Use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the extent and reasons that Canadian emergency physicians (EPs) and emergency medicine residents use personal mobile devices to record patient data in the emergency department (ED).

A national survey was distributed to Canadian EPs and residents between 27/02/17 and 23/03/17. This captured demographics, frequency, and purpose of personal mobile device use to record patient data in the ED. It also asked about obtaining consent, security of information, implications for patient care, and knowledge of relevant regulations.

The response rate was 23.1% (406 participants). A third (31.5%) reported using personal mobile devices to record patient data. Most (78.1%) did so more than once a month, and 7.0% did so every shift. Reasons cited included beliefs that using personal mobile devices to record patient data improves care by consultants (36.7%), expedites care (31.3%), and advances medical education (32.8%). Consent was rarely or never documented and a minority of participants (10.9%) indicated they did not obtain consent. More than half of participants (53.2%) reported being unaware of applicable regulations.

This is the first Canadian study on the use of personal mobile devices to record patient data in the ED. Our findings demonstrate current practice may risk privacy breaches. Personal mobile device use to record patient data in the ED is common and Canadian EPs and residents believe that this practice enhances patient care.

Incentive Spirometry is commonly used for respiratory recovery. The literature on incentive spirometry and its impact on patients with rib fracture is unclear and there are no recommendations regarding its use in the Emergency Department (ED), particularly in rib fracture patients, which are known for increasing the risk of pulmonary complication. Therefore, the objective of this study was to assess the use of incentive spirometry and to measure its impacts on delayed complications in patients discharged from the ED with confirmed rib fracture.

This is a planned sub-study of a prospective observational cohort recruited in 4 Canadians ED between November 2006 and May 2012. Non-admitted patients over 16 y.o. with at least one confirmed rib fracture on radiographs were included. Prescription of incentive spirometry was left to attending physician. Main outcomes were development of pneumonia, atelectasis, and hemothorax within 14 days. Propensity score matching analyses were performed.

439 patients were included and 182 (41.5%) patients received incentive spirometry. There were 99 cases of hemothorax (22.6%), 103 cases of atelectasis (23.5%) and 4 cases of pneumonia (0.9%). The use of incentive spirometry was not protector for hemothorax [RR = 1.03 (0.66–1.64)] and atelectasis or pneumonia [RR = 1.07 (0.68–1.72)].

Our results suggest that unsupervised incentive spirometry use does not have a protective effect against delayed pulmonary complications after rib fracture. Further research should be conducted to assess the usefulness of incentive spirometry in specific injured population in the ED.

Methoxyflurane is an inhalation analgesic used in the emergency department (ED) but also has minimal sedative properties. The major aim of this study was to evaluate the success rate of methoxyflurane for acute anterior shoulder dislocation (ASD) reduction. The secondary aim was to assess the impact of methoxyflurane on ED patient flow compared to propofol.

A health record review was performed for all patients presenting with ASD who underwent reduction with either methoxyflurane or propofol over a 13-month period (December 2016 – December 2017). The primary outcome was reduction success for methoxyflurane, while secondary outcomes such as recovery time and ED length of stay (LOS) were also assessed compared to propofol. Patients with fracture dislocations, polytrauma, intravenous, or intramuscular opioids in the pre-hospital setting, no sedation for reduction, and alternative techniques of sedation or analgesia for reduction were excluded.

A total of 151 patients presented with ASD during the study period. Eighty-two patients fulfilled our inclusion criteria. Fifty-two patients had ASD reduction with propofol while 30 patients had methoxyflurane. Successful reduction was achieved in 80% (95% CI 65.69% to 94.31%) patients who used methoxyflurane. The median recovery time and ED LOS were 30 minutes [19.3-44] and 70.5 minutes [49.3-105], which was found to be shorter for the methoxyflurane group, who had successful reductions compared to sedation with propofol.

Methoxyflurane was used successfully in 30% of the 82 patients undergoing reduction for ASD, while potentially improving ED efficiency.

To determine the rate of recurrent major trauma (i.e., trauma recidivism) using a provincial population-based trauma registry. We compared outcomes between recidivists and non-recidivists, and assessed factors associated with recidivism and mortality.

Review of all adult (>17 years) major trauma patients in Nova Scotia (2001–2015) using data from the Nova Scotia Trauma Registry. Outcomes of interest were mortality, duration of hospital stay, and in-hospital complications. Multiple regression was used to assess factors associated with recidivism and mortality.

Of 9,365 major trauma patients, 2% (150/9365) were recidivists. Mean age at initial injury was 52 ± 21.5 years; 73% were male. The mortality rate for both recidivists and non-recidivists was 31%. However, after adjusting for potential confounders the likelihood of mortality was over 3 times greater for recidivists compared to non-recidivists (OR 3.67, 95% CI 2.06–6.54). Other factors associated with mortality included age, male gender, penetrating injury, Injury Severity Score, trauma team activation (TTA) and admission to the intensive care unit. The only variables associated with recidivism were age (OR 0.98, 95% CI 0.97–1.00) and TTA (OR 0.59, 95% CI 0.34–0.96).

This is the first provincial investigation of major trauma recidivism in Canada. While recidivism was infrequent (2%), the adjusted odds of mortality were over three times greater for recidivists. Further research is warranted to determine the effectiveness of strategies for reducing rates of major trauma recidivism such as screening and brief intervention in cases of violence or substance abuse.

Cannabis hyperemesis syndrome is characterized by bouts of protracted vomiting in regular users of cannabis. We wondered whether this poorly understood condition is idiosyncratic, like motion sickness or hyperemesis gravidarum, or the predictable dose-response effect of prolonged heavy use.

Adults with an emergency department visit diagnosed as cannabis hyperemesis syndrome, near-daily use of cannabis for ≥6 months, and ≥2 episodes of severe vomiting in the previous year were age- and sex-matched to two control groups: RU controls (recreational users without vomiting), and ED controls (patients in the emergency department for an unrelated condition). Δ9-Tetrahydrocannabinol (THC), cannabinol (CBN), cannabidiol, and 11-nor-9-carboxy-THC concentrations in scalp hair were compared for subjects with positive urine THC.

We obtained satisfactory hair samples from 46 subjects with positive urine THC: 16 cases (age 26.8 ± 9.2 years; 69% male), 16 RU controls and 14 ED controls. Hair cannabinoid concentrations were similar between all three groups (e.g. cases THC 220 [median; IQR 100,730] pg/mg hair, RU controls 150 [71,320] and ED controls 270 [120,560]). Only the THC:CBN ratio was different between groups, with a 2.6-fold (95%CI 1.3,5.7) lower age- and sex-adjusted ratio in cases than RU controls. Hair cannabidiol concentrations were often unquantifiably low in all subjects.

Similar hair cannabinoid concentrations in recreational users with and without hyperemesis suggest that heavy use is necessary but not sufficient for hyperemesis cannabis. Our results underline the high prevalence of chronic heavy cannabis use in emergency department patients and our limited understanding of this plant's adverse effects.

In the current opioid epidemic, identifying high-risk patients among those with substance and opioid use may prevent deaths. The objective of this study was to determine whether frequent emergency department (ED) use and degree of frequent use are associated with mortality among ED patients with substance and opioid use.

This cohort study used linked population-based ED (National Ambulatory Care Reporting System) and mortality data from Alberta. All adults ≥ 18 years with substance or opioid use-related visits based on diagnostic codes from April 1, 2012, to March 31, 2013, were included (n = 16,389). Frequent use was defined by ≥ 5 visits in the previous year. Outcomes were unadjusted and adjusted (for age, sex, income) mortality within 90 days (primary), and 30 days, 365 days, and 2 years (secondary). To examine degree, frequent use was subcategorized into 5–10, 11–15, 16–20, and > 20 visits.

Frequent users were older, lower income, and made lower acuity visits than non-frequent users. Frequent users with substance use had higher mortality at 365 days (hazard ratio [HR] 1.36 [1.04, 1.77]) and 2 years (HR 1.32 [1.04, 1.67]), but not at 90 or 30 days. Mortality did not differ for frequent users with opioid use overall. By degree, patients with substance use and > 20 visits/year and with opioid use and 16–20 visits/year demonstrated a higher 365-day and 2-year mortality.

Among patients with substance use, frequent ED use and extremely frequent use (> 20 visits/year) were associated with long-term but not short-term mortality. These findings suggest a role for targeted screening and preventive intervention.

Opioid-related emergency department (ED) visits have increased significantly in recent years. Our objective was to evaluate an ED-initiated buprenorphine/naloxone program, which provided rapid access to an outpatient community-based addictions clinic, for patients in opioid withdrawal.

A retrospective chart review was completed within a health system encompassing four community EDs in Ontario, Canada. Patients were screened for opioid withdrawal between April 2017-December 2017 and offered buprenorphine/naloxone treatment and referral to outpatient addictions follow-up. The main outcome measure was treatment retention in the six-month period after the index visit.

The overall sample (N = 49) showed high healthcare utilization in the year prior to the index ED visit. 88% of patients (n = 43) consented to ED-initiated buprenorphine/naloxone and were referred to outpatient addictions follow-up, with 54% attending the initial follow-up visit. In the 6-month follow-up period from the index ED visit, 35% of patients were receiving ongoing buprenorphine/naloxone treatment and 2.3% were weaned off opioids. Patients with ongoing treatment had significantly lower number of ED visits at 3 and 6 months (3 and 10, respectively) compared to patients who did not show up for outpatient follow-up (28, 40) or started/stopped treatment (23, 41).

Screening for opioid use disorder in the ED and initiating buprenorphine/naloxone treatment with rapid referral to an outpatient community-based addictions clinic led to a 6-month treatment retention rate of 37% and a significant reduction in ED visits at 3 and 6 months. Buprenorphine/naloxone initiation in the ED appears to be an effective intervention, but further research is needed.

Syncope accounts for 1% of emergency department (ED) visits, yet few experience a serious adverse event (SAE). Two-thirds of syncope patients are transported to the ED by ambulance, placing considerable burden on emergency medical services (EMS), and many of these transports may be unnecessary. We estimated the proportion of syncope patients who fell into a low-risk category based on an ED diagnosis of vasovagal syncope and the absence of EMS intervention, hospitalization, or SAE.

We conducted a multicentre prospective cohort study enrolling adult syncope patients transported to the ED by ambulance over 13 months. We collected demographics and EMS interventions, and followed patients for 30 days to identify all SAE, including death, dysrhythmia, myocardial infarction, aortic dissection, pulmonary embolism, subarachnoid hemorrhage, significant hemorrhage, and related procedural interventions.

Of 990 (67.2%) patients transported to the ED by ambulance, 121 had EMS interventions, 137 suffered 30-day SAE, 393 (39.7%; 95%CI 36.6, 42.8) were deemed low risk, 41 patients with vasovagal syncope were lost to follow-up, and 298 patients were diagnosed with non-vasovagal syncope. During transport, 121 (12.2%; 95%CI 10.2, 14.3) patients underwent some EMS intervention, and 137 (14.6%; 95%CI 12.4, 16.9) suffered SAEs within 30 days.

About 40% of patients transported to the ED by ambulance are at low risk and may not benefit from paramedic care or transport to a hospital. A robust clinical decision tool would help identify patients safe for treat-and-release, diversion to alternative care, or rapid offload into low-acuity ED areas, potentially reducing EMS workload and cost.

Emergency department (ED) and hospital overcrowding cause offload delays that remove emergency medical services (EMS) crews from service and compromise care delivery. Prolonged ED boarding and delays to inpatient care are associated with increased hospital length of stay (LOS) and patient mortality, but the effects of EMS offload delays have not been well studied.

We used administrative data to study all high-acuity Canadian Triage Acuity Scale 2–3 EMS arrivals to Calgary adult EDs from July 2013 to June 2016. Patients offloaded to a care space within 15 minutes were considered controls, whereas those delayed ≥ 60 minutes were considered “delayed.” Propensity matching was used to create comparable control and delayed cohorts. The primary outcome was 7-day mortality. Secondary outcomes included hospital LOS and 30-day mortality.

Of 162,002 high-acuity arrivals, 70,711 had offload delays <15 minutes and 41,032 had delays > 60 minutes. Delayed patients were more likely to be female, older, to have lower triage acuity, to live in dependent living situations, and to arrive on weekdays and day or evening hours. Delayed patients less often required admission and, when admitted, were more likely to go to the hospitalist service. Main outcomes were similar for propensity-matched control and delayed cohorts, although delayed patients experienced longer ED LOS and slightly lower 7-day mortality rates.

In this setting, high-acuity EMS arrivals exposed to offload delays did not have prolonged hospital LOS or higher mortality than comparable patients who received timely access.

Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.

In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.

In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.

After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.

Transesophageal echocardiography (TEE) is a relatively new resuscitation tool in the emergency department. Recent studies have demonstrated that it can impact diagnosis and management of critically ill patients. The objective of this study is to determine the effectiveness of a simulation-based curriculum for teaching emergency medicine residents a five-view TEE protocol.

Emergency medicine residents with previous ultrasound experience were invited to attend a 1-hour TEE training session. The training consisted of a didactic lecture followed by guided practice on a simulator. Performance was measured prior to training, after the training session, and by a transfer test 1 to 2 weeks after training. The primary outcome was the percentage of successful image generation using a scoring tool by two blinded reviewers.

Twenty-two residents completed the study. The percentage of successful views increased from 44.5% (SD 27.9) at baseline to 98.6% (SD 3.5) after training (p < 0.001), and was 86.8% (SD 12.1) on transfer testing (p < 0.001).

A brief simulation-based teaching session was effective for teaching emergency medicine residents a five-view resuscitative TEE protocol. Future studies are needed to determine optimal methods for long-term skill retention.

The Royal College of Physicians and Surgeons of Canada (RCPSC) emergency medicine (EM) programs transitioned to the Competence by Design training framework in July 2018. Prior to this transition, a nation-wide survey was conducted to gain a better understanding of EM faculty and senior resident attitudes towards the implementation of this new program of assessment.

A multi-site, cross-sectional needs assessment survey was conducted. We aimed to document perceptions about competency-based medical education, attitudes towards implementation, perceived/prompted/unperceived faculty development needs. EM faculty and senior residents were nominated by program directors across RCPSC EM programs. Simple descriptive statistics were used to analyse the data.

Between February and April 2018, 47 participants completed the survey (58.8% response rate). Most respondents (89.4%) thought learners should receive feedback during every shift; 55.3% felt that they provided adequate feedback. Many respondents (78.7%) felt that the ED would allow for direct observation, and most (91.5%) participants were confident that they could incorporate workplace-based assessments (WBAs). Although a fair number of respondents (44.7%) felt that Competence by Design would not impact patient care, some (17.0%) were worried that it may negatively impact it. Perceived faculty development priorities included feedback delivery, completing WBAs, and resident promotion decisions.

RCPSC EM faculty have positive attitudes towards competency-based medical education-relevant concepts such as feedback and opportunities for direct observation via WBAs. Perceived threats to Competence by Design implementation included concerns that patient care and trainee education might be negatively impacted. Faculty development should concentrate on further developing supervisors’ teaching skills, focusing on feedback using WBAs.

We conducted an environmental scan of quality improvement and patient safety (QIPS) infrastructure and activities in academic emergency medicine (EM) programs and departments across Canada.

We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee. “Survey 1” was sent by email to all 17 Canadian medical school affiliated EM department Chairs and Academic Hospitals department Chiefs; “Survey 2” to 12 identified QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey.

22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. Many described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per centre ranging from 1–10 over the past 5 years. Few respondents reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%).

This environmental scan provides a snapshot of QIPS activities in EM across academic centres in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

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.