The emergency department trigger tool: Multicenter trigger query validation.

OBJECTIVES: We previously described derivation and validation of the emergency department trigger tool (EDTT) for adverse event (AE) detection. As the first step in our multicenter study of the tool, we validated our computerized screen for triggers against manual review, establishing our use of this automated process for selecting records to review for AEs. METHODS: This is a retrospective observational study of visits to three urban, academic EDs over 18 months by patients ≥ 18 years old. We reviewed 912 records: 852 with at least one of 34 triggers found by the query and 60 records with none. Two first-level reviewers per site each manually screened for triggers. After completion, computerized query results were revealed, and reviewers could revise their findings. Second-level reviewers arbitrated discrepancies. We compare automated versus manual screening by positive and negative predictive values (PPVs, NPVs), present population trigger frequencies, proportions of records triggered, and how often manual ratings were changed to conform with the query. RESULTS: Trigger frequencies ranged from common (>25%) to rare (1/1000) were comparable at U.S. sites and slightly lower at the Canadian site. Proportions of triggered records ranged from 31% to 49.4%. Overall query PPV was 95.4%; NPV was 99.2%. PPVs for individual trigger queries exceeded 90% for 28-31 triggers/site and NPVs were >90% for all but three triggers at one site. Inter-rater reliability was excellent, with disagreement on manual screening results less than 5% of the time. Overall, reviewers amended their findings 1.5% of the time when discordant with query findings, more often when the query was positive than when negative (47% vs. 23%). CONCLUSIONS: The EDTT trigger query performed very well compared to manual review. With some expected variability, trigger frequencies were similar across sites and proportions of triggered records ranged 31%-49%. This demonstrates the feasibility and generalizability of implementing the EDTT query, providing a solid foundation for testing the triggers' utility in detecting AEs.

RAFF-5 Study to Improve the Quality and Safety of Care for Patients Seen in the Emergency Department With Acute Atrial Fibrillation and Flutter.

BACKGROUND: We sought to improve the immediate and subsequent care of emergency department (ED) patients with acute atrial fibrillation (AF) and flutter (AFL) by implementing the principles of the Canadian Association of Emergency Physicians AF/AFL Best Practices Checklist. METHODS: This cohort study included 3 periods: before (7 months), intervention introduction (1 month), and after (7 months), and was conducted at a major academic centre. We included patients who presented with an episode of acute AF or AFL and used multiple strategies to support ED adoption of the Canadian Association of Emergency Physicians checklist. We developed new cardiology rapid-access follow-up processes. The main outcomes were unsafe and suboptimal treatments in the ED. RESULTS: We included 1108 patient visits, with 559 in the before and 549 in the after period. In a comparison of the periods, there was an increase in use of chemical cardioversion (20.6% vs 25.0%; absolute difference [AD], 4.4%) and in electrical cardioversion (39.2% vs 51.2%; AD, 12.0%). More patients were discharged with sinus rhythm restored (66.9% vs 75.0%; AD, 8.1%). The proportion seen in a follow-up cardiology clinic increased from 24.2% to 39.9% (AD, 15.7%) and the mean time until seen decreased substantially (103.3 vs 49.0 days; AD, -54.3 days). There were very few unsafe cases (0.4% vs 0.7%) and, although there was an increase in suboptimal care (19.5% vs 23.1%), overall patient outcomes were excellent. CONCLUSIONS: We successfully improved the care for ED patients with acute AF/AFL and achieved more frequent and more rapid cardiology follow-up. Although cases of unsafe management were uncommon and patient outcomes were excellent, there are opportunities for physicians to improve their care of acute AF/AFL patients. GOV IDENTIFIER: NCT05468281.

Resource allocation decisions under pandemic conditions: A cross-sectional survey of Ontario physicians.

The COVID-19 pandemic has forced physicians to confront difficult choices regarding the allocation of scarce resources, such as ventilators and critical care beds. Developing policies to guide the allocation of such resources has proven challenging. An understanding of physicians' attitudes and beliefs surrounding resource allocation could help inform policymaking. As a replication and extension of a survey of Ottawa physicians conducted in 2020, we surveyed physicians across Ontario, Canada in April 2021. This survey examined physicians' sense of preparedness to allocate critical care resources during the pandemic, attitudes concerning resource allocation policy, and approaches to resource allocation decision-making. Of the 253 responses included for analysis, the majority (67%) of respondents indicated feeling "somewhat" or "a little prepared" to make resource allocation decisions, while 20% indicated feeling "not at all prepared." Most respondents (86%) agreed that a policy to guide resource allocation in the event of scarcity should exist. Physicians overwhelmingly agreed that important factors to consider when making resource allocation decisions included the patient likelihood of survival, frailty index, comorbidities, and cognitive status. Responses from the province-wide survey conducted in 2021 resemble the results of an analogous survey of Ottawa physicians conducted in 2020. Physicians generally felt underprepared to make resource allocation decisions and agreed that official policies should guide such decisions. Identification of factors relevant to resource allocation was remarkably consistent across this sample and that taken in 2020.

Canadian Association of Radiologists Diagnostic Imaging Referral Guidelines: a guideline development protocol.

BACKGROUND: Comprehensive diagnostic imaging referral guidelines are an important tool to assist referring clinicians and radiologists in determining the safest and best-clinical-value diagnostic imaging study for their patients; the Canadian Association of Radiologists (CAR) last produced its diagnostic imaging referral guidelines in 2012. In partnership with several national organizations, referring clinicians, radiologists, and patient and family advisors from across Canada, the association is redoing its referral guidelines using a new methodology for guideline development, and these guideline recommendations will be suited for integration into clinical decision support systems. METHODS: Expert panels of radiologists, referring clinicians and a patient advisor will work with epidemiologists at the CAR to create guidelines across 13 clinical sections. The expert panel for each section will first create a comprehensive list of clinical and diagnostic scenarios to include in the guidelines. Canadian Association of Radiologists epidemiologists will then conduct a systematic rapid scoping review to identify systematically produced guidelines from other guideline groups. The corresponding expert panel will develop diagnostic imaging recommendations for each clinical and diagnostic scenario using the recommendations identified from the scoping review and contextualize them to the Canadian health care systems. The expert panels will accomplish this using an adapted Grading of Recommendations Assessment, Development and Evaluation framework, which reflects the benefits and harms, values and preferences, equity, accessibility, resources and cost. INTERPRETATION: Freely available, up-to-date, comprehensive Canadian-specific diagnostic imaging referral guidelines are needed. A transparent and structured guideline-development approach will aid the CAR and its partners in producing guidelines across its 13 sections.

Physician experience with the Epic electronic health record (EHR) system: longitudinal findings from an emergency department implementation.

OBJECTIVES: In June 2019, The Ottawa Hospital launched the Epic electronic health record system, which transitioned all departments from a primarily paper-based system to an electronic system using a 1-day "big bang" approach. We sought to evaluate emergency physicians' satisfaction with system implementation and perception of its impact on clinical practice in an academic emergency department (ED) setting. METHODS: Four electronic surveys were distributed to staff during pre-implementation (1-month prior [May 2019]) and post-implementation (1-month [July 2019], 9-month [March 2020], and 20-month [February 2021]) time periods. 5-point Likert scales were used to rate agreement with statements. Responses were compared using the Cochran-Mantel-Haenszel trend test to assess for significant differences. RESULTS: Response rates were consistent, ranging between 41 and 51%, with the exception of +9 months which was 27%. The majority of respondents were staff, working 8-15 shifts/month, with ≤ 10 years in practice. General satisfaction and confidence improved substantially from pre-implementation to 20 months post-implementation. Personalization sessions were perceived as not effective and lacking in quality, particularly immediately after Epic launch. Although clinical workflow tasks got easier, there were sustained challenges in efficiency and patient flow, including number of patients seen/hour, time spent after shift-end, and time spent on post-shift documentation. CONCLUSIONS: Although satisfaction and system confidence improved over time, there were sustained difficulties in overall efficiency long after implementation, with opportunities for future optimization. Training was lacking in terms of relevance to emergency physician workflow. These factors should be considered in future electronic health record implementations in ED settings.

RéSUMé: OBJECTIFS: En juin 2019, l'Hôpital d'Ottawa a lancé le système de dossiers de santé électroniques Epic, ce qui a permis de faire passer tous les services d'un système principalement basé sur le papier à un système électronique en utilisant une approche " big bang " d'une journée. Nous avons cherché à évaluer la satisfaction des médecins urgentistes quant à la mise en œuvre du système et la perception de son impact sur la pratique clinique dans un service d'urgence universitaire. MéTHODES: Quatre sondages électroniques ont été distribués au personnel pendant les périodes précédant la mise en œuvre (1 mois avant [mai 2019]) et suivant la mise en œuvre (1 mois [juillet 2019], 9 mois [mars 2020] et 20 mois [février 2021]). Des échelles de Likert à 5 points ont été utilisées pour évaluer l'accord avec les énoncés. Les réponses ont été comparées à l'aide du test de tendance de Cochran-Mantel-Haenszel pour évaluer les différences significatives. RéSULTATS: Les taux de réponse étaient constants, allant de 41 % à 51 %, à l'exception de celui de +9 mois qui était de 27 %. La majorité des répondants étaient des employés, travaillant de 8 à 15 quarts par mois, avec moins de 10 ans de pratique. La satisfaction générale et la confiance se sont considérablement améliorées entre la période précédant la mise en œuvre et la période de 20 mois suivant la mise en œuvre. Les sessions de personnalisation ont été perçues comme inefficaces et manquant de qualité, en particulier immédiatement après le lancement d'Epic. Bien que les tâches du flux de travail clinique aient été facilitées, l'efficacité et le flux de patients ont continué à poser problème, notamment le nombre de patients vus par heure, le temps passé après la fin du quart de travail et le temps consacré à la documentation après le quart de travail. CONCLUSIONS: Bien que la satisfaction et la confiance dans le système se soient améliorées au fil du temps, il y a eu des difficultés persistantes dans l'efficacité globale longtemps après la mise en œuvre, avec des possibilités d'optimisation future. La formation manquait de pertinence par rapport au flux de travail des médecins urgentistes. Ces facteurs devraient être pris en compte dans les futures mises en œuvre de dossiers médicaux électroniques dans les services d'urgence.

Flow impacts of hot/cold zone infection control procedures during the COVID-19 pandemic in the emergency department.

BACKGROUND: The COVID-19 pandemic forced emergency departments (EDs) to change operations to minimize nosocomial infection risk. Many EDs cohort patients using provincial screening tools at triage. Despite cohorting, staff exposures occurred in the 'cold zone' due to lack of personal protective equipment (PPE) use with patients deemed low risk, resulting in staff quarantines. The cohorting strategy was perceived to lengthen time to physician initial assessment and ED length of stay times in our ED without protecting staff well enough due to varying PPE use. The objective of this study was to assess the impact of hot/cold zones for patient cohorting during a viral pandemic on ED length of stay. METHODS: We conducted an interrupted time series analysis 3 weeks before and after the removal of hot/cold zone care space cohorting in our ED. In the before period, staff did not routinely wear full PPE to see cold zone patients. After removal, staff wore full PPE to see almost all patients. We collected data on ED length of stay, physician initial assessment times, arrival-to-room times, patient volumes, Canadian Triage Acuity Score (CTAS), admissions, staff hours of coverage, as well as proportions of patients on droplet/contact precautions and COVD-19 positive patients. The primary outcome was median ED length of stay. RESULTS: After the removal of the hot/cold divisions, there was a decrease in the adjusted median ED length of stay by 24 min (95% CI 14; 33). PPE use increased in the after arm of the study. The interrupted time series analysis suggested a decrease in median ED length of stay after removal, although the change in slope and difference did not reach statistical significance. CONCLUSION: Cohorted waiting areas may provide a safety benefit without operational compromise, but cohorting staff and care spaces is likely to compromise efficiency and create delays.

RéSUMé: CONTEXTE: La pandémie de COVID-19 a contraint les services d'urgence (SU) à modifier leur fonctionnement afin de minimiser le risque d'infection nosocomiale. De nombreux SU regroupaient des patients à l'aide d'outils de dépistage provinciaux au triage. Malgré la constitution de cohortes, les expositions du personnel se sont produites dans la "zone froide" en raison du manque d'utilisation d'équipements de protection individuelle (EPI) avec des patients jugés à faible risque, ce qui a entraîné la mise en quarantaine du personnel. Dans notre service d'urgence, la stratégie de cohorte a été perçue comme prolongeant l'évaluation initiale des médecins et la durée du séjour dans le service sans pour autant protéger suffisamment le personnel en raison de l'utilisation variable des EPI. L'objectif de cette étude était d'évaluer l'impact des zones chaudes/froides pour le regroupement de patients lors d'une pandémie virale sur la durée du séjour à l'urgence. MéTHODES: Nous avons réalisé une analyse de séries chronologiques interrompues trois semaines avant et après la suppression de la cohorte d'espace de soins en zone chaude/froide dans nos urgences. Au cours de la période précédente, le personnel ne portait pas systématiquement un EPI complet pour voir les patients des zones froides. Après le retrait, le personnel a porté un EPI complet pour voir presque tous les patients. Nous avons recueilli des données sur la durée du séjour aux urgences, les délais d'évaluation initiale par les médecins, les délais d'arrivée en salle, le volume de patients, L'échelle canadienne de triage et de gravité (ÉTG), les admissions, les heures de couverture du personnel, ainsi que les proportions de patients ayant reçu des précautions contre les gouttelettes et les contacts et de patients positifs au COVD-19. Le critère de jugement principal était la durée médiane du séjour aux urgences. RéSULTATS: Après la suppression des divisions chaudes/froides, la durée médiane ajustée du séjour aux urgences a diminué de 24 minutes (IC à 95 % : 14 ; 33). L'utilisation des EPI a augmenté dans le groupe suivant de l'étude. L'analyse des séries chronologiques interrompues suggère une diminution de la durée médiane de séjour aux urgences après le retrait, bien que le changement de la pente et de la différence n'ait pas atteint la signification statistique. CONCLUSION: Les zones d'attente en cohorte peuvent offrir un avantage en matière de sécurité sans compromis sur le plan opérationnel, mais le regroupement du personnel et des espaces de soins est susceptible de compromettre l'efficacité et de créer des retards.

Availability of Emergency Department Wait Times Information: A Patient-Centered Needs Assessment.

INTRODUCTION: Many Emergency Departments (ED) publish wait times; however, the patient perspective in what information is requested and the quantity of information to post is limited. METHODS: We conducted a mixed-methods study at a tertiary care academic center. First, we conducted focus groups of 7 patients. We then generated themes following content analysis to create a patient survey. We administered in-person surveys to patients in ED waiting rooms at sites randomized for survey administration. We used preassigned shifts utilized for even patient perspective representation of the 24 hours-a-day/7 days-a-week service. We included waiting room patients over 18 years of age and excluded patients directly referred to a specialty service or who did not speak French or English. We analyzed survey data using descriptive statistics. RESULTS: We identified nine dominant focus group themes: wait time definition, wait time notification, communication, education, patient expectations, utilization of the ED, patient behaviour, physical comfort, and patient empowerment. Of the 240 patient questionnaires administered, 81.3% of respondents wanted to know ED wait times before hospital arrival hospital and 90.8% wanted ED wait times posted in the waiting room. Website (46.7%) was the most popular choice for publishing wait times outside the ED. Within the ED, patients had no preference regarding display modality, if times were displayed (39.6%). Overall, 76.7% stated that their satisfaction with the ED would be improved if wait times were posted. CONCLUSION: ED patients strongly supported having access to wait time information. Patients believed having wait time information will have a positive impact on their overall ED satisfaction.

The impact of adoption of an electronic health record on emergency physician work: A time motion study.

OBJECTIVE: We assessed the impact of the transition from a primarily paper-based electronic health record (EHR) to a comprehensive EHR on emergency physician work tasks and efficiency in an academic emergency department (ED). METHODS: We conducted a time motion study of emergency physicians on shift in our ED. Fifteen emergency physicians were directly observed for two 4-hour sessions prior to EHR implementation, during go live, and then during post-implementation. Observers performed continuous observation and measured times for the following tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other. We compared time spent on tasks during the 3 phases of transition and analyzed mean times for the tasks per patient and per shift using 2-tailed t test for comparison. RESULTS: Physicians saw fewer patients per shift during go-live (0.51 patient/hour, P < 0.01), patient efficiency increased in post-implementation but did not recover to baseline (-0.31 patient/hour, P = 0.03). From pre-implementation to post-implementation, we observed a trend towards increased physician time spent charting (+54 seconds/patient, P = 0.05) and documenting (+36 seconds/patient, P = 0.36); time spent doing direct patient care trended towards decreasing (-0.43 seconds/patient, P = 0.23). A small percentage of shifts were spent receiving technical support and time spent on teaching activities remained relatively stable during EHR transition. CONCLUSION: A new EHR impacts emergency physician task allocation and several changes are sustained post-implementation. Physician efficiency decreased and did not recover to baseline. Understanding workflow changes during transition to EHR in the ED is necessary to develop strategies to maintain quality of care.

The Impact of COVID-19 Pandemic on Emergency Department Visits at a Canadian Academic Tertiary Care Center.

INTRODUCTION: Public health response to the coronavirus 2019 (COVID-19) pandemic has emphasized social distancing and stay-at-home policies. Reports of decreased emergency department (ED) visits in non-epicenters of the outbreak have raised concerns that patients with non-COVID-19 emergencies are delaying or avoiding seeking care. We evaluated the impact of the pandemic on ED visits at an academic tertiary care center. METHODS: We conducted an observational health records review between January 1-April 22, 2020, comparing characteristics of all ED visits between pre- and post-pandemic declaration by the World Health Organization. Measures included triage acuity, presenting complaints, final diagnoses, disposition, and mortality. We further examined three time-sensitive final diagnoses: stroke; sepsis; and acute coronary syndrome (ACS). RESULTS: In this analysis, we included 44,497 ED visits. Average daily ED visits declined from 458.1 to 289.0 patients/day (-36.9%). For the highest acuity triaged patients there was a drop of 1.1 patients/day (-24.9%). Daily ED visits related to respiratory complaints increased post-pandemic (+14.1%) while ED visits for many other complaints decreased, with the greatest decline in musculoskeletal (-52.5%) and trauma (-53.6%). On average there was a drop of 1.0 patient/day diagnosed with stroke (-17.6%); a drop of 1.6 patients/day diagnosed with ACS (-49.9%); and no change in patients diagnosed with sepsis (pre = 2.8 patients/day; post = 2.9 patients/day). CONCLUSION: Significant decline in ED visits was observed immediately following formal declaration of the COVID-19 pandemic, with potential for delayed/missed presentations of time-sensitive emergencies. Future research is needed to better examine long-term clinical outcomes of the decline in ED visits during pandemics.

Relaxin Attenuates Organ Fibrosis via an Angiotensin Type 2 Receptor Mechanism in Aged Hypertensive Female Rats.

Background: The antifibrotic effects of recombinant human relaxin (RLX) in the kidney are dependent on an interaction between its cognate receptor (RXFP1) and the angiotensin type 2 receptor (AT2R) in male models of disease. Whether RLX has therapeutic effects, which are also mediated via AT2R, in hypertensive adult and aged/reproductively senescent females is unknown. Thus, we determined whether treatment with RLX provides cardiorenal protection via an AT2R-dependent mechanism in adult and aged female stroke-prone spontaneously hypertensive rats (SHRSPs). Methods: In 6-month-old (6MO) and 15-month-old ([15MO]; reproductively senescent) female SHRSP, systolic BP (SBP), GFR, and proteinuria were measured before and after 4 weeks of treatment with vehicle (Veh), RLX (0.5 mg/kg per day s.c.), or RLX+PD123319 (AT2R antagonist; 3 mg/kg per day s.c.). Aortic endothelium-dependent relaxation and fibrosis of the kidney, heart, and aorta were assessed. Results: In 6MO SHRSP, RLX significantly enhanced GFR by approximately 25% (P=0.001) and reduced cardiac fibrosis (P=0.01) as compared with vehicle-treated counterparts. These effects were abolished or blunted by PD123319 coadministration. In 15MO females, RLX reduced interstitial renal (P=0.02) and aortic (P=0.003) fibrosis and lowered SBP (13±3 mm Hg; P=0.04) relative to controls. These effects were also blocked by PD123319 cotreatment (all P=0.05 versus RLX treatment alone). RLX also markedly improved vascular function by approximately 40% (P<0.001) in 15MO SHRSP, but this was not modulated by PD123319 cotreatment. Conclusions: The antifibrotic and organ-protective effects of RLX, when administered to a severe model of hypertension, conferred cardiorenal protection in adult and reproductively senescent female rats to a great extent via an AT2R-mediated mechanism.

Physician preparedness for resource allocation decisions under pandemic conditions: A cross-sectional survey of Canadian physicians, April 2020.

BACKGROUND: Under the pandemic conditions created by the novel coronavirus of 2019 (COVID-19), physicians have faced difficult choices allocating scarce resources, including but not limited to critical care beds and ventilators. Past experiences with severe acute respiratory syndrome (SARS) and current reports suggest that making these decisions carries a heavy emotional toll for physicians around the world. We sought to explore Canadian physicians' preparedness and attitudes regarding resource allocation decisions. METHODS: From April 3 to April 13, 2020, we conducted an 8-question online survey of physicians practicing in the region of Ottawa, Ontario, Canada, organized around 4 themes: physician preparedness for resource rationing, physician preparedness to offer palliative care, attitudes towards resource allocation policy, and approaches to resource allocation decision-making. RESULTS: We collected 219 responses, of which 165 were used for analysis. The majority (78%) of respondents felt "somewhat" or "a little prepared" to make resource allocation decisions, and 13% felt "not at all prepared." A majority of respondents (63%) expected the provision of palliative care to be "very" or "somewhat difficult." Most respondents (83%) either strongly or somewhat agreed that there should be policy to guide resource allocation. Physicians overwhelmingly agreed on certain factors that would be important in resource allocation, including whether patients were likely to survive, and whether they had dementia and other significant comorbidities. Respondents generally did not feel confident that they would have the social support they needed at the time of making resource allocation decisions. INTERPRETATION: This rapidly implemented survey suggests that a sample of Canadian physicians feel underprepared to make resource allocation decisions, and desire both more emotional support and clear, transparent, evidence-based policy.

Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. OBJECTIVE: To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. METHODS: The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. MEASUREMENTS: The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. RESULTS: Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). CONCLUSIONS: The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Evaluating the potential impact of an emergency department extracorporeal resuscitation (ECPR) program: a health records review.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program. METHODS: This retrospective health records review included patients aged 18-75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both "liberal" and "restrictive" ECPR criteria were defined and applied to our cohort. RESULTS: A total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31-53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR. CONCLUSION: At our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Using emergency physicians' abilities to predict patient admission to decrease admission delay time.

BACKGROUND: In many EDs, emergency physicians (EPs) do not have admitting privileges and must wait for consultants to further assess and admit patients. This delays bed requests and increases ED crowding. We measured EPs' abilities to predict patient admission prior to consultation and estimated the potential ED stretcher time saved if EPs requested a bed with consultation. METHODS: We conducted a prospective cohort study in an academic centre in Canada between October 2017 and February 2018 using a convenience sample of ED patient encounters requiring consultation. We excluded patients under 18 years or those clearly likely to be admitted (traumas, strokes, S-T elevation myocardial infarctions and Canadian Triage and Acuity Scale of 1). EPs predicted patient admission just before consultation. Potential ED stretcher time saved was estimated for correctly predicted admissions assuming bed requests were initiated with consultation and a constant time to inpatient bed. RESULTS: Characteristics of 454 patients were: mean age 60.1 years, 48.5% male, 46.9% evening presentation, 69.4% admitted and median time to bed request of 3.5 hours (IQR 2.0-5.3 hours). Overall, EPs prediction sensitivity, specificity, positive predictive value and negative predictive value were 90.5% (95% CI 86.7% to 93.5%), 84.2% (95% CI 77.0% to 89.8%), 92.8% (95% CI 89.8% to 95.0%) and 79.6% (95% CI 73.4% to 84.7%). Approximately 922.1 hours of ED stretcher time could have been saved during the 5-month study period if EPs initiated a bed request with consultation. CONCLUSION: Crowding is a reality for EDs worldwide, and many systems could benefit from EP-initiated hospital admissions to decrease the amount of time admitted patients wait in the ED.

Development and implementation of a standardised emergency department intershift handover tool to improve physician communication.

BACKGROUND: Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians. AIM: Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months. METHODS: We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling. MEASURES: Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics. RESULTS: We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education. CONCLUSIONS: We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

Decision fatigue in the Emergency Department: How does emergency physician decision making change over an eight-hour shift?

INTRODUCTION: We examined emergency physician disposition decisions and computed tomography (CT) ordering as markers of decision fatigue over an eight-hour shift. METHODS: Administrative database analysis of patients presenting to an academic, tertiary care, emergency department (ED) over two years. Patients were grouped by the hour of the shift that they were initially assessed by an emergency physician. For each hour, we evaluated the proportions of patients who had CT head, chest, or abdomen, consultations, and consultations not resulting in admission. For patients discharged without consultation, we evaluated return visits within 72 h and ED length-of-stay (LOS). Statistical significance was assessed using random effects regression accounting for clustering by physician. RESULTS: We analyzed 87,752 patients and there were no important differences in consultations, consultations not resulting in admission, or return visits in relation to the hour of shift the patient was seen. Rates of CT head and abdomen and ED LOS decreased as the shift progressed. From the first to the last hour, CT head ordering decreased from 15.8% to 12.2% (OR 0.73, 95% CI 0.66-0.80, p < 0.0001), CT abdomen ordering decreased from 9.6% to 7.6% (OR 0.72, 95% CI 0.64-0.80, p < 0.0001), and ED LOS decreased from 5.5 h to 4.9 h (relative difference 0.83, 95% CI 0.81-0.85, p < 0.0001). CONCLUSIONS: Emergency physician decisions about patient disposition did not change throughout the shift. The rates of CT head and abdomen and ED LOS decreased as the shift progressed. We did not find evidence of decision fatigue among emergency physicians over an eight-hour shift.

Residents' perspective of quality improvement and patient safety education in Canadian emergency medicine residency programs.

OBJECTIVES: Quality improvement and patient safety (QIPS) competencies are increasingly important in emergency medicine (EM) and are now included in the CanMEDS framework. We conducted a survey aimed at determining the Canadian EM residents' perspectives on the level of QIPS education and support available to them. METHODS: An electronic survey was distributed to all Canadian EM residents from the Royal College and Family Medicine training streams. The survey consisted of multiple-choice, Likert, and free-text entry questions aimed at understanding familiarity with QIPS, local opportunities for QIPS projects and mentorship, and the desire for further QIPS education and involvement. RESULTS: Of 535 EM residents, 189 (35.3%) completed the survey, representing all 17 medical schools; 77.2% of respondents were from the Royal College stream; 17.5% of respondents reported that QIPS methodologies were formally taught in their residency program; 54.7% of respondents reported being "somewhat" or "very" familiar with QIPS; 47.2% and 51.5% of respondents reported either "not knowing" or "not having readily available" opportunities for QIPS projects and QIPS mentorship, respectively; 66.9% of respondents indicated a desire for increased QIPS teaching; and 70.4% were interested in becoming involved with QIPS training and initiatives. CONCLUSIONS: Many Canadian EM residents perceive a lack of QIPS educational opportunities and support in their local setting. They are interested in receiving more QIPS education, as well as project and mentorship opportunities. Supporting residents with a robust QIPS educational and mentorship framework may build a cohort of providers who can enhance the local delivery of care.

A Health Records Review of Outpatient Referrals from the Emergency Department.

OBJECTIVES: Many patients discharged home from the emergency department (ED) require urgent outpatient consultation with a specialty service. We sought to identify the best- and worst-performing services with regard to time to outpatient consultation, the proportion of patients lost to follow-up, the rate of related return ED visits prior to consultation, and common strategies used by our top-performing clinics. METHODS: We conducted a health records review of The Ottawa Hospital ED visits during four 1-week periods. All consecutive adult outpatient consultation requests were included for chart review and were followed up to 12 months. Outcome measures included demographics, referral attendance rates, incomplete referrals, return ED visits, and time intervals. Services with at least 15 consultation requests were included for data analysis and qualitative mapping of their referral processes. RESULTS: Of the 963 patients who met inclusion criteria, 803 (83.4%) attended their appointment, while 160 (16.6%) were lost to follow-up. The overall median time to successful consultation was 9 days (IQR = 2-27). 92 (9.6%) patients returned to the ED with a related complaint. The top-performing clinics included ophthalmology, orthopedics, and thrombosis (median = 1, 8, 1 days; incomplete consultation = 3%, 4%, 6%; return ED visits = 0%, 6%, 2% respectively). The bottom-performing clinics included otorhinolaryngology, neurology, and gynecology (median = 47, 39, 27 days; incomplete consultation = 50%, 41%, 37%; return ED visits = 11%, 15%, 26%, respectively). Processes incorporated by top-performing clinics included reserving appointment slots for emergency referrals, structured referral forms, and centralized booking. CONCLUSIONS: We found a substantial variability in both the waiting times and reliability of outpatient referrals from the ED. Top-performing clinics incorporate common referral processes.