To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Choosing Wisely Canada (CWC) is a national initiative designed to encourage patient-clinician discussions about the appropriate, evidence-based use of medical tests, procedures and treatments. The Canadian Association of Emergency Physicians’ (CAEP) Choosing Wisely Canada (CWC) working group developed and released ten recommendations relevant to Emergency Medicine in June 2015 (items 1–5) and October 2016 (items 6–10). In November 2016, the CAEP CWC working group developed a process for updating the recommendations. This process involves: 1) Using GRADE to evaluate the quality of evidence, 2) reviewing relevant recommendations on an ad hoc basis as new evidence emerges, and 3) reviewing all recommendations every five years. While the full review of the CWC recommendations will be performed in 2020, a number of high-impact studies were published after our initial launch that prompted an ad hoc review of the relevant three of our ten recommendations prior to the full review in 2020. This paper describes the results of the CAEP CWC working group's ad hoc review of three of our ten recommendations in light of recent publications.
The application of evidence-informed practice in emergency medicine (EM) is critical to improve the quality of patient care. EM is a specialty with a broad knowledge base making it daunting for a junior resident to know where to begin the acquisition of evidence-based knowledge. Our study’s objective was to formulate a list of “top papers” in the field of EM using a Delphi approach to achieve an expert consensus.
Participants were recruited from all 14 specialty EM programs across Canada by a nomination process by the program directors. The modified Delphi survey consisted of three study rounds, each round sent out via email. The study tool was piloted first with McMaster University’s specialty EM residents. During the first round, participants individually listed top papers relevant to EM. During the two subsequent rounds, participants ranked the papers listed in the first round, with a chance to adjust ranking based on group responses.
A total of eight EM specialty programs responded with 30 responses across the three rounds. There were 119 studies suggested in the first round, and, by the third round, a consensus of>70% agreement was reached to generate the final list of 29 studies.
We produced, via an expert consensus, a list of top studies relevant for Canadian EM physicians in training. It can be used as an educational resource for junior residents as they transition into practice.
Choosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians’ (CAEP) top five list of recommendations, and the process undertaken to generate them.
The CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus.
The top five CAEP CWC recommendations are: 1) Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don’t prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don’t order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don’t order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.
The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.
Penetrating penile injuries occur mostly in industrial/work accidents, automobile accidents, or as a result of sexual curiosity and attempts at self-expression/mutilation. In this case report, the authors describe an accidental nailgun injury to the penis of a 46-year-old man. We discuss the management of such injuries in the emergency department, including the utility of a dorsal penile block for regional anesthesia. Although exceptionally rare, familiarity with penetrating lower urinary tract injuries may reduce their long-term repercussions on genitourinary and sexual health.
Clinical practice guidelines are an important vehicle for knowledge translation and improving patient care. For most learners, these documents can be daunting and confusing. We describe a novel educational experience that clarified the guideline generation process for learners while at the same time creating clinical educational guidelines (simplified learning aids) for junior learners in the emergency department (ED). We devised a system using near-peer mentors to generate a series of clinical education guideline learning materials created by residents and junior learners for the evaluation of undifferentiated chest pain in the ED. This process assisted in teaching residents and junior learners and generated an endurable educational product.
To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.
Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.
There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygen saturation (< 95% on room air or < 98% on any supplemental oxygen), chest radiograph, respiratory rate ≥ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).
In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.
Medical licensing bodies and professional colleges require their members to maintain a broad spectrum of knowledge, skills and attitudes, which, when taken together, define a competent emergency physician (EP). The objectives of this pilot study were: 1) to determine the resources used by academic EPs to maintain competence and 2) to determine academic EPs' learning priorities.
Using a modified Dillman method, we surveyed EPs from 2 Canadian academic tertiary health sciences centres.
Thirty-seven (68.5%) of 54 EPs responded. Of those responding, 14 (37.8%) attended grand rounds 3 times or more annually, and 34 (91.7%) attended a medical conference or course at least once annually. Thirty-three (89.2%) respondents read journal articles at least once monthly, with 22 (59.5%) of those reading synopses of original articles. Twenty-three (62.1%) received clinical updates via email, and 11 (29.7%) subscribed to an audio journal or podcast of reviews of original research. Among the CanMEDS roles, Medical Expert, Scholar and Manager were selected as top professional development priorities by more than one-third of respondents. The topics that were not selected as priorities by respondents included patient communication and charting (Communicator); conflict resolution skills and teamwork abilities (Collaborator); advocate for patient and promote health in emergency department populations (Health Advocate) and ethical conflict resolution (Professional).
The results of this pilot study suggest that in order to maintain clinical competence in emergency medicine, traditional formats of professional development (e.g., grand rounds, print media and original research) are being substituted for independent study, online media and reviews of original research. This study also suggests a strong preference for Medical Expert topics, while Professional, Health Advocate, Collaborator and Communicator topics are not a reported priority for professional development.
In this issue of the Journal, Auer and colleagues conclude that serum levels of neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, may have clinical utility for the prediction of survival to hospital discharge in patients experiencing the return of spontaneous circulation following at least 5 minutes of cardiopulmonary resuscitation. The authors used a receiver operating characteristic (ROC) curve to illustrate and evaluate the diagnostic (prognostic) performance of NSE. We explain ROC curve analysis in the following paragraphs.