To evaluate the psychometric properties of HEARTSMAP, an emergency psychosocial assessment and management tool, and its impact on patient care and flow measures.

We conducted the study in two phases: first validating the tool using extracted information from a retrospective cohort, then evaluating implementation on a prospective cohort of youth presenting with mental health complaints to a tertiary Pediatric Emergency Department (PED). In phase 1, six PED clinicians applied HEARTSMAP to extracted narratives and we calculated inter-rater agreement for referral recommendations using Cohen’s Kappa and the sensitivity and specificity for identifying youth requiring psychiatric consultation and hospitalization. In phase 2, PED clinicians prospectively used HEARTSMAP and we assessed the impact of the tool’s implementation on patient-related outcomes and Emergency department (ED) flow measures.

We found substantial agreement (κ=0.7) for cases requiring emergent psychiatric consultation and moderate agreement for cases requiring community urgent and non-urgent follow-up (κ=0.4 each). The sensitivity was 76% (95%CI: 63%, 90%) and specificity was 65% (95%CI: 55%, 71%) using retrospective cases. During pilot implementation, 62 patients received HEARTSMAP assessments: 46 (74%) of HEARTSMAP assessments triggered a recommendation for ED psychiatry assessment, 39 (63%) were evaluated by psychiatry and 13 (21%) were admitted. At follow-up, all patients with HEARTSMAP’s triggered recommendations had accessed community resources. For those hospitalized for further psychiatric care at their index or return visit within 30 days, 100% were initially identified by HEARTSMAP at the index visit as requiring ED psychiatric consultation.

HEARTSMAP has strong reliability, and when applied prospectively is a safe and effective management tool.

Emergency medicine residents may be transitioning to practice with minimal training on how to supervise and assess trainees. Our study sought to examine: 1) physician comfort with supervision and assessment, 2) what the current training gaps are within these competencies, and 3) what barriers or enablers might exist in implementing curricular improvements.

Qualitative data were collected in two phases through individual interviews from September 2016 to November 2017, at the University of Toronto and McMaster University after receiving ethics approval from both sites. Eligible participants were final year emergency medicine residents, residents pursuing an enhanced skills program in emergency medicine, and attendings within their first 3 years of practice. A semi-structured interview guide was developed and refined after phase one, to reflect content identified in the first set of interviews. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory.

A thematic analysis revealed five themes: 1) Supervision and assessment skills were acquired passively through modelling, 2) the training available in these areas is variably used, creating a diversity of comfort levels, 3) competing priorities in the emergency department represent significant barriers to improving supervision and assessment; 4) providing negative feedback is difficult and often avoided; and 5) competence by design will act as an impetus for formal curriculum development in these areas.

As programs transition to competence by design, there will be a need for formal training in supervision and assessment, with a focus on negative feedback, to achieve a standardized level of competence among emergency physicians.

With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.

We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).

We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25–60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2–7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).

Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.

Patient sleep quality has a significant impact on recovery. However, most hospital units do not provide an optimal environment for sleep and there are currently no data available on how well patients sleep during their emergency department stay. The main objective of this study was to assess the subjective quality of nighttime sleep and factors that affect sleep in the emergency department (ED).

A prospective sample of patients aged 18 years and older who presented to the ED from July 2015 to October 2015 was investigated. All participants were on stretcher and slept at least one night in the ED. Participants were asked to complete a sleep questionnaire adapted to the ED environment on sleep quality and its potentially modifying factors.

A total of 235 patients participated in the study (mean age: 64±20 years, 51% women). Compared to the week at home prior to admission, subjective sleep quality was lower in the ED (p<0.001): almost half the participants took more than 30 minutes to fall asleep, and they reported waking up 3.5 times per night on average. Lower subjective sleep quality in the ED was associated with higher stress, noise, and pain, as well as with stretcher comfort and lower home sleep quality the week prior to admission.

Subjective sleep quality in the emergency department is not optimal, and is influenced by stress, noise, pain, and stretcher comfort, all potentially modifiable factors.

Our objective was to determine emergency department (ED) patient adherence to outpatient specialized geriatric services (SGS) following ED evaluation by the geriatric emergency management (GEM) nurse, and identify barriers and facilitators to attendance.

We conducted a prospective cohort study at two academic EDs between July and December 2016, enrolling a convenience sample of patients ≥ 65 years, seen by a GEM nurse, referred to outpatient SGS, and consented to study participation. We completed a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used.

We enrolled 103/285 eligible patients (86 eligible but not enrolled, 86 declined specialized geriatric referrals, and 10 declined study participation). Patients were mean age of 83.1 years, 59.2% female, and 73.2% cognitively impaired. Reasons for referral included mobility (86.4%), cognition (56.3%), pain (38.8%), mood (35.0%), medications (33.0%), and nutrition (31.1%). Referrals were to Geriatric Day Hospital (GDH) programs (50.5%), geriatric outreach (26.2%), falls clinic (12.6%), and geriatric psychiatry (8.7%). Adherence with follow-up was 59.2%. Barriers to attendance included patient did not feel SGS were needed (52.1%), inability to recall GEM consultation (53.4%), and dependence on family for transportation (72.6%). Home-based assessments had the highest adherence (81.5%).

Adherence of older ED patients referred by the GEM team to SGS is suboptimal, and a large proportion of patients decline these referrals in the ED. Future work should examine the efficacy of home-based assessments in a larger confirmatory setting and focus on interventions to increase referral acceptance and address barriers to attendance.

Problematic alcohol use is associated with detrimental cognitive, physiological and social consequences. In the emergency department (ED), Screening, Brief Intervention, and Referral to Treatment (SBIRT) is the recommended approach to identify and treat adolescent alcohol-related concerns, but is underused by physicians.

This study examined pediatric emergency physicians’ perceptions of adolescent drinking and treatment, and their current self-reported SBIRT practices.

Physicians in the Pediatric Emergency Research Canada database (n=245) received a 35-item questionnaire that was administered through a web-based platform and paper-based mail-outs. Recruitment followed a modified Dillman four-contact approach.

From October 2016 to January 2017, 166 pediatric emergency physicians (46.4% males; mean age=43.6 years) completed the questionnaire. The response rate was 67.8%. Physicians recognized the need (65%) and responsibility (86%) to address adolescent alcohol problems. However, confidence in knowledge and abilities for SBIRT execution was low. Twenty-five percent of physicians reported never having practiced all, or part of, SBIRT while 1.3% reported consistent SBIRT delivery for adolescents with alcohol-related visits. More alcohol education and counselling experience was associated with higher SBIRT use; however, physicians generally reported to have received minimal alcohol training. SBIRT practices were also associated with physician perceptions of problematic alcohol use and its treatability.

Pediatric emergency physicians acknowledge the need to address problematic adolescent alcohol use, but routine SBIRT use is lacking. Strategies to educate physicians about SBIRT and enhance perceived self-competency may improve SBIRT use. Effectiveness trials to establish SBIRT impact on patient outcomes are also needed.

The purpose of this study was to identify 1) the proportion of patients discharged from the emergency department (ED) with a diagnosis of concussion and return within 14 days, and 2) the characteristics that prompt a return.

A health records review was conducted on adult patients with a discharge diagnosis of a concussion who accessed care through Hamilton Health Sciences EDs and Urgent Care Centre in 2016. Subsequent data were collected from those who returned to the ED within 14 days. Clinical characteristics of returners were compared to those of non-returners.

Of the 389 patients included in the study, 38 (10%) returned within 14 days. Patients who sustained a concussion in a sport-related context or were referred to a specialized clinic were less likely to return (p = 0.03). Those who suffered an assault-related concussion were more likely to return (p = 0.01). Of those who did return, 42% received a CT scan with normal results, and 42% were given new discharge instructions.

Approximately 10% of patients diagnosed with a concussion in a Canadian hospital setting returned to the ED within 14 days of their index visit. Our study suggests the opportunity to reduce this burden to both the healthcare system and the patient through careful discharge instructions outlining anticipated symptoms following a concussion (specifically, headache) or referral to a concussion clinic.

Quality improvement (QI) analytic methodology is rarely encountered in the emergency medicine literature. We sought to comparatively apply QI design and analysis techniques to an existing data set, and discuss these techniques as an alternative to standard research methodology for evaluating a change in a process of care.

We used data from a previously published randomized controlled trial on triage-nurse initiated radiography using the Ottawa ankle rules (OAR). QI analytic tools were applied to the data set from this study and evaluated comparatively against the original standard research methodology.

The original study concluded that triage nurse-initiated radiographs led to a statistically significant decrease in mean emergency department length of stay. Using QI analytic methodology, we applied control charts and interpreted the results using established methods that preserved the time sequence of the data. This analysis found a compelling signal of a positive treatment effect that would have been identified after the enrolment of 58% of the original study sample, and in the 6th month of this 11-month study.

Our comparative analysis demonstrates some of the potential benefits of QI analytic methodology. We found that had this approach been used in the original study, insights regarding the benefits of nurse-initiated radiography using the OAR would have been achieved earlier, and thus potentially at a lower cost. In situations where the overarching aim is to accelerate implementation of practice improvement to benefit future patients, we believe that increased consideration should be given to the use of QI analytic methodology.

Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.

An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.

Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.

A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

There is increasing evidence to support integration of simulation into medical training; however, no national emergency medicine (EM) simulation curriculum exists. Using Delphi methodology, we aimed to identify and establish content validity for adult EM curricular content best suited for simulation-based training, to inform national postgraduate EM training.

A national panel of experts in EM simulation iteratively rated potential curricular topics, on a 4-point scale, to determine those best suited for simulation-based training. After each round, responses were analyzed. Topics scoring <2/4 were removed and remaining topics were resent to the panel for further ratings until consensus was achieved, defined as Cronbach α ≥ 0.95. At conclusion of the Delphi process, topics rated ≥ 3.5/4 were considered “core” curricular topics, while those rated 3.0-3.5 were considered “extended” curricular topics.

Forty-five experts from 13 Canadian centres participated. Two hundred eighty potential curricular topics, in 29 domains, were generated from a systematic literature review, relevant educational documents and Delphi panellists. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 93-100%. Twenty-eight topics, in eight domains, reached consensus as “core” curricular topics. Thirty-five additional topics, in 14 domains, reached consensus as “extended” curricular topics.

Delphi methodology allowed for achievement of expert consensus and content validation of EM curricular content best suited for simulation-based training. These results provide a foundation for improved integration of simulation into postgraduate EM training and can be used to inform a national simulation curriculum to supplement clinical training and optimize learning.

Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification.

We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system.

Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0–2.08) for intervention patients and 9 minutes (5–18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8–14.5) faster for the intervention group.

A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.

The Quebec Emergency Department Management Guide (QEDMG) is a unique document with 78 recommendations designed to improve the organization of emergency departments (EDs) in the province of Quebec. However, no study has examined how this guide is perceived or used by rural health care management.

We invited all directors of professional services (DPS), directors of nursing services (DNS), head nurses (HN), and emergency department directors (EDD) working in Quebec’s rural hospitals to complete an online survey (144 questions). Simple frequency analyses (percentage [%] and 95% confidence interval) were conducted to establish general familiarity and use of the QEDMG, as well as perceived usefulness and implementation of its recommendations.

Seventy-three percent (19/26) of Quebec’s rural EDs participated in the study. A total of 82% (62/76) of the targeted stakeholders participated. Sixty-one percent of respondents reported being “moderately or a lot” familiar with the QEDMG, whereas 77% reported “almost never or sometimes” refer to this guide. Physician management (DPS, EDD) were more likely than nursing management (DNS and especially HN) to report “not at all” or “little” familiarity on use of the guide. Finally, 98% of the QEDMG recommendations were considered useful.

Although the QEDMG is considered a useful guide for rural EDs, it is not optimally known or used in rural EDs, especially by physician management. Stakeholders should consider these findings before implementing the revised versions of the QEDMG.