Global emergency medicine: four part series : Paper 4: Global EM education and professionalization.

In 2018, the Canadian Association of Emergency Physicians (CAEP) academic symposium included developing recommendations on supporting global emergency medicine (EM) in Canadian departments and divisions. Members of CAEP's Global EM committee created a four-part series to be published in CJEM that would build upon the symposium recommendations. The objective is to offer practical tools to EM physicians interested in becoming involved in Global EM, as well as provide departments with successful Canadian case examples that foster, facilitate, and grow Global EM efforts. This submission is the fourth paper of the series which focuses on education and continuing professional development for Global EM. It includes resources for resident global EM electives, fellowship training and ongoing or additional CPD training for practicing EM physicians. It also highlights the importance of pre-departure training and other required elements of engaging responsibly in Global EM work.

RéSUMé: En 2018, le symposium universitaire de l'Association canadienne des médecins d'urgence (ACMU) comprenait l'élaboration de recommandations sur le soutien de la médecine d'urgence mondiale (MU) dans les départements et divisions canadiens. Les membres du comité mondial de la GU de l'ACMU proposent une série de quatre articles qui seront publiés dans la MCEM et qui s'appuieront sur les recommandations du symposium. L'objectif est d'offrir des outils pratiques aux médecins en GU qui souhaitent s'impliquer dans la GU mondiale, ainsi que de fournir aux départements des exemples de cas canadiens réussis qui favorisent, facilitent et développent les efforts en GU mondiale. Ce mémoire est le quatrième article de la série qui se concentre sur l'éducation et le développement professionnel continu pour Global EM. Il comprend des ressources pour les cours au choix internationaux de GU des résidents, la formation de fellowship et la formation continue ou supplémentaire de DPC pour les médecins praticiens de GU. Il souligne également l'importance de la formation préalable au départ et d'autres éléments requis pour s'engager de manière responsable dans le travail de gestion des urgences à l'échelle mondiale.

Emergency medicine resident perceptions of simulation-based training and assessment in competence by design.

OBJECTIVES: With the launch of competence by design (CBD) in emergency medicine (EM) in Canada, there are growing recommendations on the use of simulation for the training and assessment of residents. Many of these recommendations have been suggested by educational leaders and often exclude the resident stakeholder. This study sought to explore their experiences and perceptions of simulation in CBD. METHODS: Qualitative data were collected from November 2020 to May 2021 at McMaster University and the University of Toronto after receiving ethics approval from both sites. Eligible participants included EM residents who were interviewed by a trained interviewer using a semi-structured interview guide. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory. RESULTS: A total of seventeen residents participated. Thematic analysis revealed three major themes: 1) impact of CBD on resident views of simulation; 2) simulation's role in obtaining entrustable professional activities (EPAs) and filling educational gaps; and 3) conflicting feelings on the use of high-stakes simulation-based assessment in CBD. CONCLUSIONS: EM residents strongly support using simulation in CBD and acknowledge its ability to bridge educational gaps and fulfill specific EPAs. However, this study suggests some unintended consequences of CBD and conflicting views around simulation-based assessment that challenge resident perceptions of simulation as a safe learning space. As CBD evolves, educational leaders should consider these impacts when making future curricular changes or recommendations.

RéSUMé: OBJECTIFS: Avec le lancement de la compétence par conception (CPC) en médecine d'urgence (MU) au Canada, il existe des recommandations croissantes sur l'utilisation de la simulation pour la formation et l'évaluation des résidents. Beaucoup de ces recommandations ont été suggérées par des leaders éducatifs et excluent souvent la partie prenante résidente. Cette étude visait à explorer leurs expériences et leurs perceptions de la simulation dans la CPC. MéTHODES: Des données qualitatives ont été collectées de novembre 2020 à mai 2021 à l'Université McMaster et à l'Université de Toronto après avoir reçu l'approbation éthique des deux sites. Les participants éligibles étaient des résidents en MU qui ont été interviewés par un interviewer formé à l'aide d'un guide d'entretien semi-structuré. Toutes les interviews ont été enregistrées, transcrites, codées et regroupées en thèmes. L'analyse des données a été guidée par la théorie ancrée constructiviste. RéSULTATS: Au total, dix-sept résidents ont participé. L'analyse thématique a révélé trois thèmes majeurs : (1) l'impact de la CPC sur les opinions des résidents sur la simulation ; (2) le rôle de la simulation dans l'obtention des activités professionnelles confiables (APC) et le comblement des lacunes éducatives ; et (3) des sentiments contradictoires sur l'utilisation de l'évaluation basée sur la simulation à hauts enjeux dans la CPC. CONCLUSIONS: Les résidents en MU soutiennent fortement l'utilisation de la simulation dans la CPC et reconnaissent sa capacité à combler les lacunes éducatives et à remplir des APC spécifiques. Cependant, cette étude suggère quelques conséquences imprévues de la CPC et des opinions divergentes sur l'évaluation basée sur la simulation qui remettent en question les perceptions des résidents de la simulation comme un espace d'apprentissage sécuritaire. À mesure que la CPC évolue, les leaders éducatifs devraient tenir compte de ces impacts lorsqu'ils apportent des changements ou des recommandations curriculaires futurs.

Global health competencies in postgraduate medical education: a scoping review and mapping to the CanMEDS physician competency framework.

Background: Global Health opportunities are popular, with many reported benefits. There is a need however, to identify and situate Global Health competencies within postgraduate medical education. We sought to identify and map Global Health competencies to the CanMEDS framework to assess the degree of equivalency and uniqueness between them. Methods: JBI scoping review methodology was utilized to identify relevant papers searching MEDLINE, Embase, and Web of Science. Studies were reviewed independently by two of three researchers according to pre-determined eligibility criteria. Included studies identified competencies in Global Health training at the postgraduate medicine level, which were then mapped to the CanMEDS framework. Results: A total of 19 articles met criteria for inclusion (17 from literature search and two from manual reference review). We identified 36 Global Health competencies; the majority (23) aligned with CanMEDS competencies within the framework. Ten were mapped to CanMEDS roles but lacked specific key or enabling competencies, while three did not fit within the specific CanMEDS roles. Conclusions: We mapped the identified Global Health competencies, finding broad coverage of required CanMEDS competencies. We identified additional competencies for CanMEDS committee consideration and discuss the benefits of their inclusion in future physician competency frameworks.

Contexte: Les opportunités de santé mondiale sont populaires, avec de nombreux avantages rapportés. Il est toutefois nécessaire d'identifier et de situer les compétences en santé mondiale dans la formation médicale postdoctorale. Nous avons cherché à identifier et à mapper les compétences en santé mondiale au cadre le référentiel CanMEDS d'évaluer le degré d'équivalence et d'unicité entre elles. Méthodologie: La méthodologie de revue exploratoire de JBI a été utilisée pour identifier les articles pertinents qui recherchent MEDLINE, Embase et Web of Science. Les études ont été examinées indépendamment par deux des trois chercheurs selon des critères d'admissibilité prédéterminés. Les études incluses ont permis d'identifier les compétences dans la formation en santé mondiale au niveau de la médecine postdoctorale, qui ont ensuite été mises en correspondance avec le cadre le référentiel CanMEDS. Résultats: Au total, 19 articles répondaient aux critères d'inclusion (17 provenant d'une recherche documentaire et 2 d'un examen manuel des références). Nous avons identifié 36 compétences en santé mondiale; la majorité (23) correspondait aux compétences CanMEDS dans le cadre. Dix d'entre eux ont été mappés à des rôles canMEDS, mais n'avaient pas de compétences clés ou habilitantes précises, tandis que trois ne correspondaient pas aux rôles spécifiques de CanMEDS. Conclusions: Nous avons cartographié les compétences en santé mondiale identifiées, en trouvant une large couverture des compétences CanMEDS requises. Nous avons identifié d'autres compétences à examiner par le comité CanMEDS et nous discutons des avantages de leur inclusion dans les futurs cadres de compétences des médecins.

A river basin spatial model to quantitively advance understanding of riverine tree response dynamics to water availability and hydrological management.

Ecological condition continues to decline in arid and semi-arid river basins globally due to hydrological over-abstraction combined with changing climatic conditions. Whilst provision of water for the environment has been a primary approach to alleviate ecological decline, how to accurately monitor changes in riverine trees at fine spatial and temporal scales, remains a substantial challenge. This is further complicated by constantly changing water availability across expansive river basins with varying climatic zones. Within, we combine rare, fine-scale, high frequency temporal in-situ field collected data with machine learning and remote sensing, to provide a robust model that enables broadscale monitoring of physiological tree water stress response to environmental changes via actual evapotranspiration (ET). Physiological variation of Eucalyptus camaldulensis (River Red Gum) and E. largiflorens (Black Box) trees across 10 study locations in the southern Murray-Darling Basin, Australia, was captured instantaneously using sap flow sensors, substantially reducing tree response lags encountered by monitoring visual canopy changes. Actual ET measurement of both species was used to bias correct a national spatial ET product where a Random Forest model was trained using continuous timeseries of in-situ data of up to four years. Precise monthly AMLETT (Australia-wide Machine Learning ET for Trees) ET outputs in 30 m pixel resolution from 2012 to 2021, were derived by incorporating additional remote sensing layers such as soil moisture, land surface temperature, radiation and EVI and NDVI in the Random Forest model. Landsat and Sentinal-2 correlation results between in-situ ET and AMLETT ET returned R2 of 0.94 (RMSE 6.63 mm period-1) and 0.92 (RMSE 6.89 mm period-1), respectively. In comparison, correlation between in-situ ET and a national ET product returned R2 of 0.44 (RMSE 34.08 mm period-1) highlighting the need for bias correction to generate accurate absolute ET values. The AMLETT method presented here, enhances environmental management in river basins worldwide. Such robust broadscale monitoring can inform water accounting and importantly, assist decisions on where to prioritize water for the environment to restore and protect key ecological assets and preserve floodplain and riparian ecological function.

Emergency department care experiences among members of equity-deserving groups: quantitative results from a cross-sectional mixed methods study.

BACKGROUND: Emergency departments (EDs) serve an integral role in healthcare, particularly for vulnerable populations. However, marginalized groups often report negative ED experiences, including stigmatizing attitudes and behaviours. We engaged with historically marginalized patients to better understand their ED care experiences. METHOD: Participants were invited to complete an anonymous mixed-methods survey about a previous ED experience. We analysed quantitative data including controls and equity-deserving groups (EDGs) - those who self-identified as: (a) Indigenous; (b) having a disability; (c) experiencing mental health issues; (d) a person who uses substances; (e) a sexual and gender minority; (f) a visible minority; (g) experiencing violence; and/or (h) facing homelessness - to identify differences in their perspectives. Differences between EDGs and controls were calculated with chi squared tests, geometric means with confidence ellipses, and the Kruskal-Wallis H test. RESULTS: We collected a total of 2114 surveys from 1973 unique participants, 949 controls and 994 who identified as equity-deserving. Members of EDGs were more likely to attribute negative feelings to their ED experience (p < 0.001), to indicate that their identity impacted the care received (p < 0.001), and that they felt disrespected and/or judged while in the ED (p < 0.001). Members of EDGs were also more likely to indicate that they had little control over healthcare decisions (p < 0.001) and that it was more important to be treated with kindness/respect than to receive the best possible care (p < 0.001). CONCLUSION: Members of EDGs were more likely to report negative ED care experiences. Equity-deserving individuals felt judged and disrespected by ED staff and felt disempowered to make decisions about their care. Next steps will include contextualizing findings using participants' qualitative data and identifying how to improve ED care experiences among EDGs to make it more inclusive and better able to meet their healthcare needs.

Pre-departure and Post-elective Requirements for Global Health Electives: Survey of Canadian Royal College Emergency Medicine Programs.

OBJECTIVES: Global Health (GH) electives offer unique learning opportunities; however, risks to trainees and host populations should be minimized through pre-departure training and post-elective debriefing. In a 2016 study, only three Canadian residency programs mandated such training, although specific data on Emergency Medicine (EM) programs is lacking. This study aimed to identify GH elective requirements and perceived training gaps among EM programs. METHODS: We conducted two email surveys (one each for EM program directors [PDs] and residents) regarding training requirements and perceived gaps for GH electives. We also contacted university postgraduate medical education (PGME) and GH offices, via their online publicized emails, to assess university-wide requirements and resources. RESULTS: Nine PDs responded, with 78% reporting having residents participate in GH electives. Many PDs (67%) believed residents were moderately prepared for GH electives, while 33% felt they were unprepared to some degree. Forty seven out of an estimated 380 EM residents responded with 35% having completed a GH elective during residency. Of those, only one (6%) reported feeling very prepared, and 43% believed there was a need to improve trainings. Uncertainty around training requirements was reported, and residents identified challenges faced on electives, as well as priority topics for training. Responses from PGME and GH offices indicated that pre-departure training and post-elective debriefing were required or available at more universities than was indicated by the PD and resident respondents. However university requirements varied widely, with some exclusively requiring basic travel information and Health and Safety checklists or modules. The disparate responses indicate that residents and PDs may either be unaware of university requirements or not utilize available training resources for GH electives. CONCLUSIONS: Although Canadian EM residents participate in GH electives, the majority of training programs do not require pre-departure training or post-elective debriefing. PDs and residents report varying levels of preparedness, and residents acknowledge a variety of challenges during GH electives. This information can be used to inform pre-departure training and post-elective debriefing and encourage EM residents to access available university-wide training.

Implementation of Chest Compression Feedback Technology to Improve the Quality of Cardiopulmonary Resuscitation in the Emergency Department: A Quality Initiative Test-of-change Study.

Background Cardiopulmonary resuscitation (CPR) metrics including compression rate and depth are associated with improved outcomes and the need for high-quality CPR is emphasized in both the American Heart Association (AHA) and Heart and Stroke Foundation of Canada (HSFC) guidelines. While these metrics can be utilized to assess the quality of CPR, they are infrequently measured in an objective fashion in the emergency department. Objectives As part of an Emergency Department (ED) Quality Improvement (QI) project, we sought to determine the impact of real-time audio-visual (AV) feedback during CPR amongst ED healthcare providers. Methods Participants performed two minutes of uninterrupted CPR without AV feedback, followed by two minutes of CPR with AV feedback after a two-minute rest period in a simulated CPR setting. CPR metrics were captured by the defibrillator and uploaded to review software for analysis of each event. Results The use of real-time AV feedback resulted in a significant improvement in the number of participants meeting AHA/HSFC recommended depth (38%, p = 0.0003) and rate (35%, p = 0.0002). Importantly, 'compressions in target', where participants met both rate and depth simultaneously, improved with AV feedback (19 vs 61%, p < 0.0001). Conclusions We found a significant improvement in compliance with CPR depth and rate targets as well as 'compressions in target' with the use of real-time AV feedback during simulation training. Future research is needed to ascertain whether these results would be replicated in other settings. Our findings do provide a robust argument for the implementation of real-time AV CPR feedback in Hamilton Emergency Departments.

Creation of a national emergency medicine enhanced competency directory for residency training.

Canadian emergency medicine Royal College residency training allows for pursuing extra training in enhanced competency areas. A wealth of enhanced competency training opportunities exist nationally. However, the search for the right fit is a challenging one because there is no centralized resource that catalogues all of these opportunities. A working group of the Canadian Association of Emergency Physicians (CAEP) Resident Section was assembled in 2016 to create a freely accessible and comprehensive directory of Canadian enhanced competency areas. The working group used stakeholder surveys (of residents, recent graduates, and faculty members), social media engagement, and program website searches. Information was collated into the first edition of a national enhanced competency directory, which is available at no cost at http://caep.ca/sites/caep.ca/files/enhancedcompdoc.pdf. Limitations include the scope defined by the working group and survey responses. A biannual update is also incorporated into the CAEP Resident Section portfolio to ensure it remains up-to-date.

Does Early Coronary Angiography Improve Survival After out-of-Hospital Cardiac Arrest? A Systematic Review With Meta-Analysis.

BACKGROUND: In patients with out-of-hospital cardiac arrest who achieve return of spontaneous circulation, coronary angiography (CAG) might improve outcomes. We conducted a systematic review and meta-analysis to elucidate the benefit and optimal timing of early CAG in comatose out-of-hospital cardiac arrest patients with return of spontaneous circulation. METHODS: We searched MEDLINE, EMBASE, and Cochrane from 1990 to May 2017. Studies reporting survival and/or neurological survival in early (< 24-hour) vs late/no CAG were selected. We used the Clinical Advances Through Research and Information Translation (CLARITY) risk of bias in cohort studies tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria to assess risk of bias and quality of evidence, respectively. Results were pooled using random effects and presented as risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS: After screening 9185 titles/abstracts and 631 full-text articles, we included 23 nonrandomized studies. Short (to discharge or 30 days) and long-term (1-5 years) survival were significantly improved (52% and 56%, respectively) in the early < 24-hour CAG group compared with the late/no CAG group (RR, 1.52; 95% CI, 1.32-1.74; P < 0.00001; I2, 94% and RR, 1.56; 95% CI, 1.14-2.14; P = 0.006; I2, 86%). Survival with good neurological outcome was also improved by 69% in the < 24-hour CAG group at short- (RR, 1.69; 95% CI, 1.40-2.04; P < 0.00001; I2, 93%) and intermediate-term (3-11 months; RR, 1.49; 95% CI, 1.27-1.76; P < 0.00001; I2, 67%). We found consistent benefits in the < 2-hour and < 6-hour subgroups. Early CAG was associated with significantly better outcomes in studies of patients without ST-elevation, but the results did not reach statistical significance in studies of patients with ST-elevation. CONCLUSIONS: On the basis of very low quality, but consistent evidence, early CAG (< 24 hours) was associated with significantly higher survival and better neurologic outcomes.

Evaluation of a regional ST-elevation myocardial infarction primary percutaneous coronary intervention program at the Rouge Valley Health System.

BACKGROUND: ST-elevation myocardial infarction (STEMI) remains the second leading cause of death in Canada. Primary percutaneous coronary intervention (PCI) has been recognized as an effective method for treating STEMI. Improved access to primary PCI can be achieved through the implementation of regional PCI centres, which was the impetus for implementing the PCI program in an east Toronto hospital in 2009. As such, the purpose of this study was to measure the efficacy of this program regional expansion. METHODS: A retrospective review of 101 patients diagnosed with STEMI from May to Sept 2010 was conducted. The average door-to-balloon time for these STEMI patients was calculated and the door-to-balloon times using different methods of arrival were analyzed. Method of arrival was by one of three ways: paramedic initiated referral; patient walk-ins to PCI centre emergency department; or transfer after walk-in to community hospital emergency department. RESULTS: The study found that mean door-to balloon time for PCI was 112.5 minutes. When the door-to-balloon times were compared across the three arrival methods, patients who presented by paramedic-initiated referral had significantly shorter door-to-balloon times, (89.5 minutes) relative to those transferred (120.9 minutes) and those who walked into a PCI centre (126.7 minutes) (p = 0.047). CONCLUSIONS: The findings suggest that the partnership between the hospital and its EMS partners should be continued, and paramedic initiated referral should be expanded across Canada and EMS systems where feasible, as this level of coverage does not currently exist nationwide. Investments in regional centres of excellence and the creation of EMS partnerships are needed to enhance access to primary PCI.