National survey of emergency physicians on the risk stratification and acceptable miss rate of acute aortic syndrome

CJEM ◽  
2020 ◽  
Vol 22 (3) ◽  
pp. 309-312
Author(s):  
Robert Ohle ◽  
Sarah McIsaac ◽  
Justin Yan ◽  
Krishan Yadav ◽  
Debra Eagles ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
National Survey ◽  
Decision Aid ◽  
Electronic Mail ◽  
Clinical Decision ◽  
Acute Aortic Syndrome ◽  
Emergency Physicians ◽  
Canadian Association ◽  
Academic Teaching Hospital

ABSTRACTObjectivesOne in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians’ opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool.MethodsWe surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is requiredResultsWe had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate.ConclusionsOur national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.

scholarly journals MP05: Validation of the Canadian clinical practice guideline clinical decision aid for acute aortic syndrome

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S43-S44
Author(s):  
B. Paige ◽  
A. Maeng ◽  
D. Savage ◽  
R. Ohle ◽  
MBBCh MA
Keyword(s):  
Computed Tomography ◽  
Clinical Practice ◽  
High Risk ◽  
Confidence Intervals ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.

scholarly journals P096: Prospective pilot implementation of a clinical decision aid for acute aortic syndrome

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S98
Author(s):  
R. Ohle ◽  
N. Fortino ◽  
O. Montpellier ◽  
M. Ludgate ◽  
S. McIsaac ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Length Of Stay ◽  
Decision Aid ◽  
Tertiary Care ◽  
Clinical Decision ◽  
Acute Aortic Syndrome ◽  
Pilot Implementation ◽  
Test Probability ◽  
D Dimer

Introduction: The RAPID RIP clinical decision aid was developed to identify patients at high-risk for acute aortic syndrome (AAS) who require investigations. It stratifies patients into low (no further testing) intermediate (D-dimer if no alternative diagnosis) and High risk (Computed tomography (CT) aorta). Our objectives were to assess its impact on: a) Documentation of high risk features/pre test probability for AAS b) D-dimers ordered c) CT ordered and d) Emergency department length of stay. Methods: We conducted a prospective pilot before/after study at a single tertiary-care emergency department between August and September 2018. Consecutive alert adults with chest, abdominal, flank, back pain or stroke like symptoms were included. Patients with pain &gt;14 days or secondary to trauma were excluded. Results: We enrolled 1,340 patients, 656 before and 684 after implementation, including 0 AAS. Documentation of pre test probability assessment increased (0% to 3%, p &lt; 0.009) after implementation. The proportion who had D-dimer performed increased (5.8% to 9.2% (p &lt; 0.2), while the number of CT to rule out AAS remained stable (0.59% versus 0.58%; p = 0.60). The mean length of ED stay was stable (2.31+/−2.0 to 2.28+/−1.5 hours; p = 0.45) and slightly decreased in those with pre test probability documented (2.1+/−1.4 p &lt; 0.09). The specificity of the decision aid for CT was 100%( 95%CI 71.5- 100%). If it were applied to all patients with high-risk clinical features of AAS the specificity would be 92.6% (95%CI 90.1-94.6%). Conclusion: Implementation of the RAPID RIP increased documentation of important high-risk features for AAS. The RAPID RIP strategy increased use of D-dimer without increasing the number of CT and had a trend towards decreased length of stay.

scholarly journals P114: Barriers and facilitators affecting implementation of a decision aid for the diagnosis of acute aortic syndrome: a qualitative study

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S106-S106
Author(s):  
C. Dmitriew ◽  
R. Ohle
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Practice Guidelines ◽  
Resource Use ◽  
Decision Aid ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Acute Aortic Syndrome ◽  
D Dimer

Introduction: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed in order to reduce the frequency of misdiagnoses and number of diagnostic tests. As part of the guidelines, a clinical decision aid was developed in order to facilitate clinician decision-making based on practice recommendations. The objective of this study was to identify barriers and facilitators among physicians to implementation of the decision aid. Methods: We conducted semi-structured interviews with emergency room physicians working at 5 sites distributed between urban academic and rural settings. We used purposive sampling, contacting ED physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators affecting the probability of decision aid uptake and accurate application of the tool. Two independent raters coded interview transcripts using an integrative approach to theme identification, combining an inductive approach to identification of themes within an organizing framework (Theoretical Domains Framework), discrepancies in coding were resolved through discussion until consensus was reached. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification while reducing resource use and missed diagnoses. Facilitators identified included validation and publication of the guidelines as well as adoption by peers. Barriers to implementation and application of the tool included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. Furthermore, scoring components were, at times, out of alignment with clinician practices and understanding of risk factors. The complexity of the decision aid was also identified as a potential barrier to accurate use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use, particularly within rural contexts. Key barriers identified included the complexity of scoring and inclusion criteria, and the variable acceptance of D-dimer among clinicians. These barriers should be addressed prior to implementation of the decision aid during validation studies of the clinical practice guidelines.

scholarly journals Barriers and facilitators affecting implementation of the Canadian clinical practice guidelines for the diagnosis of acute aortic syndrome

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Caitlin Dmitriew ◽  
Robert Ohle
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Decision Aid ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Acute Aortic Syndrome ◽  
Potential Barriers

Abstract Background Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The 2020 Canadian clinical practice guidelines for the diagnosis of AAS incorporate all available evidence into four key recommendations. In order to facilitate the implementation of these recommendations, a clinical decision aid was created. The objective of this study was to identify barriers and facilitators among physicians prior to implementation of the guideline recommendations in a multicentre step wedge cluster randomized control trial. Methods We conducted semi-structured interviews with nine emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to guideline recommendation uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified. Results Two themes and six subthemes encompassing 13 theoretical domains were identified. These included clinical decision-making support, awareness of the evidence, social factors, expected consequences, ability of physicians to acquire the necessary data and ease of use. A majority of interviewees anticipated that the guideline recommendations would support clinical decision making and more effectively risk-stratify patients. Other facilitators included endorsement of the guidelines by professional organizations and peers. Barriers to implementation include the fact that laboratory testing and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the clinical decision aid and concerns about test specificity were also identified as potential barriers to use. Conclusion Physicians were amenable to using the AAS guideline recommendations to support clinical decision-making and to reduce resource use. A structured intervention should be developed to address the identified barriers and leverage the facilitators in order to ensure successful implementation. Our findings may have implications for the implementation of other guidelines used in emergency departments.

scholarly journals Barriers and Facilitators Affecting Implementation of a Clinical Decision aid for the Diagnosis of Acute Aortic Syndrome: A Qualitative Study

2020 ◽  
Author(s):  
Caitlin Dmitriew ◽  
Robert Ohle
Keyword(s):  
Decision Making ◽  
Decision Aid ◽  
Clinical Decision Making ◽  
Theoretical Domains Framework ◽  
Clinical Decision ◽  
Barriers And Facilitators ◽  
Acute Aortic Syndrome ◽  
Structured Interviews ◽  
Potential Barriers ◽  
D Dimer

Abstract Background: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed to improve patient outcomes and include a clinical decision aid designed to facilitate clinician decision-making. The objective of this study was to prospectively identify barriers and facilitators among physicians prior to implementation of the decision aid.Methods: We conducted semi-structured interviews with emergency room physicians working at five sites distributed between urban academic and rural settings. We used purposive sampling, contacting physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators to decision aid uptake and use. Responses were analysed according to the Theoretical Domains Framework, and overarching themes describing these barriers and facilitators were identified. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification. Potential facilitators identified included guideline validation and publication and endorsement by peers. Barriers to implementation and application of the aid included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. The complexity of the decision aid and insufficient specificity of D-dimer were also identified as potential barriers to use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use. The barriers identified should be addressed prior to implementation in order to support decision aid uptake and use.

scholarly journals Strategies for managing a busy emergency department

CJEM ◽  
2004 ◽  
Vol 6 (04) ◽  
pp. 271-276 ◽  
Author(s):  
Samuel G. Campbell ◽  
Douglas E. Sinclair ◽  
Keyword(s):  
Emergency Department ◽  
Clinical Decision Making ◽  
Patient Flow ◽  
Management Strategies ◽  
Clinical Decision ◽  
Emergency Physicians ◽  
Flow Management ◽  
Time Space ◽  
Canadian Association ◽  
Exit Block

ABSTRACT In a time of increased patient loads and emergency department (ED) exit block, the need for strategies to manage patient flow in the ED has become increasingly important. In March 2002 we contacted all 1282 members of the Canadian Association of Emergency Physicians and asked them to delineate strategies for enhancing ED patient flow and ED productivity without increasing stress levels, reducing care standards or compromising patient safety. Thirty physicians responded. Their suggested flow management strategies, which ranged from clinical decision-making to communication to choreography of time, space and personnel, are summarized here.

scholarly journals National Survey of Emergency Physicians to Define Functional Decline in Elderly Patients with Minor Trauma

CJEM ◽  
2015 ◽  
Vol 17 (6) ◽  
pp. 639-647 ◽  
Author(s):  
Kasim Abdulaziz ◽  
Jamie Brehaut ◽  
Monica Taljaard ◽  
Marcel Émond ◽  
Marie-Josée Sirois ◽  
...  
Keyword(s):  
High Risk ◽  
Decision Rule ◽  
Functional Decline ◽  
Clinical Decision ◽  
Screening Tools ◽  
Trauma Patients ◽  
Emergency Physicians ◽  
Clinical Decision Rule ◽  
Minor Injury ◽  
Elderly Trauma Patients

AbstractBackgroundThere are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury.MethodsAfter a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman’s Tailored Design Method.ResultsOf 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks.ConclusionsA drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.

scholarly journals Endometrial Cancer Molecular Characterization: The Key to Identifying High-Risk Patients and Defining Guidelines for Clinical Decision-Making?

Cancers ◽  
2021 ◽  
Vol 13 (16) ◽  
pp. 3988
Author(s):  
Regina Esi Mensimah Baiden-Amissah ◽  
Daniela Annibali ◽  
Sandra Tuyaerts ◽  
Frederic Amant
Keyword(s):  
Decision Making ◽  
High Risk ◽  
Risk Stratification ◽  
Clinical Decision Making ◽  
Treatment Decision ◽  
Risk Groups ◽  
Clinical Decision ◽  
The Cancer Genome Atlas ◽  
Type I ◽  
Molecular Features

Endometrial carcinomas (EC) are the sixth most common cancer in women worldwide and the most prevalent in the developed world. ECs have been historically sub-classified in two major groups, type I and type II, based primarily on histopathological characteristics. Notwithstanding the usefulness of such classification in the clinics, until now it failed to adequately stratify patients preoperatively into low- or high-risk groups. Pieces of evidence point to the fact that molecular features could also serve as a base for better patients’ risk stratification and treatment decision-making. The Cancer Genome Atlas (TCGA), back in 2013, redefined EC into four main molecular subgroups. Despite the high hopes that welcomed the possibility to incorporate molecular features into practice, currently they have not been systematically applied in the clinics. Here, we outline how the emerging molecular patterns can be used as prognostic factors together with tumor histopathology and grade, and how they can help to identify high-risk EC subpopulations for better risk stratification and treatment strategy improvement. Considering the importance of the use of preclinical models in translational research, we also discuss how the new patient-derived models can help in identifying novel potential targets and help in treatment decisions.

scholarly journals Lack of consensus on corneal abrasion management: results of a national survey

CJEM ◽  
2004 ◽  
Vol 6 (06) ◽  
pp. 402-407 ◽  
Author(s):  
Lisa Calder ◽  
Sowmya Balasubramanian ◽  
Ian Stiell
Keyword(s):  
Foreign Body ◽  
National Survey ◽  
Teaching Hospitals ◽  
Full Time ◽  
Emergency Physicians ◽  
Topical Antibiotics ◽  
Canadian Association ◽  
Email Address ◽  
Management Preferences

ABSTRACT:Objectives:Our objective was to determine the practice patterns of Canadian emergency physicians with respect to the management of traumatic corneal abrasions.Methods:After developing our instrument and pilot testing it on a sample of emergency residents, we randomly surveyed 470 members of the Canadian Association of Emergency Physicians, using a modified Dillman technique. We distributed a pre-notification letter, an 18-item survey, and appropriate follow-up surveys to non-responders. Those members with an email address (n= 400) received a Web-based survey, and those without (n= 70) received a survey by post. The survey focused on the indications and utilization of analgesics (oral and topical), cycloplegics, eye patches and topical antibiotics.Results:Our response rate was 64% (301/470), and the median age of respondents was 38 years. Most (77.7%) were male, 71.8% were full-time emergency physicians, 76.5% were emergency medicine certified, and 64.4% practised in teaching hospitals. Pain management preferences (offered usually or always) included oral analgesics (82.1%), cycloplegics (65.1%) and topical nonsteroidal anti-inflammatory drugs (NSAIDs) (52.8%). Only 21.6% of respondents performed patching, and most (71.2%) prescribed topical antibiotics, particularly for contact lens wearers and patients with ocular foreign bodies. Two-thirds of the respondents provided tetanus toxoid if a foreign body was present, and 46.2% did so even if a foreign body was not present. Most respondents (88.0%) routinely arranged follow-up.Conclusions:This national survey of emergency physicians demonstrates a lack of consensus on the management of traumatic corneal abrasions. Further study is indicated to determine the optimal treatment, particularly regarding the use of topical NSAIDs.

scholarly journals Choosing Wisely Canada®: Five tests, procedures and treatments to question in Emergency Medicine

CJEM ◽  
2017 ◽  
Vol 19 (S2) ◽  
pp. S9-S17 ◽  
Author(s):  
Amy H. Y. Cheng ◽  
Sam Campbell ◽  
Lucas B. Chartier ◽  
Tom Goddard ◽  
Kirk Magee ◽  
...  
Keyword(s):  
Emergency Medicine ◽  
Head Injuries ◽  
Clinical Decision ◽  
Choosing Wisely ◽  
Emergency Physicians ◽  
Spinal Imaging ◽  
Canadian Association ◽  
Frequency Of Use ◽  
Expert Working Group ◽  
Adults And Children

AbstractObjectivesChoosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians’ (CAEP) top five list of recommendations, and the process undertaken to generate them.MethodsThe CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus.ResultsThe top five CAEP CWC recommendations are: 1) Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.ConclusionsThe CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.

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