Bron Qui Ol It is Principi 2016

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Copyright 2016 American Medical Association. All rig hts reserved.

EffectofOxygen Desaturations onSubsequentMedical Visits

in Infants DischargedFrom the Emergency Department

WithBronchiolitis

Tania Principi,MD, FRCPC,MSc;AllanL. Coates, MD;Patricia C. Parkin, MD, FRCPC;Derek Stephens,MSc;

ZeliaDaSilva,RT; Suzanne Schuh, MD,FRCPC

IMPORTANCE Reliance on pulse oximetry has been associated with increased hospitalizations,

prolonged hospital stay, and escalation of care.

OBJECTIVE To examine whether there is a difference in theproportion of unscheduled

medical visitswithin 72 hours of emergencydepartment dischargein infants with

bronchiolitis whohave oxygen desaturations to lower than 90%for at least 1 minuteduring

home oximetry monitoring vs those without desaturations.

DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study conducted from February 6,

2008,to April 30, 2013,at a tertiary care pediatric emergencydepartment in Toronto,Ontario, Canada, among118 otherwise healthy infants aged 6 weeks to 12 monthsdischarged

home from theemergency department with a diagnosisof acute bronchiolitis.

MAINOUTCOMES AND MEASURES The primary outcome was unscheduledmedical visits for

bronchiolitis, includinga visit to any healthcare professional due to concerns about

respiratory symptoms,within 72 hours of discharge in infants with and without

desaturations. Secondary outcomes included examination of the severity and duration of the

desaturations, delayed hospitalizations within 72 hours of discharge,and the effect of activity

on desaturations.

RESULTS A totalof 118infantswere included (mean [SD] age, 4.5 [2.1] months; 69 male

[58%]). During a mean (SD) monitoring periodof 19 hours 57 minutes (10hours37 minutes),

75 of 118infants(64%) hadat least 1 desaturationevent(median continuous duration,3 minutes 22 seconds; interquartile range,1 minute54 seconds to 8 minutes 50 seconds).

Among the 118 infants,59 (50%) hadat least 3 desaturations, 12 (10%) haddesaturation for

more than 10%of themonitored time, and51 (43%)had desaturations lasting 3 or more

minutes continuously. Of the75 infants whohad desaturations, 59 (79%) haddesaturation to

80% orlessfor atleast 1 minute and 29 (39%) had desaturationto 70% or lessfor atleast

1 minute. Of the75 infants with desaturations, 18 (24%) hadan unscheduled visit for

bronchiolitisas compared with 11 of the 43 infants without desaturation (26%) (difference,

−1.6%; 95% CI,−0.15 to ; P = .66).One of the75 infants with desaturations (1%) and2 of the

43 infants without desaturations (5%)were hospitalized within 72 hours (difference, −3.3%;

95% CI,−0.04 to 0.10;P = .27). Among the62 infants with desaturations whohad diary

information,48 (77%) experienced them duringsleepor while feeding.

CONCLUSIONS AND RELEVANCE The majority of infants with mild bronchiolitisexperienced

recurrent or sustained desaturations after discharge home. Children with and without

desaturations hadcomparable rates of returnfor care, with no difference in unscheduled

return medical visits and delayed hospitalizations.

JAMAPediatr . doi:10.1001/jamapediatrics.2016.0114

Published onlineFebruary29, 2016.

Editorial

AuthorAudioInterviewat

jamapediatrics.com

Author Affiliations: Research

Institute,The Hospital for SickChildren, Toronto, Ontario, Canada

(Principi, Coates, Parkin, Stephens,

Schuh); Departmentof Pediatrics,

TheHospital for SickChildren,

Toronto,Ontario,Canada (Principi,

Parkin, DaSilva, Schuh).

Corresponding Author: Suzanne

Schuh, MD,FRCPC, Departmentof

Pediatrics, TheHospital for Sick

Children, 555 UniversityAve,

Toronto,ON M5G 1X8,Canada

([email protected]).

Research

Original Investigation

(Reprinted) E1


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Bronchiolitis is themost commonlowerrespiratory tract

infectionamong infants, characterized by wheeze and

respiratory distress. To date, the benefit of pharma-

cotherapy in the treatment of bronchiolitishas notbeen dem-

onstrated, and adequate hydration and oxygenation consti-

tuteimportant disposition criteria forthisdisease.-Following

the introduction of routine oximetry in the s, thehospi-

talization ratefor bronchiolitisrose from . per to .

per . Experts feel that this increase in hospital admis-

sions may have happened owing to a high reliance on

oximetry.- Currently, bronchiolitis represents the leading

cause of infant hospitalizations in theUnited States, at an es-

timated annual cost of $. billion.

The recent American Academy of Pediatrics bronchiolitis

guideline suggests that physicians may choose not to admin-

ister supplemental oxygen to children with oxygen satura-

tions of %and greater. However,the criteriafor using oxy-

gen therapy vary widely,,, without evidence that oxygen

saturations predict diseaseprogression. Indeed, pulse oxim-

etry in bronchiolitis is sometimes used as a proxy for illness

severity despite poorcorrelationbetween theseparameters.

This focus on and credence given to oximetry may in part re-

late to lackof evidence on the natural history of desaturations

in bronchiolitis, which are often transient, self-resolving,

and frequently not accompanied by increased respiratory

distress.

Transient desaturationsoccur in young healthy infants,

especially during sleep, and may also occur in infants with

mild bronchiolitis at home. Although it is known that many

infants with bronchiolitis remainin thehospitalowing to de-

saturations whenotherclinical discharge criteriaare met,no

studyto ourknowledgehas investigateddesaturationsin bron-

chiolitis after discharge home from the emergency depart-

ment (ED) and theireffect onuse of healthcareresources. De-

saturations occurring in infants with mild bronchiolitis in anED often resultin hospitalizations or prolonged hospital stay.

Information on the frequency, severity, and effect of desatu-

rationsin infantswith mildbronchiolitiswill helpto shedlight

on the natural course of bronchiolitis and may provide a bet-

ter perspective on the clinical significance of these events.

The primary objective of this study of infants with acute

bronchiolitis was to determine whether there is a difference

in the proportion of unscheduled medical visits within

hours of ED discharge in infants with desaturations to less

than % for at least minute during home oximetry moni-

toring vs those without desaturations. Secondary objectives

were to describe the duration and frequency of the desatura-

tions and to examine the association between desaturationsand both all-cause medical visits within hours and

delayed hospitalizations.

Methods

StudyDesignandPopulation

This was a prospective cohort study comparing outcomes of

infants discharged home with acute bronchiolitis from a ter-

tiary care pediatric ED between February , , and April

, . We included previously healthy infants aged

weeks to months diagnosed as having bronchiolitis,

defined as the first episode of respiratory distress with

coryza, cough, wheezing or crackles, and tachypnea or chest

retractions. Children with cardiopulmonary, neuromuscu-

lar, immunologic, hematologic, or airway anomalies, prema-

turity with weeks’ gestation or less, or known chronic

hypoxia were excluded, as were those needing inpatient care

and those with poor command of the English language. Writ-

ten informed consent was obtained from all participating

families. The Hospital for Sick Children Research Ethics

Board approved the study.

StudyProcedure

Infants diagnosed as having acutebronchiolitis aboutto be dis-

charged home from theED, without the need forsupplemen-

taloxygen,werescreened foreligibility andapproachedfor en-

rollment by trained research nurses on duty between noon

and midnight daysperweek. Theymaintained a logof all po-

tentiallyeligiblechildren. A structured datacollectionform wasused to document presenting demographic and clinical para-

meters. Six portable oxygen saturation monitors (Radical-;

Masimo Corp) were used for home monitoring.

Prior todischargehome,thestudynurses appliedthe satu-

ration probe to a foot of theparticipating infants andsecured

itspositionwitha self-adherent wrap andsockto minimize the

possibility of displacement. Parents were asked to keep the

monitor connected to an electrical outlet whenever possible

to avoid battery drainand instructed to avoid submerging the

infant’s foot in water. Because the standard of home care in

childrenwith bronchiolitisdoes notincludeoximetry, thestudy

monitor threshold alarms and the display of saturation val-

ues were turned off. We did use an alarm for probe dislodg-ment and instructed caretakers in how to reapply the probe.

The caretakerswerealso askedto fill outa brief diary, with in-

formation regarding the timeof sleeping,feeding, or sittingin

a car seat.

Follow-up

The study monitors and diaries were collected from patients’

homes by a courier service anddelivered to ourhospital’s de-

partmentof respiratory therapy for dataanalysis. Using stan-

dard interviewingtechniques, thestudynurses,blindedto the

KeyPoints

Question: Is there a difference in unscheduled medical visits

within 72 hoursof emergency departmentdischarge in infants

with bronchiolitis withvs without desaturations during home

oximetry monitoring?

Findings: In this cohortstudyof 118infants, 64% ofinfants hadat

least1 desaturation event. Unscheduled medical visitsoccurred in

24%of infants with desaturations vs 26%withoutdesaturations,

a nonsignificant difference.

Meaning:Themajorityof infants withmild bronchiolitis

experience desaturations afterdischarge home. Desaturations

do notpredictthe need for additional medical visits.

Research Original Investigation Oxygen Desaturations AfterDischargeof Infants WithBronchiolitis

E 2 JA MA P ed iat ri cs Published onlineFebruary 29,2016 (Reprinted) jamapediatrics.com



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oximetry results, conducted telephone follow-up of all par-

ticipants hours after discharge to identify unscheduled

medical visits for bronchiolitis and delayed hospitalizations.

Definitions

Desaturationswere definedas atleast documenteddesatura-

tionto lessthan% lasting minuteor more. Major desatura-

tions were definedas thefollowing:recurrent, ie,consisting of

atleastdesaturationstolessthan%foratleastminute;pro-

longed, ie,saturationsof less than % for%or more of the

monitored time; or sustained, ie, saturations of lessthan %

lasting or moreminutes continuously. Unscheduledmedical

visit was defined as a visit to any health care professional due

toconcernabout respiratorysymptoms. Tofurther evaluate dif-

ferencesin oxygensaturationsbetween the cohorts, a cumu-

lative hypoxemia score was calculated based on the following

previouslypublished formula withminor modification to fit

our data capture method: [(percentage of recording time with

oxygen saturation of % to %) × .] + [(percentage of re-

cording time with oxygen saturation of % or less) × ].

OutcomeMeasuresThe oxygen saturation data were downloaded and analyzed

from the study monitors using specialized software(PROFOX

Oximetry Software; PROFOX Associates, Inc). This software

wascustomizedby PROFOX Associates,Inc to capturethe key

datapointsfor desaturationeventsas defined in thisstudy. This

provided accurateand consistent analysisof the downloaded

data and generated a comprehensive report for each patient.

ThePROFOXsoftwaretechnology also allowed forthe analy-

sisof only valid sampling, excluding any artifactsor poor sig-

nal. This software eliminatesartifacts and distinguishes poor

tracingsfrom true desaturations. The PROFOX technology has

beenusedclinically around the worldand was alsousedin sev-

eral researchstudies.

The respiratory therapistwas blindedto the infants’ outcome and the software independently de-

termined whether there wasa desaturation event, ie,oxygen

saturation less than % for at least minute. The compre-

hensive report also included the number of desaturation

events, duration of desaturation, mean oxygen saturation,

and percentage of time spent with saturations between %

and % as well as less than %.

In keeping with the aforementioned definitions, partici-

pants were divided into those with desaturations and those

without as well as those with major desaturations and those

without. The primary outcome measure was an unscheduled

medical visit for bronchiolitis within hours of discharge in

infants withand without desaturations.

,

Thesecondaryout-comes werethe following: ()to describethe durationand fre-

quency of desaturations; () to examine the association be-

tween desaturations and all-cause medical visits within

hours, delayed hospitalizations, and infant activity such as

sleepingand feeding;and () to determinethe association be-

tweenmajor desaturationsand unscheduled medical visits. We

also investigated the association between desaturation and

plausible predictors thereof such as age, duration of respira-

torydistress,previous visits forbronchiolitis,history of atopy,

estimated feeding less than % of the usual amount, pre-

senting ED oxygen saturation, Respiratory Disease Assess-

ment Instrument severity level at discharge from theED, and

the useof inhaled epinephrine in the ED.The Respiratory Dis-

ease Assessment Instrument (range of possible scores, -)

is used in bronchiolitis studies to quantify the degree of re-

spiratoryabnormality by using severityof chest retractionsand

wheezing. Exploratory outcomes included a determination

of the cumulative hypoxemia score and mean oxygen satu-

ration in infants with desaturations and those without.

Sample Size

The sample size was estimated to provide % power for a

targeted % difference in the primary outcome between

the groups. Based on previous literature, we have estimated

the overall proportion of bronchiolitis revisits at %.

Assuming revisit rates of % and % in infants with vs

without desaturation, respectively, and further estimating

that % of infants with bronchiolitis have desaturation dur-

ing sleep, we estimated a sample size requirement of

approximately analyzable patients, with experiencing

desaturations and not.

StatisticalAnalysis

A statistician blinded to the study hypothesis carried out the

analysis using SAS version . statistical software (SAS Insti-

tute, Inc). Becausethe primary hypothesis was-sided(ie, do

infantswith desaturationexperiencemore revisitsthan those

without desaturation?), the difference in the primary out-

comebetween thegroupswas comparedusingthe -sidedun-

adjusted Fisher exacttest. All otheranalyseswere -tailed. The

Fisherexact test wasalso used to detect the difference in all-

causemedical visitsandhospitalizationsin the groupsas well

as forthe calculationof thedifferenceintheunscheduledmedi-

cal visits in infantswith andwithoutmajor desaturations. The

relevant% confidence intervalswere determined. Univari-ate analysis was used to identify patient characteristics to be

included in the multiple logistic regression, which deter-

mined whether there was a significant independent associa-

tion between unscheduled visits for bronchiolitis as a depen-

dent variable and the aforementioned plausible predictors

thereof. Clinicallysignificant,uncorrelated variables with uni-

variate P < . were included in thefinalmodel. Toselect the

final model, α = . was used for statistical significance.

Results

Duringthe study period, patients were screened, metenrollment criteria,and were enrolled inthe study(Figure).

A total of patients presented outside the study hours and

were missed. Most refusals occurred because of a lack of

interest in research;some parents felthomemonitoring would

incur too much inconvenience. The mean (SD) age of the in-

cluded childrenwas comparable with that of those whowere

missedand thosewho refused participation(.[.], .[.],

and . [.] months, respectively). Of the patients who

agreed to participate, had both successful follow-up and

oximetry records and participants had diary data.

Oxygen Desaturations After Discharge of Infants WithBronchiolitis Original Investigation Research

jamapediatrics.com (Reprinted) JAMA Pediatrics Published onlineFebruary 29, 2016 E3





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Among the infants included in the analysis ( male

[%]), the infants with andwithout desaturations had com-

parablecharacteristics, withthe exceptionof morepriormedi-

cal visits in the group with desaturations (Table ). However,

this difference was not significant when adjusted for mul-

tiple comparisons. Overall, the mean (SD) monitoring pe-

riod was hours minutes( hours minutes). The mean

duration of monitoring was . hours (% CI, .-.) in

children with desaturations and . hours (% CI, .-

.) in those without desaturations ( P = .).

PrimaryOutcomeOf the infants, (%) had unscheduled medical visits

for bronchiolitis within hours of the index ED visit: re-

turned to their primary care physician, visited an ED, and

both saw their primary care physician and visitedan ED. Ten

of the returninginfants (%) received additional medica-

tion: received albuterol, received inhaled corticosteroids,

received oralcorticosteroids, received antibiotics,and re-

ceived inhaled epinephrine. Among the infants, (%)

had at least desaturation to less than % lasting minute

or longerand (%) had no desaturations.Of the infants

with desaturations, (%) spent more than minute with

oxygensaturationsof %or lessand (%) spent morethan

minute with oxygen saturations of % or less. The median

continuous desaturation lasted minutes seconds (inter-

quartile range[IQR], minute seconds to minutes sec-

onds) andthe median percentage of monitoredtime spent with

oxygen saturations below % was .% (IQR, .%-.%).

There were infantswith unscheduled medical visits for

bronchiolitis symptoms among the infants with desatura-

Figure. Enrollment of PatientsInto theStudy

1019 Patients screened

139 Enrolled

118 Analyzed

880 Excluded671 Did not meet eligibility criteria

154 Comorbidities

145 Previous wheeze

26 Did not speak English

18 Admitted to hospital

5 Previously enrolled

3 Outside catchment area

2 Did not meet age criteria

1 No telephone

7 Other/unknown

209 Refused to participate

310 Did not meet definitionof bronchiolitis

10 Lost to follow-up

10 Had no oximetry data

1 Admitted before leavingemergency department

Table 1.DemographicandClinicalCharacteristics of theParticipatingInfantsa

CharacteristicDesaturation(n = 75)

No Desaturation(n = 43) Difference (95% CI)

Age, mean (SD), mo 4.6 (2.3) 4.4 (2.1) 0.2 (−0.66 to 1.02)

Male, No. (%) 41 (55) 28 (65) −10 (−0.29 to 0.08)

Temperature ≥38°C within 48 h, No. (%) 44 (59) 28 (65) −6 (−0.25 to 0.12)

History of atopy, No. (%) 57 (77) 33 (77) 0 (−0.16 to 0.16)

Family history of atopy, No. (%) 36 (48) 26 (60) −12 (−0.31 to 0.06)

Duration of respiratory distress,mean (SD), h

49 (33) 49 (77) 0 (−20.5 to 20.3)

Previous medical visit, No. (%) 52 (70) 21 (49) 21 (0.02 to 0.39)

Feeding


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tions (%) vs returning infants among the without de-

saturations(%)(difference, −.%;% CI,−.to; P = .)

(Table ).

SecondaryOutcomes

All-cause medical visits within hours of enrollment were

made by of the infantswith desaturations(%)vs of

the infants withoutdesaturations (%) (difference, −.%;

% CI, −. to .; P = .). One of the infants with de-

saturations (%) and of the without desaturations (%)

werehospitalizedwithin hours (difference, −.%; %CI,

−. to .; P = .) (Table ).

Among the participating infants, (%) experi-

enced major desaturations at home; infants (%) had re-

current desaturations, (%) had prolonged desaturations,

and (%) had sustained desaturations. Unscheduled medi-

cal visits for bronchiolitis symptoms were made by of the

infants with major desaturations (%) as compared with

of the infants without major desaturations (%) (dif-

ference, −.%; %CI, −.to .; P = .). Themediancu-

mulative hypoxemic score was . (IQR, . to .) in in-

fants with desaturations and . (IQR, . to .) in thosewithout desaturations (difference, .; % CI, . to .;

P < .). An increasein thecumulative hypoxemicscore was

not associated withincreasedunscheduledmedical visits (rela-

tive risk = ; P = .).

Based on the univariate analysis, the following variables

were included in the multivariate regression: family history

of atopy, previous medical visit,feeding less than % of the

usual amount, and the use of inhaled epinephrine in the ED.

The multivariable regression analysis showed the previous

medical visits to be independently associated with desatura-

tion (odds ratio = .; % CI, .-.; P = .). Of the in-

fants with desaturations, (%) had diary information. Of

these infants, (%) experienced desaturations duringsleep or while feeding.

Discussion

Our study shows that the majority of infants with mild bron-

chiolitisexperienced recurrent or sustained desaturationsaf-

ter discharge home.Children with and without desaturations

hadcomparable rates of returnfor care, with no difference in

unscheduled return medical visits and delayed hospitaliza-

tions within hours. These findings challenge the concept

that infants with desaturations were sicker and suggest that

pulse oximetryis notan effectivetool topredict morbiditylead-

ing to escalated return for care.

Bronchiolitis occurs in young infants who are subject to

numerous age-related physiological factors that make this

population hypoxia prone. Episodic hypoxia with saturation

nadirs as low as % to % have been previously docu-

mented in healthy young infants.,Sleeping state, feeding,

sitting in a car seat, and air travel augment the probability of

desaturations, ,- and the first factors also proved to be

true in this study.

Oxygen saturation is routinely used for assessment of

bronchiolitis, often with an expectation that an oximetry

readingrepresents a keyindicator of a child’s healthandiden-

tifieschildrenat riskfor deterioration.However, to datethere

is no informationabout howdesaturations, which occur with-

out a change in respiratory status yet are severe and long

enough to trigger monitor alarms, affect outcomes. Typi-

cally, oximeter alarmsare preset at saturationthresholds in the

vicinity of %. If the saturation reading reaches below this

threshold, the intensity of monitoring is frequently escalatedand supplemental oxygen therapy begun. To accommodate

practice variation in oximetry interpretation-andgiventhe

lackof evidenceas totheoptimalsaturation threshold onwhich

to act,the latestAmericanAcademy of Pediatrics guideline in-

cludes an option not to initiateoxygen therapyin infantswith

saturation of %or greater. Perceived needfor supplemen-

taloxygenin bronchiolitis is reported asthe sole reasonforhos-

pitalization, prolongation of hospital stay, delay in discharge

from observation units, and use of oxygen after discharge

home.,,- The results of this study suggest that infants

withbronchiolitis whoaredeemedsuitablefor dischargehome

from a respiratoryand hydration pointof view should notun-

dergo further oximetry measurements. Thisopinionhas beenexpressed in a recent editorial on the frequency of oximetry

monitoring in bronchiolitis that points out that well-

hydrated infants withbronchiolitisand saturationsof %or

greater shouldgo home and notbe monitored further. Are-

centmultisite randomized trial of continuous vs intermittent

oximetry concludedthat intermittentmonitoring can be rou-

tinely considered in stable inpatients with bronchiolitis, ow-

ing to lackof associated escalation of care,diagnostic testing,

or respiratory interventions. One advantage of spot check-

ing is that this approach is less likely to detect transient de-

Table2.Outcomesof InfantsWith andWithoutDesaturation

OutcomeDesaturation(n = 75)

No Desaturation(n = 43) Difference (95% CI)a

Primary

Unscheduled medical visits, No. (%) 18 (24) 11 (26) −1.6 (−0.15 to )

Secondary

All-cause medical visits, No. (%) 24 (32) 16 (37) −5.2 (−0.13 to 0.23)

Hospitalizations, No. (%) 1 (1) 2 (5) −3.3 (−0.04 to 0.10)

Exploratory

Cumulative hypoxemic score,median (IQR)

10.7 (2.7 to 22.6) 0.5 (0.25 to 0.75) 10.2 (6.6 to 13.8)

Abbreviation:IQR, interquartile

range.

a

Differences are expressedasdifferencein percentages where

appropriate and as difference in

medians for valuesnot expressed

as percentages.







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saturations of questionable significance. The results of our

study underscore the conclusion of the aforementioned trial

that thedesaturations missed by intermittentoximetry moni-

toring are likely clinically unimportant in the context of sat-

isfactory clinicalstatus.Of note, many of ourparticipantswith

desaturations would have undergone significant medical in-

terventions if they had been in a hospital monitoring setting.

Our definition of a desaturation event may be perceived

as arbitrary because it was based on expert opinion and ob-

served practice of interpreting oximetry results for escala-

tion of c are. Nevertheless, we have also demonstrated a lack

of association between the hypoxemic index in our popula-

tion andboth unscheduled returnmedical visitsand delayed

hospitalizations, which strengthens the study result. An-

other limitation of ourstudy is the lack of informationon out-

comes beyond hours.It is therefore possible that somechil-

dren required return for care after this time. However, most

escalation of bronchiolitismanagementhappens within theini-

tialfew daysfollowingED discharge.Althoughwe cannot gen-

eralize our study results to the inpatient population, many

stable infants with mild to moderate bronchiolitis are ob-

servedand monitoredin theED setting prior todischarge.Such

infants with self-resolving desaturations should not be sub-

jected to unnecessary medical interventions. The results of

this study also do notapplyto infants with chronic desatura-

tionsdue to chronic respiratory conditions. Theeffect of brief

hypoxia on the developing brainis not wellcharacterized and

is well beyondthe scope of this study. While chronic hypoxia

in infants andlow sleepsaturationin school-aged childrenhave

been linked to suboptimal academic performance, there is

no evidence that transient desaturations during acute bron-

chiolitis are associated with adverse outcomes.

Conclusions

Themajority of infantswithmild bronchiolitis experienced re-

currentor sustained desaturations after discharge home. Chil-

drenwith and without desaturationshad comparable rates of

return forcare,with no differencein unscheduled return medi-

cal visits and delayed hospitalizations. Pulse oximetry is not

an effective tool to predict subsequent return for care.

ARTICLE INFORMATION

Accepted for Publication: January 5, 2016.

Published Online: February 29,2016.

doi:10.1001/jamapediatrics.2016.0114.

Author Contributions: Dr Principi hadfull accessto

allof thedatain thestudy andtakes responsibility

forthe integrityof thedataand theaccuracyof the

data analysis.

Study concept and design: Principi, Coates, Parkin,

Schuh.

Acquisition, analysis, or interpretation of data: All

authors.

Drafting of themanuscript:Principi, Coates, Schuh.

Critical revision of themanuscriptfor important

intellectual content: All authors.

Statistical analysis: Stephens.

Obtained funding: Principi, Schuh.

Administrative, technical, or material support:

Principi, DaSilva, Schuh.

Study supervision: Principi, Schuh.

Conflict of Interest Disclosures: Nonereported.

Funding/Support: This studywas supported bythe

Physician’s Services IncorporatedFoundation and

the Canadian Association of Emergency Physicians.

Roleof the Funder/Sponsor:Thefundershad no

rolein thedesign andconductof thestudy;

collection, management,analysis,and

interpretation of the data;preparation, review, or

approval of themanuscript; anddecisionto submit

the manuscriptfor publication.

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