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Introduction Emergency medicine (EM) postgraduate medical education in Canada has transitioned from traditional time-based training to competency-based medical education (CBME). In order to promote residents through stages of training, simulated assessments are needed to evaluate residents in high-stakes but low-frequency medical emergencies. There remains a gap in the literature pertaining to the use of evaluative tools in simulation, such as the Resuscitation Assessment Tool (RAT) in the new CBME curriculum design. Methods We completed a pilot study of resident physicians in one Canadian EM training program to evaluate the effectiveness and reliability of a simulation-based RAT for pediatric resuscitation. We recorded 10 EM trainees completing simulated scenarios and had nine EM physicians use the RAT tool to evaluate their performances. Generalizability theory was used to evaluate the reliability of the RAT tool. Results The mean RAT score for the management of pediatric myocarditis, cardiac arrest, and septic shock (appendicitis) across raters was 3.70, 3.73, and 4.50, respectively. The overall generalizability coefficient for testing simulated pediatric performance competency was 0.77 for internal consistency and 0.75 for absolute agreement. The performance of senior participants was superior to that of junior participants in the management of pediatric myocarditis (p = 0.01) but not statistically significant in the management of pediatric septic shock (p=0.77) or cardiac arrest (p =0.61). Conclusion Overall, our findings suggest that with an appropriately chosen simulated scenario, the RAT tool can be used effectively for the simulation of high-stakes and low-frequency scenarios for practice to enhance the new CBME curriculum in emergency medicine training programs.
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Objectives The Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients. Methods Data was retrospectively collected from patients, ages 18-50 and Canadian Triage and Acuity Scale (CTAS) codes 2-5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging. Results Data from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues. Conclusion Considerable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.
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Background Many specialty societies have found that neuroimaging in headache is a low-value intervention for benign presentations. This study describes factors that influence Emergency Room (ER) physicians' adherence to Choosing Wisely (CW) recommendations for low-risk headache patients presenting to Calgary's Emergency Departments (EDs). Emergency medicine has yet to address imaging in headache as a CW topic; however, this study may inform that decision. Methods Data were retrospectively collected for all patients presenting to Calgary EDs with headaches from April 1, 2014 to March 31, 2016. Patients were deemed low-risk by virtue of discharge home from the ED, age < 50, and no lumbar puncture (LP), trauma, neurology, or neurosurgery consult or red flags on history. The primary outcome was computed tomography (CT) ordering rates with an eye to medical doctor (MD) practice variation. Patient, physician, and environmental factors were analyzed to compare patients who did and did not receive a CT. Results Two thousand seven hundred and thirty-four headache patients met the eligibility criteria. A total of 117 Calgary ER physicians were included, all of whom had seen 10 or more headache patients over the study period. Physician practice variation was vast, with a mean ordering rate of 38.0% and a range of 0% to 95% (M = 39.0%, IQR = 21.0%). CTs were ordered more often in males than females (39.9%; 34.1%; p = 0.002) and in patients presenting during the day and evening (38.1%; 39.0%) compared to the night (29.7%; p < 0.001). Patients were divided into quartiles by age, with the oldest group (41.6 - 50 years) receiving significantly more head CTs (45.1%) than the other quartiles (34.9%; 34.9%; 27.5%; p < 0.001). Longer triage-to-discharge times were associated with an increase in CT ordering rates (12% for < 2.95 hours; 35% for > 4 hour wait; p < 0.001). Lastly, patients who did not have a CT were more likely to revisit the ED within seven days compared to those who did (6.9% vs 4.0%; p = 0.003), but their seven-day admission rate was unaffected (0.6% in the group that got CTs and 0.3% in the group that did not get a CT). Time to assessment, the day of the week, physician gender, years of experience, and training program did not influence CT ordering practices. Conclusion To our knowledge, this is the first study to assess how patient, physician, and environmental factors relate to the use of CT scans in low-risk headaches presenting to the ED. CW guidelines are not optimally adhered to, and the findings in this study findings may inspire new ideas for maximizing the judicious use of healthcare resources.
