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Biomedical subjects

Brian R Holroyd

Publications and source records attributed to Brian R Holroyd.

12 recordsLinked to original sources
PubMed2007

Predictive validity of a computerized emergency triage tool.

BACKGROUND: Emergency department (ED) triage prioritizes patients on the basis of the urgency of need for care. eTRIAGE is a Web-based triage decision support tool that is based on the Canadian Triage and Acuity Scale (CTAS), a five level triage system (CTAS 1 = resuscitation, CTAS 5 = nonurgent). OBJECTIVES: To examine the validity of eTRIAGE on the basis of resource utilization and cost as measures of acuity. METHODS: Scores on the CTAS, specialist consultations, computed-tomography use, ED length of stay, ED disposition, and estimated ED and hospital costs (if the patient was subsequently admitted to hospital) were collected for each patient over a six month period. These data were queried from a database that captures all regional ED visits. Correlations between CTAS score and each outcome were measured by using logistic regression models (categorical variables), univariate analysis of variance (continuous variables), and the Kruskal-Wallis analysis of variance (costs). A multivariate regression model that used cost as the outcome was used to identify interaction between the variables presented. RESULTS: Over the six month study, 29,524 patients were triaged by using eTRIAGE. When compared with CTAS level 3, the odds ratios for consultation, CT scan, and admission were significantly higher in CTAS 1 and 2 and were significantly lower in CTAS 4 and 5 (p < 0.001). When compared with CTAS levels 2-5 combined, the odds ratio for death in CTAS 1 was 664.18 (p < 0.001). The length of stay also demonstrated significant correlation with CTAS score (p < 0.001). Costs to the ED and hospital also correlated significantly with increasing acuity (median costs for CTAS levels in Canadian dollars: CTAS 1 = 2,690 dollars, CTAS 2 = 433 dollars, CTAS 3 = 288 dollars, CTAS 4 = 164 dollars, CTAS 5 = 139 dollars, and p < 0.001). Significant interactions between the data collected were found in a multivariate regression model, although CTAS score remained highly associated with costs. CONCLUSIONS: Acuity measured by eTRIAGE demonstrates excellent predictive validity for resource utilization and ED and hospital costs. Future research should focus on specific presenting complaints and targeted resources to more accurately assess eTRIAGE validity.

Adult↗
PubMed2006

Characteristics of patients who leave emergency departments without being seen.

OBJECTIVES: Patients leaving the emergency department (ED) without being seen (LWBS) by a physician have become a growing concern in overcrowded EDs. The purpose of this study was to determine the acuity level, reasons, and outcomes of LWBS cases. METHODS: LWBS patients (or their guardians) from two linked Canadian EDs (one adult, one pediatric), identified during 11 sampling periods of seven days' duration each, were contacted by telephone. Descriptive statistics are provided. RESULTS: A total of 711 (4.5%) of 15,660 registered emergency patients left without being seen (50% male; median age, 33 years). Triage-matched controls waited a median of 87 minutes before seeing a physician. Of the 711 LWBS cases, 512 (72%) were contacted and 498 agreed to participate. The most common major reason for leaving was "fed up with waiting" (44.8%). Overall, 60% of LWBS cases sought medical attention within one week; 14 patients were hospitalized, and one required urgent surgery. Triage level was not associated with the probability of subsequently seeking medical attention (61%, 61%, and 60% in triage levels 3, 4, and 5, respectively). Of the 198 (39%) who did not subsequently seek medical attention, 50 patients (26%) had been triaged as urgent and one patient died six days after ED registration. CONCLUSIONS: The most common reason for LWBS is impatience during peak ED periods. Many of these patients seek medical care within one week. Complications occurred rarely; however, "high-risk" patients who leave without being seen do experience adverse health outcomes. Further research is required to examine ways to reduce LWBS cases.

Adult↗
PubMed2006

Reliability of computerized emergency triage.

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.

Adult↗
PubMed2006

Educational intervention to reduce falls and fear of falling in patients after fragility fracture: results of a controlled pilot study.

OBJECTIVES: Falls and fear of falling are a major health problem. We sought to determine the effectiveness of an educational intervention in reducing fear of falling and preventing recurrent falls in community-dwelling patients after a fragility fracture. METHODS: One hundred two community-dwelling patients aged 50 years or older who fell and sustained a wrist fracture and were treated at Emergency Departments in Edmonton, Alberta, Canada (2001-2002) were allocated to either standardized educational leaflets and post-discharge telephone counseling regarding fall prevention strategies ("intervention") or attention-controls ("controls"). Main outcomes were fear of falling and recurrent falls 3 months after fracture. RESULTS: Mean age was 67 years and most patients were female (80%). The majority of falls (76%) leading to fracture occurred outdoors. Three months post-fracture, almost half of patients (48%) reported increased fear of falling and 11 of 102 (11%) reported falling again. The intervention did not reduce the fear of falling (43% had increased fear vs. 53% of controls, adjusted P value=0.55) or decrease recurrent falls (17% fell vs. 5% of controls, adjusted P value=0.059) within 3 months of fracture. CONCLUSIONS: An educational intervention undertaken in the Emergency Department was no more effective than usual care in reducing fear of falling or recurrent falls in community-dwelling patients. Future strategies must address a number of dimensions beyond simple education.

Accidental Falls↗
PubMed2005

Emergency triage: comparing a novel computer triage program with standard triage.

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.

Canada↗
PubMed2004

Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules.

This study examined whether emergency physicians (EPs) exposed to multiple dissemination strategies for the Ottawa Ankle Rules (OARs) would reduce extremity radiography use. We conducted a prospective cohort study comparing intervention (n = 2) with control (n = 2) hospitals over a 2-year period. All EPs received the paper-based rules during the run-in phase; EPs in the intervention hospitals were also subjected in sequence to valid dissemination approaches. Provincewide dissemination of the OARs did not decrease radiography during the run-in period (92% vs. 93%; P =.36). Sequential directed education and personalized feedback strategies failed to reduce radiographic ordering rates (P =.54) or the ordering of both foot and ankle radiographs (P =.11) over time. The use of radiography did not decrease despite the use of a variety of dissemination strategies. Additional research is required to determine the most effective methods of incorporating guidelines into emergency practice.

Adult↗
PubMed2004

Current political issues facing emergency medicine in Canada.

Health care in Canada is universal, accessible, transferable and publicly funded. Each of Canada's provinces has the responsibility for health care funding and delivery through its ministry of health, controlled by the governing provincial party and overseen by a Minister of Health. The Federal Government is responsible for ensuring the provinces conform to the spirit and regulations within the Canada Health Act and for broad programme funding, through the federal Minister of Health. As such, access to emergency health services is available to all Canadians free of direct charge. Some aspects of health care are the direct responsibility of citizens, such as ambulance services, medications (for those who can afford them), and 'non-essential' services. For most Canadians, however, care for acute illness and injury is provided without barriers in EDs while generalists such as family physicians and paediatricians provide primary care.

Canada↗
PubMed2004

Supporting clinical practice at the bedside using wireless technology.

OBJECTIVES: Despite studies that show improvements in both standards of care and outcomes with the judicious application of clinical practice guidelines (CPGs), their clinical utilization remains low. This randomized controlled trial examined the use of a wirelessly networked mobile computer (MC) by physicians at the bedside with access to an emergency department information system, decision support tools (DSTs), and other software options. METHODS: Each of ten volunteer emergency physicians was randomized using a matched-pair design to work five shifts in standard fashion (desktop computer [DC] access) and five shifts with a wirelessly networked MC. Work pattern issues and electronic CPG/DST use were compared using end-of-shift satisfaction questionnaires and review of a CPG/DST database. Repeated-measures analysis of variance was used to examine between-shift differences. RESULTS: A total of 100 eight-hour shifts were evaluated; 99% compliance with postshift questionnaires was achieved. Using a seven-point Likert scale (MC values first), MCs were rated as being as fast (5.04 vs. 4.54; p=0.13) and convenient (5.08 vs. 4.14; p=0.07) as DCs. Overall, physicians rated MCs to be less efficient (3.18 vs. 4.30; p=0.02) but encouraged more frequent use of DSTs (4.10 vs. 3.47; p=0.03) without impacting doctor-patient communication (2.78 vs. 2.96; p=0.51). During the study period, physician use of an intranet Web application (eCPG) was more frequent during shifts assigned to the MC when compared with the DC (eCPG uses/shift, 3.6 vs. 2.0; p=0.033). CONCLUSIONS: The MC technology permitted physicians to access information at the bedside and increased the use of CPG/DST tools. According to physicians, patients appeared to accept their use of information technology to assist in decision making. Development of improved computer technology may address the major limitation of MC portability.

Computers↗
PubMed2002

Adherence to practice guidelines for transient ischemic attacks in an emergency department.

OBJECTIVE: To evaluate the investigation and treatment of patients with a diagnosis of transient ischemic attacks (TIA) in the emergency department (ED) a tertiary care teaching hospital with a neuroscience referral program. METHODS: A chart review was conducted in the hospital. Consecutive ED charts with a diagnosis of TIA were included; each was reviewed by independent coders using a standardized data form. RESULTS: Two hundred and ninety-three TIA charts were reviewed; the gender ratio was 1:1 with a mean age of 66 years. Most patients (75%; 95% CI: 70, 80) were evaluated by ED physicians; the remaining patients were seen directly by referral services. The median time from symptom onset to ED arrival was 29 hours and the duration of symptoms was 4.6 hours. Most patients received CT scans (81%; 95% CI: 73, 85), complete blood counts (74%; 95% CI: 68, 79), and electrocardiograms (75%; 95% CI: 70, 80) in the ED. In 16% (95% CI: 13, 22) a carotid doppler was performed and in 26% (95% CI: 21, 31) an outpatient doppler was booked. Among those who were discharged (75%; 95% CI: 70, 80), antithrombotic medications were not prescribed to 28% (95% CI: 22, 34). CONCLUSION: Practice variation exists with respect to the investigation and treatment of TIAs in this tertiary-care teaching hospital. Carotid doppler investigation and use of anti-platelet therapy for patients with TIA are suboptimal. Clinical practice guidelines and rapid assessment TIA clinics may change these results.

Aged↗
PubMed2002

Evaluation of patient satisfaction and outcomes after assessment for acute ankle injuries.

Physicians argue that patient preferences influence their test ordering and their potential for compliance with clinical practice guidelines (CPG). This study was conducted to evaluate patient satisfaction with clinical practice in emergency department (ED) settings using a validated and widely publicized set of CPGs. Patients presenting to 4 hospital EDs were eligible if they had sustained acute ankle or foot injuries. All sites were involved with the dissemination of radiography CPG, and use of radiography was determined by treating physicians. Telephone follow-up was attempted for all patients who did not receive ankle or foot radiography (Group 1). A random sample of 25% of patients who had a normal radiograph interpretation (Group 2) was also chosen for follow-up. Structured telephone interviews were administered and included information on post-encounter health care utilization, subsequent radiography, and patient satisfaction. A structured questionnaire was administered to all ED physicians (N = 60) to elicit their perspectives on the clinical practice guidelines. In Group 1, 342 (69%) of 494 non-radiographed patients were successfully contacted. In Group 2, 623 (77%) of 812 patients with normal ED radiographs, were successfully contacted. After ED discharge, 86 (25%) Group 1 and 191 (31%) Group 2 patients had visited another physician within 2 weeks of the initial ED encounter (P =.07). Subsequent ankle radiography was similar between the groups (38 [11%] in Group 1 vs. 59 [10%] in Group 2; P =.38). Patients appeared to be similarly highly satisfied with physician care (P =.58) and with discharge instructions (P =.12) in both groups. Overall, 76% of physicians supported the use of CPGs; however, 78% reported that patient expectations influenced their application of the Ottawa Ankle Rules. This study suggests that patients are equally satisfied with care, access additional health care services similarly and obtain the same percentage of radiographs irrespective of the initial ED ankle/foot radiograph ordering. These results may help physicians in re-evaluating their perceptions that patient expectation influence utilization and have important implications in guideline development.

Adult↗