associations between patients' age, sex and ADE characteristics, and estimate the re-dispensation rate of culprit medications in community pharmacies. METHODS We conducted a prospective observational study of ADE reporting in four BC hospitals between April 1, 2020 and October 31, 2022. We described the characteristics of ADEs reported into ActionADE, used logistic regression modelling to examine associations between age and sex and ADE characteristics, and calculated rates of avoided culprit drug re-dispensations using community pharmacists' responses to ActionADE alerts. RESULTS In total, 3591 ADE reports were initiated by hospital clinicians, 3174 of which were included in this analysis. Serious or life-threatening ADEs resulting in permanent disability, hospitalisation, extended hospitalisation, and/or death accounted for 28.5% (906/3174; 95% CI 27.0-30.1%) of reports. Males were more likely to have non-adherence reported compared to females and experienced life threatening ADEs at a younger age than females. Of 592 patients who had ≥ 1 adverse drug reaction or allergy report (a subset of ADEs) transmitted to community pharmacies, 200 subsequently attempted to re-fill the culprit or a same class drug. Community pharmacists responded to preventative alerts by avoiding re-dispensation in 33.0% (66/200; 95% CI 26.5-39.5%). INTERPRETATION ActionADE is the first interoperable system that communicates ADEs via a central medication database to community pharmacies. Every 10th ADE reported in ActionADE and shared to PharmaNet resulted in community pharmacists' avoiding one culprit or same class drug re-exposure. Further research is needed to understand ActionADE's impact on patient and health system outcomes.
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Affiliation(s)
- Amber Cragg
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Serena S Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Erica Lau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adrianna Rowe
- Emergency Department, University Health Network, Toronto, ON, Canada
| | - Anthony Lau
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
| | - Katherine Butcher
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada.
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Hohl CM, Cragg A, Purssel E, McAlister FA, Ting DK, Scheuermeyer F, Stachura M, Grant L, Taylor J, Kanu J, Hau JP, Cheng I, Atzema CL, Bola R, Morrison LJ, Landes M, Perry JJ, Rosychuk RJ. Comparing methods to classify admitted patients with SARS-CoV-2 as admitted for COVID-19 versus with incidental SARS-CoV-2: A cohort study. PLoS One 2023; 18:e0291580. [PMID: 37751455 PMCID: PMC10522023 DOI: 10.1371/journal.pone.0291580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
INTRODUCTION Not all patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection develop symptomatic coronavirus disease 2019 (COVID-19), making it challenging to assess the burden of COVID-19-related hospitalizations and mortality. We aimed to determine the proportion, resource utilization, and outcomes of SARS-CoV-2 positive patients admitted for COVID-19, and assess the impact of using the Center for Disease Control's (CDC) discharge diagnosis-based algorithm and the Massachusetts state department's drug administration-based classification system on identifying admissions for COVID-19. METHODS In this retrospective cohort study, we enrolled consecutive SARS-CoV-2 positive patients admitted to one of five hospitals in British Columbia between December 19, 2021 and May 31,2022. We completed medical record reviews, and classified hospitalizations as being primarily for COVID-19 or with incidental SARS-CoV-2 infection. We applied the CDC algorithm and the Massachusetts classification to estimate the difference in hospital days, intensive care unit (ICU) days and in-hospital mortality and calculated sensitivity and specificity. RESULTS Of 42,505 Emergency Department patients, 1,651 were admitted and tested positive for SARS-CoV-2, with 858 (52.0%, 95% CI 49.6-54.4) admitted for COVID-19. Patients hospitalized for COVID-19 required ICU admission (14.0% versus 8.2%, p<0.001) and died (12.6% versus 6.4%, p<0.001) more frequently compared with patients with incidental SARS-CoV-2. Compared to case classification by clinicians, the CDC algorithm had a sensitivity of 82.9% (711/858, 95% CI 80.3%, 85.4%) and specificity of 98.1% (778/793, 95% CI 97.2%, 99.1%) for COVID-19-related admissions and underestimated COVID-19 attributable hospital days. The Massachusetts classification had a sensitivity of 60.5% (519/858, 95% CI 57.2%, 63.8%) and specificity of 78.6% (623/793, 95% CI 75.7%, 81.4%) for COVID-19-related admissions, underestimating total number of hospital and ICU bed days while overestimating COVID-19-related intubations, ICU admissions, and deaths. CONCLUSION Half of SARS-CoV-2 hospitalizations were for COVID-19 during the Omicron wave. The CDC algorithm was more specific and sensitive than the Massachusetts classification, but underestimated the burden of COVID-19 admissions. TRIAL REGISTRATION Clinicaltrials.gov, NCT04702945.
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Affiliation(s)
- Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Elizabeth Purssel
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Finlay A. McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
- Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Daniel K. Ting
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, St. Paul’s & Mount Saint Joseph Hospitals, Vancouver, British Columbia, Canada
| | - Maja Stachura
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Emergency Department, Lions Gate Hospital, North Vancouver, British Columbia, Canada
| | - Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada
- Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - John Taylor
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Josephine Kanu
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ivy Cheng
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clare L. Atzema
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rajan Bola
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurie J. Morrison
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Megan Landes
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Jeffrey J. Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rhonda J. Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Archambault PM, Rosychuk RJ, Audet M, Bola R, Vatanpour S, Brooks SC, Daoust R, Clark G, Grant L, Vaillancourt S, Welsford M, Morrison LJ, Hohl CM. Accuracy of Self-Reported COVID-19 Vaccination Status Compared With a Public Health Vaccination Registry in Québec: Observational Diagnostic Study. JMIR Public Health Surveill 2023; 9:e44465. [PMID: 37327046 DOI: 10.2196/44465] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The accuracy of self-reported vaccination status is important to guide real-world vaccine effectiveness studies and policy making in jurisdictions where access to electronic vaccine registries is restricted. OBJECTIVE This study aimed to determine the accuracy of self-reported vaccination status and reliability of the self-reported number of doses, brand, and time of vaccine administration. METHODS This diagnostic accuracy study was completed by the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive patients presenting to 4 emergency departments (EDs) in Québec between March 24, 2020, and December 25, 2021. We included adult patients who were able to consent, could speak English or French, and had a proven COVID-19 infection. We compared the self-reported vaccination status of the patients with their vaccination status in the electronic Québec Vaccination Registry. Our primary outcome was the accuracy of the self-reported vaccination status (index test) ascertained during telephone follow-up compared with the Québec Vaccination Registry (reference standard). The accuracy was calculated by dividing all correctly self-reported vaccinated and unvaccinated participants by the sum of all correctly and incorrectly self-reported vaccinated and unvaccinated participants. We also reported interrater agreement with the reference standard as measured by unweighted Cohen κ for self-reported vaccination status at telephone follow-up and at the time of their index ED visit, number of vaccine doses, and brand. RESULTS During the study period, we included 1361 participants. At the time of the follow-up interview, 932 participants reported at least 1 dose of a COVID-19 vaccine. The accuracy of the self-reported vaccination status was 96% (95% CI 95%-97%). Cohen κ for self-reported vaccination status at phone follow-up was 0.91 (95% CI 0.89-0.93) and 0.85 (95% CI 0.77-0.92) at the time of their index ED visit. Cohen κ was 0.89 (95% CI 0.87-0.91) for the number of doses, 0.80 (95% CI 0.75-0.84) for the brand of the first dose, 0.76 (95% CI 0.70-0.83) for the brand of the second dose, and 0.59 (95% CI 0.34-0.83) for the brand of the third dose. CONCLUSIONS We reported a high accuracy of self-reported vaccination status for adult patients without cognitive disorders who can express themselves in English or French. Researchers can use self-reported COVID-19 vaccination data on the number of doses received, vaccine brand name, and timing of vaccination to guide future research with patients who are capable of self-reporting their vaccination data. However, access to official electronic vaccine registries is still needed to determine the vaccination status in certain susceptible populations where self-reported vaccination data remain missing or impossible to obtain. TRIAL REGISTRATION Clinicaltrials.gov NCT04702945; https://clinicaltrials.gov/ct2/show/NCT04702945.
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Affiliation(s)
- Patrick M Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Department of Anesthesiology and Intensive Care, Université Laval, Québec, QC, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Martyne Audet
- Centre de recherche intégrée pour un système de santé apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Rajan Bola
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shabnam Vatanpour
- Center for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Raoul Daoust
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Gregory Clark
- Department of Emergency Medicine, Faculty of Medicine, McGill University, Montréal, QC, Canada
| | - Lars Grant
- Department of Emergency Medicine, Faculty of Medicine, McGill University, Montréal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, QC, Canada
| | - Samuel Vaillancourt
- Department of Emergency Medicine, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Laurie J Morrison
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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10
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Lau EY, Small SS, Butcher K, Cragg A, Loh GW, Shalansky S, Hohl CM. An external facilitation intervention to increase uptake of an adverse drug event reporting intervention. Front Health Serv 2023; 3:1106586. [PMID: 37332530 PMCID: PMC10272762 DOI: 10.3389/frhs.2023.1106586] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/09/2023] [Indexed: 06/20/2023]
Abstract
Background Adverse drug events (ADEs) are a leading cause of emergency department visits and hospital admissions in Canada. ActionADE prevents repeat ADEs by enabling clinicians to document and communicate standardized ADE information across care settings. We used an external facilitation intervention to promote the uptake of ActionADE in four hospitals in British Columbia, Canada. This study examined whether, how and in what context external facilitation influenced the uptake of ActionADE. Methods In this convergent-parallel mixed-methods study, an external facilitator used a four-step iterative process to support site champions using context-specific implementation strategies to increase the ADE reporting rate at their sites. We extracted archival data to assess implementation determinants before and after the implementation of the external facilitation and implementation strategies. We also retrieved data on the mean monthly counts of reported ADEs for each user from the ActionADE server. Zero-inflated Poisson models were used to examine changes in mean monthly counts of reported ADEs per user between pre-intervention (June 2021 to October 2021) and intervention (November 2021 to March 2022) periods. Results The external facilitator and site champions co-created three functions: (1) educate pharmacists about what and how to report in ActionADE, (2) educate pharmacists about the impact of ActionADE on patient outcomes, and (3) provide social support for pharmacists to integrate ADE reporting into clinical workflows. Site champions used eight forms to address the three functions. Peer support and reporting competition were the two common strategies used by all sites. Sites' responses to external facilitation varied. The rate of mean monthly counts of reported ADEs per user significantly increased during the intervention period compared to the pre-intervention period at LGH (RR: 3.74, 95% CI 2.78 to 5.01) and RH (RR: 1.43, 95% CI 1.23 to 1.94), but did not change at SPH (RR: 0.68, 95% CI: 0.43 to 1.09) and VGH (RR: 1.17, 95% CI 0.92 to 1.49). Leave of absence of the clinical pharmacist champion and failure to address all identified functions were implementation determinants that influenced the effectiveness of external facilitation. Conclusion External facilitation effectively supported researchers and stakeholders to co-create context-specific implementation strategies. It increased ADE reporting at sites where clinical pharmacist champions were available, and where all functions were addressed.
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Affiliation(s)
- Erica Y. Lau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Centre, Centre for Clinical Epidemiology andEvaluation, Vancouver, BC, Canada
| | - Serena S. Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Centre, Centre for Clinical Epidemiology andEvaluation, Vancouver, BC, Canada
| | - Kate Butcher
- Vancouver Coastal Health Research Centre, Centre for Clinical Epidemiology andEvaluation, Vancouver, BC, Canada
- Pharmaceutical Science, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Amber Cragg
- Vancouver Coastal Health Research Centre, Centre for Clinical Epidemiology andEvaluation, Vancouver, BC, Canada
| | - Gabriel W. Loh
- Richmond Hospital Pharmacy Department, Lower Mainland Pharmacy Services, Richmond, BC, Canada
| | - Steve Shalansky
- Pharmacy Department, St. Paul’s Hospital, Providence Health Care, Vancouver, BC, Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Centre, Centre for Clinical Epidemiology andEvaluation, Vancouver, BC, Canada
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11
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Small SS, Lau E, McFarlane K, Archambault PM, Longstaff H, Hohl CM. Research recruitment and consent methods in a pandemic: a qualitative study of COVID-19 patients' perspectives. BMC Med Res Methodol 2023; 23:113. [PMID: 37170077 PMCID: PMC10173898 DOI: 10.1186/s12874-023-01933-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Virtual data collection methods and consent procedures adopted in response to the COVID-19 pandemic enabled continued research activities, but also introduced concerns about equity, inclusivity, representation, and privacy. Recent studies have explored these issues from institutional and researcher perspectives, but there is a need to explore patient perspectives and preferences. This study aims to explore COVID-19 patients' perspectives about research recruitment and consent for research studies about COVID-19. METHODS We conducted an exploratory qualitative focus group and interview study among British Columbian adults who self-identified as having had COVID-19. We recruited participants through personal contacts, social media, and REACH BC, an online platform that connects researchers and patients in British Columbia. We analyzed transcripts inductively and developed thematic summaries of each coding element. RESULTS Of the 22 individuals recruited, 16 attended a focus group or interview. We found that autonomy and the feasibility of participation, attitudes toward research about COVID-19, and privacy concerns are key factors that influence participants' willingness to participate in research. We also found that participants preferred remote and virtual approaches for contact, consent, and delivery of research on COVID-19. CONCLUSIONS Individuals who had COVID-19 are motivated to participate in research studies and value autonomy in their decision to participate, but researchers must be sensitive and considerate toward patient preferences and concerns, particularly as researchers adopt virtual recruitment and data collection methods. Such awareness may increase research participation and engagement.
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Affiliation(s)
- Serena S Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Ave, 7th Fl, Vancouver, BC, Canada
| | - Erica Lau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Ave, 7th Fl, Vancouver, BC, Canada
| | | | - Patrick M Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, QC, Canada
- Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Holly Longstaff
- Provincial Health Services Authority, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Ave, 7th Fl, Vancouver, BC, Canada.
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada.
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12
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McAlister FA, Hau JP, Atzema C, McRae AD, Morrison LJ, Grant L, Cheng I, Rosychuk RJ, Hohl CM. The burden of incidental SARS-CoV-2 infections in hospitalized patients across pandemic waves in Canada. Sci Rep 2023; 13:6635. [PMID: 37095174 PMCID: PMC10123574 DOI: 10.1038/s41598-023-33569-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023] Open
Abstract
Many health authorities differentiate hospitalizations in patients infected with SARS-CoV-2 as being "for COVID-19" (due to direct manifestations of SARS-CoV-2 infection) versus being an "incidental" finding in someone admitted for an unrelated condition. We conducted a retrospective cohort study of all SARS-CoV-2 infected patients hospitalized via 47 Canadian emergency departments, March 2020-July 2022 to determine whether hospitalizations with "incidental" SARS-CoV-2 infection are less of a burden to patients and the healthcare system. Using a priori standardized definitions applied to hospital discharge diagnoses in 14,290 patients, we characterized COVID-19 as (i) the "Direct" cause for the hospitalization (70%), (ii) a potential "Contributing" factor for the hospitalization (4%), or (iii) an "Incidental" finding that did not influence the need for admission (26%). The proportion of incidental SARS-CoV-2 infections rose from 10% in Wave 1 to 41% during the Omicron wave. Patients with COVID-19 as the direct cause of hospitalization exhibited significantly longer LOS (mean 13.8 versus 12.1 days), were more likely to require critical care (22% versus 11%), receive COVID-19-specific therapies (55% versus 19%), and die (17% versus 9%) compared to patients with Incidental SARS-CoV-2 infections. However, patients hospitalized with incidental SARS-CoV-2 infection still exhibited substantial morbidity/mortality and hospital resource use.
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Affiliation(s)
- Finlay A McAlister
- The Division of General Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, 5-134C Clinical Sciences Building, 11350 83 Avenue, Edmonton, AB, T6G 2G3, Canada.
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Canada.
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Clare Atzema
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Laurie J Morrison
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Ivy Cheng
- Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
- Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
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13
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Leeies M, Rosychuk RJ, Ismath M, Xu K, Archambault P, Fok PT, Audet T, Jelic T, Hayward J, Daoust R, Chandra K, Davis P, Yan JW, Hau JP, Welsford M, Brooks SC, Hohl CM. Intubation practices and outcomes for patients with suspected or confirmed COVID-19: a national observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). CAN J EMERG MED 2023; 25:335-343. [PMID: 37017802 PMCID: PMC10075161 DOI: 10.1007/s43678-023-00487-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Intubation practices changed during the COVID-19 pandemic to protect healthcare workers from transmission of disease. Our objectives were to describe intubation characteristics and outcomes for patients tested for SARS CoV-2 infection. We compared outcomes between patients testing SARS COV-2 positive with those testing negative. METHODS We conducted a health records review using the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. We included consecutive eligible patients who presented to one of 47 EDs across Canada between March 1, 2020 and June 20, 2021, were tested for SARS-CoV-2 and intubated in the ED. The primary outcome was the proportion of patients experiencing a post-intubation adverse event during the ED stay. Secondary outcomes included first-pass success, intubation practices, and hospital mortality. We used descriptive statistics to summarize variables with subgroup differences examined using t tests, z tests, or chi-squared tests where appropriate with 95% CIs. RESULTS Of 1720 patients with suspected COVID-19 who were intubated in the ED during the study period, 337 (19.6%) tested SARS-CoV-2 positive and 1383 (80.4%) SARS-CoV-2 negative. SARS-CoV-2 positive patients presented to hospital with lower oxygen levels than SARS-CoV-2 negative patients (mean pulse oximeter SaO2 86 vs 94%, p < 0.001). In total, 8.5% of patients experienced an adverse event post-intubation. More patients in the SARS-CoV-2 positive subgroup experienced post-intubation hypoxemia (4.5 vs 2.2%, p = 0.019). In-hospital mortality was greater for patients who experienced intubation-related adverse events (43.2 vs 33.2%, p = 0.018). There was no significant difference in adverse event-associated mortality by SARS-CoV-2 status. First-pass success was achieved in 92.4% of all intubations, with no difference by SARS-CoV-2 status. CONCLUSIONS During the COVID-19 pandemic, we observed a low risk of adverse events associated with intubation, even though hypoxemia was common in patients with confirmed SARS-CoV-2. We observed high rates of first-pass success and low rates of inability to intubate. The limited number of adverse events precluded multivariate adjustments. Study findings should reassure emergency medicine practitioners that system modifications made to intubation processes in response to the COVID-19 pandemic do not appear to be associated with worse outcomes compared to pre-COVID-19 practices.
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Affiliation(s)
- Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Rady Faculty of Health Sciences, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Muzeen Ismath
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ke Xu
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine and Department of Anesthesiology and Intensive Care, Université Laval, Québec, QC, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Thomas Audet
- Department of Internal Medicine, Université Laval, Québec, QC, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Raoul Daoust
- Department of Family and Emergency Medicine, University of Montreal, Montreal, QC, Canada
| | - Kavish Chandra
- Department of Emergency Medicine, Dalhousie University, Saint John, NB, Canada
| | - Phil Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University and Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
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14
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Lin K, Xu K, Daoust R, Taylor J, Rosychuk RJ, Hau JP, Davis P, Clark G, McRae AD, Hohl CM. Prognostic association between d-dimer thresholds and 30-day pulmonary embolism diagnosis among emergency department patients with suspected SARS-CoV-2 infection: a Canadian COVID-19 Emergency Department Rapid Response Network study. CAN J EMERG MED 2023; 25:134-142. [PMID: 36624252 PMCID: PMC9838465 DOI: 10.1007/s43678-022-00440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The primary objective was to quantify the prognostic association between various D-dimer thresholds and 30-day PE diagnosis among emergency department (ED) patients with suspected SARS-CoV-2 infection. METHODS This was a retrospective study of patients enrolled in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) registry from March 1, 2020 to July 2, 2021. We included consecutive adults (≥ 18 years) presenting to 49 EDs with chest pain, shortness of breath, hypoxia, syncope, presyncope, or hemoptysis who were tested for both SARS-CoV-2 and D-dimer at index ED visit. The primary outcome measure was the sensitivity, specificity, and negative predictive value of D-dimer test thresholds for the outcome of 30-day PE diagnosis. RESULTS Among 10,837 patients included in our study, 404 (3.7%) were diagnosed with PE at 30-days. A standard D-Dimer threshold of 500 ng/mL had a sensitivity of 97.8% (95% confidence interval [CI] 95.8-99.0%), specificity of 40.9% (95% CI 39.9-41.8%), and negative predictive value of 99.8% (95% CI 99.6-99.9%). An age-adjusted D-dimer threshold had a sensitivity of 96.0% (95% CI 93.6-97.7%), specificity of 48.5% (95% CI 47.5-49.4%), and negative predictive value of 99.7% (95% CI 99.5-99.8%). D-dimer testing had slightly lower prognostic performance among SARS-CoV-2 positive compared to SARS-CoV-2 negative patients in predicting 30-day PE diagnosis. CONCLUSIONS Among ED patients with suspected SARS-CoV-2, the standard 500 ng/mL and age-adjusted D-dimer thresholds were comparable for the prediction of PE at 30-days. The prognostic performance of D-dimer was lower among SARS-CoV-2 positive patients. TRIAL REGISTRATION Clinicaltrials.gov, NCT04702945.
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Affiliation(s)
- Katie Lin
- Department of Emergency Medicine, Room C231 Foothills Medical Centre, University of Calgary, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada. .,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.
| | - Ke Xu
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
| | - Raoul Daoust
- grid.14848.310000 0001 2292 3357Department of Family Medicine and Emergency Medicine, University of Montreal, Quebec, Canada
| | - John Taylor
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada
| | - Rhonda J. Rosychuk
- grid.17089.370000 0001 2190 316XDepartment of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - Jeffrey P. Hau
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
| | - Phil Davis
- grid.25152.310000 0001 2154 235XDepartment of Emergency Medicine, University of Saskatchewan, Saskatoon, SK Canada
| | - Greg Clark
- grid.14709.3b0000 0004 1936 8649Department of Emergency Medicine, McGill University, Montreal, QC Canada
| | - Andrew D. McRae
- grid.22072.350000 0004 1936 7697Department of Emergency Medicine, University of Calgary, Calgary, AB Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Corinne M. Hohl
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
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15
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Hohl CM, Hau JP, Vaillancourt S, Grant J, Brooks SC, Morrison LJ, Perry JJ, Rosychuk RJ. Sensitivity and Diagnostic Yield of the First SARS-CoV-2 Nucleic Acid Amplification Test Performed for Patients Presenting to the Hospital. JAMA Netw Open 2022; 5:e2236288. [PMID: 36223119 PMCID: PMC9557877 DOI: 10.1001/jamanetworkopen.2022.36288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Early and accurate diagnostic testing for SARS-CoV-2 is essential to initiate appropriate treatment and infection control and prevention measures among patients presenting to the hospital. OBJECTIVE To evaluate the diagnostic sensitivity of the SARS-CoV-2 nucleic acid amplification test (NAAT) performed within 24 hours of arrival to the emergency department among a nationally representative sample of patients. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study was conducted at 47 hospitals across 7 provinces in Canada participating in the Canadian COVID-19 Rapid Response Emergency Department Network among consecutive eligible patients presenting to a participating emergency department who were tested for SARS-CoV-2 from March 1, 2020, to December 31, 2021. Patients not tested within 24 hours of arrival and those presenting with a positive result from a test performed in the community were excluded. MAIN OUTCOMES AND MEASURES The primary outcome was a positive result from the SARS-CoV-2 NAAT. Outcome measures were the diagnostic sensitivity and yield of the SARS-CoV-2 NAAT. RESULTS Of 132 760 eligible patients (66 433 women [50.0%]; median age, 57 years [IQR, 37-74 years]), 17 174 (12.9%) tested positive for SARS-CoV-2 within 14 days of their first NAAT. The diagnostic sensitivity of the SARS-CoV-2 NAAT was 96.2% (17 070 of 17 740 [95% CI, 95.9%-96.4%]) among all of the tests performed. Estimates ranged from a high of 97.7% (1710 of 1751 [95% CI, 96.8%-98.3%]) on day 2 of symptoms to a low of 90.4% (170 of 188 [95% CI, 85.3%-94.2%]) on day 11 of symptoms among patients presenting with COVID-19 symptoms. Among patients reporting COVID-19 symptoms, the sensitivity of the SARS-CoV-2 NAAT was 97.1% (11 870 of 12 225 [95% CI, 96.7%-97.3%]) compared with 87.6% (812 of 927 [95% CI, 85.2%-89.6%]) among patients without COVID-19 symptoms. The diagnostic yield of the SARS-CoV-2 NAAT was 12.0% (18 985 of 158 004 [95% CI, 11.8%-12.2%]) and varied from a high of 20.0% (445 of 2229 [95% CI, 18.3%-21.6%]) among patients tested on day 10 after symptom onset to a low of 8.1% (1686 of 20 719 [95% CI, 7.7%-8.5%]) among patients presenting within the first 24 hours of symptom onset. CONCLUSIONS AND RELEVANCE This study suggests that the diagnostic sensitivity was high for the first SARS-CoV-2 NAAT performed in the hospital and did not vary significantly by symptom duration. Repeated testing of patients with negative test results should be avoided unless their pretest probability of disease is high.
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Affiliation(s)
- Corinne M. Hohl
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Samuel Vaillancourt
- Department of Emergency Medicine, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Grant
- Division of Medical Microbiology and Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven C. Brooks
- Department of Emergency Medicine, Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Laurie J. Morrison
- Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jeffrey J. Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rhonda J. Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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16
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Davis P, Rosychuk R, Hau JP, Cheng I, McRae AD, Daoust R, Lang E, Turner J, Khangura J, Fok PT, Stachura M, Brar B, Hohl CM. Diagnostic yield of screening for SARS-CoV-2 among patients admitted to hospital for alternate diagnoses: an observational cohort study. BMJ Open 2022; 12:e057852. [PMID: 35948378 PMCID: PMC9378945 DOI: 10.1136/bmjopen-2021-057852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the diagnostic yield of screening patients for SARS-CoV-2 who were admitted with a diagnosis unrelated to COVID-19 and to identify risk factors for positive tests. DESIGN Cohort from the Canadian COVID-19 Emergency Department Rapid Response Network registry. SETTING 30 acute care hospitals across Canada. PARTICIPANTS Patients hospitalised for non-COVID-19-related diagnoses who were tested for SARS-CoV-2 between 1 March and 29 December 2020. MAIN OUTCOME Positive nucleic acid amplification test for SARS-CoV-2. OUTCOME MEASURE Diagnostic yield. RESULTS We enrolled 15 690 consecutive eligible adults who were admitted to hospital without clinically suspected COVID-19. Among these patients, 122 tested positive for COVID-19, resulting in a diagnostic yield of 0.8% (95% CI 0.64% to 0.92%). Factors associated with a positive test included presence of fever, being a healthcare worker, having a positive household contact or institutional exposure, and living in an area with higher 7-day average incident COVID-19 cases. CONCLUSIONS Universal screening of hospitalised patients for COVID-19 across two pandemic waves had a low diagnostic yield and should be informed by individual-level risk assessment in addition to regional COVID-19 prevalence. TRIAL REGISTRATION NUMBER NCT04702945.
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Affiliation(s)
- Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatchewan, Saskatoon, Canada
| | - Rhonda Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey P Hau
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ivy Cheng
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Emergency Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raoul Daoust
- Département Médecine de Famille et Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joel Turner
- Department of Emergency Medicine, McGill University, Montreal, Quebec, Canada
| | - Jaspreet Khangura
- Department of Emergency Medicine, Northeast Community Health Centre, Edmonton, Alberta, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Maja Stachura
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Baljeet Brar
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
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17
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Hohl CM, McRae AD. Antiviral treatment for COVID-19: ensuring evidence is applicable to current circumstances. CMAJ 2022; 194:E996-E997. [PMID: 35878901 PMCID: PMC9328461 DOI: 10.1503/cmaj.221012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl), University of British Columbia; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC; Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta
| | - Andrew D McRae
- Department of Emergency Medicine (Hohl), University of British Columbia; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC; Departments of Emergency Medicine and Community Health Sciences (McRae), University of Calgary, Calgary, Alta.
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18
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Moe J, Wang YE, Schull MJ, Dong K, McGregor MJ, Hohl CM, Holroyd BR, McGrail KM. Characterizing people with frequent emergency department visits and substance use: a retrospective cohort study of linked administrative data in Ontario, Alberta, and B.C., Canada. BMC Emerg Med 2022; 22:127. [PMID: 35836121 PMCID: PMC9281237 DOI: 10.1186/s12873-022-00673-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/15/2022] [Indexed: 11/22/2022] Open
Abstract
Background Substance use is common among people who visit emergency departments (EDs) frequently. We aimed to characterize subgroups within this cohort to better understand care needs/gaps, and generalizability of characteristics in three Canadian provinces. Methods This was a retrospective cohort study (April 1st, 2013 to March 31st, 2016) of ED patients in Ontario, Alberta, and British Columbia (B.C.) We included patients ≥ 18 years with substance use-related healthcare contact during the study period and frequent ED visits, defined as those in the top 10% of ED utilization when all patients were ordered by annual ED visit number. We used linked administrative databases including ED visits and hospitalizations (all provinces); mental heath-related hospitalizations (Ontario and Alberta); and prescriptions, physician services, and mortality (B.C.). We compared to cohorts of people with (1) frequent ED visits and no substance use, and (2) non-frequent ED visits and substance use. We employed cluster analysis to identify subgroups with distinct visit patterns and clinical characteristics during index year, April 1st, 2014 to March 31st, 2015. Results In 2014/15, we identified 19,604, 7,706, and 9,404 people with frequent ED visits and substance use in Ontario, Alberta, and B.C (median 37–43 years; 60.9–63.0% male), whose ED visits and hospitalizations were higher than comparison groups. In all provinces, cluster analyses identified subgroups with “extreme” and “moderate” frequent visits (median 13–19 versus 4–6 visits/year). “Extreme” versus “moderate” subgroups had more hospitalizations, mental health-related ED visits, general practitioner visits but less continuity with one provider, more commonly left against medical advice, and had higher 365-day mortality in B.C. (9.3% versus 6.6%; versus 10.4% among people with frequent ED visits and no substance use, and 4.3% among people with non-frequent ED visits and substance use). The most common ED diagnosis was acute alcohol intoxication in all subgroups. Conclusions Subgroups of people with “extreme” (13–19 visits/year) and “moderate” (4–6 visits/year) frequent ED visits and substance use had similar utilization patterns and characteristics in Ontario, Alberta, and B.C., and the “extreme” subgroup had high mortality. Our findings suggest a need for improved evidence-based substance use disorder management, and strengthened continuity with primary and mental healthcare. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00673-x.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada. .,Department of Emergency Medicine, Vancouver General Hospital, 920 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada. .,BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
| | - Yueqiao Elle Wang
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Michael J Schull
- Institute for Clinical Evaluative Sciences, G1 06, 075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, ON, M5S 1A1, Canada
| | - Kathryn Dong
- Department of Emergency Medicine, University of Alberta, 790 University Terrace Building, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada
| | - Margaret J McGregor
- Department of Family Practice, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11th Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.,Department of Emergency Medicine, Vancouver General Hospital, 920 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, 790 University Terrace Building, 8303 - 112 Street, Edmonton, AB, T6G 2T4, Canada.,Emergency Strategic Clinical Network, Alberta Health Services, 14th Floor, North Tower, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada
| | - Kimberlyn M McGrail
- School of Population and Public Health and Centre for Health Services and Policy Research, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T1Z3, Canada
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19
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Hohl CM, Rosychuk RJ, Hau JP, Hayward J, Landes M, Yan JW, Ting DK, Welsford M, Archambault PM, Mercier E, Chandra K, Davis P, Vaillancourt S, Leeies M, Small S, Morrison LJ. Correction to: Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). CAN J EMERG MED 2022; 24:461-462. [PMID: 35451805 PMCID: PMC9026034 DOI: 10.1007/s43678-022-00314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada. .,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Megan Landes
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel K Ting
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Patrick M Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada.,Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Levis, QC, Canada
| | - Eric Mercier
- Centre de Recherche, CHU de Québec, Université Laval, Quebec, QC, Canada.,VITAM (Centre de recherche en santé durable), Quebec, QC, Canada
| | - Kavish Chandra
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada.,Department of Emergency Medicine, Saint John Regional Hospital, Saint John, NB, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Samuel Vaillancourt
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.,Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Serena Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Laurie J Morrison
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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20
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Hohl CM, Rosychuk RJ, Hau JP, Hayward J, Landes M, Yan JW, Ting DK, Welsford M, Archambault PM, Mercier E, Chandra K, Davis P, Vaillancourt S, Leeies M, Small S, Morrison LJ. Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). CAN J EMERG MED 2022; 24:397-407. [PMID: 35362857 PMCID: PMC8972682 DOI: 10.1007/s43678-022-00275-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
Background Treatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves. Methods This observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes. Results We enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2–8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4–0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6–0.8) and critical care admission (OR 0.7; 95% CI 0.6–0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5–1.1). Interpretation In patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes. Trial registration Clinicaltrials.gov, NCT04702945. Supplementary Information The online version contains supplementary material available at 10.1007/s43678-022-00275-3.
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Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada. .,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Megan Landes
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel K Ting
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Patrick M Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada.,Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Levis, QC, Canada
| | - Eric Mercier
- Centre de Recherche, CHU de Québec, Université Laval, Quebec, QC, Canada.,VITAM (Centre de recherche en santé durable), Quebec, QC, Canada
| | - Kavish Chandra
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada.,Department of Emergency Medicine, Saint John Regional Hospital, Saint John, NB, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Samuel Vaillancourt
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.,Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Serena Small
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Laurie J Morrison
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.,Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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21
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Hohl CM, Rosychuk RJ, Archambault PM, O'Sullivan F, Leeies M, Mercier É, Clark G, Innes GD, Brooks SC, Hayward J, Ho V, Jelic T, Welsford M, Sivilotti MLA, Morrison LJ, Perry JJ. The CCEDRRN COVID-19 Mortality Score to predict death among nonpalliative patients with COVID-19 presenting to emergency departments: a derivation and validation study. CMAJ Open 2022; 10:E90-E99. [PMID: 35135824 PMCID: PMC9259439 DOI: 10.9778/cmajo.20210243] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Predicting mortality from COVID-19 using information available when patients present to the emergency department can inform goals-of-care decisions and assist with ethical allocation of critical care resources. The study objective was to develop and validate a clinical score to predict emergency department and in-hospital mortality among consecutive nonpalliative patients with COVID-19; in this study, we define palliative patients as those who do not want resuscitative measures, such as intubation, intensive care unit care or cardiopulmonary resuscitation. METHODS This derivation and validation study used observational cohort data recruited from 46 hospitals in 8 Canadian provinces participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). We included adult (age ≥ 18 yr) nonpalliative patients with confirmed COVID-19 who presented to the emergency department of a participating site between Mar. 1, 2020, and Jan. 31, 2021. We randomly assigned hospitals to derivation or validation, and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting emergency department and in-hospital mortality in a validation cohort. RESULTS Of 8761 eligible patients, 618 (7.0%) died. The CCEDRRN COVID-19 Mortality Score included age, sex, type of residence, arrival mode, chest pain, severe liver disease, respiratory rate and level of respiratory support. The area under the curve was 0.92 (95% confidence interval [CI] 0.90-0.93) in derivation and 0.92 (95% CI 0.90-0.93) in validation. The score had excellent calibration. These results suggest that scores of 6 or less would categorize patients as being at low risk for in-hospital death, with a negative predictive value of 99.9%. Patients in the low-risk group had an in-hospital mortality rate of 0.1%. Patients with a score of 15 or higher had an observed mortality rate of 81.0%. INTERPRETATION The CCEDRRN COVID-19 Mortality Score is a simple score that can be used for level-of-care discussions with patients and in situations of critical care resource constraints to accurately predict death using variables available on emergency department arrival. The score was derived and validated mostly in unvaccinated patients, and before variants of concern were circulating widely and newer treatment regimens implemented in Canada. STUDY REGISTRATION ClinicalTrials.gov, no. NCT04702945.
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Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont.
| | - Rhonda J Rosychuk
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Patrick M Archambault
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Fiona O'Sullivan
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Murdoch Leeies
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Éric Mercier
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Gregory Clark
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Grant D Innes
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Steven C Brooks
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Jake Hayward
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Vi Ho
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Tomislav Jelic
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Michelle Welsford
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Marco L A Sivilotti
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Laurie J Morrison
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
| | - Jeffrey J Perry
- Department of Emergency Medicine (Hohl, O'Sullivan, Ho), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Hohl, O'Sullivan, Ho), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Family Medicine and Emergency Medicine (Archambault), Université Laval, Québec, Que.; Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches (Archambault), Lévis, Que.; Department of Emergency Medicine (Leeies, Jelic) and Section of Critical Care Medicine (Leeies), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Centre de recherche (Mercier), CHU de Québec, Université Laval; VITAM (Centre de recherche en santé durable) (Mercier), Québec, Que.; Department of Emergency Medicine (Clark), McGill University, Montréal, Que.; Department of Emergency Medicine and Community Health Sciences (Innes), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Brooks, Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hayward), University of Alberta, Edmonton, Alta.; Division of Emergency Medicine (Welsford), McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Kingston Health Sciences Centre (Sivilotti), Kingston, Ont.; Emergency Services (Morrison), Sunnybrook Health Sciences Centre; Division of Emergency Medicine (Morrison), Department of Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Perry), University of Ottawa; Ottawa Hospital Research Institute (Perry), Ottawa, Ont
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22
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Moe J, Wang EY, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Hohl CM, Grafstein E, O'Sullivan F, Trimble J, McGrail KM. Subgroups of people who make frequent emergency department visits in Ontario and Alberta: a retrospective cohort study. CMAJ Open 2022; 10:E232-E246. [PMID: 35292481 PMCID: PMC8929427 DOI: 10.9778/cmajo.20210132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The population that visits emergency departments frequently is heterogeneous and at high risk for mortality. This study aimed to characterize these patients in Ontario and Alberta, compare them with controls who do not visit emergency departments frequently, and identify subgroups. METHODS This was a retrospective cohort study that captured patients in Ontario or Alberta from fiscal years 2011/12 to 2015/16 in the Dynamic Cohort from the Canadian Institute for Health Information, which defined people with frequent visits to the emergency department in the top 10% of annual visits and randomly selected controls from the bottom 90%. We included patients 18 years of age or older and linked to emergency department, hospitalization, continuing care, home care and mental health-related hospitalization data. We characterized people who made frequent visits to the emergency department over time, compared them with controls and identified subgroups using cluster analysis. We examined emergency department visit acuity using the Canadian Triage and Acuity Scale. RESULTS The number of patients who made frequent visits to the emergency department ranged from 435 334 to 477 647 each year in Ontario (≥ 4 visits per year), and from 98 840 to 105 047 in Alberta (≥ 5 visits per year). The acuity of these visits increased over time. Those who made frequent visits to the emergency department were older and used more health care services than controls. We identified 4 subgroups of those who made frequent visits: "short duration" (frequent, regularly spaced visits), "older patients" (median ages 69 and 64 years in Ontario and Alberta, respectively; more comorbidities; and more admissions), "young mental health" (median ages 45 and 40 years in Ontario and Alberta, respectively; and common mental health-related and alcohol-related visits) and "injury" (increased prevalence of injury-related visits). INTERPRETATION From 2011/12 to 2015/16, people who visited emergency departments frequently had increasing visit acuity, had higher health care use than controls, and comprised distinct subgroups. Emergency departments should codevelop interventions with the identified subgroups to address patient needs.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Elle Yuequiao Wang
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Margaret J McGregor
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Michael J Schull
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Kathryn Dong
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Brian R Holroyd
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Corinne M Hohl
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Eric Grafstein
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Fiona O'Sullivan
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Johanna Trimble
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Kimberlyn M McGrail
- Department of Emergency Medicine (Moe, Wang, Hohl, Grafstein, O'Sullivan), and of Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Emergency Medicine, University of British Columbia, Vancouver, BC; ICES (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
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23
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Skutezky T, Small SS, Peddie D, Balka E, Hohl CM. Beliefs and perceptions of patient safety event reporting in a Canadian Emergency Department: a qualitative study. CAN J EMERG MED 2022; 24:867-875. [PMID: 36344901 PMCID: PMC9763130 DOI: 10.1007/s43678-022-00400-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/12/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Patient safety events (PSEs) are unwanted or unexpected events that occur during medical care. High cognitive loads and frequent interruptions make emergency departments (EDs) uniquely error prone environments. Yet, frontline clinicians rarely report PSEs using incident reporting systems. The incidence, severity, and preventability of PSEs thus remain poorly understood, and contributing factors are understudied. We sought to understand ED staff beliefs and perceptions about their PSE reporting system and what features they believe are important in such a system. METHODS We conducted a qualitative study among healthcare providers working in the ED and departmental leadership. We recruited participants via email and held a series of interviews, focus groups, and participatory workshops. We iteratively analyzed the data using the constant comparative method and used thematic analysis to establish themes. RESULTS 50 participants attended at least one focus group, interview, or workshop. Participants perceived that PSE reporting through formal channels in the ED was challenging. Clinicians had an inherent desire to report PSEs and do so through numerous informal channels, yet underreported in formal reporting systems. The current PSE reporting system did not meet frontline staff needs and was viewed as ineffective in improving care quality and safety. We identified three key features for an improved PSE reporting system: (1) clear definitions; (2) transparency; and (3) simplicity. CONCLUSIONS In this study, we have identified ideal features for PSE reporting processes to meet the needs of both frontline staff and departmental leadership based on perceptions of current PSE reporting practices. Improved PSE reporting processes have the potential to increase PSE reporting in the ED overall, increasing the availability of information about PSEs to support quality improvement and improve patient safety.
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Affiliation(s)
- Trevor Skutezky
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada
| | - Serena S. Small
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
| | - David Peddie
- grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada ,grid.61971.380000 0004 1936 7494School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Ellen Balka
- grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada ,grid.61971.380000 0004 1936 7494School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Corinne M. Hohl
- grid.17091.3e0000 0001 2288 9830Department of Emergency Medicine, University of British Columbia, Vancouver, BC Canada ,grid.417243.70000 0004 0384 4428Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC Canada
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24
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Moe J, Wang EY, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Hohl CM, Grafstein E, O'Sullivan F, Trimble J, McGrail KM. People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study. CMAJ Open 2022; 10:E220-E231. [PMID: 35292480 PMCID: PMC8929439 DOI: 10.9778/cmajo.20210131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use. METHODS This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data. RESULTS We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice. INTERPRETATION Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Elle Yuequiao Wang
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Margaret J McGregor
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Michael J Schull
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Kathryn Dong
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Brian R Holroyd
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Corinne M Hohl
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Eric Grafstein
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Fiona O'Sullivan
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Johanna Trimble
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
| | - Kimberlyn M McGrail
- Department of Emergency Medicine (Moe, Wang, Hohl, O'Sullivan), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital; Department of Family Practice (McGregor), Department of Emergency Medicine (Grafstein), University of British Columbia, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Vancouver Coastal Health (Grafstein), Vancouver, BC; Providence Health Care (Grafstein), Vancouver, BC; Patients for Patient Safety Canada (Trimble), Ottawa, Ont.; School of Population and Public Health and Centre for Health Services and Policy Research (McGrail), University of British Columbia, Vancouver, BC
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25
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Chan E, Small SS, Wickham ME, Cheng V, Balka E, Hohl CM. The Utility of Different Data Standards to Document Adverse Drug Event Symptoms and Diagnoses: Mixed Methods Study. J Med Internet Res 2021; 23:e27188. [PMID: 34890351 PMCID: PMC8709916 DOI: 10.2196/27188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/16/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Existing systems to document adverse drug events often use free text data entry, which produces nonstandardized and unstructured data that are prone to misinterpretation. Standardized terminology may improve data quality; however, it is unclear which data standard is most appropriate for documenting adverse drug event symptoms and diagnoses. OBJECTIVE This study aims to compare the utility, strengths, and weaknesses of different data standards for documenting adverse drug event symptoms and diagnoses. METHODS We performed a mixed methods substudy of a multicenter retrospective chart review. We reviewed the research records of prospectively diagnosed adverse drug events at 5 Canadian hospitals. A total of 2 pharmacy research assistants independently entered the symptoms and diagnoses for the adverse drug events using four standards: Medical Dictionary for Regulatory Activities (MedDRA), Systematized Nomenclature of Medicine (SNOMED) Clinical Terms, SNOMED Adverse Reaction (SNOMED ADR), and International Classification of Diseases (ICD) 11th Revision. Disagreements between research assistants regarding the case-specific utility of data standards were discussed until a consensus was reached. We used consensus ratings to determine the proportion of adverse drug events covered by a data standard and coded and analyzed field notes from the consensus sessions. RESULTS We reviewed 573 adverse drug events and found that MedDRA and ICD-11 had excellent coverage of adverse drug event symptoms and diagnoses. MedDRA had the highest number of matches between the research assistants, whereas ICD-11 had the fewest. SNOMED ADR had the lowest proportion of adverse drug event coverage. The research assistants were most likely to encounter terminological challenges with SNOMED ADR and usability challenges with ICD-11, whereas least likely to encounter challenges with MedDRA. CONCLUSIONS Usability, comprehensiveness, and accuracy are important features of data standards for documenting adverse drug event symptoms and diagnoses. On the basis of our results, we recommend the use of MedDRA.
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Affiliation(s)
- Erina Chan
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Vancouver General Hospital Pharmacy Department, Vancouver, BC, Canada
| | - Serena S Small
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maeve E Wickham
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Vicki Cheng
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - Corinne M Hohl
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Vancouver General Hospital Emergency Department, Vancouver, BC, Canada
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26
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McRae AD, Hohl CM, Rosychuk R, Vatanpour S, Ghaderi G, Archambault PM, Brooks SC, Cheng I, Davis P, Hayward J, Lang E, Ohle R, Rowe B, Welsford M, Yadav K, Morrison LJ, Perry J. CCEDRRN COVID-19 Infection Score (CCIS): development and validation in a Canadian cohort of a clinical risk score to predict SARS-CoV-2 infection in patients presenting to the emergency department with suspected COVID-19. BMJ Open 2021; 11:e055832. [PMID: 34857584 PMCID: PMC8640195 DOI: 10.1136/bmjopen-2021-055832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To develop and validate a clinical risk score that can accurately quantify the probability of SARS-CoV-2 infection in patients presenting to an emergency department without the need for laboratory testing. DESIGN Cohort study of participants in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. Regression models were fitted to predict a positive SARS-CoV-2 test result using clinical and demographic predictors, as well as an indicator of local SARS-CoV-2 incidence. SETTING 32 emergency departments in eight Canadian provinces. PARTICIPANTS 27 665 consecutively enrolled patients who were tested for SARS-CoV-2 in participating emergency departments between 1 March and 30 October 2020. MAIN OUTCOME MEASURES Positive SARS-CoV-2 nucleic acid test result within 14 days of an index emergency department encounter for suspected COVID-19 disease. RESULTS We derived a 10-item CCEDRRN COVID-19 Infection Score using data from 21 743 patients. This score included variables from history and physical examination and an indicator of local disease incidence. The score had a c-statistic of 0.838 with excellent calibration. We externally validated the rule in 5295 patients. The score maintained excellent discrimination and calibration and had superior performance compared with another previously published risk score. Score cut-offs were identified that can rule-in or rule-out SARS-CoV-2 infection without the need for nucleic acid testing with 97.4% sensitivity (95% CI 96.4 to 98.3) and 95.9% specificity (95% CI 95.5 to 96.0). CONCLUSIONS The CCEDRRN COVID-19 Infection Score uses clinical characteristics and publicly available indicators of disease incidence to quantify a patient's probability of SARS-CoV-2 infection. The score can identify patients at sufficiently high risk of SARS-CoV-2 infection to warrant isolation and empirical therapy prior to test confirmation while also identifying patients at sufficiently low risk of infection that they may not need testing. TRIAL REGISTRATION NUMBER NCT04702945.
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Affiliation(s)
- Andrew D McRae
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Rhonda Rosychuk
- Department of Paediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Shabnam Vatanpour
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Gelareh Ghaderi
- Department of Emergency Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Patrick M Archambault
- Department of Emergency Medicine, Universite Laval Faculte de medecine, Quebec, Quebec, Canada
| | - Steven C Brooks
- Department of Emergency Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Ivy Cheng
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Jake Hayward
- Department of Emergency Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Brian Rowe
- Department of Emergency Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Michelle Welsford
- Department of Emergency Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Laurie J Morrison
- Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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27
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Perry JJ, Vaillancourt C, Hohl CM, Thiruganasambandamoorthy V, Morris J, Emond M, Lee J, Stiell IG. Optimizing collaborative relationships in emergency medicine research. CAN J EMERG MED 2021; 23:291-296. [PMID: 33599957 DOI: 10.1007/s43678-020-00080-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the Canadian Association of Emergency Physicians (CAEP) 2020 Academic Symposium Panel was to present recommendations for collaboration on (1) writing a grant application; (2) conducting a study; (3) writing an abstract; and (4) writing a manuscript. METHODS We assembled an expert panel of eight experienced emergency medicine clinician scientists from across Canada. Panel members performed literature searches for each of the four topics. Draft recommendations were developed and refined in an iterative fashion by panel members. We solicited external feedback on the draft recommendations online from identified researchers known to CAEP and in person at the Network of Canadian Emergency Researchers meeting in February 2020. We obtained additional feedback during an online symposium presentation on October 15th, 2020, open to all members of the Canadian Association of Emergency Physicians. RESULTS Four sets of recommendations were established for each component including: 14 for writing a grant application including relevant timelines; 23 for conducting a study; 13 for writing an abstract; and 18 for writing a manuscript. Forming a strong team, including patients, appropriate methodologists, content experts and a mix of senior and junior investigators, establishing and following clear timelines, and proactive communications were common themes. CONCLUSIONS We offer recommendations for research collaboration for (1) writing a grant, (2) conducting a study, (3) writing an abstract, and (4) writing a manuscript. We believe these recommendations will help to improve the science, improve grant success, and improve the impact of the abstracts and manuscripts.
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Affiliation(s)
- Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Marcel Emond
- CHU de Québec, Hôpital de l'Enfant-Jésus, Québec City, Québec, Canada.,Division of Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - Jacques Lee
- Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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28
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Hau JP, Brasher PMA, Cragg A, Small S, Wickham M, Hohl CM. Using ActionADE to create information continuity to reduce re-exposures to harmful medications: study protocol for a randomized controlled trial. Trials 2021; 22:119. [PMID: 33546752 PMCID: PMC7866708 DOI: 10.1186/s13063-021-05061-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Repeat exposures to culprit medications are a common cause of preventable adverse drug events. Health information technologies have the potential to reduce repeat adverse drug events by improving information continuity. However, they rarely interoperate to ensure providers can view adverse drug events documented in other systems. We designed ActionADE to enable rapid documentation of adverse drug events and communication of standardized information across health sectors by integrating with legacy systems. We will leverage ActionADE's implementation to conduct two parallel, randomized trials: patients with adverse drug reactions in the main trial and those diagnosed with non-adherence in a secondary trial. Primary objective of the main trial is to evaluate the effects of providing information continuity about adverse drug reactions on culprit medication re-dispensations over 12 months. Primary objective of the secondary trial is to evaluate the effect of providing information continuity on adherence over 12 months. METHODS We will conduct two parallel group, triple-blind randomized controlled trials in participating hospitals in British Columbia, Canada. We will enroll adults presenting to hospital with an adverse drug event to prescribed outpatient medication. Clinicians will document the adverse drug event in ActionADE. The software will use an algorithm to determine patient eligibility and allocate eligible patients to experimental or control. In the experimental arm, ActionADE will transmit information to PharmaNet, where adverse drug event information will be displayed in community pharmacies when re-dispensations are attempted. In the control arm, ActionADE will retain information in the local record. We will enroll 3600 adults with an adverse drug reaction into the main trial. The main trial's primary outcome is re-dispensation of a culprit or same-class medication within 12 months; the secondary trial's primary outcome will be adherence to culprit medication. Secondary outcomes include health services utilization and mortality. DISCUSSION These studies have the potential to guide policy decisions and investments needed to drive health information technology integrations to prevent repeat adverse drug events. We present an example of how a health information technology implementation can be leveraged to conduct pragmatic randomized controlled trials. TRIAL REGISTRATION ClinicalTrials.gov NCT04568668 , NCT04574648 . Registered on 1 October 2020.
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Affiliation(s)
- Jeffrey P Hau
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.,Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Penelope M A Brasher
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.,Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Serena Small
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.,Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Maeve Wickham
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.,School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, V6T 1Z9, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada. .,Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada. .,Vancouver General Hospital, 855 West 12thAvenue, Vancouver, British Columbia, V5Z 1M9, Canada.
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29
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Identifying subgroups and risk among frequent emergency department users in British Columbia. J Am Coll Emerg Physicians Open 2021; 2:e12346. [PMID: 33532752 PMCID: PMC7823092 DOI: 10.1002/emp2.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 01/25/2023] Open
Abstract
Objective: Frequent emergency department (ED) users are heterogeneous. We aimed to identify subgroups and assess their mortality. Methods: We identified patients ≥18 years with ≥1 ED visit in British Columbia from April 1, 2012 to March 31, 2015, and linked to hospitalization, physician billing, prescription, and mortality data. Frequent users were the top 10% of patients by ED visits. We employed cluster analysis to identify frequent user subgroups. We assessed 365-day mortality using Kaplan-Meier curves and conducted Cox regressions to assess mortality risk factors within subgroups. Results: We identified 4 subgroups. Subgroup 1 ("Elderly") had median age 77 years (interquartile range [IQR]: 66-85), 5 visits/year (IQR: 4-6), median 8 prescription medications (IQR: 5-11), and 24.7% mortality. Subgroup 2 ("Mental Health and Alcohol Use") had median age 48 years (IQR: 34-61), 13 visits/year (IQR: 10-16), and 12.3% mortality. They made a median 31 general practitioner visits (IQR: 19-51); however, only 23.7% received a majority of services from 1 primary care physician. Subgroup 3 ("Young Mental Health") had median age 39 years (IQR: 28-51), 5 visits/year (IQR: 4-6), and 2.2% mortality. Subgroup 4 ("Short-term") had median age 50 years (IQR: 34-65), 4 visits/year (IQR: 4-5) regularly spaced over a short term, and 1.4% mortality. Male sex (all subgroups), long-term care ("Mental Health and Alcohol Use;" "Young Mental Health"), and rural residence ("Elderly" in long-term care; "Young Mental Health") were associated with increased mortality. Conclusions: Our results identify frequent user subgroups with varying mortality. Future research should explore subgroups' unmet needs and tailor interventions toward them.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Fiona O'Sullivan
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Margaret J. McGregor
- Department of Family PracticeUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Michael J. Schull
- Institute for Clinical Evaluative SciencesDepartment of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Kathryn Dong
- Department of Emergency MedicineUniversity of AlbertaEdmontonAlbertaCanada
| | - Brian R. Holroyd
- Department of Emergency MedicineEmergency Strategic Clinical Networ, Alberta Health ServicesUniversity of AlbertaEdmontonAlbertaCanada
| | - Eric Grafstein
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British ColumbiaDepartment of Emergency Medicine, Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Johanna Trimble
- Patients for Patient Safety CanadaRoberts CreekVancouverBritish ColumbiaCanada
| | - Kimberlyn M. McGrail
- Population Data BCSchool of Population and Public Health, University of British ColumbiaVancouverBritish ColumbiaCanada
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30
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Small SS, Hohl CM, Balka E. Patient Perspectives on Health Data Privacy and Implications for Adverse Drug Event Documentation and Communication: Qualitative Study. J Med Internet Res 2021; 23:e21452. [PMID: 33470936 PMCID: PMC7857938 DOI: 10.2196/21452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/29/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background Adverse drug events are unintended and harmful effects of medication use. Using existing information and communication technologies (ICTs) to increase information sharing about adverse drug events may improve patient care but can introduce concerns about data privacy. Objective This study aims to examine the views of patients and their caregivers about data protection when using ICTs to communicate adverse drug event information to improve patient safety. Methods We conducted an exploratory qualitative study. A total of 4 focus groups were held among patients who had experienced or were at risk of experiencing an adverse drug event, their family members, and their caregivers. We recruited participants through multiple avenues and iteratively analyzed the data using situational analysis. Results Of the 47 participants recruited, 28 attended our focus groups. We identified 3 primary themes. First, participants felt that improved information sharing about adverse drug events within their circle of care would likely improve care. Second, participants were concerned about data handling and inappropriate access but believed that the benefits of information sharing outweighed the risks of privacy breaches. Finally, participants were more concerned about data privacy in the context of stigmatized health conditions. Conclusions Current conditions for maintaining health data privacy are consistent with participants’ preferences, despite the fact that health data are susceptible to breaches and mismanagement. Information sharing that increases patient safety may justify potential privacy risks. Greater attention to patient concerns and the effect of social and contextual concerns in the design and implementation of health information technologies may increase patient confidence in the privacy of their information.
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Affiliation(s)
- Serena S Small
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Corinne M Hohl
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Emergency Department, Vancouver General Hospital, Vancouver, BC, Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Morris J, Mercier E, Macle L, Brison RJ, Thiruganasambandamoorthy V, Rowe BH, Borgundvaag B, Clement CM, Brinkhurst J, Brown E, Nemnom MJ, Wells GA, Perry JJ. A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter. CAN J EMERG MED 2021; 23:314-324. [PMID: 33959925 DOI: 10.1007/s43678-020-00067-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Affiliation(s)
- Siying S Li
- Royal College Emergency Medicine Training Program, University of British Columbia, Vancouver, BC, Canada. .,Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre 11th floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Corinne M Hohl
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre 11th floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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Moe J, O'Sullivan F, McGregor MJ, Schull MJ, Dong K, Holroyd BR, Grafstein E, Hohl CM, Trimble J, McGrail KM. Characteristics of frequent emergency department users in British Columbia, Canada: a retrospective analysis. CMAJ Open 2021; 9:E134-E141. [PMID: 33653768 PMCID: PMC8034376 DOI: 10.9778/cmajo.20200168] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Frequent emergency department users disproportionately account for rising health care costs. We aimed to characterize frequent emergency department users in British Columbia, Canada. METHODS We performed a retrospective analysis using health administrative databases. We included patients aged 18 years or more with at least 1 emergency department visit from 2012/13 to 2015/16, linked to hospital, physician billing, prescription and mortality data. We used annual emergency department visits made by the top 10% of patients to define frequent users (≥ 3 visits/year). RESULTS Over the study period, 13.8%-15.3% of patients seen in emergency departments were frequent users. We identified 205 136 frequent users among 1 196 353 emergency department visitors. Frequent users made 40.3% of total visits in 2015/16. From 2012/13 to 2015/16, their visit rates per 100 000 BC population showed a relative increase of 21.8%, versus 13.1% among all emergency department patients. Only 1.8% were frequent users in all study years. Mental illness accounted for 8.2% of visits among those less than 60 years of age, and circulatory or respiratory diagnoses for 13.3% of visits among those aged 60 or more. In 2015/16, frequent users were older and had lower household incomes than nonfrequent users; the sex distribution was similar. Frequent users had more prescriptions (median 9, interquartile range [IQR] 5-14 v. 1, IQR 1-3), primary care visits (median 15, IQR 9-27 v. 7, IQR 4-12) and hospital admissions (median 2, IQR 1-3 v. 1, IQR 1-1), and higher 1-year mortality (10.2% v. 3.5%) than nonfrequent users. INTERPRETATION Emergency department use by frequent users increased in BC between 2012/13 and 2015/16; these patients were heterogenous, had high mortality and rarely remained frequent users over multiple years. Our results suggest that interventions must account for heterogeneity and address triggers of frequent use episodes.
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Affiliation(s)
- Jessica Moe
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Fiona O'Sullivan
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Margaret J McGregor
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Michael J Schull
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kathryn Dong
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Brian R Holroyd
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Eric Grafstein
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Corinne M Hohl
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Johanna Trimble
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
| | - Kimberlyn M McGrail
- Departments of Emergency Medicine (Moe, O'Sullivan, Grafstein, Hohl) and Family Practice (McGregor), University of British Columbia; Department of Emergency Medicine (Moe, Hohl), Vancouver General Hospital, Vancouver, BC; ICES Central (Schull); Department of Medicine (Schull), University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Dong, Holroyd), University of Alberta; Emergency Strategic Clinical Network (Holroyd), Alberta Health Services, Edmonton, Alta.; Patients for Patient Safety Canada (Trimble), Roberts Creek, BC; School of Population and Public Health (McGrail), University of British Columbia; Population Data BC (McGrail), Vancouver, BC
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Hohl CM, Rosychuk RJ, McRae AD, Brooks SC, Archambault P, Fok PT, Davis P, Jelic T, Turner JP, Rowe BH, Mercier É, Cheng I, Taylor J, Daoust R, Ohle R, Andolfatto G, Atzema C, Hayward J, Khangura JK, Landes M, Lang E, Martin I, Mohindra R, Ting DK, Vaillancourt S, Welsford M, Brar B, Dahn T, Wiemer H, Yadav K, Yan JW, Stachura M, McGavin C, Perry JJ, Morrison LJ. Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study. CMAJ Open 2021; 9:E261-E270. [PMID: 33731427 PMCID: PMC8096396 DOI: 10.9778/cmajo.20200290] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19. METHODS This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry. INTERPRETATION Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies. TRIAL REGISTRATION Clinicaltrials.gov, no. NCT04702945.
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Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Rhonda J Rosychuk
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Andrew D McRae
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Steven C Brooks
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Patrick Archambault
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Patrick T Fok
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Philip Davis
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Tomislav Jelic
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Joel P Turner
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Brian H Rowe
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Éric Mercier
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Ivy Cheng
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - John Taylor
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Raoul Daoust
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Robert Ohle
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Gary Andolfatto
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Clare Atzema
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jake Hayward
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jaspreet K Khangura
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Megan Landes
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Eddy Lang
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Ian Martin
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Rohit Mohindra
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Daniel K Ting
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Samuel Vaillancourt
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Michelle Welsford
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Baljeet Brar
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Tara Dahn
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Hana Wiemer
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Krishan Yadav
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Justin W Yan
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Maja Stachura
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Colleen McGavin
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Jeffrey J Perry
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
| | - Laurie J Morrison
- Department of Emergency Medicine (Hohl, Taylor, Andolfatto, Ting, Brar, Stachura), University of British Columbia; Centre for Clinical Epidemiology & Evaluation (Hohl), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Pediatrics (Rosychuk), University of Alberta, Edmonton, Alta.; Department of Emergency Medicine (McRae), Foothills Medical Center, Calgary, Alta.; Department of Emergency Medicine (Brooks), School of Medicine, Queen's University; Kingston Health Sciences Centre (Brooks), Kingston, Ont.; Department of Family Medicine and Emergency Medicine (Archambault), Faculty of Medicine, Université Laval; VITAM (Centre de recherche en santé durable) (Archambault, Mercier), Québec, Que.; Division of EMS (Fok, Dahn, Wiemer), Department of Emergency Medicine, Dalhousie University; Charles V. Keating Emergency and Trauma Centre (Fok, Dahn, Wiemer), QEII Health Sciences Centre, Halifax, NS; Department of Emergency Medicine (Davis), College of Medicine, University of Saskatchewan, Saskatoon, Sask.; Department of Emergency Medicine (Jelic), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Emergency Department (Turner), Jewish General Hospital; Department of Emergency Medicine (Turner), Faculty of Medicine and Health Sciences, McGill University, Montréal, Que.; Department of Emergency Medicine (Rowe, Hayward, Khangura), Faculty of Medicine & Dentistry, and School of Public Health (Rowe), University of Alberta, Edmonton, Alta.; Centre de recherche (Mercier), CHU de Québec, Université Laval, Québec, Que.; Sunnybrook Health Sciences Centre (Cheng, Atzema); Division of Emergency Medicine (Cheng, Landes, Vaillancourt, Morrison), Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ont.; Emergency Department (Taylor), Royal Columbian Hospital, New Westminster, BC; Départements de médecine de famille et de médecine d'urgence (Daoust), Faculté de médecine, Université de Montréal; Hôpital du Sacré-Coeur-de-Montréal (Daoust), CIUSSS Nord-de-l'ile-de-Montréal, Montréal, Que.; Department of Emergency Medicine (Ohle), Health Sciences North; Northern Ontario School of Medicine (Ohle), Sudbury, Ont.; Lions Gate Hospital (Andolfatto, Stachura), North Vancouver, BC; ICES Central (Atzema); University Health Network (Landes), Toronto, Ont.; Department of Emergency Medicine (Lang), Cumming School of Medicine, University of Calgary; Rockyview General Hospital (Lang), Calgary, Alta.; Department of Family Practice (Martin), Faculty of Medicine, University of British Columbia, Vancouver, BC; Abbotsford Regional Hospital & Cancer Agency (Martin), Abbotsford, BC; Department of Emergency Medicine (Mohindra), North York General Hospital, North York, Ont.; Department of Emergency Medicine (Vaillancourt, Morrison), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Welsford), Department of Medicine, McMaster University; Hamilton Health Sciences (Welsford), Hamilton, Ont.; Surrey Memorial Hospital (Brar), Surrey, BC; Department of Emergency Medicine (Yadav, Perry), University of Ottawa; Ottawa Hospital Research Institute (Yadav, Perry), Ottawa, Ont.; Division of Emergency Medicine (Yan), Department of Medicine, London Health Sciences Centre; Schulich School of Medicine and Dentistry (Yan), Western University, London, Ont.; BC SUPPORT Unit (McGavin), Vancouver, BC
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Moe J, Doyle-Waters MM, O'Sullivan F, Hohl CM, Azar P. Effectiveness of micro-induction approaches to buprenorphine initiation: A systematic review protocol. Addict Behav 2020; 111:106551. [PMID: 32739588 DOI: 10.1016/j.addbeh.2020.106551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/29/2020] [Accepted: 07/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Buprenorphine is first-line opioid agonist therapy for opioid use disorder. Standard regimens require that patients be in opioid withdrawal prior to induction, which is a barrier for many. Micro-induction is a novel induction approach that does not require patients to be in withdrawal. Our primary objective is to synthesize available evidence on the effectiveness of micro-inductions on patient and clinical outcomes compared to standard dosing or other approaches, or evaluated without a comparator group. Secondary objectives are to synthesize evidence on clinical factors that influence micro-induction effectiveness, and to summarize micro-induction regimens described in the literature. METHODS We will search MEDLINE, Embase, CINAHL, Psycinfo, Science Citation Index, and the grey literature for studies that include adolescents or adults with opioid use disorder who received a buprenorphine micro-induction regimen. We will consider any patient or clinical outcomes defined by study authors. We will include controlled and non-controlled interventional studies, observational studies, case reports/series and reports from relevant organizations or guidelines pertinent to our third objective. We will select studies, extract data and assess study quality (using the Downs and Black, and Cochrane Risk of Bias tools) in duplicate. We will narratively synthesize our results, and will meta-analyze outcome measures if multiple studies report common outcomes with acceptably low heterogeneity. DISCUSSION Our review will include the most up-to-date available data on buprenorphine micro-inductions. We anticipate limitations relating to study heterogeneity and quality. We will disseminate study results widely to inform updated guidelines for opioid agonist therapy prescribers.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada; Department of Emergency Medicine, Vancouver General Hospital, Vancouver, Canada.
| | | | - Fiona O'Sullivan
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada; Department of Emergency Medicine, Vancouver General Hospital, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada.
| | - Pouya Azar
- Department of Psychiatry, University of British Columbia, Vancouver, Canada; Complex Pain and Addictions Services, Vancouver General Hospital, Vancouver, Canada
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House DR, Rijal S, Adhikari S, Cooper ML, Hohl CM. Prospective evaluation of World Health Organization guidelines for diagnosis of pneumonia in children presenting to an emergency department in a resource-limited setting. Paediatr Int Child Health 2020; 40:227-230. [PMID: 32937093 DOI: 10.1080/20469047.2020.1815483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Clinicians in resource-limited settings commonly use the World Health Organization criteria to diagnose pneumonia in children. AIM The aim of this study was to prospectively evaluate the diagnostic accuracy of the WHO criteria compared with chest radiograph for the diagnosis of pneumonia in children under 5 years of age presenting to an emergency department (ED) in Nepal. METHODS A prospective cross-sectional study of children presenting to an ED with respiratory complaints in Nepal was conducted. It included all children under 5 years of age with cough or difficulty breathing who received a chest radiograph. Paediatric pneumonia was diagnosed according to WHO criteria when a child presented with a cough or difficulty breathing and met the age-related WHO-defined respiratory rate for tachypnoea. The criterion standard was radiographic pneumonia. The primary outcome was the sensitivity and specificity of the WHO criteria for diagnosis of pneumonia. RESULTS Of 324 patients enrolled, 72 had radiographic pneumonia. The median (IQR) age was 17 (23) months. Overall, WHO criteria had a sensitivity of 71% (95% CI 59-81) and specificity of 57% (95% CI 50-63). Respiratory rate had poor diagnostic accuracy for pneumonia with an area under the curve of 0.65. CONCLUSION The WHO criteria had poor sensitivity and specificity for the diagnosis of pneumonia in children presenting to the ED in a resource-limited setting.
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Affiliation(s)
- Darlene R House
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences , Kathmandu, Nepal.,Departments of Emergency Medicine, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Suraj Rijal
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences , Kathmandu, Nepal
| | - Sunil Adhikari
- Department of General Practice and Emergency Medicine, Patan Academy of Health Sciences , Kathmandu, Nepal
| | - Matthew L Cooper
- Radiology, Indiana University School of Medicine , Indianapolis, IN, USA
| | - Corinne M Hohl
- Department of Emergency Medicine, University of British Columbia , Vancouver, BC, Canada
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Hong KL, Babiolakis C, Zile B, Bullen M, Haseeb S, Halperin F, Hohl CM, Magee K, Sandhu RK, Tian SY, Kennedy A, Lobban T, Mariano Z, Dorian P, Angaran P, Evans M, Leong-Sit P, Glover BM. Canada-wide mixed methods analysis evaluating the reasons for inappropriate emergency department presentation in patients with a history of atrial fibrillation: the multicentre AF-ED trial. BMJ Open 2020; 10:e033482. [PMID: 32303514 PMCID: PMC7201301 DOI: 10.1136/bmjopen-2019-033482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/14/2020] [Accepted: 03/12/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The primary objective of this study was to ascertain the reasons for emergency department (ED) attendance among patients with a history of atrial fibrillation (AF). DESIGN Appropriate ED attendance was defined by the requirement for an electrical or chemical cardioversion and/or an attendance resulting in hospitalisation or administration of intravenous medications for ventricular rate control. Quantitative and qualitative responses were recorded and analysed using descriptive statistics and content analysis, respectively. Random effects logistic regression was performed to estimate the OR of inappropriate ED attendance based on clinically relevant patient characteristics. PARTICIPANTS Participants ≥18 years with a documented history of AF were approached in one of eight centres partaking in the study across Canada (Ontario, Nova Scotia, Alberta and British Columbia). RESULTS Of the 356 patients enrolled (67±13, 45% female), the majority (271/356, 76%) had inappropriate reasons for presentation and did not require urgent ED treatment. Approximately 50% of patients(172/356, 48%) were driven to the ED due to symptoms, while the remainder presented on the basis of general fear or anxiety (67/356, 19%) or prior medical advice (117/356, 33%). Random effects logistic regression analysis showed that patients with a history of congestive heart failure were significantly more likely to seek urgent care for appropriate reasons (p=0.03). Likewise, symptom-related concerns for ED presentation were significantly less likely to result in inappropriate visitation (p=0.02). When patients were surveyed on alternatives to ED care, the highest proportion of responses among both groups was in favour of specialised rapid assessment outpatient clinics (186/356, 52%). Qualitative content analysis confirmed these results. CONCLUSIONS Improved education focused on symptom management and alleviating disease-related anxiety as well as the institution of rapid access arrhythmias clinics may reduce the need for unnecessary healthcare utilisation in the ED and subsequent hospitalisation. TRIAL REGISTRATION NUMBER NCT03127085.
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Affiliation(s)
- Kathryn Lauren Hong
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Brigita Zile
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Milena Bullen
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Sohaib Haseeb
- Department of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Frank Halperin
- Department of Cardiology, Interior Health Authority, Kelowna, Province of British Columbia, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kirk Magee
- Department of Emergency Medicine, Nova Scotia Health Authority, Halifax, Province of Nova Scotia, Canada
| | - Roopinder K Sandhu
- Department of Cardiology, University of Alberta, Edmonton, Western Canada, Canada
| | - Simon Yu Tian
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ashley Kennedy
- Wilkes Honors College, Florida Atlantic University, Boca Raton, Florida, USA
| | - Trudie Lobban
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zana Mariano
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Dorian
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Angaran
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marilyn Evans
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Peter Leong-Sit
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Benedict M Glover
- Department of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Kitchen SA, McGrail K, Wickham ME, Law MR, Hohl CM. Emergency department-based medication review on outpatient health services utilization: interrupted time series. BMC Health Serv Res 2020; 20:254. [PMID: 32216791 PMCID: PMC7098150 DOI: 10.1186/s12913-020-05108-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background One in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication reviews on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization. Methods Data included information from 10,783 patients who were part of a prospective, multi-centre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners (GP); medical specialists; surgical specialists; and imaging and laboratory specialists. During triage, patients deemed high-risk based on their medical history, were systematically allocated to receive either a medication review (n = 6403) or the standard of care (n = 4380). Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization. Results ED-based pharmacist-led medication review did not result in a significant level or trend change in the primary outcome of total outpatient health services utilization. There were also no differences in the secondary outcomes of primary care physician visits or ED visits relative to the standard of care in the 12 months following the intervention. Our findings were consistent when stratified by age, hospital site, and whether patients were discharged on their index visit. Conclusion This was the first study to measure long-term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community-based providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate physician acceptance of pharmacist recommendations and should encourage patient follow-up to community providers.
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Affiliation(s)
- Sophie A Kitchen
- School of Population and Public Health, 2206 East Mall, Vancouver, BC, V6T 1Z9, Canada.,Centre for Health Services and Policy Research, 201-2206 East Mall, Vancouver, BC, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, 201-2206 East Mall, Vancouver, BC, Canada
| | - Maeve E Wickham
- School of Population and Public Health, 2206 East Mall, Vancouver, BC, V6T 1Z9, Canada.,Centre for Health Services and Policy Research, 201-2206 East Mall, Vancouver, BC, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, 201-2206 East Mall, Vancouver, BC, Canada
| | - Corinne M Hohl
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 900 West 10th Ave, Vancouver, BC, V5Z 1M9, Canada. .,Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
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Stiell IG, Sivilotti MLA, Taljaard M, Birnie D, Vadeboncoeur A, Hohl CM, McRae AD, Rowe BH, Brison RJ, Thiruganasambandamoorthy V, Macle L, Borgundvaag B, Morris J, Mercier E, Clement CM, Brinkhurst J, Sheehan C, Brown E, Nemnom MJ, Wells GA, Perry JJ. Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet 2020; 395:339-349. [PMID: 32007169 DOI: 10.1016/s0140-6736(19)32994-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 11/22/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | | | - Monica Taljaard
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Birnie
- Division of Cardiology, University of Ottawa, Ottawa, ON, Canada
| | - Alain Vadeboncoeur
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Robert J Brison
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Bjug Borgundvaag
- Division of Emergency Medicine, University of Toronto, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Judy Morris
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Catherine M Clement
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jennifer Brinkhurst
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Connor Sheehan
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Erica Brown
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Wickham ME, Hohl CM. Relationship between GP visits and time spent in-hospital among insulin-dependent Canadians with type 2 diabetes. Can Fam Physician 2020; 66:e69-e77. [PMID: 32060207 PMCID: PMC7021352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine whether higher frequency of GP visits among insulin-dependent patients with type 2 diabetes is associated with reduced hospitalizations. DESIGN Nationally representative study using data from the 2013-2014 cycle of the Canadian Community Health Survey. SETTING Canada. PARTICIPANTS A study sample comprising 2203 insulin-dependent Canadians with type 2 diabetes. MAIN OUTCOME MEASURES The relationship between GP visits (no visits, 1-5 visits, ≥ 6 visits) in the past year and the number of nights spent in-hospital. Zero-inflated negative binomial Poisson regression models were used to account for overdispersion and excess zeros. RESULTS Higher numbers of GP visits were associated with spending fewer nights in-hospital. Patients with 1 to 5 GP visits had a significantly lower number of nights spent in-hospital (rate ratio of 0.38, 95% CI 0.25 to 0.56), as did those with 6 or more GP visits (rate ratio of 0.57, 95% CI 0.38 to 0.84) despite having reduced odds of not being hospitalized (odds ratio of 0.62, 95% CI 0.39 to 0.95), compared with those who did not see a GP in the past year, after adjusting for confounders. CONCLUSION We found that insulin-dependent patients with diabetes who saw GPs more frequently were hospitalized less commonly compared with those who did not see a GP in the past year. Further research is needed to examine relationships with other types of follow-up, ideally using a longitudinal design.
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Affiliation(s)
- Maeve E Wickham
- Doctoral candidate in the School of Population and Public Health at the University of British Columbia and a researcher at the Centre for Clinical Epidemiology and Evaluation at the Vancouver Coastal Research Institute.
| | - Corinne M Hohl
- Associate Professor in the Department of Emergency Medicine at the University of British Columbia and a scientist in the Centre for Clinical Epidemiology and Evaluation
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Woo SA, Cragg A, Wickham ME, Villanyi D, Scheuermeyer F, Hau JP, Hohl CM. Preventable adverse drug events: Descriptive epidemiology. Br J Clin Pharmacol 2020; 86:291-302. [PMID: 31633827 PMCID: PMC7015751 DOI: 10.1111/bcp.14139] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/28/2022] Open
Abstract
AIM Our objective was to identify preventable adverse drug events and factors contributing to their development. METHODS We performed a retrospective chart review combining data from three prospective multicentre observational studies that assessed emergency department patients for adverse drug events. A clinical pharmacist and physician independently reviewed the charts, extracted data and rated the preventability of each adverse drug event. A third reviewer adjudicated all discordant or uncertain cases. We calculated the proportion of adverse drug events that were deemed preventable, performed multivariable logistic regression to explore the characteristics of patients with preventable events, and identified contributing factors. RESULTS We reviewed the records of 1 356 adverse drug events in 1 234 patients. Raters considered 869 (64.1%) of adverse drug events probably or definitely preventable. Patients with mental health diagnoses (OR 1.8; 95% CI 1.3-2.5) and diabetes (OR 1.7; 95% CI 1.2-2.4) were more likely to present with preventable events. The medications most commonly implicated in preventable events were warfarin (9.4%), hydrochlorothiazide (4.5%), furosemide (4.0%), insulin (3.9%) and acetylsalicylic acid (2.7%). Common contributing factors included inadequate patient instructions, monitoring and follow-up, and reassessments after medication changes had been made. CONCLUSIONS Our study suggests that patients with mental health conditions and diabetes require close monitoring. Efforts to address the identified contributing factors are needed.
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Affiliation(s)
| | - Amber Cragg
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Maeve E. Wickham
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Diane Villanyi
- Vancouver General HospitalVancouverBritish ColumbiaCanada
| | | | - Jeffrey P. Hau
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Corinne M. Hohl
- Vancouver General HospitalVancouverBritish ColumbiaCanada
- Department of Emergency MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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Perry JJ, Sivilotti MLA, Émond M, Hohl CM, Khan M, Lesiuk H, Abdulaziz K, Wells GA, Stiell IG. Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke 2019; 51:424-430. [PMID: 31805846 DOI: 10.1161/strokeaha.119.026969] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Purpose- The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods- We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. Consecutive alert, neurologically intact adults with headache were included. For intervention period, physicians were given a 1-hour lecture, pocket cards, posters were installed, and physicians indicated Ottawa SAH rule criteria when ordering CTs. SAH was defined by blood on CT, xanthochromia in cerebrospinal fluid, or >1×106/L red blood cells in cerebrospinal fluid with aneurysm. Results- We enrolled 3672 patients, 1743 before and 1929 after implementation, including 188 with SAH. Proportions undergoing CT was unchanged (88.0% versus 87.5%; P=0.643). Lumbar puncture use decreased (38.9% versus 25.9%; P<0.0001). Additional testing following CT (ie, lumbar puncture or CT angiography) decreased (51.3% versus 42.2%; P<0.0001). Admissions declined (9.8% versus 7.4%; P=0.011). Mean emergency department stay was unchanged (6.3±4.0 versus 6.4±4.2 hours; P=0.685). The Ottawa SAH rule was 100% (95% CI, 98.1%-100%) sensitive, and the 6-hour-CT rule was 95.5% (95% CI, 89.8-98.5) sensitive for SAH. The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions- The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.
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Affiliation(s)
- Jeffrey J Perry
- From the Departments of Emergency Medicine (I.G.S., J.J.P.), University of Ottawa, Canada.,School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada.,the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - Marco L A Sivilotti
- the Departments of Emergency Medicine and of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada (M.L.A.S.)
| | - Marcel Émond
- the Division of Emergency Medicine, Université Laval, Quebec City, Canada (M.E.)
| | - Corinne M Hohl
- the Department of Emergency Medicine, University of British Columbia, Vancouver, Canada (C.M.H.)
| | - Maryam Khan
- the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - Howard Lesiuk
- the Division of Neurosurgery (H.L.), University of Ottawa, Canada
| | - Kasim Abdulaziz
- the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
| | - George A Wells
- School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada
| | - Ian G Stiell
- From the Departments of Emergency Medicine (I.G.S., J.J.P.), University of Ottawa, Canada.,School of Epidemiology, Public Health and Preventative Medicine (I.G.S., J.J.P., G.A.W.), University of Ottawa, Canada.,the Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada (I.G.S., J.J.P., M.K., K.A.)
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Hohl CM, Woo SA, Cragg A, Wickham ME, Ackerley C, Scheuermeyer F, Villanyi D. Repeat adverse drug events associated with outpatient medications: a descriptive analysis of 3 observational studies in British Columbia, Canada. CMAJ Open 2019; 7:E446-E453. [PMID: 31320328 PMCID: PMC6639095 DOI: 10.9778/cmajo.20180190] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Adverse drug events are an important cause of preventable emergency department visits and hospital admissions. We examined repeat adverse drug events associated with outpatient medications resulting in acute care utilization. METHODS This descriptive analysis combined data from 3 prospective multicentre observational studies, in which clinical pharmacists and physicians independently evaluated patients who visited the emergency department for adverse drug events in 3 hospitals in British Columbia. During these studies, an independent committee adjudicated all discordant and uncertain cases using a standardized algorithm. For the current study, we retrospectively reviewed the medical and research records of all patients 19 years of age and older who had been diagnosed with an adverse drug event during the primary studies to determine the proportion of repeat events. We used multivariable logistic regression to identify factors associated with repeat events; we adjusted for clustering at the hospital level for patient-level analyses and at the patient level for event-level analyses. RESULTS Among 12 977 patients, 1178 were diagnosed with 1296 adverse drug events at the point of care. Of these events, 32.5% (421 of 1296; 95% confidence interval [CI] 29.8%-35.1%) were repeat events, of which 75.3% (317 of 421; 95% CI 71.1%-79.5%) were deemed probably or definitely preventable as re-exposure to the culprit medication or repeat withdrawal of an indicated medication was inconsistent with best medical practice. Patients presenting with repeat events were more likely to have renal failure (odds ratio [OR] 2.01; 95% CI 1.32%-3.07%) or a mental health diagnosis (OR 1.39; 95% CI 1.02%-1.88%). INTERPRETATION A high proportion of adverse drug events were repeat events, most of which were deemed preventable. Interventions to ensure that care providers are aware of previously diagnosed adverse drug events when prescribing or dispensing need to be developed and evaluated and may reduce unintentional re-exposures to previously harmful medications.
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Affiliation(s)
- Corinne M Hohl
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Stephanie A Woo
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Amber Cragg
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Maeve E Wickham
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Christine Ackerley
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Frank Scheuermeyer
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
| | - Diane Villanyi
- Department of Emergency Medicine (Hohl, Cragg, Scheuermeyer), University of British Columbia; Emergency Department (Hohl), Vancouver General Hospital; Centre for Clinical Epidemiology and Evaluation (Hohl, Cragg, Wickham), Vancouver Coastal Health Research Institute; Pharmaceutical Sciences (Woo), Vancouver General Hospital; School of Population and Public Health (Wickham), University of British Columbia, Vancouver, BC; School of Communication (Ackerley), Simon Fraser University, Burnaby, BC; Division of Geriatrics (Villanyi), Department of Medicine, Vancouver General Hospital, Vancouver, BC
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Shaw LV, Moe J, Purssell R, Buxton JA, Godwin J, Doyle-Waters MM, Brasher PMA, Hau JP, Curran J, Hohl CM. Naloxone interventions in opioid overdoses: a systematic review protocol. Syst Rev 2019; 8:138. [PMID: 31186071 PMCID: PMC6560883 DOI: 10.1186/s13643-019-1048-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 05/20/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND North America is in the midst of an unabated opioid overdose epidemic due to the increasing non-medical use of fentanyl and ultra-potent opioids. Naloxone is an effective antidote to opioid toxicity, yet its optimal dosing in the context of fentanyl and ultra-potent opioid overdoses remains unknown. This review aims to determine the relationship between the first empiric dose of naloxone and reversal of toxicity, adverse events, and the total cumulative dose required among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. Secondary objectives include evaluating the relationship between the cumulative naloxone dose and toxicity reversal and adverse events, among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. METHODS To identify studies, we will search MEDLINE, Embase, CENTRAL, DARE, CDAG, CINAHL, Science Citation Index, multiple trial registries, and the gray literature. Included studies will evaluate patients with suspected or confirmed opioid toxicity from undifferentiated opioids and ultra-potent opioids, who received an empiric and possibly additional doses of naloxone. The main outcomes of interest are the relationship between naloxone dose and toxicity reversal and adverse events. We will include controlled and non-controlled interventional studies, observational studies, case reports/series, and reports from poison control centers. We will extract data and assess study quality in duplicate with discrepancies resolved by consensus or a third party. We will use the Downs and Black and Cochrane risk of bias tools for observational and randomized controlled studies. If we find sufficient variation in dose, we will fit a random effects one-stage model to estimate a dose-response relationship. We will conduct multiple subgroup analyses, including by type of opioid used and by suspected high and low prevalence of ultra-potent opioid use based on geographic location and time of the original studies. DISCUSSION Our review will include the most up-to-date available data including ultra-potent opioids to inform the current response to the opioid epidemic, addressing the limitations of recent reviews. We anticipate limitations relating to study heterogeneity. We will disseminate study results widely to update overdose treatment guidelines and naloxone dosing in Take Home Naloxone programs.
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Affiliation(s)
- Lindsay Victoria Shaw
- School of Social Dimensions of Health, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2 Canada
- Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Roy Purssell
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
| | - Jane A. Buxton
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Jesse Godwin
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Mary M. Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Penelope M. A. Brasher
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jason Curran
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
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Small SS, Hohl CM, Balka E. Organizational implications of implementing a new adverse drug event reporting system for care providers and integrating it with provincial health information systems. Healthc Manage Forum 2019; 32:208-212. [PMID: 31091996 DOI: 10.1177/0840470419845384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cross-sector collaborations between academia, government, and private industry, known as Triple Helix configurations, are increasingly common. In the health Information Technology (IT) sector, such configurations often also include health delivery organizations where technology is implemented and used. The complexity of collaborating within and between multiple organizations can present hurdles for innovators that are seldom discussed in the literature. We outline challenges we encountered in cross-sector collaboration and offer some guiding principles for decision-makers, academics, industry partners, and health delivery organizations to successfully negotiate divergent approaches to innovation and implementation. We discuss an innovative project that aims to implement a researcher-designed adverse drug event reporting system into clinical care and integrate it with provincial and health authority IT systems. Based on our experience, implementing an interoperable health IT system must extend beyond technical integration to encompass meaningful stakeholder engagement to ensure utility for end-users and beneficial impact for participating organizations.
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Affiliation(s)
- Serena S Small
- 1 Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.,2 School of Communication, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Corinne M Hohl
- 1 Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.,3 Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,4 Emergency Department, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Ellen Balka
- 1 Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.,2 School of Communication, Simon Fraser University, Burnaby, British Columbia, Canada
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Woo SA, Cragg A, Wickham ME, Peddie D, Balka E, Scheuermeyer F, Villanyi D, Hohl CM. Methods for evaluating adverse drug event preventability in emergency department patients. BMC Med Res Methodol 2018; 18:160. [PMID: 30514232 PMCID: PMC6280499 DOI: 10.1186/s12874-018-0617-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/14/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is a high degree of variability in assessing the preventability of adverse drug events, limiting the ability to compare rates of preventable adverse drug events across different studies. We compared three methods for determining preventability of adverse drug events in emergency department patients and explored their strengths and weaknesses. METHODS This mixed-methods study enrolled emergency department patients diagnosed with at least one adverse drug event from three prior prospective studies. A clinical pharmacist and physician reviewed the medical and research records of all patients, and independently rated each event's preventability using a "best practice-based" approach, an "error-based" approach, and an "algorithm-based" approach. Raters discussed discordant ratings until reaching consensus. We assessed the inter-rater agreement between clinicians using the same assessment method, and between different assessment methods using Cohen's kappa with 95% confidence intervals (95% CI). Qualitative researchers observed discussions, took field notes, and reviewed free text comments made by clinicians in a "comment" box in the data collection form. We developed a coding structure and iteratively analyzed qualitative data for emerging themes regarding the application of each preventability assessment method using NVivo. RESULTS Among 1356 adverse drug events, a best practice-based approach rated 64.1% (95% CI: 61.5-66.6%) of events as preventable, an error-based approach rated 64.3% (95% CI: 61.8-66.9%) of events as preventable, and an algorithm-based approach rated 68.8% (95% CI: 66.1-71.1%) of events as preventable. When applying the same method, the inter-rater agreement between clinicians was 0.53 (95% CI: 0.48-0.59), 0.55 (95%CI: 0.50-0.60) and 0.55 (95% CI: 0.49-0.55) for the best practice-, error-, and algorithm-based approaches, respectively. The inter-rater agreement between different assessment methods using consensus ratings for each ranged between 0.88 (95% CI 0.85-0.91) and 0.99 (95% CI 0.98-1.00). Compared to a best practice-based assessment, clinicians believed the algorithm-based assessment was too rigid. It did not account for the complexities of and variations in clinical practice, and frequently was too definitive when assigning preventability ratings. CONCLUSION There was good agreement between all three methods of determining the preventability of adverse drug events. However, clinicians found the algorithmic approach constraining, and preferred a best practice-based assessment method.
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Affiliation(s)
- Stephanie A. Woo
- Pharmaceutical Sciences, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Amber Cragg
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
| | - Maeve E. Wickham
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z9 Canada
| | - David Peddie
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- School of Communication, Simon Fraser University, Burnaby, BC Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Diane Villanyi
- Division of Geriatrics, Department of Medicine, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Research Institute, 828 West 10th Ave, Vancouver, BC V5Z 1M9 Canada
- Emergency Department, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
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Hohl CM, Badke K, Zhao A, Wickham ME, Woo SA, Sivilotti ML, Perry JJ. Prospective Validation of Clinical Criteria to Identify Emergency Department Patients at High Risk for Adverse Drug Events. Acad Emerg Med 2018. [PMID: 29517818 PMCID: PMC6175415 DOI: 10.1111/acem.13407] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objectives Adverse drug events (ADEs) cause or contribute to one in nine emergency department (ED) presentations in North America and are often misdiagnosed. EDs have insufficient clinical pharmacists to complete medication reviews in all incoming patients, even though pharmacist‐led medications reviews have been associated with improved health outcomes. Our objective was to validate clinical decision rules to identify patients presenting with ADEs so they could be prioritized for pharmacist‐led medication review. Methods This multicenter, prospective study was conducted in two tertiary and one community hospital in Canada. We enrolled 1,529 adults presenting to EDs over 12 months. We applied two clinical decision rules and collected baseline variables prior to assessments by clinical pharmacists and physicians. We compared the physician and pharmacist diagnoses with the decision rule results. The primary outcome was a moderate or severe ADE, defined as an unintended and harmful event related to medication use or misuse, which required a change in medical therapy, diagnostic testing, consultation, or admission. An independent committee adjudicated uncertain and discordant cases. We calculated the diagnostic accuracy of both rules. Results Among 1,529 patients, 184 (12.0%) were diagnosed with an ADE. Rule 1 contained the variables 1) having a preexisting medical condition or having taken antibiotics within 1 week and 2) age > 80 years or having a medication change within 28 days. They had a sensitivity of 91.3% (95% confidence interval [CI] = 86.3%–95.0%) and a specificity of 37.9% (95% CI = 35.3%–40.6%) for ADEs. Conclusions Our study validated clinical decision rules that can be applied by clinical pharmacists to limit the number of patients requiring medication review, while identifying the majority of patients presenting with clinically significant ADEs.
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Affiliation(s)
- Corinne M. Hohl
- Department of Emergency Medicine University of British Columbia VancouverBritish Columbia
- Centre for Clinical Epidemiology & Evaluation Vancouver Coastal Health Research Institute Vancouver British Columbia
- Emergency DepartmentVancouver General Hospital VancouverBritish Columbia
| | - Katherin Badke
- Department of Pharmaceutical Sciences University of British Columbia VancouverBritish Columbia
| | - Amy Zhao
- Department of Pharmaceutical Services The Ottawa Hospital Ottawa Ontario
| | - Maeve E. Wickham
- Department of Emergency Medicine University of British Columbia VancouverBritish Columbia
- Centre for Clinical Epidemiology & Evaluation Vancouver Coastal Health Research Institute Vancouver British Columbia
| | - Stephanie A. Woo
- Clinical Pharmacy Services Vancouver General Hospital VancouverBritish Columbia
| | - Marco L.A. Sivilotti
- Department of Emergency Medicine and of Biomedical and Molecular Sciences Queen's University Kingston Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine University of Ottawa Ottawa Ontario Canada
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Peddie D, Small SS, Badke K, Bailey C, Balka E, Hohl CM. Adverse Drug Event Reporting From Clinical Care: Mixed-Methods Analysis for a Minimum Required Dataset. JMIR Med Inform 2018; 6:e10248. [PMID: 29954724 PMCID: PMC6043729 DOI: 10.2196/10248] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/08/2018] [Accepted: 05/24/2018] [Indexed: 12/02/2022] Open
Abstract
Background Patients commonly transition between health care settings, requiring care providers to transfer medication utilization information. Yet, information sharing about adverse drug events (ADEs) remains nonstandardized. Objective The objective of our study was to describe a minimum required dataset for clinicians to document and communicate ADEs to support clinical decision making and improve patient safety. Methods We used mixed-methods analysis to design a minimum required dataset for ADE documentation and communication. First, we completed a systematic review of the existing ADE reporting systems. After synthesizing reporting concepts and data fields, we conducted fieldwork to inform the design of a preliminary reporting form. We presented this information to clinician end-user groups to establish a recommended dataset. Finally, we pilot-tested and refined the dataset in a paper-based format. Results We evaluated a total of 1782 unique data fields identified in our systematic review that describe the reporter, patient, ADE, and suspect and concomitant drugs. Of these, clinicians requested that 26 data fields be integrated into the dataset. Avoiding the need to report information already available electronically, reliance on prospective rather than retrospective causality assessments, and omitting fields deemed irrelevant to clinical care were key considerations. Conclusions By attending to the information needs of clinicians, we developed a standardized dataset for adverse drug event reporting. This dataset can be used to support communication between care providers and integrated into electronic systems to improve patient safety. If anonymized, these standardized data may be used for enhanced pharmacovigilance and research activities.
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Affiliation(s)
- David Peddie
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - Serena S Small
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - Katherin Badke
- Vancouver General Hospital, Department of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Chantelle Bailey
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - Corinne M Hohl
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Vancouver General Hospital, Emergency Department, Vancouver, BC, Canada
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Hohl CM, Small SS, Peddie D, Badke K, Bailey C, Balka E. Why Clinicians Don't Report Adverse Drug Events: Qualitative Study. JMIR Public Health Surveill 2018; 4:e21. [PMID: 29487041 PMCID: PMC5849794 DOI: 10.2196/publichealth.9282] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/21/2017] [Accepted: 01/07/2018] [Indexed: 12/22/2022] Open
Abstract
Background Adverse drug events are unintended and harmful events related to medications. Adverse drug events are important for patient care, quality improvement, drug safety research, and postmarketing surveillance, but they are vastly underreported. Objective Our objectives were to identify barriers to adverse drug event documentation and factors contributing to underreporting. Methods This qualitative study was conducted in 1 ambulatory center, and the emergency departments and inpatient wards of 3 acute care hospitals in British Columbia between March 2014 and December 2016. We completed workplace observations and focus groups with general practitioners, hospitalists, emergency physicians, and hospital and community pharmacists. We analyzed field notes by coding and iteratively analyzing our data to identify emerging concepts, generate thematic and event summaries, and create workflow diagrams. Clinicians validated emerging concepts by applying them to cases from their clinical practice. Results We completed 238 hours of observations during which clinicians investigated 65 suspect adverse drug events. The observed events were often complex and diagnosed over time, requiring the input of multiple providers. Providers documented adverse drug events in charts to support continuity of care but never reported them to external agencies. Providers faced time constraints, and reporting would have required duplication of documentation. Conclusions Existing reporting systems are not suited to capture the complex nature of adverse drug events or adapted to workflow and are simply not used by frontline clinicians. Systems that are integrated into electronic medical records, make use of existing data to avoid duplication of documentation, and generate alerts to improve safety may address the shortcomings of existing systems and generate robust adverse drug event data as a by-product of safer care.
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Affiliation(s)
- Corinne M Hohl
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.,Vancouver General Hospital Emergency Department, Vancouver, BC, Canada
| | - Serena S Small
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - David Peddie
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
| | - Katherin Badke
- Department of Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, BC, Canada
| | - Chantelle Bailey
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ellen Balka
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Communication, Simon Fraser University, Burnaby, BC, Canada
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Cragg A, Hau JP, Woo SA, Liu C, Doyle-Waters MM, Hohl CM. Risk factors for addiction among patients receiving prescribed opioids: a systematic review protocol. Syst Rev 2017; 6:265. [PMID: 29282114 PMCID: PMC5746013 DOI: 10.1186/s13643-017-0642-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid addiction prevention has become an urgent public health priority, with several countries declaring a state of emergency due to rising death tolls from opioid abuse. Reducing the risk of developing addiction among opioid-naïve patients exposed to prescribed opioids during the process of medical care may be an important primary prevention strategy. Our objective is to synthesize the available evidence about factors associated with the development of addiction among patients first exposed to prescribed opioids, with a focus on opioid-naïve patients. METHODS We will perform a systematic search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases in collaboration with a health information specialist using a comprehensive search strategy. We will also supplement our search with a scan of the grey literature to identify relevant ongoing and unpublished studies. We will include studies reporting on risk factors for opioid addiction in patients prescribed opioid analgesic therapy through a prescription from a licensed medical professional, with a focus on opioid-naïve patients. We will exclude studies focusing on patients who are first exposed to illicit opioids, those who use prescription opioids for cancer pain, and/or who are palliative. Two reviewers will independently review titles, abstracts, and full texts for inclusion and exclusion criteria. They will then extract data from included full texts using standardized piloted data extraction forms and assess study quality through risk of bias assessment. We will synthesize the effect sizes of risk factors derived from clinically homogenous studies with similar designs and the remaining ones qualitatively. DISCUSSION Understanding risk factors for opioid addiction among patients who require analgesia has the potential to inform clinical care and opioid prescribing guidelines aiming to reduce opioid addiction. We will also use this information as a starting point for developing interventions for primary prevention.
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Affiliation(s)
- Amber Cragg
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Stephanie A. Woo
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Christine Liu
- Department of Medicine, University of British Columbia, 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3 Canada
| | - Mary M. Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Emergency Department, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
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