Many emergency physicians (EPs) order “confirmatory” abdominal computed tomography (CT) in young flank pain patients, despite a high clinical suspicion of renal colic and the risk of radiation exposure. We measured the adverse outcome rate among flank pain patients identified as not requiring abdominal CT by the EP on a data form, regardless of whether CT was eventually ordered. Our secondary objective was to describe diagnoses other than renal colic identified by CT in this population.

We conducted a prospective observational study at two community EDs. We asked staff EPs to complete a data sheet on patients ages 18 to 50 years with a first episode of flank pain, recording 1) if the flank pain was consistent with renal colic and 2) if the EP felt abdominal CT was indicated. Adverse outcomes (defined a priori as urgent surgical procedures, disability, or death) were assessed by research assistants at 4 weeks using telephone follow-up and a hospital records search.

We enrolled 389 patients; 353 completed follow-up (91%). The average age was 38.8 years, and 72.0% were male. Of 212 patients identified in the “CT not indicated” group, 2 had another diagnosis identified (unruptured diverticulitis and a ruptured ovarian cyst), but none had adverse outcomes (95% CI 0-1.4).

Adverse events were rare (< 1.5%) among patients < 50 years old with flank pain when CT was not required according to the clinical assessment of the EP. Future research should assess the adverse outcomes of withholding CT in low-risk patients using a larger patient sample.

The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention.

PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained fromthe hospital's decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006.

There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute –7.25%: 95% CI –8.31 to –6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map.

A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

There was a higher level of agreement (κ = 0.73; 95% CI 0.68–0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ = 0.50; 95% CI 0.42–0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ = 0.80; 95% CI 0.76–0.84).

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

To define the important elements of an emergency department (ED) consultation request and to develop a simple model of the process.

From March to September 2010, 61 physicians (21 emergency medicine [EM], 20 general surgery [GS], 20 internal medicine [IM]; 31 residents, 30 attending staff) were questioned about how junior learners should be taught about ED consultation. Two investigators independently reviewed focus group and interview transcripts using grounded theory to generate an index of themes until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. All transcripts were coded using this index of themes; 30% of transcripts were coded in duplicate to determine the agreement.

A total of 245 themes and subthemes were identified. The agreement between reviewers was 77%. Important themes in the process were as follows: initial preparation and review of investigations by EM physician (overall endorsement 87% [range 70–100% in different groups]); identification of involved parties (patient and involved physicians) (100%); hypothesis of patient's diagnosis (75% [range 62–83%]) or question for the consulting physician (70% [range 55–95%]); urgency (100%) and stability (74% [range 62–80%]); questions from the consultant (100%); discussion/communication (98% [range 95–100%]); and feedback (98% [range 95–100%]). These components were reorganized into a simple framework (PIQUED). Each clinical specialty significantly contributed to the model (χ2 = 7.9; p value = 0.019). Each group contributed uniquely to the final list of important elements (percent contributions: EM, 57%; GS, 41%; IM, 64%).

We define important elements of an ED consultation with input from emergency and consulting physicians. We propose a model that organizes these elements into a simple framework (PIQUED) that may be valuable for junior learners.