Some recently published data from Alberta (Hawkins, Ann Emerg Med 2021; disclosure: I am a co-author) indicate that the one-year mortality of emergency department patients with atrial fibrillation and flutter are similar no matter whether you the patient is treated in a high-volume or low-volume ED.

However, patients in low-volume EDs are more likely to be admitted, less likely to be cardioverted, and are more likely to have a 30-day revisit than those in moderate- or high-volume EDs. The reasons for these disparities in care and outcomes are unclear, but would be of great interest. For what it is worth, the data examined patients from 2009 to 2015--the CAEP AFF guidelines were published in 2018, and these may have assisted in standardizing care across EDs. (https://caep.ca/wp-content/uploads/2018/09/caep_acute_atrial_fibrillationflutter_best_practices_checklist_final.pdf)

Thoughts?

The Hawkins paper is at https://www.annemergmed.com/article/S0196-0644(21)00227-4/fulltext (paywalled of course).

For those unfamiliar with Twitter, know first that it's just a communication platform, a tool, and like any tool, needs to be used correctly. Creating a purely professional account with good "Twitter hygiene" can ensure that it remains worthwhile. What Twitter feeds to you depends on your behaviour - who you follow, what you like, what content you click on. The algorithm thrives on keeping you engaged and it will always throw trial balloons on your feed to see what you ignore or not, all the while learning what makes you angry or sad - and then sending you more of that. If these click-bait teases are ignored, you'll get more of the content you want - rich discussions with emergency medicine leaders, researchers and policy makers from BC and across the country.

It does help to define ahead of time what it is you are most interested in professionally, then go into Twitter with those interests first and foremost guiding your behaviour. For me, it's POCUS, rural medicine, emergency and crit care and BC health policy. And that's it. No posts of family, friends, holiday photos, cats, news articles - nothing. In other words, I am a rural BC doctor on Twitter and nothing else. Posts relate to my professional interests. Patients are blocked. I post interesting ultrasound clips for learning and teaching. The people and topics I follow are only those related to my professional interests. This is MedTwitter.

Individuals or organizations with accounts are indicated by "@" followed by the name. So the BC Emergency Network is @BCEmergMedNtwrk. Dr Julian Marsden is @drmarsbar. I'm @TracyMorton. You can choose whatever name you'd like.  And topics: topics are marked with a "#" followed by the topic. This is known as a hashtag. So point-of care ultrasound is #POCUS. MedTwitter is #Medtwitter. There are gazillions of topics, all signified by the #. You can deep dive into any topic just by knowing the hashtag.

So follow your peers. Follow FOAM leaders like Scott Weingart (@emcrit), Chris Hicks (@humanfact0rz), Anton Helman (@EMcases), Amal Mattu, Salim Rezaie and Haney Mallemat. Follow ultrasound wizards like Dan Kim, Katie Wiskar, Paul Olszynski, Robert Jones, Ben Smith and Jacob Avila. And follow people who they follow.

Soon you'll be getting just the ED/POCUS/crit care content you want, and not the crap you don't.

Drs Steven Green and David Schriger have now been far more eloquent in a recent Annals of Emergency Medicine publication (2021). In brief, here are the "good" aspects:

1. The study population is relevant

2. Predictor variables recorded independently of outcomes

3. The rule is widely used, clinically sensible, easy to apply, and can be integrated into practice.

Here are the "not good" aspects:

1. Initial sample size (122 patients with 29 MACE) not justified and insufficient.

2. Many predictor variables (for example, patient sex, type of pain) were missed, and included variables had poor inter-observer reliability, especially "history".

3. No justification for coding (ie 0, 1, or 2 points) For example, patients > 65 years with 3 or more risk factors have an automatic score of 4 (moderate risk) prior to any evaluation. NOT GOOD. While HEART score was supposed to be "Apgar for chest pain" the points are too heavily weighted to EKG, risk, and age, and insufficiently for history and troponin.

4. Importantly, despite many, many studies on the score, no one has compared the rule to unstructured physician judgement.

5. The rule sensitivity is not acceptable--most physicians will accept a 1% miss rate, and the sensitivity of the HEART score and its variants is greater than this threshold.

6. The HEART score does not inform clinical decisions with respect to follow-up.

Overall, the score provides a simple, comforting algorithm--in addition to a catchy nickname--and this likely accounts for its widespread popularity. However, clinicians are encouraged to think rather carefully about widespread application of the HEART score or any of its variants.

Happy to engage in further discussion!

It's surprising how few posts there are about point-of-care ultrasound use in the ED on the BC Emergency Network. It is entirely changing patient assessment and management in rural BC, with need particularly amplified by COVID-19.

On Haida Gwaii, access to diagnostic imaging entails a 7-hour ferry ride (each way) and between 2-5 nights away from home. Compounded by high rates of COVID-19 throughout Northwest BC and the risk of acquiring and returning infected, the majority of patients are very reluctant to go for indicated formal imaging. There is an imperative to scale and support safe POCUS use in rural BC while looking at ways of improving systems-level supports.

Recognizing its potential, the Rural Coordination Centre of BC (RCCBC) launched the "Intelligent Network for POCUS" - IN PoCUS, where 50 subsidized Clarius handheld probes were distributed to 50 rural GPs with education and support. The Clarius user interface integrates secure cloud image-storage that permits image review by specialists or virtual support tools (like RTVS). Building on IN PoCUS, the RCCBC will be developing a Provincial POCUS Strategy for rural BC. A working group of POCUS leadership will develop a Strategy this year, evaluating barriers to POCUS integration and means of improving its effectiveness and safety. An effective strategy will include a higher profile on the BC EM Network.

The BC EM Network could be a place we share images and clips and discuss the geography-specific role for POCUS in the ED. For austere or remote environments without CT or diagnostic US, nothing improves bedside care more than POCUS. Embedding POCUS into physical examination allows one to look into the body, seeing things that could only have been percussed, palpated or auscultated. Imagine the "rational clinical exam" fully revamped with POCUS integration.

Tracy Morton

Haida Gwaii Hospital & Health Centre

We want to make this a minimal barrier process, ideally with patient leaving with a blister pack of Suboxone micro dose with instructions and daily partitioned doses and linkage to outpatient OAT providers.  It may take several days to get to outpatient provider so dispensing multiple days of the induction regime makes sense.

We have come up against a hard barrier of inability to dispense more than 24 hours of medication from the ED according to our pharmacy colleagues.

Is this a legislative barrier, an edict from college of pharmacies or a local health authority ( Island Health) issue?

Has anyone been able to set up a program that allows them to dispense blister packs from the ED for this vulnerable population?

It seems with the opioid death rate and the extra financial and political resources cast into this arena that this sort of barrier should be easily surmountable?

Jason Wale, Victoria BC

Just wondering if there is any work/research/thoughts anywhere about what are the minimum standards to work in an ER. I see some ERs have no lab or XRAY. Some have limited POC. Some have one nurse and others have none. In some ERs , the docs are first call.

Is there a link between the population, which in turn dictates the acuity and frequency of the cases and the minimum standards ER docs need to have to support quality care?

Just curious if anyone has ever thought about this?

Hopefully the attachment works for everyone--while the document is 102 pages, the relevant points for emergency physicians have been highlighted to avoid eyestrain and guideline rage, and most of the germane information starts on page 38 (anticoagulation) and on page 51. (ED management)

Good news: The main points of ED management are now aligned with the CAEP guidelines.

1. Ensure patient is stable, otherwise immediate cardioversion (this is rare).

2. Ensure no acute underlying cause; if there is an underlying cause, please identify and treat

3. a. For patients with acute onset atrial fibrillation or flutter, (generally less than 48 hours, but less than 12 hours if CHADS2 > 1) please use a rhythm control method.

3.b. For patients who cannot be undergo rhythm control, attempt rate control.

4. Unless a patient is still symptomatic after treatment, or if the heart rate cannot be decreased to less than 110 beats per minute, patients can be safely discharged.

5. Pay attention to anticoagulation! At least discuss with patients and document appropriately.

Bad news: CCS has again emphasized 4 weeks of anticoagulation in every patient who undergoes rhythm conversion. CAEP has published 2 editorials arguing for a more nuanced approach (ie does every 35 year old mountain biker need a month of anticoagulation) but CCS is holding firm despite admittedly weak evidence.

A group of motivated CAEP members will be updating the CAEP 2018 guidelines to ensure congruence with the CCS approach, while hopefully maintaining some flexibility.

Keep ya posted!