Point-of-care ultrasonography (PoCUS) first appeared in the 1980s in North America, but the extent of the diffusion of its adoption is unknown. We characterized early PoCUS adoption by emergency physicians in Canada and its barriers to use using Rogers' diffusion of innovations theory.

We developed a questionnaire based on a pilot study and literature review to assess past, current, and potential use of PoCUS and potential barriers to adoption. A Dillman technique for electronic surveys was used for dissemination. Using Rogers' diffusion of innovations theory, we developed and validated the Evaluation Tool for Ultrasound skills Development and Education (ETUDE). ETUDE scores allowed categorization of respondents into innovators, early adopters, majority, and nonadopters. Descriptive statistics, correlations, and x2 statistics were used to analyze the data.

The 296 respondents (36.4% of 814 surveyed) had a median age of 40 and were 72.5% male. Adoption scores using ETUDE revealed nonadopters (18.8%), majority (28.7%), early adopters (34.5%), and innovators (18.0%). Respondents endorsed “always” using PoCUS currently and in the future for focused assessment with sonography in trauma (FAST) (current 41.8%/future 88.4%), first trimester pregnancy (current 23.3%/future 73.7%), suspected abdominal aortic aneurysm (current 32.7%/future 92.6%), basic cardiac indications (current 30.7%/future 87.5%), and central venous catheterization (current 17.0%/future 80.3%). Several barriers to PoCUS were identified for part-time emergency physicians and those working in inner-city/urban/suburban settings.

This is the first study to determine the state of adoption and barriers to the introduction of PoCUS in Canadian emergency medicine practice. The novel validated ETUDE instrument should be used to evaluate the uptake of PoCUS over time.

To describe pediatric emergency medicine (PEM) physicians' reported pain management practices across Canada and explore factors that facilitate or hinder pain management.

This study was a prospective survey of Canadian pediatric emergency physicians. The Pediatric Emergency Research Canada physician database was used to identify participants, and a modified Dillman's Total Design Survey Method was used for recruitment.

The survey response rate was 68% (139 of 206). Most physicians were 31 to 50 years old (82%) with PEM training (56%) and had been in practice for less than 10 years (55%). Almost all pain screening in emergency departments (EDs) occurred at triage (97%). Twenty-four percent of physicians noted institutionally mandated pain score documentation. Ibuprofen and acetaminophen were commonly prescribed in the ED for mild to moderate pain (88% and 83%, respectively). Over half of urinary catheterizations (60%) and intravenous (53%) starts were performed without any analgesia. The most common nonpharmacologic interventions used for infants and children were pacifiers and distraction, respectively. Training background and gender of physicians affected the likelihood of using nonpharmacologic interventions. Physicians noted time restraints to be the greatest barrier to optimal pain management (55%) and desired improved access to pain medications (32%), better policies and procedures (30%), and further education (25%).

When analgesia was reported as provided, ibuprofen and acetaminophen were most commonly used. Both procedural and presenting pain remained suboptimally managed. There is a substantial evidence practice gap in children's ED pain management, highlighting the need for further knowledge translation strategies and policies to support optimal treatment.

To systematically evaluate the accuracy of text descriptions and labeling of radiologic images published in the Canadian Journal of Emergency Medicine (CJEM). Error detection by radiologists and emergency physicians and the clinical significance and educational value of these errors were assessed. Errors were also correlated with radiologist involvement in publication and imaging modality.

Thirty-three issues of CJEM were examined from January 2003 to May 2008. Electronic copies of all radiologic images published were obtained with their caption and description from the text. Identifying information was removed to present images in an anonymous fashion. Images were presented to two radiologists who, working in consensus, critically appraised each image and accompanying text. Images were then presented to two emergency department physicians who, working in consensus, critically appraised each image and accompanying text. All images with errors detected by either radiology or emergency physicians were then discussed to determine if errors would have affected clinical management or educational value. The emergency physicians also identified “underlabeled” images where it was felt that further labeling would enhance their educational value.

Forty-five articles with 82 images were obtained. At least one error was observed in 18 (40%) articles and 20 (24%) images. Two errors were present in three images, resulting in 23 errors. Of the 23 errors, 17 were image description errors and 6 were labeling errors. Five errors were detected by both radiology and emergency physicians, whereas 15 were detected only by radiologists and 3 were detected only by emergency physicians. Of these errors, 12 (52%) were rated as potentially affecting both clinical management and educational value, 5 (22%) as only affecting educational value, and 6 (26%) as nonsignificant. Radiologists were involved in six articles, including 12 images that contained no errors. There was no official radiologist involvement in 39 articles, including 70 images, 18 (26%) of which contained errors. In addition, 26 images were identified by emergency physicians as potentially benefiting from enhanced labeling to improve educational value.

Radiologic images published in the CJEM are generally of high quality; however, 23 errors were found in 82 images, 18 (78%) of which were rated as potentially affecting clinical management, educational value, or both. Radiologist involvement in the publication process may be of assistance as no errors were seen in articles that included radiologists as authors.

The Comprehensive Geriatric Assessment (CGA) is used in geriatric medicine as a means to manage the health care needs of older adults and to grade frailty. We modified the CGA so that it could be completed independently by care partners (usually family) and be used to grade frailty. Our objective was to examine the feasibility of a care partner completing the CGA at the time of the first prehospital encounter.

A prospective, observational study was conducted with a convenience sample of patients ≥ 70 years accompanied by a knowledgeable care partner. Feasibility was measured by the time required and percent completeness of items on the form based on completion by the care partner and by paramedic perception of utility.

Subjects (N 5 104) were enrolled with three postenrolment exclusions due to ineligibility. Most participants were older women living in their own home. The mean time to complete the questionnaire was 18.7 minutes (SD 11.3; median 15 minutes; interquartile range 12-20 minutes). Only 64% of the care partners recorded the time it took. Nineteen percent of paramedics completed a follow-up survey, and all felt screening for frailty was worthwhile and most (> 70%) thought that the CP-CGA may be a useful approach. The study was limited by recruitment bias of potentially eligible patients, a high level of missingness in the outcome measures of interest, and low paramedic participation rates.

We observed a high rate of item completeness of questionnaires with a mean time to complete of 18.7 minutes in a convenience sample of older patients. A small sample of paramedics universally endorsed the utility of screening for frailty in the prehospital setting, and many thought the CP-CGA was a helpful tool.

Pulmonary aspiration of gastric contents occurs 20 to 30% of the time during cardiopulmonary resuscitation (CPR) of cardiac arrest due to loss of protective airway reflexes, pressure changes generated during CPR, and positive pressure ventilation (PPV). Although the American Heart Association has recommended the laryngeal mask airway (LMA) as an acceptable alternative airway for use by emergency medical service personnel, concerns over the capacity of the device to protect from pulmonary aspiration remain.We sought to determine the occurrence of aspiration after LMA placement, CPR, and PPV.

We inserted a size 4 LMA, modified so that a vacuum catheter could be advanced past the LMA diaphragm, into the hypopharynx of 16 consecutive postexperimental mixed-breed domestic swine. Fifteen millilitres of heparinized blood was instilled into the oropharynx. Chest compressions were performed for 60 seconds with asynchronous ventilation via a mechanical ventilator. We then suctioned through the LMA for 1 minute. The catheter was removed and inspected for signs of blood. The LMA cuff was deflated, removed, and inspected for signs of blood.

None of 16 animals (95% CI 0-17%) had a positive test for the presence of blood in both the vacuum catheter and the intima of the LMA diaphragm.

In this swine model of regurgitation after LMA placement, there were no cases with evidence of blood beyond the seal created by the LMA cuff. Future studies are needed to determine the frequency of pulmonary aspiration after LMA placement during CPR and PPV in the clinical setting.

The objectives of this study were to assess current postresuscitation debriefing (PRD) practices in Canadian pediatric emergency departments (EDs) and identify areas for improvement.

A national needs assessment survey was conducted to collect information on current PRD practices and perspectives on debriefing practice in pediatric EDs. A questionnaire was distributed to ED nurses, fellows, and attending physicians at 10 pediatric tertiary care hospitals across Canada. Summary statistics are reported.

Data were analyzed from 183 participants (48.7% response rate). Although 88.8% of the participants believed that debriefing is an important process, 52.5% indicated that debriefing after real resuscitations occurs less than 25% of the time and 68.3% indicated that no expectation exists for PRD at their institution. Although 83.7% of participants believed that facilitators should have a specific skill set developed through formal training sessions, 63.4% had no previous training in debriefing. Seventy-two percent felt that medical and crisis resource management issues are dealt with adequately when PRD occurs, and 90.4% indicated thatED workload and time shortages are major barriers to effective debriefing. Most responded that a debriefing tool to guide facilitators might aid in multiple skills, such as creating realistic debriefing objectives and providing feedback with good judgment.

PRD in Canadian pediatric EDs occurs infrequently, although most health care providers agreed on its importance and the need for skilled facilitators.

To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE).

An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs.

The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5–2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4–9.4]).

Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.

Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.

A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).

Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.

Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.

The level of expertise and degree of training in neonatal resuscitation (NNR) of emergency physicians is not standardized and has not been measured. We sought to determine the self-reported comfort with, knowledge of, and experience with NNR of emergency department (ED) staff in a general ED prior to the opening of a new neonatal intensive care unit (NICU) and to explore factors associated with NNR comfort.

Using Dillman methodology, we electronically surveyed full-time emergency physicians and nurses. Participants rated knowledge, comfort, and experience on 5-point Likert scales. We used logistic regression to explore factors associated with NNR comfort.

The response rate was 67.3% (n = 107). Only 4.2% of staff reported ever participating in a NNR, and only 38.7% reported any previous NNR training. Between 75 and 85% of participants rated their comfort level in caring for neonates, sense of preparedness, and knowledge of managing a sick neonate as poor or very poor. A recent neonatal clinical encounter was the strongest predictor of perceived comfort in NNR (OR = 22.2, 95% CI 5.0-98.7), as was completion of the Neonatal Resuscitation Provider (NRP) course (OR = 3.1, 95% CI 1.4-7.0).

Perceived comfort with, knowledge of, and preparedness for NNR were poor in an urban, general ED prior to the opening of an NICU. Recent neonatal clinical encounter and participation in the NRP course were the strongest predictors of improved NNR comfort. In future work, we intend to assess the impact of simulation-based training on comfort with NNR among ED staff who primarily treat adults.