We sought to develop and validate a three-station simulation-based Objective Structured Clinical Examination (OSCE) tool to assess emergency medicine resident competency in resuscitation scenarios.

An expert panel of emergency physicians developed three scenarios for use with high-fidelity mannequins. For each scenario, a corresponding assessment tool was developed with an essential actions (EA) checklist and a global assessment score (GAS). The scenarios were (1) unstable ventricular tachycardia, (2) respiratory failure, and (3) ST elevation myocardial infarction. Emergency medicine residents were videotaped completing the OSCE, and three clinician experts independently evaluated the videotapes using the assessment tool.

Twenty-one residents completed the OSCE (nine residents in the College of Family Physicians of Canada– Emergency Medicine [CCFP-EM] program, six junior residents in the Fellow of the Royal College of Physicians of Canada–Emergency Medicine [FRCP-EM] program, six senior residents in the FRCP-EM). Interrater reliability for the EA scores was good but varied between scenarios (Spearman rho 5 [1] 0.68, [2] 0.81, [3] 0.41). Interrater reliability for the GAS was also good, with less variability (rho 5 [1] 0.64, [2] 0.56, [3] 0.62). When comparing GAS scores, senior FRCP residents outperformed CCFP-EM residents in all scenarios and junior residents in two of three scenarios (p , 0.001 to 0.01). Based on EA scores, senior FRCP residents outperformed CCFP-EM residents, but junior residents outperformed senior FRCP residents in scenario 1 and CCFPEM residents in all scenarios (p 5 0.006 to 0.04).

This study outlines the creation of a high-fidelity simulation assessment tool for trainees in emergency medicine. A single-point GAS demonstrated stronger relational validity and more consistent reliability in comparison with an EA checklist. This preliminary work will provide a foundation for ongoing future development of simulationbased assessment tools.

Little information exists regarding how accurately emergency physicians (EPs) predict the probability of acute coronary syndrome (ACS). Our objective was to determine if EPs can accurately predict ACS in a prospectively identified cohort of emergency department (ED) patients who met enrolment criteria for a study of coronary computed tomographic angiography (CCTA) and were admitted for a “rule out ACS” protocol.

A prospective observational pilot study in an academic medical centre was carried out. EPs caring for patients with chest pain provided whole-number estimates of the probability of ACS after clinical review. This substudy was part of the now published Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) study, a study of CCTA and admission of patients for a rule out ACS protocol after a nondiagnostic evaluation. Predictions were grouped into probability groups based on the validated Goldman criteria. ACS was determined by an adjudication committee using American Heart Association/American College of Cardiology/European Society of Cardiology guidelines.

A total of 334 predictions were obtained for a study population with a mean age of 54 (SD 12) years, 63% of whom were male. There were 35 ACS events. EPs predicted ACS better than by chance, and increasingly higher estimates were associated with a higher incidence of ACS (p = 0.0004). The percentage of patients with ACS was 0%, 6%, 7%, and 17%, respectively, for very low, low, intermediate, and high probability groups. EPs' estimates had a sensitivity of 63% using a > 20% probability of ACS to define a positive test. Lowering this threshold to > 7% to define a test as positive increased the sensitivity of physician estimates to 89% but lowered specificity from 65% to 24%

Our data suggest that for a selected ED cohort meeting eligibility criteria for a study of CCTA, EPs predict ACS better than by chance, with an increasing proportion of patients proving to have ACS with increasing probability estimates. Lowering the estimate threshold does not result in an overall sensitivity level that is sufficient to send patients home from the ED and is associated with a poor specificity.

A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program.

Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP.

Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001).

Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.

It is believed that when patients present to the emergency department (ED) with recent-onset atrial fibrillation or flutter (RAFF), controlling the ventricular rate before cardioversion improves the success rate. We evaluated the influence of rate control medication and other variables on the success of cardioversion.

This secondary analysis of a medical records review comprised 1,068 patients with RAFF who presented to eight Canadian EDs over 12 months. Univariate analysis was performed to find associations between predictors of conversion to sinus rhythm including use of rate control, rhythm control, and other variables. Predictive variables were incorporated into the multivariate model to calculate adjusted odds ratios (ORs) associated with successful cardioversion.

A total of 634 patients underwent attempted cardioversion: 428 electrical, 354 chemical, and 148 both. Adjusted ORs for factors associated with successful electrical cardioversion were use of rate control medication, 0.39 (95% confidence interval [CI] 0.21-0.74); rhythm control medication, 0.28 (95% CI 0.15-0.53); and CHADS2 score > 0, 0.43 (95% CI 0.15-0.83). ORs for factors associated with successful chemical cardioversion were use of rate control medication, 1.29 (95% CI 0.82-2.03); female sex, 2.37 (95% CI 1.50-3.72); and use of procainamide, 2.32 (95% CI 1.43-3.74).

We demonstrated reduced successful electrical cardioversion of RAFF when patients were pretreated with either rate or rhythm control medication. Although rate control medication was not associated with increased success of chemical cardioversion, use of procainamide was. Slowing the ventricular rate prior to cardioversion should be avoided.