To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.

Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.

There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygen saturation (< 95% on room air or < 98% on any supplemental oxygen), chest radiograph, respiratory rate ≥ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).

In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.

The Broselow Pediatric Emergency Tape (Armstrong Medical Industries, Inc., Lincolnshire, IL) (BT) is a well-established length-based tool for estimation of body weight for children during resuscitation. In view of pandemic childhood obesity, the BT may no longer accurately estimate weight. We therefore studied the BT in children from Ontario in a large recent patient cohort.

Actual height and weight were obtained from an urban and a rural setting. Children were prospectively recruited between April 2007 and July 2008 from the emergency department and outpatient clinics at the London Health Science Centre. Rural children from junior kindergarten to grade 4 were also recruited in the spring of 2008 from the Avon Maitland District School Board. Data for preschool children were obtained from three daycare centres and the electronic medical record from the Maitland Valley Medical Centre. The predicted weight from the BT was compared to the actual weight using Spearman rank correlation; agreement and percent error (PE) were also calculated.

A total of 6,361 children (46.2% female) were included in the study. The median age was 3.9 years (interquartile range [IQR] 1.56-7.67 years), weight was 17.2 kg (IQR 11.6-25.4 kg), and height was 103.5 cm (IQR 82-124.4 cm). Although the BT weight estimate correlated with the actual weight (r = 0.95577, p < 0.0001), the BT underestimated the actual weight by 1.62 kg (7.1% ± 16.9% SD, 95% CI -26.0-40.2). The BT had an ≥ 10% PE 43.7% of the time.

Although the BT remains an effective method for estimating pediatric weight, it was not accurate and tended to underestimate the weight of Ontario children. Until more accurate measurement tools for emergency departments are developed, physicians should be aware of this discrepancy.

Emergency department resuscitation requires the coordinated efforts of an interdisciplinary team. Aviationbased crisis resource management (CRM) training can improve safety and performance during complex events. We describe the development, piloting, and multilevel evaluation of “Crisis Resources for Emergency Workers” (CREW), a simulation-based CRM curriculum for emergency medicine (EM) residents.

Curriculum development was informed by an a priori needs assessment survey. We constructed a 1-day course using simulated resuscitation scenarios paired with focused debriefing sessions. Attitudinal shifts regarding team behaviours were assessed using the Human Factors Attitude Survey (HFAS). A subset of 10 residents participated in standardized pre- and postcourse simulated resuscitation scenarios to quantify the effect of CREW training on our primary outcome of CRM performance. Pre/post scenarios were videotaped and scored by two blinded reviewers using a validated behavioural rating scale, the Ottawa CRM Global Rating Scale (GRS).

Postcourse survey responses were highly favourable, with the majority of participants reporting that CREW training can reduce errors and improve patient safety. There was a nonsignificant trend toward improved teambased attitudes as assessed by the HFAS (p = 0.210). Postcourse performance demonstrated a similar trend toward improved scores in all categories on the Ottawa GRS (p = 0.16).

EM residents find simulation-based CRM instruction to be useful, effective, and highly relevant to their practice. Trends toward improved performance and attitudes may have arisen because our study was underpowered to detect a difference. Future efforts should focus on interdisciplinary training and recruiting a larger sample size.

Although evidence-based clinical practice guidelines (CPGs) exist, emergency department (ED) asthma management remains highly variable. Our objective was to compare asthma management at a tertiary care ED with that advised by the Canadian Association of Emergency Physicians' (CAEP) asthma CPG and current best practice.

This medical record study enrolled patients between the ages of 19 and 60 years with a previous diagnosis of asthma who were seen for an acute asthma exacerbation at the Vancouver General Hospital ED in 2008. Standard methodology guidelines for medical record review were followed, including explicitly defined criteria and determination of interrater reliability. Primary outcomes were the proportion of cases with the following: objective assessment of severity using peak expiratory flow (PEF), use of systemic corticosteroids (SCSs) in the ED and at discharge, prescription for any inhaled corticosteroids (ICSs), and documentation of outpatient follow-up.

A total of 204 patient encounters were enrolled. Kappa values for interrater assessment ranged from 0.93 to 1.00. Compliance with primary outcomes was as follows: measurement of PEF, 90% (95% CI 85–94); use of SCSs in the ED, 64% (95% CI 57–71); prescription of SCSs at discharge, 59% (95% CI 51–67); prescription of any ICS at discharge, 51% (95% CI 41–61); and documentation of outpatient follow-up, 78% (95% CI 71–84).

This study indicates an improvement in ED asthma care compared to previously published studies; however, discordance still exists between asthma management at a tertiary care ED and the CAEP asthma CPG and current best practice. Further research is warranted to understand the reasons for this finding.

The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner.

Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010.

Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED.

Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.

Increased emergency department (ED) wait times lead to more patients who leave without being seen and decreased patient satisfaction. Many EDs post estimated wait times either online or in the ED to guide patient expectations. The objectives of this study were to assess patients' awareness of online wait time data and to investigate patients' willingness to use this information when choosing between two academic EDs in London, Ontario.

A prospective study was conducted over a 2-month period in a tertiary ED with online available wait times. Patients over 18 years of age assigned a Canadian Triage and Acuity Scale (CTAS) score of 3, 4, or 5 were approached by trained research assistants to complete a 15-item paper-based questionnaire. Multivariable logistic regression models were used to determine factors independently associated with the outcomes.

A total of 1,211 patients completed the survey. Of these, 109 (9%) were aware that ED wait time information was available on the Internet; 544 (45%) reported that they would use the available data to make a decision on which ED to visit, and 536 (44%) indicated that they were more likely to go to the ED with a shorter wait time. Age, gender, household income, education, and Internet access were not associated with awareness of online ED wait times. Participants less than 40 years of age were more likely to use online wait time information.

There is low awareness of the availability of ED wait time data published online in the study locaton. Future research may include the delivery of a public awareness strategy for ED wait time data and a re-evaluation of ED use and patient satisfaction following this.

Les directives de l'Association canadienne des médecins d'urgence (ACMU) relatives à la sepsie, créées par le Critical Care Practice Committee de l'ACMU (C4) et publiées dans le Canadian Journal of Emergency Medicine (CJEM), constituent la plus importante publication consacrée à la prise en charge de la sepsie au sein des services des urgences (SU) canadiens. Notre intention consistait à identifier lesquels, parmi les éléments de prise en charge proposés dans ce document, sont spécifiquement nécessaires au sein du SU et de présenter ensuite ces éléments sous la forme d'une liste de contrôle à plusieurs niveaux pouvant être utilisée par n'importe quel praticien d'un SU canadien.

Les points pratiques de la publication du CJEM consacrée à la sepsie ont été identifiés afin de générer une liste pratique en plusieurs points. Les membres du C4 ont ensuite eu recours, de mai à octobre 2009, à une procédure de consensus selon la technique Delphi, par courriel, en vue de créer une liste de contrôle à plusieurs niveaux relatives aux eléménts de la prise en charge de la sepsie pouvant ou non être assurés au sein d'un SU canadien lors de la prise en charge d'un patient victime d'un choc septique. Cette liste de contrôle a ensuite été évaluée en vue de son utilisation par le biais d'un questionnaire adressé à des praticiens de SU travaillant dans divers contextes (SU rural, SU communautaire, SU tertiaire), cela de juillet à octobre 2010.

Vingt éléments de la prise en charge de la sepsie ont été identifiés dans les directives de l'ACMU relatives à la sepsie. Quinze eléménts ont été jugés nécessaires pour la prise en charge dans le cadre d'un SU. On a ensuite crée deux niveaux de liste de contrôle pouvant être utilisés dans un SU canadien. La plupart des médecins urgentistes travaillant dans des centres de soins communautaires et tertiaires ont pu réaliser toutes les parties de la liste de contrôle de niveau I pour le sepsis. Les centres ruraux rencontrent souvent des difficultés en ce qui concerne la possibilité d'obtention d'un dosage du lactate valeurs et d'un accès veineux central. Un grand nombre d'éléments de la liste de contrôle de niveau II pour le sepsis n'ont pas pu être réalisés en dehors des SU de centres de soins tertiaires.

La prise en charge de la sepsie fait toujours partie intégrante et constitue un élément majeur du domaine des SU. Les points pratiques pour la prise en charge de la sepsie qui requièrent un monitorage spécialisé et des techniques invasives sont souvent limités aux SU de soins tertiaires plus importants et, bien que bon nombre de corps médicaux soulignent leur importance, ne peuvent pas raisonnablement être attendus dans tous les centres. Lorsque les ressources d'un centre limitent la prise en charge du patient, un transfert peut s'avérer nécessaire.