Communication between consultants providing advice and referring physicians: a scoping review.

OBJECTIVE: Communication during consultations between referring and consultant physicians is often cited as a source of adverse events, medical error and professional incivility. While existing literature focuses on the role of referring physicians, few studies acknowledge the role of consultant physicians in enhancing communication during consultations. This scoping review aims to identify and synthesise available recommendations to enhance the communication practices of consultants during real-time consultations. DESIGN: A scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATA SOURCES: Medline, EMBASE and PsycINFO databases were searched from inception to August 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English-language publications which describe recommendations, strategies or frameworks to improve the communication practices of consultant physicians during real-time consultations with referring physicians. DATA EXTRACTION AND SYNTHESIS: The search strategy included the following concepts: consultation, physician, communication, interprofessional relations and best practice. Two authors independently performed each phase of title and abstract screening, full-text review and data extraction. Discrepancies were resolved by a third author. Extracted data were iteratively analysed and summarised thematically. RESULTS: Sixteen publications met the inclusion criteria. Synthesis of available recommendations identified organisation, expertise and interpersonal skills as three overarching and interconnected dimensions of communication demonstrated by consultants during effective consultations. Twelve studies identified interpersonal skills as being critical in alleviating the widespread professional incivility that is reported during consultations. Existing recommendations to improve the communication practices of consultants are limited as they lack standardised interventions and fail to comprehensively address all three elements identified in this review. CONCLUSION: This scoping review synthesises available recommendations to improve the communication practices of consultant physicians during real-time consultations. An opportunity exists to develop communication tools or educational interventions based on the findings of this review to enhance interphysician consultation encounters.

Out of hospital emergency care in Nigeria: A narrative review.

Introduction: Out of Hospital Emergency Care (OHEC) in Nigeria, the most populous country with the highest GDP in Africa, is considered inadequate. A better understanding of the current state of OHEC is essential to address the country's unique challenges and offer potential solutions. Objectives: This paper sought to identify gaps, barriers, and facilitators in implementing an OHEC model in Nigeria and provide recommendations for improvement. Methods: We searched MEDLINE (PubMed), Embase (OVID), CINAHL (EBSCO), and Google Scholar, using combinations of "emergency medical care" ('FRC,' 'PHC,' and 'EMS') OR prehospital care OR emergency training' AND 'Nigeria.' We included papers that described OHEC in Nigeria and were published in English. Of the initial 73 papers, those that met our inclusion criteria and those obtained after examination of reference lists comprised the 20 papers that contributed to our final review. Two authors independently reviewed all the papers, extracted data relevant to our objectives and performed a content analysis. All authors reviewed, discussed, and refined the proposed recommendations. Key recommendations: For OHEC to meet the needs of Nigerians and achieve international standards, the following challenges need to be addressed: harmful cultural practices, inadequate training of citizens in the provision of first aid or of professionals that provide prehospital care, lack of proper infrastructure, poor communication, absent policy, and poor funding. Based on the available literature, this paper proposes key recommendations to improve OHEC with the hope of improving the standards of living. The federal government should provide general oversight, but this will require political will on the part of the country's leadership and the provision of adequate funding.

Call to action: equity, diversity, and inclusion in emergency medicine resident physician selection.

OBJECTIVES: This call to action seeks to improve emergency care in Canada for equity-deserving communities, enabled by equitable representation among emergency physicians nationally. Specifically, this work describes current resident selection processes and makes recommendations to enhance the equity, diversity, and inclusion (EDI) of resident physician selection in Canadian emergency medicine (EM) residency programs. METHODS: A diverse panel of EM residency program directors, attending and resident physicians, medical students, and community representatives met monthly from September 2021 to May 2022 via videoconference to coordinate a scoping literature review, two surveys, and structured interviews. This work informed the development of recommendations for incorporating EDI into Canadian EM resident physician selection. At the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, these recommendations were presented to symposium attendees composed of national EM community leaders, members, and learners. Attendees were divided into small working groups to discuss the recommendations and address three conversation-facilitating questions. RESULTS: Symposium feedback informed a final set of eight recommendations to promote EDI practices during the resident selection process that address recruitment, retention, mitigating inequities and biases, and education. Each recommendation is accompanied by specific, actionable sub-items to guide programs toward a more equitable selection process. The small working groups also described perceived barriers to the implementation of these recommendations and outlined strategies for success that are incorporated into the recommendations. CONCLUSION: We call on Canadian EM training programs to implement these eight recommendations to strengthen EDI practices in EM resident physician selection and, in doing so, help to improve the care that patients from equity-deserving groups receive in Canada's emergency departments (EDs).

ABSTRAIT: OBJECTIFS: Cet appel à l'action vise à améliorer les soins d'urgence au Canada pour les collectivités méritant l'équité, grâce à une représentation équitable parmi les médecins d'urgence à l'échelle nationale. Plus précisément, ce travail décrit les processus actuels de sélection des médecins résidents et formule des recommandations pour améliorer l'équité, la diversité et l'inclusion (EDI) de la sélection des médecins résidents dans les programmes de résidence en médecine d'urgence (SE) du Canada. MéTHODES: Un groupe diversifié de directeurs du programme de résidence en GU, de médecins résidents, d'étudiants en médecine et de représentants communautaires se sont réunis mensuellement de septembre 2021 à mai 2022 par vidéoconférence pour coordonner une analyse documentaire, deux sondages et des entrevues structurées. Ces travaux ont orienté l'élaboration de recommandations pour l'intégration de l'IDE dans la sélection des médecins résidents en SE au Canada. À l'occasion du Symposium universitaire 2022 de l'Association canadienne des médecins d'urgence (ACMU), ces recommandations ont été présentées aux participants au symposium composé de dirigeants, de membres et d'apprenants de la communauté nationale de la GU. Les participants ont été divisés en petits groupes de travail pour discuter des recommandations et aborder trois questions facilitant la conversation. RéSULTATS: Les commentaires recueillis lors du symposium ont servi à formuler une dernière série de huit recommandations visant à promouvoir les pratiques de l'IDE au cours du processus de sélection des résidents qui traitent du recrutement, du maintien en poste, de l'atténuation des inégalités et des préjugés, et de l'éducation. Chaque recommandation est accompagnée de sous-éléments précis et réalisables pour orienter les programmes vers un processus de sélection plus équitable. Les petits groupes de travail ont également décrit les obstacles perçus à la mise en œuvre de ces recommandations et décrit les stratégies de réussite qui sont intégrées aux recommandations. CONCLUSION: Nous demandons aux programmes canadiens de formation en GU de mettre en œuvre ces huit recommandations afin de renforcer les pratiques d'IDE dans la sélection des médecins résidents en GU et, ce faisant, d'aider à améliorer les soins que les patients des groupes méritant l'équité reçoivent dans les services d'urgence du Canada.

"We're drowning and we're alone": a qualitative study of the lived experience of people experiencing persistent post-COVID-19 symptoms.

BACKGROUND: The "long tail" of the COVID-19 pandemic will be reflected in disabling symptoms that persist, fluctuate or recur for extended periods for an estimated 20%-30% of those who had a SARS-CoV-2 infection; development of effective interventions to address these symptoms must account for the realities faced by these patients. We sought to describe the lived experience of patients living with persistent post-COVID-19 symptoms. METHODS: We conducted a qualitative study, using interpretive description, of the lived experiences of adults experiencing persistent post-COVID-19 symptoms. We collected data from in-depth, semistructured virtual focus groups in February and March 2022. We used thematic analysis to analyze the data and met with several participants twice for respondent validation. RESULTS: The study included 41 participants (28 females) from across Canada with a mean age of 47.9 years and mean time since initial SARS-CoV-2 infection of 15.8 months. Four overarching themes were identified: the unique burdens of living with persistent post-COVID-19 symptoms; the complex nature of patient work in managing symptoms and seeking treatment during recovery; erosion of trust in the health care system; and the process of adaptation, which included taking charge and transformed self-identity. INTERPRETATION: Living with persistent post-COVID-19 symptoms within a health care system ill-equipped to provide needed resources profoundly challenges the ability of survivors to restore their well-being. Whereas policy and practice increasingly emphasize the importance of self-management within the context of post-COVID-19 symptoms, new investments that enhance services and support patient capacity are required to promote better outcomes for patients, the health care system and society.

Strength in the gap: A rapid review of principles and practices for urgent care centres.

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Trauma experiences of rural practitioners: A self assessment.

INTRODUCTION: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) physicians are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. METHODS: An anonymous self-assessment survey was e-mailed to family physicians practising rural EM in Saskatchewan regarding training, hospital resources, demographics and self-reported comfort with rural trauma management. We included physicians who had provided EM care within the past year in Saskatchewan outside of the major trauma centres. Comfort was measured on a Likert scale. RESULTS: One hundred thirteen physicians out of a total of 479 physicians contacted agreed to participate (23.6%). Thirty-nine percent (n = 31) of respondents were comfortable with paediatric trauma, and 46% (n = 37) were comfortable with vascular trauma. Nineteen percent (n = 15) were comfortable with pericardiocentesis and 25% (n = 19) were comfortable with cricothyroidotomy. In the past 12 months, 21% (n = 17) had performed paediatric endotracheal intubation, 1.3% (n = 1) had performed cricothyroidotomy, 28.8% (n = 23) had performed needle thoracentesis and 20% (n = 16) had performed central venous line access. Those who did their residency training outside of Canada were more comfortable with overall trauma care. Those who had taken emergency department echo were generally more comfortable with trauma procedures. Those who had current advanced trauma life support were more comfortable with less frequently encountered aspects of trauma care. CONCLUSIONS: This self-assessment helped us identify which aspects of rural trauma medicine are the most challenging for rural practitioners. It gave us an understanding of the procedures related to trauma medicine that are the most difficult, which critical resources are available and where training could be focused to benefit rural emergency physicians.

Résumé Introduction: Cette étude avait pour but d'identifier, par l'entremise d'une auto-évaluation, l'aisance des urgentologues en milieu rural à traiter les patients polytraumatisés en état critique, les ressources disponibles pour traiter ces patients et l'aisance avec laquelle ils exécutent les interventions de traumatologie. Méthodes: Un questionnaire d'auto-évaluation anonyme a été envoyé par courriel aux médecins de famille qui pratiquent dans les services d'urgence ruraux de la Saskatchewan; le questionnaire portait sur la formation, les ressources hospitalières, les paramètres démographiques et l'aisance rapportée par les répondants quant à la prise en charge des traumatismes en milieu rural. Nous avons inclus les médecins qui avaient dispensé dans l'année écoulée des soins d'urgence à l'extérieur des grands centres de traumatologie en Saskatchewan. L'aisance était mesurée sur une échelle Likert. Résultats: Sur un total de 479 médecins contactés, 113 ont consenti à participer (23.6%). Trente-neuf pour cent (n = 31) des répondants étaient à l'aise avec les traumatismes pédiatriques et 46% (n = 37) avec les traumatismes vasculaires. Dix-neuf pour cent (n = 15) étaient à l'aise avec la ponction péricardique et 25% (n = 19) avec la cricothyroïdotomie. Dans les 12 mois écoulés, 21% (n = 17) avaient exécuté une intubation endotrachéale pédiatrique, 1.3% (n = 1) une cricothyroïdotomie, 28,8% (n = 23) une thoracentèse à l'aiguille et 20% (n = 16) un accès veineux central. Les médecins qui avaient reçu leur formation en résidence à l'extérieur du Canada étaient plus à l'aise avec les soins de traumatologie en général. Les médecins qui avaient suivi le cours d'échographie du département d'urgence étaient en général plus à l'aise avec les interventions de traumatologie. Les médecins qui avaient une certification advanced trauma life support étaient plus à l'aise avec les aspects moins fréquents des soins de traumatologie. Conclusions: Cette auto-évaluation nous a aidés à déterminer quels aspects de la médecine de traumatologie rurale sont les plus problématiques pour les praticiens en milieu rural. Elle nous a permis de comprendre quelles sont les interventions de traumatologie qui sont les plus difficiles, quelles ressources essentielles sont disponibles et sur quels aspects la formation doit se concentrer pour profiter aux urgentologues en milieu rural. Mots-clés: prise en charge des traumatismes en milieu rural, médecine de traumatologie rurale, Trauma, rural, médecine d'urgence.

Unidentified patients in the emergency department: a historical cohort study.

OBJECTIVES: To characterize unidentified patients presenting to a single, urban emergency department (ED) in Canada. We report their demographics, ED course, post-ED discharge outcomes, and mode of identification. METHODS: We performed a retrospective chart review using descriptive analyses to assess unidentified patients admitted to Royal University Hospital and St. Paul's Hospital EDs between May 1, 2018, and April 30, 2019, in Saskatoon, Saskatchewan, Canada. We assessed demographic data, clinical presentation, mode of identification, discharge information, and major clinical outcomes. RESULTS: Unidentified patients were disproportionately male (64.9%), and mostly presented as Canadian Triage and Acuity Scale (CTAS) 1 (41.6%) and CTAS 2 (44.2%). Most patients arrived via emergency medical services (80.7%). The most common presenting complaints were substance misuse (33.3%) and trauma (24.6%). The average ED length of stay was 8.7 h (SD 18.6). Many patients received an inpatient consult (58.8%), and 22.3% received support services (e.g., social work). The 30-day mortality of all patients was 13.2%. Of those patients who survived to ED discharge, common dispositions included: home (36.0%), police services (3.5%), or emergency shelters (3.5%). Four (3.5%) patients returned to the hospital unidentified within the study period, and 6.7% of patients discharged from the ED returned within 48 hours. CONCLUSION: Unidentified patients are a high-needs demographic that present mostly with substance misuse or trauma. Repeat ED attendance, sometimes as unidentified patients again, calls for initiatives that facilitate prompt identification, better discharge planning, and linkage to social supports.

RéSUMé: OBJECTIFS: Caractériser les patients non identifiés se présentant à un seul service d'urgence urbain au Canada. Nous rapportons leurs données démographiques, leur parcours aux urgences, leurs résultats après leur sortie de l'urgence et leur mode d'identification. MéTHODES: Nous avons effectué un examen rétrospectif des dossiers à l'aide d'analyses descriptives pour évaluer les patients non identifiés admis à Royal University l'hôpital et St. Paul's Hospital aux urgences de l'hôpital entre le 1er mai 2018 et le 30 avril 2019, Saskatoon, Saskatchewan, au Canada. Nous avons évalué les données démographiques, la présentation clinique, le mode d'identification, les informations de sortie et les principaux résultats cliniques. RéSULTATS: Les patients non identifiés étaient en grande partie des hommes (64.9 %) et se présentaient principalement sous la forme d'une échelle canadienne de triage et de gravité (ÉTG) 1 (41.6 %) et ÉTG 2 (44.2 %). La plupart des patients sont arrivés via les services médicaux d'urgence (80.7 %). Les plaintes les plus courantes étaient l'abus de substances (33.3 %) et le traumatisme (24.6 %). La durée moyenne du séjour à l'urgence était de 8,7 heures (écart-type : 18.6). De nombreux patients ont reçu une consultation interne (58.8 %) et 22.3 % ont reçu des services de soutien (p. ex., travail social). La mortalité sur 30 jours de tous les patients était de 13.2 %. Parmi les patients qui ont survécu à la sortie du service d'urgence, les dispositions courantes comprenaient : domicile (36.0 %), services de police (3.5 %) ou refuges d'urgence (3.5 %). Quatre (3.5 %) patients sont retournés à l'hôpital sans être identifiés pendant la période d'étude, et 6.7 % des patients sortis des urgences sont revenus dans les 48 heures. CONCLUSION: Les patients non identifiés constituent un groupe démographique à besoins élevés qui se présente principalement avec un abus de substances ou de traumatisme. La fréquentation répétée des urgences, parfois en tant que patients non identifiés à nouveau, nécessite des initiatives qui facilitent une identification rapide, une meilleure planification de la sortie et la mise en relation avec des soutiens sociaux.

Prevalence of Cigarette Smoking Among Adult Emergency Department Patients in Canada.

INTRODUCTION: Tobacco smoking is a priority public health concern, and a leading cause of death and disability globally. While the daily smoking prevalence in Canada is approximately 9.7%, the proportion of smokers among emergency department (ED) patients has been found to be significantly higher. The purpose of this survey study was to determine the smoking prevalence of adult ED patients presenting to three urban Canadian hospitals, and to determine whether there was an increased prevalence compared to the general public. METHODS: A verbal questionnaire was administered to adult patients aged 18 years and older presenting to Royal University Hospital, St. Paul's Hospital, and Saskatoon City Hospital in Saskatoon, Saskatchewan. We compared patients' smoking habits to Fagerström tobacco dependence scores, readiness to quit smoking, chief complaints, Canadian Triage Acuity Scale scores, and willingness to partake in ED-specific cessation interventions. RESULTS: A total of 1190 eligible patients were approached, and 1078 completed the questionnaire. Adult Saskatoon ED patients demonstrated a cigarette smoking prevalence of 19.6%, which is significantly higher than the adult Saskatchewan public at 14.65% (P<0.0001). Out of the smoking cohort, 51.4% indicated they wanted to quit smoking and would partake in ED-specific cessation counselling, if available. Of the proposed interventions, ED cessation counselling was most popular among patients (62.4%), followed by receiving a pamphlet (56.2%), and referral to a smokers' quit line (49.5%). CONCLUSION: The higher smoking prevalence demonstrated among ED patients highlights the need for a targeted intervention program that is feasible for the fast-paced ED environment. Training ED staff to conduct brief cessation counselling and referral to community supports for follow-up could provide an initial point of contact for smokers not otherwise receiving cessation assistance.

Extensive Upper Airway Hematoma Secondary to Supratherapeutic Warfarin Anticoagulation.

CASE PRESENTATION: A 63-year-old female presented to the emergency department complaining of cough, neck swelling, dysphagia, and dysphonia for two days, with a past medical history of atrial fibrillation managed with warfarin. Investigations revealed a supratherapeutic international normalised ratio (greater than 10). Imaging and endoscopic examination showed an extensive retropharyngeal hematoma with significant mass effect on the airway. DISCUSSION: A rare but potentially fatal complication of warfarin anticoagulation is upper airway hematoma, with violent coughing described as an inciting cause. Signs of airway compromise necessitate specialist consultation and definitive airway management, while mild cases without airway concerns can be managed conservatively with medical anticoagulation reversal.

Emergency department referrals from a provincial medical call centre: Is it more than just 1-800-go-to-emerg?

OBJECTIVE: HealthLine is Saskatchewan's provincial 24-hour health information and support telephone line. A proportion of HealthLine's callers are referred to the emergency department (ED) for further assessment. The purpose of this study was to gain insight into the appropriateness of these referrals and assess whether they increased the burden on an already strained ED system. METHODS: A list of callers referred from HealthLine to Saskatoon EDs from January 1, 2014, to March 31, 2014 was obtained. This list was cross-referenced with Saskatoon Health Region registration data to determine which of those callers had been registered in one of the three Saskatoon EDs within 48 hours of the original call. RESULTS: During the 90-day time period in question, 707/3,938 (17.9%) of callers were referred by HealthLine to the ED. Out of those referred, 601 were identifiable and 358 attended the ED. Hospital charts were pulled for full data extraction and analysis of the 276 who met inclusion criteria. Of those who presented to the ED and met inclusion criteria, 60% had investigations performed while 66% received some form of treatment. The overall admission rate for the patient population studied was 12.0% v. 16% for non-referred patients. Referred pediatric patients had fewer investigations and treatments with a lower admission rate compared with the adult patients. CONCLUSION: The Saskatchewan HealthLine is doing an effective job at directing callers both to and away from EDs in Saskatoon and not overburdening our local EDs with unnecessary referrals.

Self-documentary in the emergency department: Perspectives on patients recording their own procedures.

OBJECTIVES: Patients often bring their smartphones to the emergency department (ED) and want to record their procedures. There was no clear ED recording policy in the Saskatoon Health Region nor is there in the new Saskatchewan Health Authority. With limited literature on the subject, clinicians currently make the decision to allow/deny the request to record independently. The purpose of this study was to examine and compare patient and clinician perspectives concerning patients recording, in general, and recording their own procedures in the ED. METHODS: Surveys were developed for patients and clinicians with respect to history and opinions about recording/being recorded. ED physicians and nurses, and patients>17 years old who entered the ED with a laceration requiring stitches were recruited to participate; 110 patients and 156 staff responded. RESULTS: There was a significant difference between the proportion of patients (61.7% [66/107]) and clinicians (28.1% [41/146]) who believed that patients should be allowed to video record their procedure. There was also a significant difference between clinicians and patients with regard to audio recording, but not "selfies" (pictures). However, with no current policy, 47.8% (66/138) of clinicians said that they would allow videos if asked, with caveats about staff and patient privacy, prior consent, and procedure/patient care. CONCLUSION: Contrary to patients' views, clinicians were not in favour of allowing audio or video recordings in the ED. Concerns around consent, staff and patient privacy, and legal issues warrant the development of a detailed policy if the decision is made in favour of recording.

Equality of care between First Nations and non-First Nations patients in Saskatoon emergency departments.

OBJECTIVE: Studies show that First Nations patients have worse health outcomes than non-First Nations patients, raising concerns that treatment within the healthcare system, including emergency care, is inequitable. METHODS: We performed a retrospective chart review of Status First Nations and non-First Nations patients presenting to two emergency departments in Saskatoon, Saskatchewan with abdominal pain and a Canadian Triage and Acuity Scale score of 3. From 190 charts (95 Status First Nations and 95 non-First Nations), data extracted included time to doctor, time to analgesia, length of stay, specialist consult, bloodwork, imaging, physical exam and history, and disposition. Univariate comparisons and multiple regression modelling were performed to compare care outcomes between patient groups. Equivalence testing comparing time intervals was also undertaken. RESULTS: No statistically significant differences in presentation characteristics were observed, although Status First Nations subjects showed a greater tendency towards weekend presentation and younger age. Care parameters were similar, although a marginally significant difference was observed in Status First Nations versus non-First Nations subjects for imaging (46% versus 60%, p=0.06), which resolved on adjustment for age and weekend presentation. Time to physician was found to be similar among First Nations patients on equivalence testing within a 15-minute margin. CONCLUSION: In this study, First Nations patients presenting with abdominal pain did not receive delayed care. There were no detectable differences in the time-related care parameters/variables that were provided relative to non-First Nations patients. Meaningful and important qualitative factors need to be examined in the future.