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ABSTRACT Objective: Stroke guideline compliance of rural Canadian prehospital emergency medical services (EMS) care in acute stroke is unknown. In this quality assurance study, we sought to compare rural and urban care by prehospital EMS evaluation/management indicators from patients assessed at an urban Canadian stroke center.Materials and Methods: One hundred adult patients were randomly selected from the stroke registry. Patients were transported through Rural EMS bypass protocols or urban EMS protocols (both bypass and direct) to our stroke center between January and December 2013. Patients were excluded if they were first evaluated at any other health center. Prehospital care was assessed using ten indicators for EMS evaluation/management, as recommended by acute stroke guidelines. Results: Compliance with acute stroke EMS evaluation/management indicators were statistically similar for both groups, except administrating a prehospital diagnostic tool (rural 31.8 vs. urban 70.3%; P = 0.002). Unlike urban EMS, rural EMS did not routinely document scene time. Conclusion: Rural EMS responders' compliance to prehospital stroke evaluation/management was similar to urban EMS responders. Growth areas for both groups may be with prehospital stroke diagnostic tool utilization, whereas rural EMS responders may also improve with scene time documentation.

Study objective Current risk stratification tools do not identify very-low-risk patients who can be safely discharged without prolonged emergency department (ED) observation, expensive rule-out protocols, or provocative testing. We seek to develop a clinical prediction rule applicable within 2 hours of ED arrival that would miss fewer than 2% of acute coronary syndrome patients and allow discharge within 2 to 3 hours for at least 30% of patients without acute coronary syndrome. Methods This prospective, cohort study enrolled consenting eligible subjects at least 25 years old at a single site. At 30 days, investigators assigned a diagnosis of acute coronary syndrome or no acute coronary syndrome according to predefined explicit definitions. A recursive partitioning model included risk factors, pain characteristics, physical and ECG findings, and cardiac marker results. Results Of 769 patients studied, 77 (10.0%) had acute myocardial infarction and 88 (11.4%) definite unstable angina. We derived a clinical prediction rule that was 98.8% sensitive and 32.5% specific. Patients have very low risk of acute coronary syndrome if they have a normal initial ECG, no previous ischemic chest pain, and age younger than 40 years. In addition, patients at least 40 years old and with a normal ECG result, no previous ischemic chest pain, and low-risk pain characteristics have very low risk if they have an initial creatine kinase-MB (CK-MB) less than 3.0 μg/L or an initial CK-MB greater than or equal to 3.0 μg/L but no ECG or serum-marker increase at 2 hours. Conclusion The Vancouver Chest Pain Rule for early discharge defines a group of patients who can be safely discharged after a brief evaluation in the ED. Prospective validation is needed.

High-fidelity simulation (HFS) is widely used in pediatric emergency medicine (PEM) training and a competent facilitator is vital for effective learning. This survey describes the characteristics, comfort, practices, and need of PEM physicians as HFS facilitators.A descriptive cross-sectional survey was electronically distributed to Pediatric Emergency Research Canada physician members, representing 14 academic pediatric emergency departments nationally.The response rate was 66.6% (92/138); 63% (56/89) of PEM physicians taught HFS. Junior attending physicians (P = 0.011) and those with an education focus (P = 0.005) were more comfortable in using HFS. Sixty-eight percent (38/56) described their facilitator training as formal. Generally, facilitators felt comfortable in running simulations (weighted mean scale, 1.53 [2 = comfortable] on a 5-point rating scale). Facilitators with formal training used verbal confidentiality agreements more frequently (P = 0.008), spent less time running the scenario (P0.05) and spent more time in debriefing (P0.05) than those without formal training. Sixty-three percent (n = 56) of facilitators identified debriefing as the most stressful aspect of HFS. Their main barrier to HFS teaching was lack of protected teaching time (mean scale, 2.02 [2 = barrier]). Seventy-six percent (35/46) of respondents desired online and printable facilitator information. Seventy percent (35/51) thought the ideal time for formal facilitator training was during fellowship.High-fidelity simulation is a widely used educational modality, and more attention must be paid to the needs of the facilitator in order to optimize the educational experience. Standardized facilitator training, focused particularly on effective debriefing techniques, would help improve facilitator comfort with HFS.

Arthroscopy has been used in the fixation of tibial plateau fractures for more than 20 years. Although not proved in randomized trials, several authors using the arthroscopic technique have demonstrated results comparable to traditional methods, using open reduction and internal fixation with standard buttress plates. Improved rehabilitation, greater range of motion, and a shortened hospital stay for patients who have undergone this technique have also been reported.

Background: Traumatic brain injury (TBI) is a primary cause of injury mortality in developed countries but less is known about the impact of TBI on postacute mortality in large study populations. This study investigates the rate and predictors of postacute mortality (1–9 years after the initial injury) of severely injured persons with TBI in the Province of Ontario from April 1, 1993 to March 31, 1995. Method: Cases were identified (n 2,721) from the Ontario Trauma Registry Comprehensive Data Set based on lead trauma hospitals in the province which also provided data on predictors. Severely injured patients (n 557) who had lower extremity injuries during the sample time period formed a control population. Results: Poisson regression modeling showed that having a TBI was a significant predictor of premature death controlling for age and injury severity. Age, the number of comorbidities, injury severity, mechanism of injury, and discharge destination were significant predictors in the multivariate analyses for the TBI population. Conclusions: This research quantifies the elevated risk of premature death in the postacute period for seriously injured adults with TBI and identifies factors most associated with highest mortality rates in this population.

Background Early warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department. Methods Participatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE. Results Using the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed. Conclusion There are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study. Electronic supplementary material The online version of this article (10.1186/s12873-018-0220-3) contains supplementary material, which is available to authorized users.

SummaryGuidelines advise performing a computed tomography head scan for all anticoagulated head injured patients, but the risk of intracranial haemorrhage (ICH) after a minor head injury is unclear. We conducted a systematic review and meta‐analysis to determine the incidence of ICH in anticoagulated patients presenting with a minor head injury and a Glasgow Coma Score (GCS) of 15. We followed Meta‐Analyses and Systematic Reviews of Observational Studies guidelines. We included all prospective studies recruiting consecutive anticoagulated emergency patients presenting with a head injury. Anticoagulation included vitamin‐K antagonists (warfarin, fluindione), direct oral anticoagulants (apixaban, rivaroxaban, dabigatran and edoxaban) and low molecular weight heparin. A total of five studies (including 4080 anticoagulated patients with a GCS of 15) were included in the analysis. The majority of patients took vitamin K antagonists (98·3%). There was significant heterogeneity between studies with regards to mechanism of injury and methods. The random effects pooled incidence of ICH was 8·9% (95% confidence interval 5·0–13·8%). In conclusion, around 9% of patients on vitamin K antagonists with a minor head injury develop ICH. There is little data on the risk of traumatic intracranial bleeding in patients who have a GSC 15 post‐head injury and are prescribed a direct oral anticoagulant.

The clinical evaluation of acute mountain sickness (AMS) is often performed in remote settings with minimal equipment. The purpose of this study was to examine the utility of heart rate variability and other cardiovascular parameters in a high-altitude clinical setting. Forty-one participants were recruited from the patient population of the clinic, and from festivalgoers [those who attended the Janai Purnima festival held at Lake Gosainkunda (4380 m) in Langtang, Nepal] in the vicinity of the clinic. Twenty-one participants were diagnosed with AMS; remaining participants were free from altitude illness. Heart rate variability (both time and frequency domain measures), arterial oxygen saturation (SpO2), blood pressure and Lake Louise Score were evaluated in all the participants. Oxygen saturation and diastolic blood pressure were negatively and positively correlated with Lake Louise Score, respectively. Receiver operating characteristic analysis indicated that an SpO2 of 86% or greater was associated with a very low likelihood of AMS at this altitude. No heart rate variability parameters were different in the AMS group as compared with the control group. In conclusion, in patients with SpO2 of 86% or more at 4380 m or higher, the likelihood of AMS is low. Diastolic blood pressure correlated with AMS severity, whereas heart rate variability was not useful in the diagnosis of AMS.