CAEP 2019 Academic Symposium: Got competence? Best practices in trainee progress decisions.

BACKGROUND: Competence committees play a key role in a competency-based system of assessment. These committees are tasked with reviewing and synthesizing clinical performance data to make judgments regarding residents' competence. Canadian emergency medicine (EM) postgraduate training programs recently implemented competence committees; however, a paucity of literature guides their work. OBJECTIVE: The objective of this study was to develop consensus-based recommendations to optimize the function and decisions of competence committees in Canadian EM training programs. METHODS: Semi-structured interviews of EM competence committee chairs were conducted and analyzed. The interview guide was informed by a literature review of competence committee structure, processes, and best practices. Inductive thematic analysis of interview transcripts was conducted to identify emerging themes. Preliminary recommendations, based on themes, were drafted and presented at the 2019 CAEP Academic Symposium on Education. Through a live presentation and survey poll, symposium attendees representing the national EM community participated in a facilitated discussion of the recommendations. The authors incorporated this feedback and identified consensus among symposium attendees on a final set of nine high-yield recommendations. CONCLUSION: The Canadian EM community used a structured process to develop nine best practice recommendations for competence committees addressing: committee membership, meeting processes, decision outcomes, use of high-quality performance data, and ongoing quality improvement. These recommendations can inform the structure and processes of competence committees in Canadian EM training programs.

Procedural sedation and analgesia in rural and regional emergency departments.

INTRODUCTION: Several agents can be administered during procedural sedation and analgesia (PSA) in the emergency department (ED). The purpose of this study was to determine the PSA agents commonly used by physicians working in nontertiary EDs, and to assess the physicians' comfort level administering the agents as well as their knowledge of adverse effects of the agents. METHODS: We distributed a confidential electronic survey to physicians working in nontertiary EDs in southwestern Ontario. Using a 5-point Likert scale, ED physicians were asked to rate their use of older and newer agents used for PSA in the ED, as well as their familiarity with the agents. RESULTS: A total of 55 physicians completed the survey. The most frequently used drugs were fentanyl (66.0% often or always) and propofol with fentanyl (59.2% often or always). Most respondents stated that they rarely used ketofol (54.2% rarely or never) or etomidate (77.1% rarely or never). Respondents were most comfortable using midazolam or fentanyl (96.1% somewhat or very comfortable), and least comfortable administering etomidate and ketofol (36.5% and 23.1% somewhat or very uncomfortable). These differences were magnified with comparison of physicians with CCFP (Certification in The College of Family Physicians) and CCFP(EM) (emergency medicine) designations. Additionally, etomidate's adverse effects were the least astutely recognized (19%), compared with midazolam combined with fentanyl (63%). CONCLUSION: Physicians practising in nontertiary EDs used more often, remained more comfortable with and were more familiar with older sedation agents than newer agents.

INTRODUCTION: On peut administrer plusieurs agents pour la sédation et l'analgésie en cours d'intervention dans les services d'urgence. Le but de cette étude était de déterminer quels sont les agents les plus couramment utilisés par les urgentologues d'établissements de soins non tertiaires, de vérifier dans quelle mesure ils se sentent à l'aise de les administrer et de mesurer leur degré de connaissances au sujet des effets indésirables de ces agents. MÉTHODES: Nous avons envoyé un sondage électronique confidentiel aux urgentologues des établissements de soins non tertiaires du Sud-Ouest de l'Ontario. En utilisant une échelle de Likert en 5 points, nous les avons invités à classer leur utilisation des agents anciens et récents pour la sédation et l'analgésie en cours d'interventionà l'urgence, de même que leur degré de connaissance de ces agents. RÉSULTATS: En tout, 55 médecins ont répondu au sondage. Les médicaments les plus souvent utilisés ont été le fentanyl (66,0 %, souvent ou toujours) et le propofol avec fentanyl (59,2 %, souvent ou toujours). La plupart des répondants ont affirmé utiliser rarement le kétofol (54,2 % rarement ou jamais) ou l'étomidate (77,1 % rarement ou jamais). Les répondants étaient le plus à l'aise avec le midazolam ou le fentanyl (96,1 % relativement ou très à l'aise) et le moins à l'aise avec l'étomidate et le kétofol (36,5 % et 23,1 % relativement ou très à l'aise). Ces différences étaient amplifiées lorsqu'on comparait les médecins détenteurs d'un CCFM (certificat du Collège des médecins de famille) et d'un CCFM(MU) (médecine d'urgence). De plus, les effets indésirables de l'étomidate étaient les moins bien reconnus (19 %), comparativement à ceux du midazolam allié au fentanyl (63 %). CONCLUSION: Les médecins qui exercent dans les services d'urgence des établissements de soins non tertiaires ont utilisé plus souvent des sédatifs plus anciens; ils se sentaient plus à l'aise d'utiliser ce type d'agents et les connaissaient mieux que les agents plus récents.

Barriers to patient care in southwestern Ontario rural emergency departments: physician perceptions.

INTRODUCTION: We sought to determine the perceptions of physicians staffing rural emergency departments (EDs) in southwestern Ontario with respect to factors affecting patient care in the domains of physical resources, available support and education. METHODS: A confidential 30-item survey was distributed through ED chiefs to physicians working in rural EDs in southwestern Ontario. Using a 5-point Likert scale, physicians were asked to rate their perception of factors that affect patient care in their ED. Demographic and practice characteristics were collected to accurately represent the participating centres and physicians. RESULTS: Twenty-seven of the 164 surveys distributed were completed (16% response rate). Responses were received from 13 (81.3%) of the 16 surveyed EDs. Most of the respondents (78%) held CCFP (Certificant of the College of Family Physicians) credentials, with no additional emergency medicine training. Crowding from inpatient boarding, and inadequate physician staffing or coverage in EDs were identified as having a negative impact on patient care. Information sharing within the hospital, access to emergent laboratory studies and physician access to medications in the ED were identified as having the greatest positive impact on patient care. Respondents viewed all questions in the domain of education as either positive or neutral. CONCLUSION: Our survey results reveal that physicians practising emergency medicine in southwestern Ontario perceive crowding as the greatest barrier to providing patient care. Conversely, the survey identified that rural ED physicians perceive information sharing within the hospital, the availability of emergent laboratory studies and access to medications within the ED as having a strongly positive impact on patient care. Interestingly, our findings suggest that physicians in rural EDs view their access to education as adequate, as responses were either positive or neutral in regard to access to training and ability to maintain relevant skills.

Diagnostic approach to pulmonary embolism in a rural emergency department.

INTRODUCTION: Pulmonary embolism (PE) is a serious condition with mortality estimates of up to 10%. We sought to investigate the diagnosis of PE, time to access imaging and diagnostic utility of each modality in a rural emergency department (Ed). METHODS: We completed a retrospective chart review to determine the investigations performed and treatments initiated in the management of suspected PE in a rural hospital. RESULTS: A total of 47 charts from a 5-year period were reviewed. Of these, 83.0% indicated a D-dimer test was ordered, and 31.9% and 40.4% indicated either ventilation-perfusion (V/Q) or computed tomography (CT) were ordered during the ED visit. Computed tomography diagnosed 11 of the 12 instances of confirmed PE. Mean time to patients undergoing V/Q or CT was 1.58 and 1.59 days, respectively. Low-molecular-weight heparin was started in 83.0% of patients. CONCLUSION: In this ED there may be over reliance on the D-dimer test, irrespective of Wells score. Access to V/Q and CT were similar to that of an urban centre. Empiric anticoagulation was started in most patients.

Ramsay Hunt syndrome presenting as simple otitis externa.

Ramsay Hunt syndrome is a rare complication of herpes zoster in which reactivation of latent varicella zoster virus infection occurs in the geniculate ganglion, causing otalgia, auricular vesicles and peripheral facial paralysis. Because these symptoms do not always present at the onset, this syndrome can be misdiagnosed. We report the case of a patient who was diagnosed with simple otitis externa after presenting to the emergency department (ED) with a 3-day history of right-sided otalgia. Her condition subsequently evolved to include right-sided auricular vesicles and right-sided facial weakness. She presented to the ED again after 2 days and was correctly diagnosed with Ramsay Hunt syndrome. We describe the clinical presentation, diagnostic findings and management of this uncommon but important entity.

Emergency medicine training demographics of physicians working in rural and regional southwestern Ontario emergency departments.

OBJECTIVES: We sought to determine the emergency medicine training demographics of physicians working in rural and regional emergency departments (EDs) in southwestern Ontario. METHODS: A confidential 8-item survey was mailed to ED chiefs in 32 community EDs in southwestern Ontario during the month of March 2005. This study was limited to nonacademic centres. RESULTS: Responses were received from 25 (78.1%) of the surveyed EDs, and demographic information on 256 physicians working in those EDs was obtained. Of this total, 181 (70.1%) physicians had no formal emergency medicine (EM) training. Most were members of the College of Family Physicians of Canada (CCFPs). The minimum qualification to work in the surveyed EDs was a CCFP in 8 EDs (32.0%) and a CCFP with Advanced Cardiac and Trauma Resuscitation Courses (ACLS and ATLS) in 17 EDs (68.0%). None of the surveyed EDs required a CCFP(EM) or FRCP(EM) certification, even in population centres larger than 50 000. CONCLUSION: The majority of physicians working in southwestern Ontario community EDs graduated from family medicine residencies, and most have no formal EM training or certification. This information is of relevance to both family medicine and emergency medicine residency training programs. It should be considered in the determination of curriculum content and the appropriate number of residency positions.