Debra Eagles

Background Vertebral compression fractures are a common ED presentation in older adults and often lead to significant pain and functional decline. Oligoanalgesia can worsen morbidity. We aimed to describe pain assessment and management practices for older adults presenting to the ED with fragility vertebral compression fractures. Methods We conducted a retrospective health records review of adults ≥ 65 years presenting to two tertiary EDs with acute thoracic or lumbar fragility vertebral compression fractures between August 2017 and August 2022. Patients with polytrauma, pathologic, or age-indeterminate fractures were excluded. Eligible cases were identified by ICD-10-CA codes, and data were abstracted using a standardized form. Primary outcomes were initial pain assessment, pain reassessment, and analgesic administration. Secondary outcomes included use of consultant and allied health services, discharge prescriptions, disposition, and 30-day return ED visits. Descriptive statistics were used. Results Of 646 screened patients, 296 met inclusion criteria. Mean age was 81.4 (SD 8.3) years; 69.0% were female. An initial pain assessment was documented in 65.5%, but only 4.1% had a discharge pain score documented. Of those who had an initial pain assessment, 51.7% had pain reassessments during their ED care. 10.1% of patients received no analgesia. Acetaminophen (68.6%), opioids (54.7%), and NSAIDs (25.7%) were most frequently used. Consultants were contacted for 45.3% of patients. Allied health services were consulted for 23.3% of patients. Nearly one-third (30.4%) were admitted, primarily for pain management (62.2%); 19.3% of discharged patients returned within 30 days. Conclusion Emergency department care of older adults presenting with acute fragility compression fractures is suboptimal. Nearly one in three older adults did not have a pain assessment and one in ten received no analgesia during their ED visit. Identifying and overcoming barriers to quality care is crucial to ensure effective pain management for this population.

Objective: To conduct a randomised, open label comparison of the effectiveness and safety of intravenous vernakalant and intravenous procainamide for the management of acute atrial fibrillation in the emergency department. Design: Randomised clinical trial (RAFF4 trial). Setting: 12 tertiary care emergency departments in Canada. Participants: Patients with acute atrial fibrillation for whom acute rhythm control was a safe option. Interventions: Patients were randomised (1:1) to an intravenous infusion of vernakalant or procainamide; when rapid conversion did not occur, patients were offered electrical cardioversion. Main outcomes and measures: The primary outcome was conversion to sinus rhythm within 30 minutes of drug infusion completion. Secondary outcomes included time to conversion to sinus rhythm and whether the patient required electrical cardioversion. Results: Of the 350 enrolled eligible patients, baseline characteristics were similar in the procainamide (n=172) and vernakalant (n=178) groups. For the primary outcome of conversion success, vernakalant was more effective (62.4% v 48.3%; adjusted absolute difference 15.0%, 95% confidence interval 4.6% to 25.0%, P=0.005; adjusted odds ratio 1.87, 95% confidence interval 1.2 to 2.9, P=0.006). With vernakalant, time to conversion was faster (21.8 v 44.7 minutes; mean difference −22.9, 95% confidence interval −29.9 to −16.0, Pv 44.2%; odds ratio 0.62, 95% confidence interval 0.39 to 0.96, P=0.033). Adverse events were similar in both groups, were generally mild and brief, and most patients were discharged home. Subgroup analysis strongly favoured vernakalant for conversion in patients younger than 70 years (73.3% v 47.2%; adjusted odds ratio 3.1, 95% confidence interval 1.7 to 5.5, P=0.001, interaction P=0.005). Conclusions: In this head-to-head comparison, vernakalant was superior to procainamide for patients with higher conversion rates and faster times to conversion. Therefore, vernakalant is a safe and highly effective intravenous alternative for the rapid cardioversion and discharge home of patients with acute atrial fibrillation. Trial registration: ClinicalTrials.gov NCT04485195

Objectives: This portion of the Geriatric Emergency Department (GED) Guidelines 2.0 focuses on delirium in the emergency department (ED). Methods: A multidisciplinary group applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and develop recommendations related to older ED patients with possible delirium. Results: The GED Guidelines 2.0 Delirium Work Group derived six evidence‐based recommendations for risk stratification, diagnosis, and brain imaging. To reduce universal screening, the Delirium Risk Score may be used to identify older adults at low risk for delirium, though the evidence certainty is very low. In adults over 65 admitted to ED observation units, Zucchelli's risk assessment tool (threshold ≥ 4) may stratify delirium risk, also with very low certainty. For adults over 75, the REDEEM Score may be used to identify low‐ or high‐risk individuals, again with very low certainty. For diagnosis, 4AT, bCAM, CAM‐ICU, mCAM, AMT‐4, or RASS may be used to rule delirium in or out, based on very low certainty. The Delirium Triage Screen (DTS) may be used to rule out, but not to rule in, delirium, also with very low certainty. For diagnostic imaging, there is very low certainty of evidence to recommend for or against obtaining a head CT as part of the evaluation for older ED patients with delirium. All recommendations are conditional, reflecting very low certainty of evidence due to the lack of high‐quality ED‐based studies and comparative effectiveness research. Conclusion: Rigorous ED‐based research is needed to strengthen evidence and guide delirium care for older adults in geriatric emergency medicine.

Objective Acute heart failure is the second most common reason for return visits to the emergency department (ED) in Canada. Half of all acute heart failure patients presenting to the ED can be discharged, suggesting admission is not always necessary. The HEARTRISK6 Scale was recently developed from prospectively collected data of 2,246 acute heart failure patients from 10 Canadian EDs. This tool comprises six routine ED criteria and aids disposition decisions by estimating the risk of poor outcomes. Currently, it is not known what ED clinicians think of the tool. This study aimed to determine the factors impacting emergency physician use of the HEARTRISK6 Scale, and to identify the relevant opportunities to increase uptake of the tool. Methods We conducted semi-structured interviews with ED attending and resident physicians at The Ottawa Hospital and nearby community sites. An interview guide based on the theoretical domains framework (TDF) was used to capture factors within the 14 domains that may influence the use of HEARTRISK6. Interview transcripts were coded using direct content analysis, and belief statements were generated to capture similar responses. Relevant and non-relevant domains were identified based on their frequencies, presence of conflicting ideas, and perceived influence. Results Sixteen interviews (thirteen attendings, three residents) were conducted with ED physicians. Eleven of the fourteen TDF domains were identified as relevant. Participants described key facilitators to be teaching about the tool, positive colleague views, increased objectivity of disposition decision, ease of access, and feeling it benefited their work. Desire for more evidence, competing demands, and need for consultant buy-in were noted as important barriers. Conclusion This study identified key barriers and facilitators to use of HEARTRISK6 Scale for acute heart failure patients. These factors provide targets for developing interventions aimed at encouraging routine use of HEARTRISK6 among ED physicians in clinical practice.

Introduction: Frailty is associated with adverse outcomes among patients attending emergency departments (EDs). While multiple frailty screens are available, little is known about which variables are important to incorporate and how best to facilitate accurate, yet prompt ED screening. To understand the core requirements of frailty screening in ED, we conducted an international, modified, electronic two-round Delphi consensus study.Methods: A two-round electronic Delphi involving 37 participants from 10 countries was undertaken. Statements were generated from a prior systematic review examining frailty screening instruments in ED (logistic, psychometric and clinimetric properties). Reflexive thematic analysis generated a list of 56 statements for Round 1 (August–September 2021). Four main themes identified were: (i) principles of frailty screening, (ii) practicalities and logistics, (iii) frailty domains and (iv) frailty risk factors.Results: In Round 1, 13/56 statements (23%) were accepted. Following feedback, 22 new statements were created and 35 were re-circulated in Round 2 (October 2021). Of these, 19 (54%) were finally accepted. It was agreed that ideal frailty screens should be short (<5 min), multidimensional and well-calibrated across the spectrum of frailty, reflecting baseline status 2–4 weeks before presentation. Screening should ideally be routine, prompt (<4 h after arrival) and completed at first contact in ED. Functional ability, mobility, cognition, medication use and social factors were identified as the most important variables to include.Conclusions: Although a clear consensus was reached on important requirements of frailty screening in ED, and variables to include in an ideal screen, more research is required to operationalise screening in clinical practice.

This clinical review is intended to assist emergency physicians manage patients who present to the emergency department (ED) with acute/recent-onset atrial fibrillation (AF) or flutter (AFL). This article is based primarily on the 2021 Canadian Association of Emergency Physicians (CAEP) Acute Atrial Fibrillation/Flutter Best Practices Checklist. We encourage readers to download the open access CAEP Checklist article (https://link.springer.com/article/10.1007/s43678-021-00167-y) and the free smartphone app (CAEP Atrial Fibrillation Guide). We focus on four key elements of ED care: assessment and risk stratification, rate and rhythm control, short-term and long-term stroke prevention, and disposition and follow-up. It is important to determine if AF/AFL with rapid ventricular response is a primary arrhythmia or secondary to medical causes. While it is unusual for patients with primary AF to be unstable, urgent cardioversion is occasionally required. The criteria for when cardioversion is safe have recently changed and it is essential that physicians are well versed in them. When rhythm control is not safe, provide effective and safe IV rate control. When rhythm control is safe, either pharmacological or electrical cardioversion acceptable, per patient and physician preference. Rapid ventricular pre-excitation (Wolff-Parkinson-White Syndrome) usually, but not always, requires urgent electrical cardioversion. ED physicians should prescribe oral anticoagulants at discharge if indicated. No specific direct oral anticoagulant is preferred, and references should be freely consulted for optimal dosing. Hospital admission is rarely required for acute AF/AFL patients, who should be given good discharge instructions.