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Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.
We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.
A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.
Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
Introduction: The Ontario emergency department (ED) Return Visit Quality Program (RVQP) launched in 2016 and aims to promote continuous quality improvement (QI) in the province's largest EDs. The program mandates routine audits of cases involving patients who had ED return visits within 72hrs that led to admission to hospital, in order to identify quality issues that can be tackled through QI initiatives. Our objective was to formally evaluate how well the RVQP achieved its aim of promoting continuous QI at participating sites using the constructivist grounded theory. Methods: Using a semi-structured interview guide, we employed a maximum variation sampling approach to ensure diverse representation across several geographical and institutional experiences (e.g., urban vs. rural, academic vs. community). Selected RVQP program leads were invited to participate in a phone interview to yield maximal insight, additionally using a snowball sampling approach to reach non-lead physicians to capture the penetration of the program. Interviews were conducted until thematic saturation was reached and no new insights were gleaned. Interviews were initially cross-performed by two members of the research team, recorded, transcribed, and de-identified. Data analysis was conducted using a constant comparative approach through the development of a coding framework and triangulation with the respondents’ ED setting. We then grouped, compared and refined our analytic categories through an inductive, iterative approach. Results: Between June and August 2018, we interviewed 32 participants, including 21 RVQP program leads and 11 non-lead physicians, from a total of 23 diverse sites (out of 84). Our analysis suggests that the RVQP provides a structured method for EDs to frame the continuous collection of data in order to channel activities towards quality improvement projects based on identified needs. Success factors included: greater involvement with QI processes prior to the RVQP leading to more openness to improvement, a more collaborative approach to RVQP implementation which led to greater front-line workers’ understanding and engagement, and more resources dedicated to implementing the RVQP as well as tackling the quality issues it identified. Conclusion: This study evaluated the impact of an innovative and large-scale program aimed at improving the culture of quality in Ontario EDs. While the program is still relatively new, early results show that there are key elements of EDs that support building a culture of QI.
Introduction: Little is known about the variety of roles volunteers play in the emergency department (ED), and the potential impact they have on patient experience. The objective of this scoping review was to identify published and unpublished reports that described volunteer programs in EDs, and determine how these programs impacted patient experiences or outcomes. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. A grey literature search was also conducted (Web of Science, ProQuest, Canadian Business and Current Affairs Database ProQuest Dissertations and Theses Global). Two reviewers independently screened titles and abstracts, reviewed full text articles, and extracted data. Results: The search strategy yielded 4,589 potentially relevant citations. After eliminating duplicate citations and articles that did not meet eligibility criteria, 87 reports were included in the review. Of the included reports, 18 were peer-reviewed articles, 6 were conference proceedings, 59 were magazine or newspaper articles, and 4 were graduate dissertations or theses. Volunteer activities were categorized as non-clinical tasks (e.g., provision of meals/snacks, comfort items and mobility assistance), navigation, emotional support/communication, and administrative duties. 52 (59.8%) programs had general volunteers in the ED and 35 (40.2%) had volunteers targeting a specific patient population, including pediatrics, geriatrics, patients with mental health and addiction issues and other vulnerable populations. 20 (23.0%) programs included an evaluative component describing how ED volunteers affected patient experiences and outcomes. Patient satisfaction, follow-up and referral rates, ED and hospital costs and length of stay, subsequent ED visits, medical complications, and malnutrition in the hospital were all reported to be positively affected by volunteers in the ED. Conclusion: This scoping review demonstrates the important role volunteers play in enhancing patient and caregiver experience in the ED. Future volunteer engagement programs implemented in the ED should be formally described and evaluated to share their success and experience with others interested in implementing similar programs in the ED.
Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.
Introduction: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple shocks during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) has been proposed as a treatment option for patients in shock refractory VF. We sought to compare DSED to standard therapy with regards to VF termination and return of spontaneous circulation (ROSC) for patients presenting in shock refractory VF. Methods: We performed a retrospective review of all treated adult OHCA who presented in VF and received a minimum of three successive shocks over a two year period beginning on Jan 1, 2015 in four Canadian EMS agencies. Using ambulance call reports and defibrillator files, we compared VF termination (defined as the absence of VF at the rhythm check following defibrillation and 2 minutes of CPR) and VF termination into a perfusing rhythm with ROSC between patients who received standard therapy (CPR, defibrillation, epinephrine and antiarrhythmics) and those who received DSED (after on-line medical consultation) for shock refractory VF. Cases of traumatic cardiac arrest and those who presented in VF but terminated VF prior to 3 successive shocks were excluded. Results: Among 197 patients who met the study criteria for shock refractory VF, 161 (81.7%) patients received standard therapy and 36 (18.3%) received DSED. For the primary outcome, VF termination was significantly higher for DSED compared to standard therapy (63.9% vs 18.0%; Δ45.9%; 95% CI: 28.3 to 60.5). For the secondary outcome of VF termination into ROSC, DSED was associated with significantly higher ROSC compared to standard care (33.3% vs 13%; Δ20.3%; 95% CI:13.0 to 33.3). The median (IQR) number of failed standard shocks prior to DSED was 8 (6, 10). When DSED terminated VF, it did so with a single DSED shock in 69.6% of cases. Conclusion: Our observational findings suggest improved VF termination and ROSC are associated with DSED compared to standard therapy for shock refractory VF. An appropriately powered randomized controlled trial is required to assess the impact of DSED on patient-important outcomes.
Introduction: The Canadian population is aging and an increasing proportion of emergency department (ED) patients are seniors. ED visits among seniors are frequently instigated by a fall at home. Some of these patients develop intracranial hemorrhage (ICH) because of falling. There has been little research on the frequency of ICH in elderly patients who fall, and on which clinical factors are associated with ICH in these patients. The aim of this study was to identify the incidence of ICH, and the clinical features which are associated with ICH, in seniors who present to the ED having fallen. Methods: This was a prospective cohort study conducted in three EDs. Patients were included if they were age >65 years, and presented to the ED within 48 hours of a fall on level ground, off a bed/chair/toilet or down one step. Patients were excluded if they fell from a height, were knocked over by a vehicle or were assaulted. ED physicians recorded predefined clinical findings (yes/no) before any head imaging was done. Head imaging was done at the ED physician's discretion. All patients were followed for 6 weeks (both by telephone call and chart review at 6 weeks) for evidence of ICH. Associations between baseline clinical findings and the presence of ICH were assessed with multivariable logistic regression. Results: In total, 1753 patients were enrolled. The prevalence of ICH was 5.0% (88 patients), of whom 74 patients had ICH on the ED CT scan and 14 had ICH diagnosed during follow-up. 61% were female and the median age was 82 (interquartile range 75-88). History included hypertension in 76%, diabetes in 29%, dementia in 27%, stroke/TIA in 19%, major bleeding in 11% and chronic kidney disease in 11%. 35% were on antiplatelet therapy and 25% were on an anticoagulant. Only 4 clinical variables were independently associated with ICH: bruise/laceration on the head (odds ratio (OR): 4.3; 95% CI 2.7-7.0), new abnormalities on neurological examination (OR: 4.4; 2.4-8.1), chronic kidney disease (OR: 2.4; 1.3-4.6) and reduced GCS from baseline (OR: 1.9; 1.0-3.4). Neither anticoagulation (OR: 0.9; 0.5-1.6) nor antiplatelet use (OR: 1.1; 0.6-1.8) appeared to be associated with ICH. Conclusion: This prospective study found a prevalence of ICH of 5.0% in seniors after a fall, and that bruising on the head, abnormal neurological examination, abnormal GCS and chronic kidney disease were predictive of ICH.
Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The objective of this study was to explore the lived experiences and perceptions of care of women treated for early pregnancy complications in the ED and early pregnancy clinic (EPC). Methods: We conducted an interpretive phenomenological qualitative study of women who presented to the ED or EPC of an urban tertiary care hospital with early pregnancy loss or threatened loss. We employed purposive sampling to recruit participants for in-depth, one-on-one telephone interviews conducted approximately 6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Our research team of two qualitative researchers, a clinician, a clinical researcher, and a research student performed a phenomenologically-informed thematic analysis including three phases of coding to identify essential patterns of lived experience and meaning across the sample. Results: Interviews were completed with 30 women between July and August 2018. Participants ranged in age from 22 to 45 years and reflected the diversity of the multicultural city where the study occurred. Four key themes of patient experience were identified: tensions between what is known and unknown by women and ED staff about early pregnancy complications and care in hospital, stigmatization of early pregnancy complications and ED use, normalization of a chaotic experience, and the overwhelm of unexpected outcomes during the ED visit. Conclusion: The perspectives of women attending the ED or EPC for early pregnancy complications highlights the ways in which the current health care system minimizes and medicalizes early pregnancy complications in this setting and fails to adequately support these women. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are traumatic for patients and families. However, the participants’ negative experiences occurring in the ED were often mitigated with their care in their follow-up with the EPC.
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
Introduction: Alcohol use disorder (AUD) is a chronic relapsing and highly comorbid disease. Patients suffering from AUD are frequently seen in the emergency department (ED) presenting intoxicated or in withdrawal. Brief interactions in the ED are often the only portal of entry to the healthcare system for many of these patients. Oral naltrexone and long acting injectable naltrexone are effective treatment options for AUD associated with decreased cravings, shorter length of hospital stay, and lower cost of healthcare utilization. This study's objective was to perform a systematic review of the literature evaluating initiation of naltrexone in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing initiation of naltrexone in patients (≥18 years) to standard care in the ED were included. Two reviewers independently screened titles and abstracts, reviewed full text articles for inclusion, assessed quality of the studies, and extracted data. Results: The search strategy yielded 183 potentially relevant citations. After eliminating duplicate citations and studies that did not meet eligibility criteria, 10 articles were retrieved for full text review. There were no published RCTs that examined naltrexone initiation in the ED. There is one ongoing study being conducted in New York, which aims to assess naltrexone initiation in the ED and measure health outcomes and quality of life of study participants, as well as potential healthcare cost savings. Conclusion: The lack of published research in this area demonstrates a significant gap in knowledge. It is clear that well-designed RCTs are needed to evaluate the effectiveness of initiating naltrexone for those with AUD at the ED visit.
Introduction: Patient assessment is a fundamental feature of non-emergency community paramedicine (CP) home visit programs. In the absence of a recognized standard for CP assessment, current assessment practices in CP programs are unknown. Without knowing what community paramedics are assessing, it is difficult to ascertain what should be included in patient care plans, whether interventions are beneficial, or whether paramedics are meeting program objectives. Our objective was to summarize the content of assessment instruments used in CP programs in order to describe the state of current practice. Methods: We performed an environmental scan of all CP programs in Ontario, Canada, and employed content analysis to describe current assessment practices in CP home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. Findings were compared at the domain and sub-domain of the ICF. Results: Of 54 paramedic services in Ontario, 43 responded to our request for information. Of 24 services with CP home visit programs, 18 provided their intake assessment forms for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Overall, most assessments included some content from each of the domains outlined in the ICF, including: Impairments of Body Functions, Impairments of Body Structures, Activity Limitation and Participation, and Environmental Factors. At the sub-domain level, only assessment of Impairments of the Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems appeared in all assessments. Few CP home visit program assessments covered most ICF sub-domain categories and many items classified to specific categories were included in only a few assessments. Conclusion: CP home visit programs complete multi-domain assessments as part of patient intake. The content of CP assessments varied across Ontario, which suggests that care planning and resources may not be consistent. Current work on practice guidelines and paramedic training can build from descriptions of assessment practices to improve quality of care and patient safety. By identifying what community paramedics assess, evaluation of the quality of CP home visit programs and their ability to meet program objectives can be improved and benchmarks in patient care can be established.
Introduction: Alberta has one of the highest rates of domestic violence (DV) in the country. Emergency departments (EDs) and urgent care centres (UCCs) are significant points of opportunity to screen for DV and intervene. In Alberta, the Calgary Zone began a universal education and direct inquiry program for DV in EDs and UCCs for patients > = 14 years in 2003. The Calgary model is unique in that (a) it provides universal education in addition to screening and (b) screening is truly universal as it includes all age groups and genders. While considering expanding this model provincially, we engaged in the GRADE Adolopment process, to achieve multi-stakeholder consensus on a provincial approach to DV screening, as herewith described. Methods: Using GRADE, we synthesized and rated the quality of evidence on DV screening and presented it to an expert panel of stakeholders from the community, EDs, and Alberta Health Services. There was moderate certainty evidence that screening improved DV identification in antenatal clinics, maternal health services and EDs. There was no evidence of harm and low certainty evidence of improvement in patient-important outcomes. As per Adolopment, the expert panel reviewed the evidence in the context of: a) values and preferences b) benefits and harms, and c) acceptability, feasibility, and resource implications. Results: The panel came to a unanimous decision to conditionally recommend universal screening, i.e., screening all adults above 14 years of age in EDs and UCCs. By conditional, the panel noted that EDs and UCCs must have support resources in place for patients who screen positive to realize the full benefit of screening and avoid harm. The panel deemed universal screening to be a logistically easier recommendation, compared to training healthcare professionals to screen certain subpopulations or assess for specific symptoms associated with DV. The panel noted that despite absence of evidence that screening would impact patient-important outcomes, there was evidence that effective interventions following a positive screen could positively impact these outcomes. The panel stressed the importance of evidence creation in the context of absence of evidence. Conclusion: A GRADE Adolopment process achieved consensus on provincial expansion of an ED-based DV screening program. Moving forward, we plan to gather evidence on patient-important outcomes and understudied subpopulations (i.e. men and the elderly).
Introduction: Frailty is a state of vulnerability affecting older adults, and has been associated with adverse events such as increased risk of institutionalization, falls, functional decline, and mortality. Previous research suggests that emergency department (ED) physicians are much less comfortable managing the complex care needs of frail, older adults. The objective of this study was to identify successful strategies and expert skills that ED physicians possess to optimally manage the frail, older patient. Methods: An interpretive descriptive qualitative study was conducted. One of the investigators contacted the site leads of 12 academic and community EDs across Canada to identify ED physicians who they perceived as being highly skilled in the care of frail, older patients. 22 individual physicians were identified and 13 physicians representing 10 EDs were invited to participate in a 30-minute semi-structured interview. Transcripts were coded by two members of the research team. Data collection is ongoing and analyses will occur until thematic saturation. Results: All participants indicated they were very comfortable managing the frail, older patient in the ED. Awareness of issues related to this patient population were triggered by both clinical and personal experiences, as well as institutional priorities. When asked how they developed their specific skills for this patient population, participants stated they received limited formal training during residency and early practise, but relied on situational learning, access to role models and engagement in self-directed learning. Participants identified three predominant management strategies for the care of the frail, older patient: thorough patient interaction at the start of the clinical encounter to maximize efficiency; engaging in teamwork to manage complex issues; and early involvement of the family/caregivers. Interestingly, not all participants used the term frailty, however most reflected principles of the concept in their discussion. Conclusion: Currently, principles of caring for frail, older adults are not widespread in emergency medicine residency training. These findings suggest that frailty care frequently requires an alternative clinical approach, which is often derived from personal experience, self-directed and experiential learning. Future educational initiatives should derive, implement and evaluate a wide-spread curriculum to teach the skills required to optimally care for these patients.
Introduction: Choosing Wisely Canada guidelines suggest that in the absence of red flags or clinical indicators suggestive of serious underlying conditions, physicians should not order radiological images for patients presenting with non-specific low back pain, and current recommendations do not endorse routine prescribing of opioids for this condition. The objective of this study was to determine how many patients presenting to the ED with non-traumatic low back pain have spinal imaging and how many are discharged home on opioids. Methods: We conducted a retrospective medical record review for adult (>17 years) patients presenting to an academic tertiary care ED with non-traumatic low back pain from April 1st 2014 to March 31st 2015 (pre-guideline) and April 1st 2017 to March 31st 2018 (post-guideline). Patients were excluded if they were >70 years old, were not discharged home, had a traumatic injury, features of cauda equina syndrome, weight loss, history of cancer, fever, night sweats, chronic use of systemic corticosteroids, chronic use of illicit intravenous drugs, first episode of low back pain over 50 years of age, abnormal reflexes, loss of motor strength or loss of sensation in the legs. Results: 1060 (545 pre-guideline, 515 post-guideline) were included. Mean (SD) age was 39.6 (12.3) years and 549 (51.8%) were female. Pre-guideline, 45 (8.3%) patients had spinal imaging, compared to 39 (7.6%) post-guideline (Δ 0.7%; 95% CI: −2.6% to 4.0%). Of the 84 (7.9%) patients who had spinal imaging, 4 (8.9%) had pathologic findings pre-guideline, compared to 10 (25.6%) patients post-guideline. The proportion of patients discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines (40.9% vs. 11.1%; Δ29.8%; 95% CI: 24.8% to 34.7%). Conclusion: Choosing Wisely Canada guidelines did not appear to alter the rate of imaging for patients presenting to the ED with non-traumatic low back pain. Overall the rate of spinal imaging was lower than expected. The proportion of patients who were discharged home with a prescription for opioids was lower after the Choosing Wisely Canada guidelines, however we don't know if this represents an overall trend in the reduction of opioid prescribing, or a specific change in practice related to the ED management of low back pain.
Despite extensive research on organizational virtue, our understanding about factors that promote virtue within organizations remains unclear. Drawing on upper echelon theory, we examine the relationship between five top management team (TMT) characteristics and organizational virtue orientation (OVO)—the integrated set of values and beliefs that support ethical traits and virtuous behaviors of an organization. Specifically, we utilize prospectuses of initial public offering (IPO) firms and 10-K post-IPO filings to explore how TMT composition with respect to member age, tenure, education, functional background, and gender influences OVO. Additionally, we examine the moderating effects of organizational size, and argue that the more expansive structures and processes associated with larger organizations diminish the main relationships. Our findings, using two sources of data, are consistent, but somewhat mixed in their support for our hypotheses. Overall, TMT characteristics do appear to influence OVO, but in more complex and counterintuitive ways than initially expected.
Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
Introduction: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised; CIWA-Ar) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a web-based curriculum to teach clinicians how to accurately assess and treat AWS. Methods: This was a three-phase educational program consisting of a series of 3 e-learning modules of core competency material, in-person seminar to orient learners to high fidelity simulation, and summative evaluation in an OSCE setting using a standardized patient. To determine the ED impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the ED pre and post training. ED length of stay, total dose of benzodiazepines administered in the ED, and number of prescriptions and unit benzodiazepine doses given upon discharge were also recorded. Results: 74 nurses from an academic ED completed the AWS curriculum. There were 130 and 126 patients in the pre and post AWS training periods, respectively. Management of AWS was not compliant with CIWA-Ar protocol in 78 (60.0%) and 46 (36.5%) patients pre and post AWS training, respectively ( 23.5%; 95% CI: 11.3%, 34.7%), resulting in administration of benzodiazepine when it was not required, or not giving benzodiazepines with a CIWA-Ar score of 10. There was an average of 4 CIWA-Ar scores per patient in both the pre and post implementation periods. Prior to AWS training, 144/560 (25.5%) CIWA-Ar scores resulted in a breach of protocol, compared to 64/547 (11.7%) following AWS training ( 13.8%; 95% CI: 9.3%, 18.3%). Median total dose of benzodiazepines administered in the ED was lower after the implementation of the AWS curriculum (40mg vs 30mg; 10 mg; 95% CI: 0mg, 20mg). ED length of stay and the amount of benzodiazepines given to patients at discharge were similar between groups. Conclusion: This AWS curriculum appears to be an effective way to train ED clinicians on the proper administration of the CIWA-Ar protocol, and results in improved patient care.
Introduction: The emergency department (ED) is often the first point of access to the health care system for patients with an acute mental health crisis. Outpatient resources are limited, typically do not operate after hours, and patients and their families often lack sufficient information on where and how to access mental health services within their communities. The objective of this study was to determine which community healthcare resources patients attempted to access for their mental health condition prior to presenting to the ED. Methods: Between April 2016 to June 2017, a convenience sample of adult ( 18 years) patients presenting to an academic ED (annual census 65,000) with a mental health complaint were invited to complete a 23-item, paper-based survey. The questionnaire was pilot-tested and peer-reviewed for feasibility and comprehension. Results: Of the 200 patients who completed the survey, mean (SD) age was 37 (16) years and 96 (48%) were male. 20 (10%) patients were brought to the ED involuntarily by police services. 175 (88%) had been previously diagnosed with a mental health condition, the most common being depression and/or anxiety (n=134, 67%). 47 (24%) patients indicated they were currently only connected to a primary care provider, while 94 (47%) patients indicated they had existing relationships with multiple mental healthcare providers. 117 (59%) patients attempted to see an alternative healthcare provider prior to coming to the ED. 78 (39%) patients had a pending scheduled appointment with a healthcare provider for their mental health condition, 44 (56%) of which were within 7 days of their ED visit, but chose to seek care in the ED. 38 (19%) patients either had a referral with no appointment date set, or had an impending mental health appointment scheduled more than 30 days from their ED visit. Conclusion: These findings suggest that most patients seeking ED care during a mental health crisis do so despite being connected to alternative healthcare providers and outpatient services. Future studies should attempt to determine reasons why patients with mental health conditions seek care in the ED, and examine barriers to mental health care in the community and outpatient setting.
Introduction: The objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the ED where ectopic pregnancy had not yet been excluded. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes and 71 (12.9%) had other outcomes which included therapeutic abortion, molar pregnancy or resolution of HCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal US during their index ED visit, 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy. Conclusion: These results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.
Introduction: Checklists used during intubation have been associated with improved patient safety. Since simulation provides an effective and safe learning environment, it is an ideal modality for training practitioners to effectively employ an airway checklist. However, physician attitudes surrounding the utility of both checklists and simulation may impede the implementation process of airway checklists into clinical practice. This study sought to characterize attitudinal factors that may impact the implementation of airway checklists, including perceptions of checklist utility and simulation training. Methods: Emergency medicine (EM) residents and physicians working more than 20 hours/month in an emergency department from two academic centres were invited to participate in a simulated, randomized controlled trial (RCT) featuring three scenarios performed with or without the use of an airway checklist. Following participation in the scenarios, participants completed either a 26-item (control group), or 35-item (checklist group) paper-based survey comprised of multiple-choice, Likert-type, rank-list and open-ended questions exploring their perceptions of the airway checklist (checklist group only) and simulation as a learning modality (all participants). Results: Fifty-four EM practitioners completed the questionnaire. Most control group participants (n=24/25, 96.0%) believed an airway checklist would have been helpful (scored 5/7 or greater) for the scenarios. The majority of checklist group participants (n=29) believed that the checklist was helpful for equipment (27, 93.1%) and patient (26, 89.6%) preparation, and post-intubation care (21, 82.8%), but that the checklist delayed definitive airway management and was not helpful for airway assessment, medication selection, or choosing to perform a surgical airway. This group also believed that using the airway checklist would reduce errors during intubation (27, 93.1%) and that the simulated scenarios were beneficial for adopting the use of the checklist (28, 96.6%). Fifty-three participants (98.1%) believed that simulation is beneficial for continuing medical education and 51 respondents (94.4%) thought that skills learned in this simulation were transferable. Conclusion: EM practitioners participating in a simulation-based RCT of an airway checklist had positive attitudes towards both the utility of airway checklists and simulation as a learning modality. Thus, simulation may be an effective process to train practitioners to use airway checklists prior to clinical implementation.
Introduction: Emergency department (ED) providers are frequently challenged with how best to treat acute pain in older patients, specifically when non-opioid analgesics are insufficient or contraindicated. Studies have documented older patients presenting to the ED with painful conditions are less likely to receive pain medications than younger patients, and this inadequate pain control has been associated with increased risk of delirium and longer hospital stays. As there are no guidelines informing best practice of analgesia in the older adult population, emergency physicians often report uncertainty regarding the ideal choice of opioid analgesic. The objective of this study was to compare the efficacy of opioid analgesics for acute pain in older adults (70 years) in the ED. Methods: Electronic searches of Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing the efficacy of 2 or more opioid analgesics for acute pain in older patients (70 years) in ambulatory settings (i.e., EDs, clinics) were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Results: After screening titles and abstracts of 1297 citations, the full-texts of 63 studies were reviewed, and 1 study met the inclusion criteria. This study allocated patients to receive either single dose of 0.0075-mg/kg IV hydromorphone versus 0.05-mg IV morphine and found no clinical or statistical difference between the two treatments in older adults presenting to an urban academic ED with acute, severe pain. Conclusion: The lack of published research in this area demonstrates a significant gap in the existing knowledge of the comparative efficacy of opioid analgesics in this growing patient population and that well-designed RCTs are urgently needed.