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Recently, many Canadian emergency departments (EDs) have struggled with physician staffing shortages. In 2006, the Ontario Ministry of Health and Long-Term Care funded a brief “emergency medicine primer” (EMP) course for family physicians to upgrade or refresh skills, with the goal of increasing their ED work intensity. We sought to determine the effect of the EMP on the ED work intensity of family physicians.
A retrospective longitudinal study was conducted of the ED work of 239 family physicians in the 2 years before and after a minimum of 6 months and up to 2 years from completing an EMP course in 2006 to 2008 compared to non-EMP physicians. ED work intensity was defined as the number of ED shifts per month and the number of ED patients seen per month. We conducted two analyses: a before and after comparison of all EMP physicians and a matched cohort analysis matching each EMP physician to four non-EMP physicians on sex, year of medical school graduation, rurality, and pre-EMP ED work intensity.
Postcourse, EMP physicians worked 0.5 more ED shifts per month (13% increase, p = 0.027). Compared to their matched controls, EMP physicians worked 0.7 more shifts per month (13% increase, p = 0.0032) and saw 15 more patients per month (17% increase, p = 0.0008) compared to matched non-EMP physicians. The greatest increases were among EMP physicians who were younger, were urban, had previous ED experience, or worked in a high-volume ED. The effect of the EMP course was negligible for physicians with no previous ED experience or working in rural areas.
The EMP course is associated with modest increases in ED work intensity among some family physicians, in particular younger physicians in urban areas. No increase was seen among physicians without previous ED experience or working in rural areas.
In Ontario, clinical decision units (CDUs) were implemented as a pilot project in 2008 by the Ministry of Health and Long-Term Care as part of its strategy to reduce emergency department (ED) waiting times. Our objective was to describe general characteristics of the program at each of the participating sites and to examine barriers and facilitators to integrating CDUs into practice.
On-site small-group interviews were conducted in two phases with ED and hospital staff at participating sites, first at 8 to 12 weeks and again at 12 months postimplementation. Interview data were analyzed using the framework approach. Unstructured field notes and CDU clinical care protocols and documentation were also reviewed.
The qualitative analysis identified 10 key themes related to integrating CDUs into EDs: shift in clinical and operational practice; administrative aspects of implementation; team building and stakeholder involvement; use of clinical care protocols; physical or virtual model of care; responsive ancillary services; involvement of specialist services; coordination with hospital and community supports; appropriate use of the CDU; and ongoing evaluation and monitoring. Each theme represents an important insight from the perspective of clinical and administrative staff at participating sites.
The implementation of CDUs is a complex process, with no single preferred clinical care or operational model. This study identifies a number of key considerations relevant to the future implementation of CDUs.
The evaluation of emergency department (ED) quality of care is hampered by the absence of consensus on appropriate measures. We sought to develop a consensus on a prioritized and parsimonious set of evidence-based quality of care indicators for EDs.
The process was led by a nationally representative steering committee and expert panel (representatives from hospital administration, emergency medicine, health information, government, and provincial quality councils). A comprehensive review of the scientific literature was conducted to identify candidate indicators. The expert panel reviewed candidate indicators in a modified Delphi panel process using electronic surveys; final decisions on inclusion of indicators were made by the steering committee in a guided nominal group process with facilitated discussion. Indicators in the final set were ranked based on their priority for measurement. A gap analysis identified areas where future indicator development is needed. A feasibility study of measuring the final set of indicators using current Canadian administrative databases was conducted.
A total of 170 candidate indicators were generated from the literature; these were assessed based on scientific soundness and their relevance or importance. Using predefined scoring criteria in two rounds of surveys, indicators were coded as “retained” (53), “discarded” (78), or “borderline” (39). A final set of 48 retained indicators was selected and grouped in nine categories (patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection). Gap analysis suggested the need for new indicators in patient satisfaction, a healthy workplace, mental health and addiction, elder care, and community-hospital integration. Feasibility analysis found that 13 of 48 indicators (27%) can be measured using existing national administrative databases.
A broadly representative modified Delphi panel process resulted in a consensus on a set of 48 evidencebased quality of care indicators for EDs. Future work is required to generate technical definitions to enable the uptake of these indicators to support benchmarking, quality improvement, and accountability efforts.
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