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ABSTRACT: This study was conducted to determine if there is practice variation for emergency physicians' (EPs) management of recent-onset atrial fibrillation (RAF) in various world regions (Canada, United States, United Kingdom, and Australasia).
The authors completed a mail and e-mail survey of members from four national emergency medicine (EM) associations. One prenotification letter and three survey letters were sent to members of the Canadian Association of Emergency Physicians (CAEP; Canada-1,177 members surveyed), American College of Emergency Physicians (ACEP; United States-500), College of Emergency Medicine UK (CEM; United Kingdom-1,864), and Australasian College for Emergency Medicine (ACEM; Australasia-1,188) as per the modified Dillman technique. The survey contained 23 questions related to the management of adult patients with symptomatic RAF (either a first episode or paroxysmal-recurrent) where onset is less than 48 hours and cardioversion is considered a treatment option. Data were analyzed using descriptive and chi-square statistics.
Response rates were as follows: overall, 40.5%; Canada, 43.0%; United States, 50.1%; United Kingdom, 38.1%; and Australasia, 38.0%. Physician demographics were as follows: 72% male and mean (±SD) age 41.7 (±8.39) years. The proportions of physicians attempting rate control as their initial strategy are United States, 94.0%; Canada, 70.7%; Australasia, 61.1%; and United Kingdom, 43.1% (p < 0.0001). Diltiazem is the predominant agent for rate control in Canada (65.36%) and the United States (95.22%), while metoprolol is used in Australasia (65.94%) and the United Kingdom (67.64%). Cardioversion is attempted at varying rates in Canada (65.9%), Australasia (49.9%), United Kingdom (49.5%), and the United States (25.9%) (p < 0.0001). Pharmacologic cardioversion is attempted first in all regions, with the preferred drug being procainamide in Canada (61.93%) and amiodarone in Australasia (63.39%), the United Kingdom (47.97%), and the United States (22.41%; p < 0.0001). If drugs fail, electrical cardioversion is then attempted in Canada (70.64%), Australasia (46.19%), the United States (29.69%), and the United Kingdom (27.78%; p < 0.0001).
There is much variation in emergency department (ED) management of RAF among world regions, most markedly for use of rate versus rhythm control, choice of drugs, and use of electrical cardioversion. Canadians are more likely to use an aggressive approach for management of RAF, whereas Americans are more likely to employ conservative management. U.K. and Australasian EPs fall somewhere in the middle. These differences demonstrate the need for better evidence, or better synthesis of existing knowledge, to create guidelines to guide ED management of this common dysrhythmia.
Academic Emergency Medicine 11/2012; 19(11):1255-60. · 1.76 Impact Factor
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ABSTRACT: Objective:There are currently no widely used guidelines to determine which older patients with acute respiratory conditions require hospital admission. This study assessed the need for clinical decision rules to help determine whether hospital admission is required for patients over 50 years for three common respiratory conditions: chronic obstructive pulmonary disease (COPD), heart failure (HF), and community-acquired pneumonia (CAP).Design:Postal survey.Setting:Emergency physicians (EPs) from the United States, Canada, and Australasia.Participants:A random sample of EPs from the United States, Canada, and Australasia.Interventions:A modified Dillman technique with a prenotification letter and up to three postal surveys.Main Outcomes:EP opinions regarding the need for and willingness to use clinical decision rules for emergency department (ED) patients over 50 years with COPD, HF, or CAP to predict hospital admission. We assessed the required sensitivity of each rule for return ED visit or death within 14 days.Results:A total of 801 responses from 1,493 surveys were received, with response rates of 55%, 60%, and 46% for Australasia, Canada, and the United States, respectively. Over 90% of EPs reported that they would consider using clinical decision rules for HF, CAP, and COPD. The median required sensitivity for death within 14 days was 97 to 98% for all conditions.Conclusions:EPs are likely to adopt highly sensitive clinical decision rules to predict the need for hospital admission for patients over 50 years with COPD, HF, or CAP.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 03/2012; 14(2):83-9. · 1.05 Impact Factor
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ABSTRACT: Four to 10% of patients with transient ischemic attack (TIA) suffer a stroke or die within 7 days. Our objectives were to determine (1) current practice for investigating and treating emergency department (ED) patients with TIA, (2) willingness to use a clinical decision rule to identify patients at high risk of impending stroke or death, and (3) the required sensitivity of this rule.
We administered a mail survey to a random sample of members of three national emergency physician associations in Australia, Canada, and the United States using a modified Dillman technique. A prenotification letter and up to three surveys were sent.
A total of 801 responses (53.7%) from 1,493 surveys were received; 53.6% (95% CI 47.5-59.7) of emergency physicians reported routinely admitting TIA patients, ranging from 6.6% in Canada to 56.7% in the United States, and 9.9% of emergency physicians have a stroke prevention clinic, with 4.7% estimating that patients are seen within 7 days. A sensitive clinical decision rule for TIA patients would be used by 96.3% (95% CI 93.9-98.7) of emergency physicians. The median required sensitivity of this rule for stroke or death within 7 days was 97%.
Almost half of all TIA patients are managed as outpatients, which is neither expedited nor in a dedicated stroke clinic. Emergency physicians indicate a willingness to use a highly sensitive clinical decision rule to triage TIA patients.
CJEM: Canadian journal of emergency medical care = JCMU: journal canadien de soins medicaux d'urgence 01/2011; 13(1):19-27. · 1.05 Impact Factor