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Emergency Medicine Research:

Emergency Medicine Research: . Creating Evidence to Improve the Safety and Effectiveness of Patient Care in the ED. Ian Stiell MD MSc FRCPC . Professor and Chair, Dept of Emergency Medicine Distinguished Professor & University Health Research Chair

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Emergency Medicine Research:

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  1. Emergency Medicine Research: Creating Evidence to Improve the Safety and Effectiveness of Patient Care in the ED

  2. Ian Stiell MD MSc FRCPC • Professor and Chair, Dept of Emergency Medicine • Distinguished Professor & University Health Research Chair • Senior Scientist, Ottawa Hospital Research Institute Disclaimer: I am an evidence guy

  3. Emergency Medicine Research: Improving Patient Care in the ED • U Ottawa clinical research in EM – identifying and filling knowledge gaps • Goals – Improve ED Patient Care • Quality: • Reduce variation and inefficiency • Improve clinical outcomes • Safety: • Reduce adverse outcomes • U Ottawa Approaches • Diagnosis and Prognosis: • Clinical decision rules and risk scales • Treatment: • Interventional trials

  4. Ottawa, Ontario

  5. U of Ottawa EM Research • One of strongest EM research programs • Grants, Publications, Presentations • 5 Supported MD Investigators • Ian Stiell – Risk scales and cardiac • Jeff Perry – Neurological emergencies • Christian Vaillancourt - CPR • Lisa Calder – Patient safety • Venkatesh Thiruganasambandamoorthy - Syncope • Strengths • $12 million peer-reviewed funding as PI • 275 peer-reviewed publications • 21 in high-impact journals • 12 fulltime and 25 part-time staff • International Research Fellowship

  6. U of Ottawa EM Research: Patient Care Issues – Knowledge Gaps • 1. Inefficiency and Variation • Imaging ankle, knee, CT head, c-spine • Management of recent-onset atrial fibrillation (RAFF) • 2. Safety • Adverse events after discharge: • HF, COPD, Headache, TIA, Syncope • 3. Effective Therapy • Poor survival cardiac arrest: • High dose epinephrine, ACD CPR, Rapid defibrillation, Prehospital ACLS, Vasopressin, Biphasic waveform, Analyze later, Bystander CPR • Recent-onset atrial fibrillation (RAFF): • Rhythm vs. rate, Best drugs, Drug vs electrical

  7. Use of Cervical Spine RadiographyCan Med Assoc J 1997

  8. 1. Variation and Inefficiency: Canadian C-Spine Rule Variation and Inefficiency (N=6,855) Can Med Assoc J 1997 Derivation of the Rule (N=8,924) JAMA 2001 Prospective Validation (N=8,283) New Engl J Med 2003 Multicentre Implementation (N=11,648) Br Med J 2009 Awareness and Use (N=1,150) AcadEmerg Med 2008 Validation by Paramedics Ann Emerg Med 2009 Validation by ED Nurses (N=3,633) Can Med Assoc J 2010

  9. 2009 N=11,648 Reduced diagnostic imaging at intervention sites No adverse outcomes

  10. The “mother of all negative trials” !!

  11. Annals of Emerg Med January 2011

  12. % Attempted Cardioversion by Hospital

  13. RAFF Management in the ED:Rhythm or Rate Control? Annals Emerg Med Jan 2011

  14. Can J Emerg Med 2010 Procainamide and electrical cardioversion N=628 Discharged home - 97% Discharged in NSR - 94% Median length of stay - 4.9 hrs

  15. 2. Patient Safety:Adverse Outcomes after Discharge • Heart Failure • COPD • Headache • TIA • Syncope

  16. Can J Emerg Med 2010

  17. Ottawa Heart Failure Risk Scale: to Identify Risk of Adverse Outcomes

  18. 2010

  19. 2003

  20. Can J Emerg Med 2010 • Ann Emerg Med 2010

  21. 3. Effective Therapy: Poor Survival in Cardiac Arrest High Dose Epinephrine (N=650) New Engl J Med 1992 ACD CPR (N=1,784) JAMA 1996 OPALS II - Rapid Defibrillation (N=6,331) JAMA 1999 Vasopressin (N=200) Lancet 2001 Quality of Life of Survivors (N=268) Circulation 2003 OPALS III - Preshospital ACLS (N=5,638) New Engl J Med 2004 Analyze Later vs Analyze Early (N=9,933) New Engl J Med 2011

  22. N Engl J Med 2004;351:647-56

  23. ROC Sites 36,000 EMS personnel 260 EMS & fire services 24 million people 287 hospitals Vancouver Seattle-KingCo Ottawa Data Coordinating Center, Seattle Milwaukee Toronto Portland Pittsburgh Alabama San Diego Dallas

  24. 2009

  25. Emergency Medicine Research: Good Patient Care Requires Good Evidence

  26. U of O Emergency Medicine Research Fellowship • 2- year MSc in Epidemiology • Junior faculty with restricted clinical and admin activities • Mentors: Ian Stiell and George Wells PhD • Principles of project management, grant writing, manuscript preparation • 15 fellows so far from Canada, U.S., Middle East, Australia

  27. Emergency Medicine Research: Creating Evidence to Improve the Safety and Effectiveness of Patient Care in the ED

  28. U of Ottawa EM Research:Publications

  29. PRIMARY OUTCOME (N=4,531)Diagnostic Imaging Rates P = 0.64 P < 0.01 P < 0.01 76.2% 80% 74.1% 67.5% 62.8% BeforePeriod AfterPeriod % Imaging 40% 0% 6 InterventionHospitals 6 Control Hospitals Study Sites

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