Objectives: Emergency department (ED) triage prioritizes patients based on urgency of care. This study compared agreement between two blinded, independent users of a Web-based triage tool (eTRIAGE) and examined the effects of ED crowding on triage reliability.Methods: Consecutive patients presenting to a large, urban, tertiary care ED were assessed by the duty triage nurse and an independent study nurse, both using eTRIAGE. Triage score distribution and agreement are reported. The study nurse collected data on ED activity, and agreement during different levels of ED crowding is reported. Two methods of interrater agreement were used: the linear-weighted kappa and quadratic-weighted kappa.Results: A total of 575 patients were assessed over nine weeks, and complete data were available for 569 patients (99.0%). Agreement between the two nurses was moderate if using linear kappa (weighted kappa = 0.52; 95% confidence interval = 0.46 to 0.57) and good if using quadratic kappa (weighted kappa = 0.66; 95% confidence interval = 0.60 to 0.71). ED overcrowding data were available for 353 patients (62.0%). Agreement did not significantly differ with respect to periods of ambulance diversion, number of admitted inpatients occupying stretchers, number of patients in the waiting room, number of patients registered in two hours, or nurse perception of busyness.Conclusions: This study demonstrated different agreement depending on the method used to calculate interrater reliability. Using the standard methods, it found good agreement between two independent users of a computerized triage tool. The level of agreement was not affected by various measures of ED crowding.

INTRODUCTION:Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention.METHODS:We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon.RESULTS:Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained.CONCLUSIONS:A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.

Journal Article Relationship between number, timing, and type of pharmacist interventions and patient outcomes Get access Theresa L. Charrois, B.Sc.(Pharm.), M.Sc., Theresa L. Charrois, B.Sc.(Pharm.), M.Sc. Research Associate Department of Medicine Search for other works by this author on: Oxford Academic Google Scholar Jeffrey A. Johnson, B.S.P., Ph.D., Jeffrey A. Johnson, B.S.P., Ph.D. Associate Professor Department of Public Health Sciences Search for other works by this author on: Oxford Academic Google Scholar Sandra Blitz, M.Sc., Sandra Blitz, M.Sc. Research Associate Division of Emergency Medicine, University of Alberta, Edmonton, Canada Search for other works by this author on: Oxford Academic Google Scholar Ross T. Tsuyuki, B.Sc.(Pharm.), Pharm.D., M.Sc., FCSHP Ross T. Tsuyuki, B.Sc.(Pharm.), Pharm.D., M.Sc., FCSHP Professor Department of Medicine, University of Alberta, Edmonton, Canada Address correspondence to Dr. Tsuyuki at the Division of Cardiology, University of Alberta, 220 College Plaza, Edmonton, Alberta, Canada T6G 2C8 (ross.tsuyuki@ualberta.ca). Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 62, Issue 17, 1 September 2005, Pages 1798–1801, https://doi.org/10.2146/ajhp040421 Published: 01 September 2005

Background: Evaluations by learners are the most common sources of information on teaching. There is some debate about the role of these assessments, but the overall evaluation of faculty by learners was found to be valid and reliable. Purpose: The purpose of this study was to examine the relationship between the level of training of family medicine residents and their evaluation of emergency medicine clinical teachers over time. Methods: A prospective cohort analysis of 6 years of faculty evaluation of 115 teachers was conducted. Results: The 562 residents returned 3,046 valid individual evaluations. There was no significant association between the level of residents' training and the ratings for clinical instruction (p >. 05). Resident evaluations did not vary by time of year (p >. 05); however, they did significantly differ by year of evaluation, showing that ratings increased over the 6 years of the study (p <. 0001). Conclusions: Neither the residents' level of training nor the timing during the academic year were significant independent predictors of perceived superior teaching performance, although ratings increased over the 6 years of the study.

OBJECTIVE To examine whether hyperglycemia at the time of presentation was associated with outcomes in patients admitted to non-intensive care settings with community-acquired pneumonia (CAP). RESEARCH DESIGN AND METHODS Prospective cohort study of consecutive patients admitted to six hospitals between 15 November 2000 and 14 November 2002. RESULTS Of the 2,471 patients in this study (median age 75 years), 279 (11%) had serum glucose at presentation >11 mmol/l: 178 of the 401 patients (44%) with a prior diagnosis of diabetes and 101 of the 2,070 patients (5%) without a history of diabetes. Of patients hospitalized with CAP, 9% died and 23% suffered an in-hospital complication. Compared with those with values < or =11 mmol/l, patients with an admission glucose >11 mmol/l had an increased risk of death (13 vs. 9%, P = 0.03) and in-hospital complications (29 vs. 22%, P = 0.01). Compared with those patients with admission glucose < or =6.1 mmol/l, the mortality risk was 73% higher (95% CI 12-168%) and the in-hospital complication risk was 52% higher (12-108%) in patients with admission glucose >11 mmol/l. Even after adjustment for factors in the Pneumonia Severity Index, hyperglycemia on admission remained significantly associated with subsequent adverse outcomes: for each 1-mmol/l increase, risk of in-hospital complications increased 3% (0.2-6%). CONCLUSIONS Hyperglycemia on admission is independently associated with adverse outcomes in patients with CAP, with the increased risks evident at lower glucose levels than previously reported.

BACKGROUND:Emergency department (ED) triage prioritizes patients based on urgency of care; however, little previous testing of triage tools in a live ED environment has been performed.OBJECTIVES:To determine the agreement between a computer decision tool and memory-based triage.METHODS:Consecutive patients presenting to a large, urban, tertiary care ED were assessed in the usual fashion and by a blinded study nurse using a computerized decision support tool. Triage score distribution and agreement between the two triage methods were reported. A random subset of patients was selected and reviewed by a blinded expert panel as a consensus standard.RESULTS:Over five weeks, 722 ED patients were assessed; complete data were available from 693 (96%) score pairs. Agreement between the two methods was poor (kappa = 0.202; 95% confidence interval [95% CI] = 0.150 to 0.254); however, agreement improved when using weighted kappa (0.360; 95% CI = 0.305 to 0.415) or "within one" level kappa (0.732; 95% CI = 0.644 to 0.821). When compared with the expert panel, the nurse triage scores showed lower agreement (0.263; 95% CI = 0.133 to 0.394) than the tool (kappa = 0.426; 95% CI = 0.289 to 0.564). There was a significant down-triaging of patients when patients were triaged without the computerized tool. Admission rates also differed between the triage systems.CONCLUSIONS:There was significant discrepancy by nurses using memory-based triage when compared with a computer tool. Triage decision support tools can mitigate this drift, which has administrative implications for EDs.

BACKGROUND:Asthma exacerbations can be frequent and range in severity from relatively mild to status asthmaticus. The use of magnesium sulfate (MgSO4) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO4 has been demonstrated, little is known about inhaled MgSO4. OBJECTIVES:To examine the efficacy of inhaled MgSO4 in the treatment asthma exacerbations. SEARCH STRATEGY:Randomised controlled trials were identified from the Cochrane Airways Group "Asthma and Wheez*" register. These trials were supplemented with trials found in the reference list of published studies, studies found using extensive electronic search techniques, as well as a review of the gray literature and conference proceedings. SELECTION CRITERIA:Randomised (or pseudo-randomised) controlled trials were eligible for inclusion. Studies were included if patients were treated with nebulised MgSO4 alone or in combination with beta2-agonist and where compared to beta2-agonist alone or inactive control. DATA COLLECTION AND ANALYSIS:Trial selection, data extraction and methodological quality were assessed by two independent reviewers. Efforts were made to collect missing data from authors. Results from fixed effects models are presented as standardized mean differences (SMD) for pulmonary functions and relative risks (RR) for hospital admission; both are displayed with their 95% confidence intervals (95% CI). MAIN RESULTS:Six trials involving 296 patients were included. Four studies compared nebulised MgSO4 with beta2-agonist to beta2-agonist and two studies compared MgSO4 to beta2-agonist alone. Three studies enrolled only adults and 2 enrolled exclusively pediatric patients; three of the studies enrolled severe asthmatics. Overall, there was a significant difference in pulmonary function between patients whose treatments included nebulised MgSO4 in addition to beta2-agonist (SMD: 0.37; 95% CI: 0.1 to 0.63; 4 studies); however, hospitalizations were similar between the groups (RR: 0.64; 95% CI: 0.40 to 1.04; 3 studies). Subgroup analyses did not demonstrate significant differences in lung function improvement between adults and children, or between severe and mild to moderate asthmatics. Conclusions regarding treatment with nebulised MgSO4 alone are difficult to draw due to lack of studies in this area. AUTHORS' CONCLUSIONS:Nebulised inhaled magnesium sulfate in addition to beta2-agonist in the treatment of an acute asthma exacerbation, appears to have benefits with respect to improved pulmonary function and there is a trend towards benefit in hospital admission. Heterogeneity between trials included in this review precludes a more definitive conclusion.

BACKGROUND:The incidence of Achilles tendon ruptures specific to the North American population has not been previously reported and current epidemiological data are primarily reported from European communities. The purpose of this study was to determine the incidence of Achilles tendon ruptures in the city of Edmonton, Alberta, Canada, and to compare this data to those reported in European studies. METHODS:A retrospective chart review from all five acute care hospitals in Edmonton from 1998 to 2002 (inclusive) were reviewed for Achilles tendon ruptures. Data such as gender, age, side, mechanism of injury, and season of injury were obtained. RESULTS:The incidence of Achilles tendon ruptures ranged from an annual average of 5.5 ruptures to 9.9 ruptures per 100,000 inhabitants with an overall mean of 8.3 ruptures per 100,000 people. There was a statistically significant difference in Achilles tendon ruptures over the last two study years for both genders (women, p < 0.02; men, p < 0.03). The mean age for an Achilles tendon rupture was 40.6 years for men and 44.5 years for women. The Achilles tendon ruptures occurred most frequently in the 30 to 39 and 40 to 49 year old age groups in both men and women, respectively (p < 0.02). Most ruptures occurred in the spring season, but there was no statistical difference in the incidence of Achilles tendon ruptures by season (p > 0.05). CONCLUSIONS:The incidence of Achilles tendon ruptures in this community was comparable to those reported in European communities (range 6 to 37 ruptures per 100,000 people), although a bimodal age distribution of rupture previously reported was not observed in this study.

OBJECTIVES To determine if an educational intervention in the acute stage of whiplash injury may improve the recovery rate. METHODS Consecutive subjects were randomized to one of two treatment groups: educational intervention or usual care. The intervention group received an educational pamphlet based on the current evidence. The control group did not receive these materials but received usual emergency department care and a standard nondirected discharge information sheet. Both groups underwent follow-up by telephone interview at two weeks and three months. The primary outcome measure of recovery was the patient's response to the question, "How well do you feel you are recovering from your injuries?" RESULTS A total of 112 subjects agreed to participate. Age, gender, precollision employment level and health, initial symptoms, collision parameters, and emergency treatments were similar between the groups. At two weeks postcollision, 7.3% in the treatment group reported recovery compared with 8.8% in the control group (absolute risk difference, -1.5%; 95% confidence interval = -12.6% to 9.7%). At three months postcollision, 21.8% in the treatment group reported complete recovery compared with 21.0% in the control group (absolute risk difference, 0.8%; 95% confidence interval = -14.4% to 16.0%). At three months, there were no clinically or statistically significant differences between groups in severity of remaining symptoms, limitations in daily activities, therapy use, medications used, lost time from work, or litigation. CONCLUSIONS An evidence-based educational pamphlet provided to patients at discharge from the emergency department is no more effective than usual care for patients with grade 1 or 2 whiplash-associated disorder.

Background: Despite the high risk for future fractures and the availability of effective treatments, fewer than 10% to 20% of patients who sustain a fragility fracture are tested or treated for osteoporosis.Objectives: To improve rates of testing and treatment for osteoporosis in patients with wrist fractures who are seen in the emergency department.Design: Nonrandomized, controlled trial with blinded ascertainment of outcomes.Setting: Emergency departments in Edmonton, Alberta, Canada.Patients: Persons 50 years of age or older who were treated for a wrist fracture and their physicians. Patients admitted to the hospital or treated for osteoporosis were excluded. Overall, 572 consecutive patients with fractures were screened, and 102 patients (55 intervention, 47 control) and 101 physicians were studied.Measurements: The primary end point was the prescription of osteoporosis treatment 6 months after fracture. Secondary end points included rates of testing for bone mineral density and patients' knowledge, satisfaction, and quality of life.Intervention: Faxed physician reminders that contained osteoporosis treatment guidelines endorsed by local opinion leaders and patient education. Control patients received usual care and information about falls and home safety.Results: The median patient age was 66 years. Most patients were female (78%) and white (79%); 70% of patients reported a previous fracture, and 22% had a fall with injury in the previous year. The intervention increased the rates of testing for bone mineral density to 62% (vs. 17% for controls; adjusted relative increase, 3.6 [P < 0.001]) and the rates of osteoporosis treatment to 40% (vs. 10% for controls; adjusted relative increase, 3.8 [P = 0.002]) within 6 months of fracture. Intervention patients were more likely to report a diagnosis of osteoporosis, but other patient-reported outcomes did not differ significantly between groups.Limitations: This was a small, nonrandomized, controlled study with process-based outcomes.Conclusions: in a multifaceted intervention directed at patients and their physicians, the rates of testing and treatment for osteoporosis after emergency department care for a fragility fracture were more than 3 times those of controls.