To define the range of clinical conditions Canadian emergency pediatricians consider appropriate formanagement by physician assistants (PAs) and the degree of autonomy PAs should have in the pediatric emergency department (PED).

We conducted a cross–sectional, pan-Canadian survey using electronic questionnaire technology: the Active Campaign Survey tool. We targeted PED physicians using the Pediatric Emergency Research Canada (PERC) network database (N = 297). Three outcome measures were assessed: demographic information, familiarity with PAs, and PA clinical roles in the PED. The level of PA involvement was assessed for 57 common nonemergent clinical conditions.

Of 297 physicians, 152 completed the survey, for a response rate of 51.2%. None of the 57 clinical categories achieved at least 85% agreement regarding PA management without direct physician involvement. Twenty-four clinical conditions had ≥ 15% agreement that any PA involvement would be inappropriate. For the remaining 33 clinical conditions, more than 85% of respondents felt that PA could appropriately manage but were divided between requiring direct and only indirect physician supervision. Respondents' selection of the number of conditions felt to be appropriate for PA involvement varied between the size of the emergency department (ED) in which they work (larger EDs 87.7–89.1% v. smaller EDs 74.2%) and familiarity with the clinical work of PAs in the ED (90.5–91.5% v. 82.2–84.7%).

This national survey of Canadian PED physicians suggests that they feel PAs could help care for a large number of nonemergent clinical cases coming to the PED, but these clinical encounters would have to be directly supervised by a physician.

To determine the willingness of parents of children visiting a pediatric emergency department to have a physician assistant (PA) assess and treat their child and the waiting time reduction sufficient for them to choose to receive treatment by a PA rather than wait for a physician.

After describing the training and scope of practice of PAs, we asked caregivers of children triaged as urgent to nonurgent if they would be willing to have their child assessed and treated by a PA on that visit: definitely, maybe, or never. We also asked the minimum amount of waiting time reduction they would want to see before choosing to receive treatment by a PA rather than wait for a physician.

We approached 320 eligible subjects, and 273 (85.3%) consented to participate. Regarding whether they would be willing to have their child receive treatment by a PA, 140 (51.3%) respondents answered definitely, 107 (39.2%) said maybe, and 26 (9.2%) said never. Most respondents (64.1%) would choose to have their child seen by a PA instead of waiting for a physician if the waiting time reduction were at least 60 minutes (median 60 minutes [interquartile range 60 minutes]). Respondents' perception of the severity of their child's condition was associated with unwillingness to receive treatment by a PA, whereas child's age, presenting complaint, and actual waiting time were not.

Only a small minority of parents of children visiting a pediatric emergency department for urgent to nonurgent issues are unwilling to have their child treated by PAs.

Current documentation methods for patients with skin and soft tissue infections receiving outpatient parenteral anti-infective therapy (OPAT) include written descriptions and drawings of the infection that may inadequately communicate clinical status. We undertook a study to determine whether photodocumentation (PD) improves the duration of outpatient treatment of skin and soft tissue infections.

A single-blinded, prospective, randomized trial was conducted in the emergency departments of a community hospital and an academic tertiary centre. Participants included consecutive patients age ≥ 14 years presenting with noninvasive skin and soft tissue infections requiring OPAT. Patients in the intervention arm were treated with standard of care plus PD at each emergency physician assessment. Control subjects received care provided at the discretion of the treating physician and non-photographic documentation. The primary outcome was duration of therapy measured in half-days. The required sample size to detect a difference of one half-day was 253 patients per group (α = 0.05). Secondary outcomes included (1) completion and therapeutic failure rates, (2) patient satisfaction, and (3) physician and nurse satisfaction.

Enrolment was slower and follow-up rates lower than anticipated, and the trial was terminated when funds were exhausted. A total of 468 subjects with similar age and gender characteristics were enrolled, with 244 receiving the intervention and 224 in the control arm. The mean OPAT duration was similar in the two groups (3.6 days v. 3.5 days, p = 0.73). No differences in the rate for completion and therapeutic failure were observed (71% v. 68% and < 1% for both, respectively). Survey response rates varied significantly: patients, 65%; nurses, 17%; and physicians, 87%. Physicians endorsed more comfort with their assessment and OPAT judgment with PD (65% and 64%, respectively). Physicians cited too much time lost with technological challenges, which would affect implementation in a busy ED.

PD as an intervention is acceptable to patients and has reasonable endorsement by the majority of physicians. This trial had significant limitations that threatened the integrity of the study, so the results are inconclusive.

To identify factors known prior to triage that might have predicted hospital admission for patients triaged by the Canadian Triage Acuity Scale (CTAS) as level 5 (CTAS 5, nonurgent) and to determine whether inappropriate triage occurred in the admitted CTAS 5 patients.

We reviewed the triage records of patients triaged as CTAS 5 at the emergency departments (EDs) of three tertiary care hospitals between April 2002 and September 2009. Two triage nurses unaware of the study objective independently assigned the CTAS level in 20% of randomly selected CTAS 5 patients who were admitted. We used the kappa statistic (κ) to measure the agreement among the raters in CTAS level between the assessment of the research nurses and the original triage assessment and regression analysis to identify independent predictors of admission to hospital.

Of the 37,416 CTAS 5 patients included in this study, 587 (1.6%) were admitted. Agreement on CTAS assignment in CTAS 5 patients who were admitted was κ −0.9, (95% confidence interval [CI] 20.96 to 20.84). Age over 65 (odds ratio [OR] 5.46, 95% CI 4.57 to 6.53) and arrival by ambulance (OR 7.42, 95% CI 6.15 to 8.96) predicted hospital admission in CTAS 5 patients.

Most of the CTAS 5 patients who were subsequently admitted to hospital may have qualified for a higher triage category. Two potential modifiers, age over 65 and arrival by ambulance, may have improved the prediction of admission in CTAS 5 patients. However, the consistent application of existing CTAS criteria may also be important to prevent incorrect triage.