Implementing digital emergency medicine: a call to action.

As digital technologies continue to impact medicine, emergency medicine providers have an opportunity to work together to harness these technologies and shape their implementation within our healthcare system. COVID-19 and the rapid scaling of virtual care provide an example of how profoundly emergency medicine can be affected by digital technology, both positively and negatively. This example also strengthens the case for why EM providers can help lead the integration of digital technologies within our broader healthcare system. As virtual care becomes a permanent fixture of our system, and other technologies such as AI and wearables break into Canadian healthcare, more advocacy, research, and health system leadership will be required to best leverage these tools. This paper outlines the purpose and outputs of the newly founded CAEP Digital Emergency Medicine (DigEM) Committee, with the hope of inspiring further interest amongst CAEP members and creating opportunities to collaborate with other organizations within CAEP and across EM groups nationwide.

Referral pathways for chronic pain patients from Canadian emergency departments: emergency physicians' practices, perspectives, and recommendations.

BACKGROUND: Patients with chronic pain account for 12-20% of total emergency department (ED) and was the primary presenting concern among 37% of patients who visited the ED > 12 times per year. Despite this, emergency physicians receive little focused training managing these patients, and there is a paucity of effective referral pathways from EDs, despite strong evidence that chronic pain is best treated longitudinally in multidisciplinary clinics. This study sought to explore the practices, perspectives, and recommendations of current Canadians emergency physicians in better serving the chronic pain patient (CPP) population in the ED. METHODS: An electronic cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of 16 multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter-quartile range (IQR) for quantitative variables. RESULTS: The study was completed by 169/1635 respondents for a response rate of 10%. The most common presentations respondents saw were neuropathic pain and centrally mediated disorders (23% each) and low back pain (19%). 86% of respondents felt that chronic pain patients did not get appropriate referrals from the ED, and 70% of respondents were unaware of where they could even refer chronic pain patients from the ED. 96% of respondents felt that their ED did not have an effective referral pathway for chronic pain patients. Rapid access clinics for common conditions, reduced pain clinic wait times, and clear ED referral pathways were the commonest recommendations by respondents. CONCLUSION: There is a clear need to increase the accessibility to outpatient pain medicine clinics for chronic pain patients presenting to the ED. ED and pain medicine providers must collaborate to establish mutually beneficial referral pathways from EDs, and to advocate for increased funding for rapid access outpatient pain clinics.

RéSUMé: CONTEXTE: Les patients souffrant de douleur chronique représentent de 12 à 20% de l'ensemble du service d'urgence (SU) et constituaient la principale préoccupation chez 37% des patients qui ont visité le SU > 12 fois par année. Malgré cela, les urgentologues reçoivent peu de formation ciblée sur la gestion de ces patients, et il y a peu de voies d'aiguillage efficaces de la part des urgences, malgré de solides preuves que la douleur chronique est mieux traitée longitudinalement dans les cliniques multidisciplinaires. Cette étude visait à explorer les pratiques, les perspectives et les recommandations des médecins d'urgence canadiens actuels pour mieux servir la population de patients souffrant de douleur chronique (RPC) à l'urgence. MéTHODES: Un sondage transversal électronique a été administré aux membres de l'Association canadienne des médecins d'urgence (ACMU), comprenant seize questions à choix multiples et réponses numériques. Les réponses ont été résumées de façon descriptive sous forme de pourcentages et de fourchette médiane et inter quartile (IQR) pour les variables quantitatives. RéSULTATS: : L'étude a été complétée par 169/1635 répondants pour un taux de réponse de 10%. Les présentations les plus courantes que les répondants ont vues étaient des douleurs neuropathiques et des troubles médiés centraux (23% chacun) et des douleurs lombaires (19%). 86% des répondants estimaient que les patients souffrant de douleur chronique n'obtenaient pas de références appropriées de la part de l'urgence, et 70% des répondants ne savaient même pas où ils pouvaient référer les patients souffrant de douleur chronique de l'urgence. 96% des répondants estimaient que leur DE n'avait pas de voie d'aiguillage efficace pour les patients souffrant de douleur chronique. Les cliniques d'accès rapide pour les affections courantes, la réduction des temps d'attente dans les cliniques de traitement de la douleur et des voies d'aiguillage claires vers le service d'urgence étaient les recommandations les plus courantes des répondants. CONCLUSION: Il est clairement nécessaire d'accroître l'accessibilité aux cliniques de traitement de la douleur ambulatoire pour les patients souffrant de douleur chronique qui se présentent à l'urgence. Les fournisseurs de soins de l'urgence et de médicaments contre la douleur doivent collaborer pour établir des voies d'aiguillage mutuellement avantageuses à partir des urgences. et plaider en faveur d'un financement accru pour des cliniques de traitement de la douleur en consultation externe à accès rapide.

Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review.

BACKGROUND: In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions. METHODS: A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS: A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions. CONCLUSION: There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Throughput interventions to reduce emergency department crowding: A systematic review.

OBJECTIVE: Emergency department (ED) throughput efficiency is largely dependent on staffing and process, and many operational interventions to increase throughput have been described. METHODS: We systematically searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to find studies describing the impact of throughput strategies on ED length of stay and left without being seen rates. Two independent reviewers screened studies, evaluated quality and risk of bias, and stratified eligible studies by intervention type. We assessed statistical heterogeneity using the chi-squared statistic and the I-squared (I2) statistic, and pooled results where appropriate. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Ninety-four (94) studies met inclusion criteria (Cohen's k = 0.7). Most were observational, five were determined to be low quality (Cohen's k = 0.6), and almost all reported modest reductions in length of stay and left without being seen rates, although there was substantial variability within and between intervention types. Fast track and patient streaming interventions showed the most consistent reduction in length of stay and left without being seenrates. Shifting high-level providers to triage appears effective and generally cost neutral. Evidence for enhanced testing strategies and alternative staffing models was less compelling. CONCLUSIONS: Introducing a fast track and optimizing processes for important case-mix groups will likely enhance throughput efficiency. Expediting diagnostic and treatment decisions by shifting physician-patient contact to the earliest possible process point (e.g., triage) is an effective cost-neutral strategy to increase flow. Focusing ED staff on operational improvement is likely to improve performance, regardless of the intervention type.

Three Nontraditional Approaches to Improving the Capacity, Accessibility, and Quality of Mental Health Services: An Overview.

To provide evidence for wider use of peer workers and other nonprofessionals, the authors examined three approaches to mental health service provision-peer support worker (PSW) programs, task shifting, and mental health first-aid and community advocacy organizations-summarizing their effectiveness, identifying similarities and differences, and highlighting opportunities for integration. Relevant articles obtained from PubMed, MEDLINE, and Google Scholar searches are discussed. Studies indicate that PSWs can achieve outcomes equal to or better than those achieved by nonpeer mental health professionals. PSWs can be particularly effective in reducing hospital admissions and inpatient days and engaging severely ill patients. When certain care tasks are given to individuals with less training than professionals (task shifting), these staff members can provide psychoeducation, engage service users in treatment, and help them achieve symptom reduction and manage risk of relapse. Mental health first-aid and community organizations can reduce stigma, increase awareness of mental health issues, and encourage help seeking. Most PSW programs have reported implementation challenges, whereas such challenges are fewer in task-shifting programs and minimal in mental health first-aid. Despite challenges in scaling and integrating these approaches into larger systems, they hold promise for improving access to and quality of care. Research is needed on how these approaches can be combined to expand a community's capacity to provide care. Because of the serious shortage of mental health providers globally and the rising prevalence of mental illness, utilizing nontraditional providers may be the only solution in both low- and high-resource settings, at least in the short term.