There is no evidence-based description of electrocardiogram (ECG) interpretation competencies for emergency medicine (EM) trainees. The first step in defining these competencies is to develop a prioritized list of adult ECG findings relevant to EM contexts. The purpose of this study was to categorize the importance of various adult ECG diagnoses and/or findings for the EM trainee.

We developed a list of potentially important adult ECG diagnoses/findings and conducted a Delphi opinion-soliciting process. Participants used a 4-point Likert scale to rate the importance of each diagnosis for EM trainees. Consensus was defined as a minimum of 75% agreement at the second round or later. In the absence of consensus, stability was defined as a shift of 20% or less after successive rounds.

A purposive sampling of 22 emergency physicians participated in the Delphi process, and 16 (72%) completed the process. Of those, 15 were from 11 different EM training programs across Canada and one was an expert in EM electrocardiography. Overall, 78 diagnoses reached consensus, 42 achieved stability and one diagnosis achieved neither consensus nor stability. Out of 121 potentially important adult ECG diagnoses, 53 (44%) were considered “must know” diagnoses, 61 (50%) “should know” diagnoses, and 7 (6%) “nice to know” diagnoses.

We have categorized adult ECG diagnoses within an EM training context, knowledge of which may allow clinical EM teachers to establish educational priorities. This categorization will also facilitate the development of an educational framework to establish EM trainee competency in ECG interpretation.

Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing. The objectives of this study were to 1) measure the effectiveness of prehospital CPAP on morbidity, mortality, and transport times; and 2) audit the selection of patients by medics for appropriateness and safety.

We conducted a before-and-after study from August 1 to October 31 in 2010 and 2011, before and after the implementation of prehospital CPAP in a city of one million people with large rural areas. Medics were trained to apply CPAP to patients with respiratory distress and a presumed diagnosis of ACPE or AECOPD. Charts were selected using the search criteria of the chief complaint of shortness of breath, emergent transport to hospital, and any patients receiving CPAP in the field. Data extracted from ambulance call reports and hospital records were analysed with appropriate univariate statistics.

A total of 373 patients enrolled (186 pre-non-invasive ventilation [NIV] and 187 post-NIV), mean age 71.5 years, female 51.4%, and final diagnoses of ACPE 18.9%, AECOPD 21.9%. In the post group of 84 patients meeting NIV criteria, 41.6% received NIV; and of 102 patients not meeting the criteria, 5.2% received NIV. There were 12 minor adverse events in 36 applications (33.3%) as per protocol. Comparing post versus pre, there were higher rates of emergency department (ED) NIV (20.0% v. 13.4%, p<0.0001) and higher overall mortality (18.8% v. 14.9%, p<0.0001). There were no differences in ED intubation (2.1% v. 2.3%, p<0.001) and length of stay (6.8 v. 8.7 days, p=0.24).

Despite the robust in-hospital data supporting its use, we could not find benefit from CPAP in our prehospital setting with respect to morbidity, mortality, and length of stay. EMS must exercise caution in making the decision to invest in the equipment and training required to implement prehospital CPAP.

The initial management of a trauma patient often involves imaging in the form of x-rays, computed tomography (CT) and other radiographic studies, which expose the patient to ionizing radiation, an entity known to cause tissue injury and malignancy at high doses. The purpose of this study was to use a calculation-based method to determine the radiation exposure of trauma patients undergoing trauma team activation in a Canadian tertiary-care trauma centre.

A retrospective chart review was conducted using the Nova Scotia Provincial Trauma Registry. All patients age 16 years old and over who underwent trauma team activation between March 1, 2008 and March 1, 2009 were included. Patients who died prior to imaging tests were excluded. Dose reports for each CT were used to calculate a whole-body radiation dose for each patient.

There were 230 trauma team activations during the study period, of which 206 had CT imaging. Data were available for 162 patients. The mean whole-body radiation exposure for all patients was 24.4±10.3 mSv, which may correlate to one additional cancer death for every 100 trauma patients scanned.

Trauma patients are exposed to significant amounts of radiation during their initial trauma work-up, which may increase the risk of fatal cancer. Clinicians who care for these patients must be aware of the radiation exposure, and take measures to limit radiation exposure of trauma patients.

A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA.

We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography.

Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).

Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.

As an aging population continues to place strain on the health care system, many older adults are living with unmet social and medical needs. In response, Emergency Medical Services (EMS) have initiated programs that encourage paramedics to refer patients in need to community based support services. This qualitative study explores frontline paramedic experiences with referral programs to identify opportunities and challenges in their practice.

This study used an intepretivist qualitative study design involving interviews of frontline paramedics employed in a region where referral programs were in place. Interviews were semi-structured and one-on-one. Data were transcribed verbatim and analyzed using inductive open coding throughout, then grouped to identify themes. Data collection and analysis were conducted simultaneously and flexibly until saturation.

Twenty-three interviews were conducted representing 6 regions. When participating with referral programs the data revealed that frontline paramedics appear to experience (a) role confusion, (b) an inadequate knowledge base, (c) inadequate feedback, (d) undefined accountability, and (e) strong patient advocacy.

In a strained health care system, EMS and paramedics have an opportunity to better serve patients by initiating referrals for patients they encounter with unmet social and medical needs. However, referral programs face a number of challenges that, if left poorly addressed, may threaten the success of such programs.

There are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury.

After a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman’s Tailored Design Method.

Of 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks.

A drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.

Fast tracks are one approach to reduce emergency department (ED) crowding. No studies have assessed the use of fast tracks in smaller hospitals with single physician coverage. Our study objective was to determine if implementation of an ED fast track in a single physician coverage setting would improve wait times for low-acuity patients without negatively impacting those of higher acuity.

A daytime fast track opened in 2010 at Strathroy Middlesex General Hospital, a southwestern Ontario community hospital. Before and after intervention groups comprised of ED visits in 2009 and 2011 were compared. Pooled comparison of all Canadian Triage and Acuity Scale (CTAS) patients in each period, and between subgroups CTAS 2-5 comparisons were performed for: wait time (WT), length of stay (LOS), WTs that met national CTAS time guidelines (MNCTG), and proportion of patients that left without being seen (LWBS).

WT and LOS were six minutes (88 min to 82 min, p=0.002) and 15 minutes (158 min to 143 min, p<0.001) lower, respectively, in the post-intervention period. Subgroup analysis showed CTAS 4 had the most pre- to post-intervention decrease in WT, of 13 minutes (98 min to 85 min, p<0.001). There was statistical improvement in MNCTG in the post-intervention period. No differences were found in outcome measures for higher-acuity patients or LWBS rates.

Implementation of a fast track in a medium-volume community hospital with single physician coverage can improve patient throughput by decreasing WT and LOS without negatively impacting high-acuity patients. This may be clinically relevant, particularly for hospital administrators, given the improvement in meeting national WT standards we found post-intervention.

Diabetes is the most common pediatric endocrine disorder, and diabetic ketoacidosis (DKA) is the leading cause of diabetes-related morbidity and mortality. This article reviews pediatric DKA treatment protocols from across Canada and identifies similarities and differences.

Pediatric tertiary centres in Canada were asked for a copy of their DKA treatment protocol. For each protocol, we collected information on the amount of initial fluid bolus, maintenance fluid rate, insulin infusion rate, potassium replacement, monitoring and adjustment for serum glucose, administration of bicarbonate, and treatment for cerebral edema.

Responses were obtained from 13 sites. Treatment guidelines were consistent in their recommendations on timing and dosage of intravenous insulin, potassium replacement, monitoring and adjusting for serum glucose, and management of cerebral edema. Variability in treatment protocols was found chiefly in volume of initial fluid bolus (range: 5–20 mL/kg) and length of time boluses should be administered (20–120 min), maintenance fluid rates (based on weight or a 48-hr deficit), and the role of bicarbonate administration.

This is the first review of treatment protocols for pediatric DKA in Canada. It identified many common approaches but noted specific differences in fluid boluses, maintenance fluid rates, and bicarbonate administration. The extent of variation indicates the need for further study, as well as national guidelines that are evidence-based and consistent with best practices.

By the end of residency training, pediatric emergency medicine (PEM) residents are expected to have developed the confidence and abilities required to manage acutely ill children. Acquisition of competence requires exposure and/or supplemental formal education for critical and noncritical medical clinical presentations. Simulation can provide experiential learning and can improve trainees’ knowledge, skills, and attitudes. The primary objective of this project was to identify the content for a simulation-based national curriculum for PEM training.

We recruited participants for the Delphi study by contacting current PEM program directors and immediate past program directors as well as simulation experts at all of the Canadian PEM fellowship sites. We determined the appropriate core content for the Delphi study by combining the PEM core content requirements of the Royal College of Physicians and Surgeons of Canada (RCPSC) and the American Board of Pediatrics (ABP). Using the Delphi method, we achieved consensus amongst the national group of PEM and simulation experts. The participants completed a three-round Delphi (using a four-point Likert scale).

Response rates for the Delphi were 85% for the first round and 77% for second and third rounds. From the initial 224 topics, 53 were eliminated (scored <2). Eighty-five topics scored between 2 and 3, and 87 scored between 3 and 4. The 48 topics, which were scored between 3.5 and 4.0, were labeled as “key curriculum topics.”

We have iteratively identified a consensus for the content of a national simulation-based curriculum.

Offload delay is a prolonged interval between ambulance arrival in the emergency department (ED) and transfer of patient care, typically occurring when EDs are crowded. The offload zone (OZ), which manages ambulance patients waiting for an ED bed, has been implemented to mitigate the impact of ED crowding on ambulance availability. Little is known about the safety or efficiency. The study objectives were to process map the OZ and conduct a hazard analysis to identify steps that could compromise patient safety or process efficiency.

A Health Care Failure Mode and Effect Analysis was conducted. Failure modes (FM) were identified. For each FM, a probability to occur and severity of impact on patient safety and process efficiency was determined, and a hazard score (probability X severity) was calculated. For any hazard score considered high risk, root causes were identified, and mitigations were sought.

The OZ consists of six major processes: 1) patient transported by ambulance, 2) arrival to the ED, 3) transfer of patient care, 4) patient assessment in OZ, 5) patient care in OZ, and 6) patient transfer out of OZ; 78 FM were identified, of which 28 (35.9%) were deemed high risk and classified as impact on patient safety (n=7/28, 25.0%), process efficiency (n=10/28, 35.7%), or both (n=11/28, 39.3%). Seventeen mitigations were suggested.

This process map and hazard analysis is a first step in understanding the safety and efficiency of the OZ. The results from this study will inform current policy and practice, and future work to reduce offload delay.

In unconscious patients of out-of-hospital cardiac arrest, does targeted temperature management to 36°C (96.8°F) improve outcomes compared to the standard target of 32°C–34°C (89.6°F–93.2°F)?

Nielson N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013;369:2197-2206.

To determine which temperature, 33°C (91.4°F) or 36°C (96.8°F), is associated with lower mortality and better neurologic function after cardiac arrest.

Ebinger M, Winter B, Wendt M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014;311(16):1622-31.

Does prehospital thrombolysis in specialized ambulances reduce delay to thrombolysis in acute ischemic stroke?

To determine the effect of prehospital thrombolysis for acute ischemic stroke administered in specialized ambulances on delay in thrombolytic administration, thrombolysis rate, post-thrombolysis intracerebral hemorrhage, and 7-day mortality.