In a time of major medical education transformation, emergency medicine (EM) needs to nurture education scholars who will influence EM education practice. However, the essential ingredients to ensure a career with impact in EM education are not clear.

To describe how to prepare EM educators for a high-impact career.

The Canadian Association of Emergency Physicians (CAEP) Academic Section commissioned an “Education Impact” working group (IWG) to guide the creation of consensus recommendations from the EM community. EM educators from across Canada were initially recruited from the networks of the IWG members, and additional educators were recruited via snowball sampling. “High impact educators” were nominated by this network. The high impact educators were then interviewed using a structured question guide. These interviews were transcribed and coded for themes using qualitative methods. The process continued until no new themes were identified. Proposed themes and recommendations were presented to the EM community at the CAEP 2016 Academic Symposium. Feedback was then incorporated into a final set of recommendations.

Fifty-five (71%) of 77 of identified Canadian EM educators participated, and 170 names of high impact educators were submitted and ranked by frequency. The IWG achieved sufficiency of themes after nine interviews. Five recommendations were made: 1) EM educators can pursue a high impact career by leveraging either traditional or innovative career pathways; 2) EM educators starting their education careers should have multiple senior mentors; 3) Early-career EM educators should immerse themselves in their area of interest and cultivate a community of practice, not limited to EM; 4) Every academic EM department and EM teaching site should have access to an EM educator with protected time and recognition for their EM education scholarship; and 5) Educators at all stages should continuously compile an impact portfolio.

We describe a unique set of recommendations to develop educators who will influence EM, derived from a consensus from the EM community. EM leaders, educators, and aspiring educational scholars should consider how to implement this guide towards enhancing our specialty’s educational mission.

Bier block (BB) is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet remains infrequently used in the pediatric emergency department (PED). No standardized methods of BB training have previously been described. The objective of this study was to determine whether a multimodal instructional course increases comfort with BB and translates to increased use of this technique.

A novel interdisciplinary simulation and Web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre-/post-training, and at 2 and 6 months regarding their comfort with BB. In parallel, we prospectively assessed the clinical use of BB for children ages 6 to 18 years requiring closed reduction of forearm fractures during the 24-month post-course period.

Course participation included 26 physicians and 12 nurses. Survey response rate was 100%. Course participation increased both comfort (10% pre-training v. 89% post-training, p<0.001) and the willingness to use BB (51% pre-training v. 95% post-training, p<0.001), an effect sustained at 6 months post-course (66% and 92%, respectively, p<0.001 for both). In clinical practice, there were no BBs performed prior to course administration. We observed a consistent and sustained increase in clinical use among the BB-trained physicians, with 37% of all forearm reductions performed using BB at 24 months post-course completion.

A novel combined simulation and Web-based training course increased comfort and willingness to use BB and was associated with increased use of this technique for forearm fracture reduction in the PED.

Emergency department (ED) lengths of stay are measured from the time of patient registration or triage. The time that patients wait in line prior to registration and triage has not been well described. We sought to characterize pre-triage wait times and compare them to recommended physician response times, as per the Canadian Triage and Acuity Scale (CTAS).

This observational study documented the time that consenting patients entered the ED and the time that they were formally registered and triaged. Participants’ CTAS scores were collected from the electronic record. Patients arriving to the ED by ambulance were excluded.

A total of 536 participants were timed over 13 separate intervals. Of these, 11 left without being triaged. Participants who scored either CTAS 1 or 2 (n=53) waited a median time of 3.1 (interquartile range [IQR]: 0.43, 11.1) minutes. Patients triaged as CTAS 3 (n=187) waited a median of 11.4 (IQR: 1.6, 24.9) minutes, CTAS 4 (n=139) a median of 16.6 (IQR: 6.0, 29.7) minutes, and CTAS 5 (n=146) a median of 17.5 (IQR: 6.8, 37.3) minutes. Of patients subsequently categorized as CTAS 1 or 2, 20.8% waited longer than the recommended time-to-physician of 15 minutes to be triaged.

All urban EDs closely follow patients’ wait times, often stratified according to triage category, which are assumed to be time-stamped upon a patient’s arrival in the ED. We note that pre-triage times exceed the CTAS recommended time-to-physician in a possibly significant proportion of patients. EDs should consider documenting times to treatment from the moment of patient arrival rather than registration.

To study the operational impact of process improvements on emergency department (ED) patient flow. The changes did not require any increase in resources or expenditures.

This was a 36-month pre- and post-intervention study to evaluate the effect of implementing process improvements at a community ED from January 2010 to December 2012. The intervention comprised streamlining triage by having patients accepted into internal waiting areas immediately after triage. Within the ED, parallel processes unfolded, and there was no restriction on when registration occurred or which health care provider a patient saw first. Flexible nursing ratios allowed nursing staff to redeploy and move to areas of highest demand. Last, demand-based physician scheduling was implemented. The main outcome was length of stay (LOS). Secondary outcomes included time to physician initial assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed to quantify the impact of the intervention, and whether it was sustained.

Patients totalling 251,899 attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, mean LOS decreased by 0.64 hours (p<0.005). LOS for non-admitted Canadian Triage and Acuity Scale 2 (-0.58 hours, p<0.005), 3 (-0.75 hours, p<0.005), and 4 (-0.32 hours, p<0.005) patients also decreased. There were reductions in PIA (43.81 minutes, p<0.005), LWBS (35.2%, p<0.005), and LAMA (61.9%, p<0.005).

A combination of process improvements in the ED was associated with clinically significant reductions in LOS, PIA, LWBS, and LAMA for non-resuscitative patients.

Early reperfusion therapy in the treatment of ST segment elevation myocardial infarction (STEMI) patients can improve outcomes. Silent myocardial infarction is associated with poor prognosis, but little is known about its effect on treatment delays. We aimed to characterize STEMI patients presenting without complaints of pain to the emergency departments (EDs) in Singapore.

Retrospective data were requested from the Singapore Myocardial Infarction Registry (SMIR), a national level registry in Singapore. Painless STEMI was defined as the absence of pain (chest, back, shoulder, jaw, and epigastric pain) during ED presentation. The primary outcome was door-to-balloon (D2B) time, defined as the earliest time a patient arrived in the ED to balloon inflation. Secondary outcomes were 1-month and 1-year mortality and occurrence of adverse events.

From January 2010 to December 2012, the SMIR collected 6412 cases; 10.9% of patients presented without any pain. These patients were older (median age =75 v. 58 years old), more likely to be females (39.9% v. 16.1%), Chinese (74.9% v. 62.7%), obese (median body mass index [BMI] =24.5 v. 22.1), and with history of hypertension (71.1% v. 54.6%), diabetes mellitus (48.6% v. 37.0%), and acute myocardial infarction (20.0% v. 12.3%). They had a longer median D2B (80.5 v. 63 minutes, p<0.001) and a higher occurrence of 30-day (38.4% v. 5.7%) and 1-year mortality rates (47.3% v. 8.5%).

A small proportion of STEMI patients presented without any pain to the ED. They tended to have a higher D2B and risks of mortality. Targeted effort is required to improve diagnostic and treatment efficiency in this group.

To determine if changes to the Ontario Highway Traffic Act (OHTA) in 2009 and 2010 had an effect on the proportion of alcohol-related motor vehicle collisions (MVCs) presenting to a trauma centre over a 10-year period.

A retrospective review of the trauma registry at a Level I trauma centre in southwestern Ontario was undertaken. The trauma registry is a database of all trauma patients with an injury severity score (ISS) ≥12 and/or who had trauma team activation. Descriptive statistics were calculated. Interrupted time series analyses with ARIMA modeling were performed on quarterly data from 2004-2013.

A total of 377 drivers with a detectable serum ethanol concentration (SEC) were treated at our trauma centre over the 10-year period, representing 21% of all MVCs. The majority (330; 88%) were male. The median age was 31 years, median SEC was 35.3 mmol/L, and median ISS was 21. A total of 29 (7.7%) drinking drivers died from their injuries after arriving to hospital. There was no change in the proportion of drinking drivers after the 2009 amendment, but there was a significant decline in the average SEC of drinking drivers after changes to the law. There was no difference in the proportion of drinking drivers ≤21 years after introduction of the 2010 amendment for young and novice drivers.

There was a significance decline in the average SEC of all drinking drivers after the 2009 OHTA amendment, suggesting that legislative amendments may have an impact on drinking before driving behaviour.

Antibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such as Clostridium difficile (C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers.

To determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage.

Interventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital’s ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED.

There was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p<0.001) by 2.26 urine cultures per 100 ED patient visits.

FLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.

A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from “always” to “never” to capture usual practice.

The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would “always/often” be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would “always/often” administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).

Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Triage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice.

Variables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTAS arrival) score was compared to the initial nursing CTAS score (CTAS initial) and the final nursing CTAS score (CTAS final) incuding nursing overrides. Interrater reliability between ED CTAS initial and EMS CTAS arrival scores was assessed. Interrater reliability between ED CTAS final and EMS CTAS arrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated.

Our primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTAS arrival and ED CTAS initial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTAS arrival) score and the final ED triage CTAS score (CTAS final) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466).

Interrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.

Approximately 4.3 million Canadians are without a primary care physician, of which 13% choose the emergency department (ED) as their regular access point to health care. We sought to identify factors associated with preferential ED use over other health services. We hypothesized that socioeconomic barriers (i.e., employment, health status, education) to primary care would also prevent access to ED alternatives.

Data from the Canadian Community Health Survey, 2007 to 2008, were analysed (N=134,073; response rate 93.5%). Our study population comprised 14,091 individuals identified without a primary care physician. Socioeconomic variables included employment, health, and education. Covariates included chronic health conditions, immigrant status, gender, age, and mental health. Prevalence estimates and 95% confidence intervals (CIs) for each variable were calculated. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors and their interactions after adjustment for relevant covariates.

The sample comprised 57.2% males from across Canada. Employment (OR 0.73 [95% CI: 0.59-0.90]), good health (OR 0.73 [95% CI 0.57-0.88]), and post-secondary education (OR 0.68 [95% CI 0.53-0.88]) reduced respondents use of the ED. The reduced odds of ED use were independent of chronic conditions, mental health, gender, poor mobility, province, and age.

Low socioeconomic status dictates preferential ED use in those without a primary care physician. Specific policy and system development targeting this at-risk population are indicated to alter ED use patterns in this population.

To compare emergency department triage nurses’ time to triage and accuracy of a simulated mass casualty incident (MCI) population using a computerized version of CTAS or START systems.

This pilot study was a prospective trial using a convenience sample. A total of 20 ED triage nurses, 10 in each arm of the study, were recruited. The paper-based questionnaire contained nine simulated MCI vignettes. An expert panel arrived at consensuses on the wording of the vignettes and created a standard triage score from which to compare the study participants. Linear regression and chi-squared test were used to examine the time to triage and accuracy of triage, respectively.

The mean triage time for computerized CTAS (cCTAS) and START were 138 seconds/patient and 33 seconds/patient, respectively. The effect size due to triage method was 108 seconds/patient (95% CI 83-134 seconds/patient). The cumulative triage accuracy for the cCTAS and START tools were 70/90 (77.8%) and 65/90 (72.2%), respectively. The percent difference between cumulative triage was 6% (95% CI −19-8%).

Triage nurses completed START triage 105 seconds/patient faster when compared to cCTAS triage and a similar level of accuracy between the two methods was achieved. However, when the typing time is taken into consideration cCTAS took 45 seconds/patient longer. The use of either CTAS or START in the ED during a MCI may be reasonable but choosing one method over another is not justified from this investigation.

Pediatric acute gastroenteritis (AGE) is a common condition with high health care utilization, persistent practice variation, and substantial family burden. An initial approach to resolve these issues is to understand the patient/caregiver experience of this illness. The objective of this study was to describe caregivers’ experiences of pediatric AGE and identify their information needs, preferences, and priorities.

A qualitative, descriptive study was conducted. Caregivers of a child with AGE were recruited for this study in the pediatric emergency department (ED) at a tertiary hospital in a major urban centre. Individual interviews were conducted (n=15), and a thematic analysis of interview transcripts was completed using a hybrid inductive/deductive approach.

Five major themes were identified and described: 1) caregiver management strategies; 2) reasons for going to the ED; 3) treatment and management of AGE in the ED; 4) caregivers’ information needs; and 5) additional factors influencing caregivers’ experiences and decision-making. A number of subthemes within each major theme were identified and described.

This qualitative descriptive study has identified caregiver information needs, preferences, and priorities regarding pediatric AGE. This study also identified inconsistencies in the treatment and management of pediatric AGE at home and in the ED that influence health care utilization and patient outcomes related to pediatric AGE.

The objective of this study was to evaluate the impact of a novel injury prevention intervention designed to prompt patients to initiate an injury prevention discussion with the ED physician, thus enabling injury prevention counselling and increasing bicycle helmet use among patients.

A repeated measures 2 x 3 randomized controlled trial design was used. Fourteen emergency physicians were observed for two shifts each between June and August 2013. Each pair of shifts was randomized to either an injury prevention shift, during which the emergency physician would wear a customized scrub top, or a control shift. The outcomes of interest were physician time spent discussing injury prevention, current helmet use, and self-reported change in helmet use rates at one year. Logistic regression analyses were used to examine the impact of the intervention.

The average time spent on injury prevention for all patients was 3.3 seconds. For those patients who actually received counselling, the average time spent was 17.0 seconds. The scrub top intervention did not significantly change helmet use rates at one year. The intervention also had no significant impact on patient decisions to change or reinforcement of helmet use.

Our study showed that the intervention did not increase physician injury prevention counselling or self-reported bicycle helmet use rates among patients. Given the study limitations, replication and extension of the intervention is warranted.

In South Korea, injury is a public health problem due to its high incidence and high mortality. To improve emergency medical systems, the government announced plans to increase the emergency medical resources for each region. This study investigated the association between regional emergency medical resources and mortality during hospitalization in severely injured inpatients.

To analyse mortality for severely injured inpatients, we used the Korean National Hospital Discharge In-depth Survey data, consisting of 18,621 hospitalizations from 2005-2012. Generalized estimating equations were analysed to examine the association between mortality during hospitalization and both individual and regional variables.

Mortality during hospitalization occurred in 913 (4.9%) cases. Patients in regions with a higher number of emergency departments (odds ratio [OR]=0.94, 95% confidence interval [CI]: 0.91-0.98), a higher number of ambulances (OR=0.99, 95% CI: 0.98-0.99), and a higher number of registered nurses per emergency department (OR=0.88, 95% CI: 0.83-0.94) had a lower risk of mortality during hospitalization.

Our findings suggest that regional emergency medical resources are associated with a lower risk of mortality during hospitalization in severely injured patients. Thus, health care policymakers need to determine the proper distribution of emergency medical resources for each region and the function of emergency departments to provide a superior quality of emergency medical services to patients.

In 2008–2009, the Canadian Institute for Health Information reported over 30,000 cases of sepsis hospitalizations in Canada, an increase of almost 4,000 from 2005. Mortality rates from severe sepsis and septic shock continue to remain greater than 30% in Canada and are significantly higher than other critical conditions treated in the emergency department (ED). Our group formed a multidisciplinary sepsis committee, conducted an ED process of care analysis, and developed a quality improvement protocol. The objective of this study was to evaluate the effects of this sepsis management bundle on patient mortality.

This before and after study was conducted in two large Canadian tertiary care EDs and included adult patients with suspected severe infection that met at least two systemic inflammatory response syndrome (SIRS) criteria. We studied the implementation of a sepsis bundle including triage flagging, RN medical directive, education campaign, and a modified sepsis protocol. The primary outcomes were 30-day all-cause mortality and sepsis protocol use.

We included a total of 167 and 185 patients in the pre- and post-intervention analysis, respectively. Compared to the pre-intervention group, mortality was significantly lower in the post-intervention group (30.7% versus 17.3%; absolute difference, 13.4%; 95% CI 9.8–17.0; p=0.006). There was also a higher rate of sepsis protocol use in the post-intervention group (20.3% versus 80.5%, absolute difference 60.2%; 95% CI 55.1–65.3; p<0.001). Additionally, we found shorter time-intervals from triage to MD assessment, fluid resuscitation, and antibiotic administration as well as lower rates of vasopressor requirements and ICU admission.

The implementation of our multidisciplinary ED sepsis bundle, including improved early identification and protocolized medical care, was associated with improved time to achieve key therapeutic interventions and a reduction in 30-day mortality. Similar low-cost initiatives could be implemented in other EDs to potentially improve outcomes for this high-risk group of patients.

Gingivostomatitis is a common, painful pediatric presentation, and yet, few studies are available to guide management. We aimed to describe pediatric emergency physicians’ current practice patterns, with respect to analgesic use in children with acute gingivostomatitis, in order to inform future studies.

A national survey was conducted at all 15 national academic pediatric centres.

Electronic surveys were distributed to pediatric emergency physicians using a modified Dillman protocol; non-respondents received paper surveys via post. Data were collected regarding demographic characteristics, clinical behaviour, factors that may influence practice, and future directions.

Response rate was 74% (150/202). Most physicians (72%) preferred the combination of acetaminophen and ibuprofen to either agent alone (ibuprofen 19%, acetaminophen 7%). The preferred second-line analgesics were oral morphine (48%, 72/150) and compounded topical formulas (42%, 64/150). The most commonly cited compounded agent was Benadryl plus Maalox (23%, 35/150). Clinical experience with a medication had the greatest influence on practice pattern, with 52% (78/149) strongly agreeing. The most commonly cited barrier to adequate analgesia was difficulty in the administration of topical or oral medication to children.

As with many other painful conditions, the combination of acetaminophen and ibuprofen was preferred, followed by either agent alone. Oral morphine and topical compounded agents were also frequently prescribed. Regardless of patient age, physicians preferred oral morphine as a second-line agent to treat pain from severe gingivostomatitis. Future research will focus on determining which analgesic and route (oral or topical) is the most effective and best-tolerated choice.