PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-10 (10)
 

Clipboard (0)
None

Select a Filter Below

Journals
Year of Publication
Document Types
1.  Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study 
Background:
To assist physicians with difficult decisions about hospital admission for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) presenting in the emergency department, we sought to identify clinical characteristics associated with serious adverse events.
Methods:
We conducted this prospective cohort study in 6 large Canadian academic emergency departments. Patients were assessed for standardized clinical variables and then followed for serious adverse events, defined as death, intubation, admission to a monitored unit or new visit to the emergency department requiring admission.
Results:
We enrolled 945 patients, of whom 354 (37.5%) were admitted to hospital. Of 74 (7.8%) patients with a subsequent serious adverse event, 36 (49%) had not been admitted after the initial emergency visit. Multivariable modelling identified 5 variables that were independently associated with adverse events: prior intubation, initial heart rate ≥ 110/minute, being too ill to do a walk test, hemoglobin < 100 g/L and urea ≥ 12 mmol/L. A preliminary risk scale incorporating these and 5 other clinical variables produced risk categories ranging from 2.2% for a score of 0 to 91.4% for a score of 10. Using a risk score of 2 or higher as a threshold for admission would capture all patients with a predicted risk of adverse events of 7.2% or higher, while only slightly increasing admission rates, from 37.5% to 43.2%.
Interpretation:
In Canada, many patients with COPD suffer a serious adverse event or death after being discharged home from the emergency department. We identified high-risk characteristics and developed a preliminary risk scale that, once validated, could be used to stratify the likelihood of poor outcomes and to enable rational and safe admission decisions.
doi:10.1503/cmaj.130968
PMCID: PMC3971051  PMID: 24549125
2.  Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries 
Background:
The Low Risk Ankle Rule is a validated clinical decision rule that has the potential to safely reduce radiography in children with acute ankle injuries. We performed a phased implementation of the Low Risk Ankle Rule and evaluated its effectiveness in reducing the frequency of radiography in children with ankle injuries.
Methods:
Six Canadian emergency departments participated in the study from Jan. 1, 2009, to Aug. 31, 2011. At the 3 intervention sites, there were 3 consecutive 26-week phases. In phase 1, no interventions were implemented. In phase 2, we activated strategies to implement the ankle rule, including physician education, reminders and a computerized decision support system. In phase 3, we included only the decision support system. No interventions were introduced at the 3 pair-matched control sites. We examined the management of ankle injuries among children aged 3–16 years. The primary outcome was the proportion of children undergoing radiography.
Results:
We enrolled 2151 children with ankle injuries, 1055 at intervention and 1096 at control hospitals. During phase 1, the baseline frequency of pediatric ankle radiography at intervention and control sites was 96.5% and 90.2%, respectively. During phase 2, the frequency of ankle radiography decreased significantly at intervention sites relative to control sites (between-group difference −21.9% [95% confidence interval [CI] −28.6% to −15.2%]), without significant differences in patient or physician satisfaction. All effects were sustained in phase 3. The sensitivity of the Low Risk Ankle Rule during implementation was 100% (95% CI 85.4% to 100%), and the specificity was 53.1% (95% CI 48.1% to 58.1%).
Interpretation:
Implementation of the Low Risk Ankle Rule in several different emergency department settings reduced the rate of pediatric ankle radiography significantly and safely, without an accompanying change in physician or patient satisfaction. Trial registration: ClinicalTrials.gov, no. NCT00785876.
doi:10.1503/cmaj.122050
PMCID: PMC3796622  PMID: 23939215
3.  A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments 
Background
The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments.
Methods
We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head.
Results
Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the “before” period (62.8%) to the “after” period (76.2%) (difference +13.3%, 95% CI 9.7%–17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%–10.8%). The change in mean imaging rates from the “before” period to the “after” period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes.
Interpretation
Our knowledge–translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252)
doi:10.1503/cmaj.091974
PMCID: PMC2950184  PMID: 20732978
4.  Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial 
Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments.
Design Matched pair cluster randomised trial.
Setting University and community emergency departments in Canada.
Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals.
Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites.
Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods.
Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred.
Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide.
Trial registration Clinical trials NCT00290875.
doi:10.1136/bmj.b4146
PMCID: PMC2770593  PMID: 19875425
5.  The Saskatchewan Farm Injury Cohort: Rationale and Methodology 
Public Health Reports  2008;123(5):567-575.
SYNOPSIS
The Saskatchewan Farm Injury Cohort (SFIC) is a major new Canadian study that was developed to evaluate potential causes of injury among farmers and their family members. The cohort involves 2,390 farms and 5,492 farm people being followed over a two-year period. The article describes the rationale and methodology for the baseline and longitudinal components of this study. The SFIC is one of the first studies to apply population health theory to the modeling of risks for injury in a defined Canadian population. In doing so, the relative influence of several potential causes of farm injury, including physical, socioeconomic, and cultural factors, will be estimated. Study findings will inform the content and targeting of injury prevention initiatives specific to the farm occupational environment.
PMCID: PMC2496929  PMID: 18828411
6.  A matched-pair cluster design study protocol to evaluate implementation of the Canadian C-spine rule in hospital emergency departments: Phase III 
Background
Physicians in Canadian emergency departments (EDs) annually treat 185,000 alert and stable trauma victims who are at risk for cervical spine (C-spine) injury. However, only 0.9% of these patients have suffered a cervical spine fracture. Current use of radiography is not efficient. The Canadian C-Spine Rule is designed to allow physicians to be more selective and accurate in ordering C-spine radiography, and to rapidly clear the C-spine without the need for radiography in many patients. The goal of this phase III study is to evaluate the effectiveness of an active strategy to implement the Canadian C-Spine Rule into physician practice. Specific objectives are to: 1) determine clinical impact, 2) determine sustainability, 3) evaluate performance, and 4) conduct an economic evaluation.
Methods
We propose a matched-pair cluster design study that compares outcomes during three consecutive 12-months "before," "after," and "decay" periods at six pairs of "intervention" and "control" sites. These 12 hospital ED sites will be stratified as "teaching" or "community" hospitals, matched according to baseline C-spine radiography ordering rates, and then allocated within each pair to either intervention or control groups. During the "after" period at the intervention sites, simple and inexpensive strategies will be employed to actively implement the Canadian C-Spine Rule. The following outcomes will be assessed: 1) measures of clinical impact, 2) performance of the Canadian C-Spine Rule, and 3) economic measures. During the 12-month "decay" period, implementation strategies will continue, allowing us to evaluate the sustainability of the effect. We estimate a sample size of 4,800 patients in each period in order to have adequate power to evaluate the main outcomes.
Discussion
Phase I successfully derived the Canadian C-Spine Rule and phase II confirmed the accuracy and safety of the rule, hence, the potential for physicians to improve care. What remains unknown is the actual change in clinical behaviors that can be affected by implementation of the Canadian C-Spine Rule, and whether implementation can be achieved with simple and inexpensive measures. We believe that the Canadian C-Spine Rule has the potential to significantly reduce health care costs and improve the efficiency of patient flow in busy Canadian EDs.
doi:10.1186/1748-5908-2-4
PMCID: PMC1802999  PMID: 17288613
7.  Stages of development and injury patterns in the early years: a population-based analysis 
BMC Public Health  2006;6:187.
Background
In Canada, there are many formal public health programs under development that aim to prevent injuries in the early years (e.g. 0–6). There are paradoxically no population-based studies that have examined patterns of injury by developmental stage among these young children. This represents a gap in the Canadian biomedical literature. The current population-based analysis explores external causes and consequences of injuries experienced by young children who present to the emergency department for assessment and treatment. This provides objective evidence about prevention priorities to be considered in anticipatory counseling and public health planning.
Methods
Four complete years of data (1999–2002; n = 5876 cases) were reviewed from the Kingston sites of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP), an ongoing injury surveillance initiative. Epidemiological analyses were used to characterize injury patterns within and across age groups (0–6 years) that corresponded to normative developmental stages.
Results
The average annual rate of emergency department-attended childhood injury was 107 per 1000 (95% CI 91–123), with boys experiencing higher annual rates of injury than girls (122 vs. 91 per 1000; p < 0.05). External causes of injury changed substantially by developmental stage. This lead to the identification of four prevention priorities surrounding 1) the optimization of supervision; 2) limiting access to hazards; 3) protection from heights; and 4) anticipation of risks.
Conclusion
This population-based injury surveillance analysis provides a strong evidence-base to inform and enhance anticipatory counseling and other public health efforts aimed at the prevention of childhood injury during the early years.
doi:10.1186/1471-2458-6-187
PMCID: PMC1569842  PMID: 16848890
8.  Fatal agricultural injuries in preschool children: risks, injury patterns and strategies for prevention 
Background
Agricultural injuries are an important health concern for pediatric populations and particularly for children of pre school age. This study was conducted to estimate rates and determine patterns of fatal agricultural injury among young children exposed to agricultural hazards and to identify strategies to prevent such injuries.
Methods
A national case series was assembled retrospectively for the years 1990–2001. We identified children aged 1–6 years who were fatally injured during the course of agricultural work or through contact with a hazard of an agricultural worksite. Using a standardized survey instrument, we collected data from provincial coroners' and medical examiners' case files. Fatal agricultural injury rates (calculated with denominator data from the Canada Census of Agriculture) were compared with national all-cause, unintentional fatal injury rates in the general population of Canadian children during the same period (calculated with denominator data from the Canada Census of Population).
Results
The annual rate of fatal agricultural injury was substantially higher than that of all-cause, unintentional fatal injury among Canadian children aged 1–6 years (14.9 v. 8.7 per 100 000 person-years, respectively). Differences in risk were attributed to elevated fatal agricultural injury rates among boys. Most injuries occurred in the agricultural worksite, largely (84/115 [73%]) the result of 3 mechanisms: being run over by agricultural machinery as a bystander (29%) or as an extra rider who fell from the machine (22%), or asphyxia due to drowning (23%). Major crush injuries (of the head, chest and abdomen) and asphyxia from drowning were the most frequent mechanisms of injury.
Interpretation:
Preschool-aged children exposed to agricultural worksites are at high risk of fatal injuries. Prevention strategies should focus on restricting children's access to these worksites. Physicians and allied health care professionals who care for rural families could take on a proactive role in communicating the nature and magnitude of these risks.
doi:10.1503/cmaj.050857
PMCID: PMC1471822  PMID: 16754900
9.  Dealing with office emergencies. Stepwise approach for family physicians. 
Canadian Family Physician  2002;48:1464-1472.
OBJECTIVE: To develop a simple stepwise approach to initial management of emergencies in family physicians' offices; to review how to prepare health care teams and equipment; and to illustrate a general approach to three of the most common office emergencies. QUALITY OF EVIDENCE: MEDLINE was searched from January 1980 to December 2001. Articles were selected based on their clinical relevance, quality of evidence, and date of publication. We reviewed American family medicine, pediatric, dental, and dermatologic articles, but found that the area has not been well studied from a Canadian family medicine perspective. Consensus statements by specialty professional groups were used to identify accepted emergency medical treatments. MAIN MESSAGE: Family medicine offices are frequently poorly equipped and inadequately prepared to deal with emergencies. Straightforward emergency response plans can be designed and tailored to an office's risk profile. A systematic team approach and effective use of skills, support staff, and equipment is important. The general approach can be modified for specific patients or conditions. CONCLUSION: Family physicians can plan ahead and use a team approach to develop a simple stepwise response to emergency situations in the office.
PMCID: PMC2214108  PMID: 12371305
10.  A population-based study of potential brain injuries requiring emergency care 
Background
Brain injury is an important health concern, yet there are few population-based analyses on which to base prevention initiatives. This study aimed, first, to calculate rates of potential brain injury within a defined Canadian population and, second, to describe the external causes, natures and disposition from the emergency department of these injuries.
Methods
We studied all cases of blunt head injury that resulted in a visit to an emergency department for all residents of Greater Kingston during 1998. We used data from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) and augmented this by examining all records of emergency or inpatient care received at all hospitals in the area.
Results
In 202 (27%) of 760 cases of head injury, there was potential for brain injury. Annual rates of potential brain injury were 16 and 7 per 10 000 population for males and females respectively. CT was performed on 114 (56%) of 202 cases, of which 60 (53%) demonstrated an intracranial pathology, with 11 (10%) showing a diffuse axonal injury pattern on the initial scan. Falls from heights accounted for 14 (47%) of 30 injuries observed in children aged 0–9 years. Individuals aged 10–44 years sustained 32 (63%) of 51 motor vehicle injuries, 15 (88%) of 17 bicycle injuries, 22 (100%) of 22 sports injuries and 8 (89%) of 9 fight-related injuries. Falls accounted for 15 (71%) of 21 injuries among adults aged 65 years or more.
Interpretation
The results indicate the relative importance of several external causes of injury. The findings from our geographically distinct population are useful in establishing rational priorities for the prevention of brain injury.
PMCID: PMC81328  PMID: 11517644

Results 1-10 (10)