Cross-cultural adaptation and its impact on research in emergency care.

The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.

PROM-ED: Development and Testing of a Patient-Reported Outcome Measure for Emergency Department Patients Who Are Discharged Home.

STUDY OBJECTIVE: Common outcomes of care valued by emergency department (ED) patients who are not hospitalized have been characterized, but no measurement instrument has been developed to date. We developed and validated a patient-reported outcome measure for use with adult ED patients who are discharged home (PROM-ED). METHODS: In previous research, 4 main outcomes of importance to ED patients were defined: symptom relief, understanding, reassurance, and having a plan. We developed a bank of potential questions (phase 1) that were first tested for suitability through cognitive debriefing with patients (phase 2). Revised questions were then tested quantitatively with a large panel of participants who had recently received ED care (phase 3). Informed by these results, a panel of experts used a modified Delphi process to make decisions on item reduction. The resulting instrument (PROM-ED 1.0) was then evaluated for its measurement properties (structural validity, hypothesis testing, and reliability). RESULTS: Sixty-seven questions divided among 4 scales (1 for each outcome domain) were assembled. In accordance with cognitive debriefing with 8 patients (phase 2), 15 questions were modified and 13 removed. Testing of these questions with 444 participants (phase 3) identified problematic floor or ceiling effects (n=10), excessive correlations between items (n=11), and low item-total correlations (n=7). The expert panel (22 participants, phase 4) made decisions using this information on the exclusion of items, resulting in 22 questions across 4 scales that together constitute the PROM-ED 1.0. Testing provided good evidence of validity and test-retest reliability (n=200). CONCLUSION: The PROM-ED enables the measurement of patient-centered outcomes of importance to patients receiving care in the ED who are not hospitalized. These data could have important applications in research and care improvement.

Updated framework on quality and safety in emergency medicine.

OBJECTIVES: Quality and safety of emergency care is critical. Patients rely on emergency medicine (EM) for accessible, timely and high-quality care in addition to providing a 'safety-net' function. Demand is increasing, creating resource challenges in all settings. Where EM is well established, this is recognised through the implementation of quality standards and staff training for patient safety. In settings where EM is developing, immense system and patient pressures exist, thereby necessitating the availability of tiered standards appropriate to the local context. METHODS: The original quality framework arose from expert consensus at the International Federation of Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care (UK, 2011). The IFEM Quality and Safety Special Interest Group members have subsequently refined it to achieve a consensus in 2018. RESULTS: Patients should expect EDs to provide effective acute care. To do this, trained emergency personnel should make patient-centred, timely and expert decisions to provide care, supported by systems, processes, diagnostics, appropriate equipment and facilities. Enablers to high-quality care include appropriate staff, access to care (including financial), coordinated emergency care through the whole patient journey and monitoring of outcomes. Crowding directly impacts on patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritised as components of an improvement strategy which should be developed, tailored and implemented in each setting. CONCLUSION: EDs globally have a remit to deliver the best care possible. IFEM has defined and updated an international consensus framework for quality and safety.

Characterizing the impact of snowfall on patient attendance at an urban emergency department in Toronto, Canada.

OBJECTIVES: We sought to determine whether addition of a snowfall variable improves emergency department (ED) patient volume forecasting. Our secondary objective was to characterize the magnitude of effect of snowfall on ED volume. METHODS: We used daily historical patient volume data and local snowfall records from April 1st, 2011 to March 31st, 2018 (2542 days) to fit a series of four generalized linear models: a baseline model which included calendar variables and three different snowfall models with an indicator variable for either any snowfall (>0 cm), moderate snowfall (≥1 cm), or large snowfall (≥5 cm). To evaluate model fit, we examined the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Incident rate ratios were calculated to determine the effect of snowfall in each model. RESULTS: All three snowfall models demonstrated improved model fit compared to the model without snowfall. The best fitting model included a binary variable for snowfall (<1 cm vs. ≥1 cm). This model showed a statistically significant decrease in daily ED volume of 2.65% (95% CI: 1.23%-4.00%) on snowfall days. DISCUSSION: The addition of a snowfall variable results in improved model performance in short-term ED volume forecasting. Snowfall is associated with a modest, but statistically significant reduction in ED volume.

Patients' Perspectives on Outcomes of Care After Discharge From the Emergency Department: A Qualitative Study.

STUDY OBJECTIVE: Much effort has been expended to understand what care experiences patients value in the emergency department (ED), yet little is known about which outcomes patients value after ED care. Our goal is to define outcomes of ED care that are valued by patients discharged from the ED, with the goal of informing the development of a patient-reported outcome measure for ED care. METHODS: We conducted qualitative semistructured interviews with patients recruited during their care at 1 of 2 EDs and interviewed in either English or French 1 to 9 days after their visit. Patients who were hospitalized were excluded. Interviews focused on perceived outcomes of care since the ED visit and expectations of care before the ED visit. We identified themes with standard descriptive content analysis techniques and a modified version of the constant comparative method, drawing on grounded theory methods. RESULTS: We interviewed 46 patients in English (n=38) or French (n=8). Participants with diverse reasons for seeking care appeared to value common outcomes from ED care that centered around 4 themes: understanding the cause and expected trajectory of their symptoms; reassurance; symptom relief; and having a plan to manage their symptoms, resolve their issue, or pursue further medical care. These themes were also reflected in the expectations participants recalled having when they decided to seek care in the ED. CONCLUSION: The 4 outcomes defined constitute areas for improvement and will inform the development of an ED patient-reported outcome questionnaire. Consideration should be given to measuring patient-reported outcomes separately from patient experience.

Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians.

OBJECTIVE: We delivered a point-of-care ultrasound training programme in a resource-limited setting in Rwanda, and sought to determine participants' knowledge and skill retention. We also measured trainees' assessment of the usefulness of ultrasound in clinical practice. METHODS: This was a prospective cohort study of 17 Rwandan physicians participating in a point-of-care ultrasound training programme. The follow-up period was 1 year. Participants completed a 10-day ultrasound course, with follow-up training delivered over the subsequent 12 months. Trainee knowledge acquisition and skill retention were assessed via observed structured clinical examinations (OSCEs) administered at six points during the study, and an image-based assessment completed at three points. RESULTS: Trainees reported minimal structured ultrasound education and little confidence using point-of-care ultrasound before the training. Mean scores on the image-based assessment increased from 36.9% (95% CI 32-41.8%) before the initial 10-day training to 74.3% afterwards (95% CI 69.4-79.2; P < 0.001). The mean score on the initial OSCE after the introductory course was 81.7% (95% CI 78-85.4%). The mean OSCE performance at each subsequent evaluation was at least 75%, and the mean OSCE score at the 58-week follow up was 84.9% (95% CI 80.9-88.9%). CONCLUSIONS: Physicians providing acute care in a resource-limited setting demonstrated sustained improvement in their ultrasound knowledge and skill 1 year after completing a clinical ultrasound training programme. They also reported improvements in their ability to provide patient care and in job satisfaction.

Big data in global health: improving health in low- and middle-income countries.

Over the last decade, a massive increase in data collection and analysis has occurred in many fields. In the health sector, however, there has been relatively little progress in data analysis and application despite a rapid rise in data production. Given adequate governance, improvements in the quality, quantity, storage and analysis of health data could lead to substantial improvements in many health outcomes. In low- and middle-income countries in particular, the creation of an information feedback mechanism can move health-care delivery towards results-based practice and improve the effective use of scarce resources. We review the evolving definition of big data and the possible advantages of - and problems in - using such data to improve health-care delivery in low- and middle-income countries. The collection of big data as mobile-phone based services improve may mean that development phases required elsewhere can be skipped. However, poor infrastructure may prevent interoperability and the safe use of patient data. An appropriate governance framework must be developed and enforced to protect individuals and ensure that health-care delivery is tailored to the characteristics and values of the target communities.

Au cours de la dernière décennie, une augmentation massive de la collecte et de l'analyse des données s'est produite dans de nombreux domaines. Dans le secteur de la santé, cependant, il y a eu relativement peu de progrès en matière d'analyse et d'application des données malgré une hausse rapide de la production des données. Grâce à une gouvernance adéquate, les améliorations en matière de qualité, de quantité, de stockage et d'analyse des données de santé pourraient se traduire en des améliorations substantielles pour de nombreux résultats cliniques. Dans les pays à revenu faible et intermédiaire en particulier, la création d'un mécanisme de retour d'information peut faire évoluer la prestation des soins de santé vers une pratique axée sur les résultats et améliorer l'utilisation efficace des ressources limitées. Nous examinons l'évolution de la définition des mégadonnées («big data¼) et les avantages ­ et les problèmes ­ possibles de l'utilisation de ces données pour améliorer la prestation des soins de santé dans les pays à revenu faible et intermédiaire. Alors que les services basés sur la téléphonie mobile s'améliorent, la collection des mégadonnées peut signifier que les phases de développement requises ailleurs peuvent être omises. Cependant, une infrastructure faible peut empêcher l'interopérabilité et l'utilisation en toute sécurité des données du patient. Un cadre de gouvernance approprié doit être développé et appliqué pour protéger les individus et assurer que la prestation des soins de santé est adaptée aux caractéristiques et aux valeurs des communautés cibles.

En la última década, la recolección y análisis de datos ha aumentado enormemente en muchos campos. Sin embargo, en el sector de la sanidad ha habido relativamente pocos avances en el análisis y la aplicación de datos, a pesar de un aumento rápido en la generación de datos. Con una gestión adecuada, las mejoras en la calidad, cantidad, almacenamiento y análisis de datos de salud podrían conducir a mejoras considerables en muchos de los resultados sanitarios. En los países de ingresos bajos y medios en particular, la creación de un mecanismo de retroalimentación de información puede impulsar la prestación de servicios sanitarios hacia la práctica basada en resultados y mejorar el uso eficaz de los recursos escasos. Se revisó la definición cambiante de los grandes volúmenes de datos y las posibles ventajas ­ y problemas ­ de utilizar dichos datos para mejorar la prestación de servicios sanitarios en países de ingresos bajos y medios. La recogida de grandes volúmenes de datos a medida que mejoran los servicios basados en la telefonía móvil podría permitir la omisión de las fases de desarrollo requeridas en otros lugares. Sin embargo, una infraestructura deficiente puede impedir la interoperabilidad y el uso seguro de los datos del paciente. Es necesario desarrollar y aplicar un marco de gestión adecuado para proteger a las personas y garantizar que la prestación de servicios sanitarios se adapta a las características y los valores de las comunidades destinatarias.

Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study.

STUDY OBJECTIVE: Early diagnosis of children with meningitis or septicemia remains a significant challenge in emergency medicine. We seek to describe the frequency of repeated emergency department (ED) visits among children admitted with meningitis or septicemia in Ontario, Canada. METHODS: In this retrospective cohort study, using health administrative data, we included all children aged 30 days to 5 years who were hospitalized with a final diagnosis of meningitis or septicemia in Ontario between 2005 and 2010. ED visits at any hospital in the preceding 5 days were identified as potential repeated ED visits. We used generalized estimating equations to model the association of sex, age, triage score, immunocompromised state, visit timing, type of ED, and annual patient volume on the risk of repeated ED visits. RESULTS: Of 521 children, 114 (21.9%) had repeated ED visits before admission. Children admitted on initial visit and those with repeated visits had similar median lengths of stay (13 versus 12 days), critical care use (21.1% versus 16.7%), and mortality (mean 2.9%). One in 3 children repeating visits returned to a different hospital. Repeated visits were associated with older age, a less acute triage score, and initial visit to a community hospital without available pediatric consultation. CONCLUSION: In this cohort, repeated ED visits among children with meningitis or septicemia were common, yet they had health outcomes similar to those of children admitted on initial visit. One in 3 returned to a different ED, making it unlikely that EDs and clinicians can learn from these critical events without a regionalized reporting system.

Using archetypes to design services for high users of healthcare.

A subset of people with complex health and social needs account for the majority of healthcare costs in Ontario. There is broad agreement that better solutions for these patients could lead to better health outcomes and lower costs, but we have few tools to design services around their diverse needs. Predictive modelling may help determine numbers of high users, but design methods such as user archetypes may offer important ways of understanding how to meet their needs. We studied a range of patient profiles and interviews with frequent emergency department users to develop four archetypes of patients with complex needs to orient the service design process. These can be refined and adapted for use within initiatives like Health Links to help provide more appropriate cost-effective care.

Characteristics and Practices of High-Performing Centers in Organ Donor Identification and Referral: A Qualitative Study.

Background: The identification and referral (ID&R) of potential organ donors to provincial organ donation organizations (ODOs) is a critical first step in the organ donation process. However, even in provinces with mandatory referral legislation, there remains variability in ID&R rates across critical care units, with some units demonstrating high performance despite experiencing similar constraints associated with existing structures, policies, and practices. Objective: We sought to identify the enablers and specific strategies that high-performing critical care units leveraged to achieve their exceptional performance. Design: We conducted a descriptive qualitative study to inform ID&R improvement efforts as part of a positive deviance initiative. Setting: We identified three high-performing critical care units as study sites. Participants: Clinicians working in identified critical care units. Methods: At each site, we interviewed clinical team members about their perceptions and experiences of ID&R. Data analysis followed a thematic analysis approach. Results: We outline three themes describing how the high-performing hospitals achieve strong ID&R practices. First, all units demonstrated a high degree of integration between the concepts of high-quality end-of-life care and organ donation. Team members were consistently notified of successful transplants stemming from their unit, and all missed ID&Rs were tracked and discussed. Second, participants described a team approach with strong medical leadership, where all team members embrace their role in ensuring that no potential donor is missed. Finally, the units adopted strategies to support and simplify ID&R such as collectively simplifying triggers for referral, developing strong working relationships with provincial donor coordinators, and creating informal avenues of communication between clinicians and donor coordinators. Limitations: The lack of comparable data for potential organ donor referral rates across Canada impacted our ability to identify high-performing hospitals based on data. Instead, we contacted the ODOs directly to identify high-performing units that met our criteria. Second, our study sample was limited to three hospital sites from three different provinces and the three hospitals perform organ recovery and transplant on-site. Conclusion: Critical care units can adopt strategies and implement interventions to support ID&R improvement efforts. We provide examples informed by this study. We also highlight considerations that require attention when engaging in this work such as ensuring that all team members are aware of changes in care plans and physicians consistently engage in discussions about organ donation. Local medical leadership is critical to supporting these changes.

Contexte: L'identification et l'aiguillage (ID+AIG) des donneurs d'organes potentiels vers les organismes provinciaux de don d'organes (OPDO) constituent une première étape essentielle du processus de don d'organes. Toutefois, même dans les provinces où la loi oblige l'aiguillage des donneurs potentiels, les taux d'ID+AIG varient entre les unités de soins intensifs, certaines affichant un rendement élevé malgré des contraintes similaires associées aux structures, aux politiques et aux pratiques existantes. Objectif: Nous cherchions à identifier les facilitateurs et les stratégies que les unités de soins intensifs hautement performantes ont exploités pour atteindre des taux exceptionnels d'ID+AIG. Conception: Nous avons mené une étude qualitative descriptive afin de guider les efforts d'amélioration des taux d'ID+AIG dans le cadre d'une initiative de déviation positive. Cadre: Trois unités de soins intensifs hautement performantes ont été désignées comme sites d'étude. Participants: Les cliniciens exerçant dans les unités de soins intensifs identifiées. Méthodologie: À chaque site, nous avons interrogé des membres de l'équipe clinique sur leurs perceptions et leurs expériences d'ID+AIG. L'analyze des données a suivi une approche d'analyze thématique. Résultats: Nous présentons trois thèmes décrivant la manière dont les hôpitaux les plus performants parviennent à mettre en place de solides pratiques d'ID+AIG. Premièrement, toutes ces unités démontrent un degré élevé d'intégration entre les concepts de soins de fin de vie de haute qualité et le don d'organes. Les membres de l'équipe sont informés sur une base régulière des greffes réussies provenant de leur unité et toutes les occasions d'ID+AIG manquées font l'objet d'un suivi et de discussion. Deuxièmement, les participants ont décrit une approche d'équipe, menée par un solide leadership médical, où tous les membres assument leur rôle en s'assurant qu'aucun donneur potentiel ne soit manqué. Enfin, nous avons constaté que les unités hautement performantes adoptent des stratégies visant à soutenir et à simplifier l'ID+AIG, comme la simplification collective des critères d'aiguillage, le développement de solides relations de travail avec les coordonnateurs de dons provinciaux et la création de voies de communication informelles entre les cliniciens et les coordonnateurs de dons. Limites: L'absence de données comparables sur les taux d'aiguillage des donneurs d'organes potentiels au Canada a limité notre capacité à identifier les hôpitaux les plus performants à partir des données. Nous avons plutôt communiqué directement avec les OPDO pour identifier les unités les plus performantes répondant à nos critères. Aussi, notre échantillon était limité à trois hôpitaux de trois provinces différentes, qui procèdent tous au prélèvement et à la transplantation d'organes sur place. Conclusion: Les unités de soins intensifs peuvent adopter des stratégies et mettre en œuvre des interventions pour soutenir les efforts d'amélioration des taux d'ID+AIG. Notre étude en fournit des exemples. Nous mettons également en évidence les aspects qui nécessitent une attention particulière lorsqu'on s'engage dans cette voie; notamment s'assurer que tous les membres de l'équipe sont au courant des changements apportés aux plans de soins et que les médecins participent systématiquement aux discussions sur le don d'organes. Du leadership médical local est essentiel pour soutenir ces changements.

Recommendations for patient-centered emergency care.

INTRODUCTION: Patient-centred care is more than just an aspiration, it represents a fundamental shift in the way healthcare must be delivered. Patient-centred emergency care is important for improving the patient and clinician experience and is essential for optimizing health outcomes. Creating a patient-centred emergency department emphasizes the importance of the patient's experience, preferences, and values. METHODS: To formulate recommendations for patient-centred care, we synthesized a literature review, stakeholder interviews, consensus from an expert panel of diverse healthcare professionals and a patient advocate, and reviewed our recommendations for feedback with a presentation at the Canadian Association of Emergency Physicians (CAEP) 2023 Annual Conference Academic Symposium. RESULTS: This paper gives practical recommendations for areas and strategies to improve patient-centredness in Emergency Medicine. It delves into the various dimensions of this approach, including the role of the physical environment, communications and interpersonal interactions, systems of care, and measurement, all of which are essential in providing optimal care to match the patients' needs. CONCLUSION: We seek to inspire a renewed commitment of placing the patient at the heart of emergency care, recognizing that patient-centredness is not merely an option but a fundamental aspect of delivering high quality, compassionate and effective healthcare in the emergency setting. In an era marked by technological advancements and evolving healthcare paradigms, the essence of medicine as a deeply human endeavour is becoming in some ways more possible, if we seize the opportunities.

RéSUMé: INTRODUCTION: Les soins axés sur le patient sont plus qu'une simple aspiration, ils représentent un changement fondamental dans la façon dont les soins de santé doivent être dispensés. Les soins d'urgence axés sur les patients sont importants pour améliorer l'expérience des patients et des cliniciens et sont essentiels pour optimiser les résultats pour la santé. La création d'un service d'urgence axé sur le patient souligne l'importance de l'expérience, des préférences et des valeurs du patient. MéTHODES: Afin de formuler des recommandations pour les soins axés sur les patients, nous avons synthétisé une analyse documentaire, des entrevues avec les intervenants, le consensus d'un comité d'experts composé de divers professionnels de la santé et d'un défenseur des patients. et nous avons examiné nos recommandations en matière de rétroaction lors d'une présentation au colloque universitaire annuel 2023 de l'Association canadienne des médecins d'urgence (ACMU). RéSULTATS: Ce document donne des recommandations pratiques sur les domaines et les stratégies pour améliorer l'orientation des patients en médecine d'urgence. Il examine les diverses dimensions de cette approche, y compris le rôle de l'environnement physique, les communications et les interactions interpersonnelles, les systèmes de soins et la mesure, qui sont tous essentiels pour fournir des soins optimaux afin de répondre aux besoins des patients. CONCLUSION: Nous cherchons à inspirer un engagement renouvelé à placer le patient au cœur des soins d'urgence, reconnaissant que l'orientation du patient n'est pas seulement une option, mais un aspect fondamental de la prestation de soins de santé de haute qualité, compatissants et efficaces en milieu d'urgence. À une époque marquée par les progrès technologiques et l'évolution des paradigmes de la santé, l'essence de la médecine en tant qu'entreprise profondément humaine devient à certains égards plus possible, si nous saisissons les opportunités.

Development of a Patient-Reported Experience Measure Tool for Ambulatory Patients With Acute Unexpected Needs: The APEX Questionnaire.

Background: The aim of this study was to develop a patient-reported experience measure (PREM) for comparing the experience of care received by ambulatory patients with acute unexpected needs presenting in emergency departments (EDs), walk-in clinics, and primary care practices. Methods: The Ambulatory Patient EXperience (APEX) questionnaire was developed using a 5-phase mixed-methods approach. The questionnaire was pretested by asking potential users to rate its clarity, usefulness, redundancy, content and face validities, and discrimination on a 9-point scale (1 = strongly disagree to 9 = strongly agree). The pre-final version was then tested in a pilot study. Results: The final questionnaire is composed of 61 questions divided into 7 sections. In the pretest (n = 25), median responses were 8 and above for all dimensions assessed. In the pilot study, 63 participants were enrolled. Adjusted results show that access, cleanliness, and feeling treated with respect and dignity by nurses and physicians were significantly better in the clinics than in the ED. Conclusion: We developed a questionnaire to assess and compare experience of ambulatory care in different clinical settings.

Post-COVID-19 condition symptoms among emergency department patients tested for SARS-CoV-2 infection.

Symptoms of the Post-COVID-19 Condition are often non-specific making it a challenge to distinguish them from symptoms due to other medical conditions. In this study, we compare the proportion of emergency department patients who developed symptoms consistent with the World Health Organization's Post-COVID-19 Condition clinical case definition between those who tested positive for Severe Acute Respiratory Syndrome Coronavirus-2 infection and time-matched patients who tested negative. Our results show that over one-third of emergency department patients with a proven acute infection meet Post-COVID-19 Condition criteria 3 months post-index visit. However, one in five test-negative patients who claim never having been infected also report symptoms consistent with Post-COVID-19 Condition highlighting the lack of specificity of the clinical case definition. Testing for SARS-CoV-2 during the acute phase of a suspected infection should continue until specific biomarkers of Post-COVID-19 Condition become available for diagnosis and treatment.

Web-Based Co-design in Health Care: Considerations for Renewed Participation.

The COVID-19 pandemic has shifted the work environment to a new reality of remote work and virtual collaboration. This shift has occurred in various work settings with an impact on spaces, approaches, applied techniques, and tools. This has resulted in the broad use of virtual tools in the health care sector to avoid physical encounters and in-person interactions that will likely outlast the COVID-19 pandemic. Developing effective virtual approaches requires the knowledge and skills of using digital technologies collaboratively combined with a deep understanding of the context or contexts in which these approaches may be used. The implementation of virtual health design methods, including web-based co-design, has increased to meet the realities of COVID-19 restrictions and is likely to outlast them. Adapting the use of co-design methodologies to a virtual configuration requires rethinking methods of collaboration and communication, adapting to virtual environments, and creating new methods of engagement and facilitation. With this viewpoint, we reviewed the current work on co-design (in person and web based) to propose techniques for the design, planning, and implementation of web-based co-design. We propose 7 considerations that may enable web-based co-design projects in the health care sector. The key considerations that affect the success of a web-based co-design approach should be considered in the process of planning, developing, and conducting web-based co-design sessions. These include facilitation, collaboration, accessibility and equity, communication, sensemaking, tangible tools and games, and web-based research ethics. We illustrate this work with a case study of co-design for an emergency department discharge tool developed during the pandemic.

Trends in the role of security services in the delivery of emergency department care.

BACKGROUND: Security services in most settings are an essential part of emergency department (ED) care, but their role remains poorly understood. We sought to:(1) identify the frequency of security services involvement in ED care;(2) characterise the events security services are called for; and (3) identify temporal trends in use. METHODS: We used a hospital-wide security database at a tertiary care ED in downtown Toronto, Ontario. Data from January 2017 to June 2021 related to the ED, patient or visitor related safety calls were included. We categorised calls by type of event (e.g.: Code White or Restraints). Call numbers were calculated as rates to adjust for visit volumes for each period. Univariate analyses were used to assess association between security services' calls and shift time, day of week, and month of the year. RESULTS: Over the 4.5-year study period, 20,033 ED-related calls were recorded. On average, we identified 61 calls per 1000 patient visits. On univariate analysis, no increase in security calls were found based on day of week or month, but a disproportionate number of security calls were recorded overnight. CONCLUSION: This study reveals high security services involvement in the delivery of care in one urban ED. Security databases can inform improvement work and could be augmented by better coding of violent events and linkage with electronic health records when involving patients.

RéSUMé : CONTEXTE: Dans la plupart des contextes, les services de sécurité constituent un élément essentiel des soins dispensés dans les services d'urgence, mais leur rôle reste mal compris. Nous avons cherché à: (1) identifier la fréquence de l'intervention des services de sécurité dans les soins aux urgences; (2) caractériser les événements pour lesquels les services de sécurité sont requis; et (3) identifier les tendances temporelles de l'utilisation. MéTHODES: Nous avons utilisé une base de données de sécurité à l'échelle de l'hôpital dans un service d'urgence de soins tertiaires du centre-ville de Toronto, en Ontario. Les données de janvier 2017 à juin 2021 relatives aux appels de sécurité liés aux urgences, aux patients ou aux visiteurs ont été incluses. Nous avons catégorisé les appels par type d'événement (par exemple : Code blanc ou Contraintes). Les nombres d'appels ont été calculés sous forme de taux afin d'ajuster les volumes de visites pour chaque période. Des analyses univariées ont été utilisées pour évaluer l'association entre les appels des services de sécurité et l'heure du quart de travail, le jour de la semaine et le mois de l'année. RéSULTATS: Au cours des 4,5 années de l'étude, 20 033 appels liés aux urgences ont été enregistrés. En moyenne, nous avons recensé 61 appels pour 1 000 visites de patients. L'analyse univariée n'a révélé aucune augmentation des appels de sécurité en fonction du jour de la semaine ou du mois, mais un nombre disproportionné d'appels de sécurité a été enregistré pendant la nuit. CONCLUSION: Cette étude révèle une forte implication des services de sécurité dans la prestation des soins dans un service d'urgence urbain. Les bases de données sur la sécurité peuvent servir de base aux travaux d'amélioration et pourraient être complétées par un meilleur codage des événements violents et une liaison avec les dossiers médicaux électroniques lorsqu'ils concernent des patients.

Accuracy of Self-Reported COVID-19 Vaccination Status Compared With a Public Health Vaccination Registry in Québec: Observational Diagnostic Study.

BACKGROUND: The accuracy of self-reported vaccination status is important to guide real-world vaccine effectiveness studies and policy making in jurisdictions where access to electronic vaccine registries is restricted. OBJECTIVE: This study aimed to determine the accuracy of self-reported vaccination status and reliability of the self-reported number of doses, brand, and time of vaccine administration. METHODS: This diagnostic accuracy study was completed by the Canadian COVID-19 Emergency Department Rapid Response Network. We enrolled consecutive patients presenting to 4 emergency departments (EDs) in Québec between March 24, 2020, and December 25, 2021. We included adult patients who were able to consent, could speak English or French, and had a proven COVID-19 infection. We compared the self-reported vaccination status of the patients with their vaccination status in the electronic Québec Vaccination Registry. Our primary outcome was the accuracy of the self-reported vaccination status (index test) ascertained during telephone follow-up compared with the Québec Vaccination Registry (reference standard). The accuracy was calculated by dividing all correctly self-reported vaccinated and unvaccinated participants by the sum of all correctly and incorrectly self-reported vaccinated and unvaccinated participants. We also reported interrater agreement with the reference standard as measured by unweighted Cohen κ for self-reported vaccination status at telephone follow-up and at the time of their index ED visit, number of vaccine doses, and brand. RESULTS: During the study period, we included 1361 participants. At the time of the follow-up interview, 932 participants reported at least 1 dose of a COVID-19 vaccine. The accuracy of the self-reported vaccination status was 96% (95% CI 95%-97%). Cohen κ for self-reported vaccination status at phone follow-up was 0.91 (95% CI 0.89-0.93) and 0.85 (95% CI 0.77-0.92) at the time of their index ED visit. Cohen κ was 0.89 (95% CI 0.87-0.91) for the number of doses, 0.80 (95% CI 0.75-0.84) for the brand of the first dose, 0.76 (95% CI 0.70-0.83) for the brand of the second dose, and 0.59 (95% CI 0.34-0.83) for the brand of the third dose. CONCLUSIONS: We reported a high accuracy of self-reported vaccination status for adult patients without cognitive disorders who can express themselves in English or French. Researchers can use self-reported COVID-19 vaccination data on the number of doses received, vaccine brand name, and timing of vaccination to guide future research with patients who are capable of self-reporting their vaccination data. However, access to official electronic vaccine registries is still needed to determine the vaccination status in certain susceptible populations where self-reported vaccination data remain missing or impossible to obtain. TRIAL REGISTRATION: Clinicaltrials.gov NCT04702945; https://clinicaltrials.gov/ct2/show/NCT04702945.

Sensitivity and Diagnostic Yield of the First SARS-CoV-2 Nucleic Acid Amplification Test Performed for Patients Presenting to the Hospital.

Importance: Early and accurate diagnostic testing for SARS-CoV-2 is essential to initiate appropriate treatment and infection control and prevention measures among patients presenting to the hospital. Objective: To evaluate the diagnostic sensitivity of the SARS-CoV-2 nucleic acid amplification test (NAAT) performed within 24 hours of arrival to the emergency department among a nationally representative sample of patients. Design, Setting, and Participants: This diagnostic study was conducted at 47 hospitals across 7 provinces in Canada participating in the Canadian COVID-19 Rapid Response Emergency Department Network among consecutive eligible patients presenting to a participating emergency department who were tested for SARS-CoV-2 from March 1, 2020, to December 31, 2021. Patients not tested within 24 hours of arrival and those presenting with a positive result from a test performed in the community were excluded. Main Outcomes and Measures: The primary outcome was a positive result from the SARS-CoV-2 NAAT. Outcome measures were the diagnostic sensitivity and yield of the SARS-CoV-2 NAAT. Results: Of 132 760 eligible patients (66 433 women [50.0%]; median age, 57 years [IQR, 37-74 years]), 17 174 (12.9%) tested positive for SARS-CoV-2 within 14 days of their first NAAT. The diagnostic sensitivity of the SARS-CoV-2 NAAT was 96.2% (17 070 of 17 740 [95% CI, 95.9%-96.4%]) among all of the tests performed. Estimates ranged from a high of 97.7% (1710 of 1751 [95% CI, 96.8%-98.3%]) on day 2 of symptoms to a low of 90.4% (170 of 188 [95% CI, 85.3%-94.2%]) on day 11 of symptoms among patients presenting with COVID-19 symptoms. Among patients reporting COVID-19 symptoms, the sensitivity of the SARS-CoV-2 NAAT was 97.1% (11 870 of 12 225 [95% CI, 96.7%-97.3%]) compared with 87.6% (812 of 927 [95% CI, 85.2%-89.6%]) among patients without COVID-19 symptoms. The diagnostic yield of the SARS-CoV-2 NAAT was 12.0% (18 985 of 158 004 [95% CI, 11.8%-12.2%]) and varied from a high of 20.0% (445 of 2229 [95% CI, 18.3%-21.6%]) among patients tested on day 10 after symptom onset to a low of 8.1% (1686 of 20 719 [95% CI, 7.7%-8.5%]) among patients presenting within the first 24 hours of symptom onset. Conclusions and Relevance: This study suggests that the diagnostic sensitivity was high for the first SARS-CoV-2 NAAT performed in the hospital and did not vary significantly by symptom duration. Repeated testing of patients with negative test results should be avoided unless their pretest probability of disease is high.

Treatments, resource utilization, and outcomes of COVID-19 patients presenting to emergency departments across pandemic waves: an observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN).

BACKGROUND: Treatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves. METHODS: This observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes. RESULTS: We enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2-8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4-0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6-0.8) and critical care admission (OR 0.7; 95% CI 0.6-0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5-1.1). INTERPRETATION: In patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

RéSUMé: CONTEXTE: Le traitement de la maladie à coronavirus 2019 (COVID-19) a évolué entre les vagues pandémiques. Notre objectif était de comparer les traitements, l'utilisation des soins aigus et les résultats des patients atteints de la maladie COVID-19 se présentant aux urgences à travers les vagues de pandémie. MéTHODES: Cette étude observationnelle a recruté des patients COVID-19 éligibles consécutifs se présentant à 46 services d'urgence participant au Réseau canadien de réponse rapide aux services d'urgence COVID-19 (CCEDRRN) entre le 1er mars et le 31 décembre 2020. Nous avons recueilli des données au moyen d'un examen rétrospectif des dossiers. Notre principal résultat a été la mortalité à l'hôpital. Les résultats secondaires incluaient les traitements, les admissions à l'hôpital et aux soins intensifs, les revisites aux urgences et les réadmissions. La modélisation par régression logistique a évalué l'impact de la vague de pandémie sur les résultats. RéSULTATS: Nous avons recruté 9 967 patients dans 8 provinces, 3 336 de la première vague et 6 631 de la deuxième vague. Les patients de la deuxième vague étaient plus jeunes, moins nombreux à répondre aux critères de gravité de la COVID-19 et plus nombreux à quitter les urgences. Après ajustement en fonction des caractéristiques des patients et de la gravité de la maladie, le recours aux stéroïdes a augmenté (rapport de cotes [RC] 7.4 ; intervalle de confiance à 95 % [IC] 6.2­8.9) et la ventilation mécanique invasive a diminué (RC 0.5 ; IC à 95 % 0.4­0.7) lors de la deuxième vague par rapport à la première. Après ajustement pour tenir compte des différences dans les caractéristiques des patients et la gravité de la maladie, les probabilités d'hospitalisation (RC 0.7 ; IC à 95 % 0.6­0.8) et d'admission en soins intensifs (RC 0.7 ; IC à 95 % 0.6­0.9) ont diminué, tandis que la mortalité est restée inchangée (RC 0.7 ; IC à 95 % 0.5­1.1). INTERPRéTATION: Chez les patients se présentant dans les établissements de soins de santé, nous avons observé une adoption rapide des thérapies fondées sur des données probantes et un moindre recours aux thérapies expérimentales lors de la deuxième vague. Nous avons observé une augmentation des taux de sortie des services d'urgence et une diminution de l'utilisation des ressources hospitalières et des soins intensifs au fil du temps. Les réductions substantielles de la ventilation mécanique n'étaient pas associées à une augmentation de la mortalité. Les progrès réalisés dans les stratégies de traitement ont permis d'améliorer l'efficacité des systèmes de santé sans compromettre les résultats pour les patients.

Recommendations for enhancing collaboration between the Canadian emergency department quality improvement and research communities.

OBJECTIVES: While quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal-to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities. METHODS: An expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms. RESULTS: The final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both. CONCLUSION: Six recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes.

RéSUMé: OBJECTIFS: Bien que l'amélioration de la qualité (AQ) et la recherche clinique représentent deux approches scientifiques distinctes, elles ont le même but ultime: améliorer la santé et les résultats des soins aux patients. En tirant profit de leurs atouts respectifs, les chances d'obtenir et de soutenir des améliorations de santé sont plus élevées. Notre objectif était de créer des recommandations pour renforcer la collaboration entre les communautés d'AQ et de recherche clinique en médecine d'urgence canadienne. MéTHODES: Un groupe d'experts de huit cliniciens des services d'urgence dotés d'une expertise diversifiée en matière d'AQ et de recherche clinique a rédigé une liste de recommandations basées sur leur expertise professionnelle et un examen de la revue de littérature. Ces recommandations ont été affinées en consultation avec les parties prenantes nationales et examinées lors du Symposium académique virtuel de ACMU 2020, où des commentaires ont été reçus via plusieurs plateformes virtuelles. RéSULTATS: Les six recommandations finales incluent que tous les prestataires des services de médecine d'urgence devraient: (1) comprendre le rôle et l'application de la recherche clinique et de la science de l'AQ; que les médecins universitaires en médecine d'urgence devraient: (2) contribuer à la fois à l'adoption locale et à la diffusion large des résultats de projets, (3) tirer parti des méthodologies d'AQ dans les projets de recherche afin d'améliorer l'application des connaissances, et (4) veiller à ce que les résultats de projet donnent la priorité aux soins aux patients; et que les dirigeants universitaires devraient: (5) améliorer l'infrastructure de surveillance des projets de recherche et d'AQ, et (6) encourager la collaboration entre les chercheurs et les experts en AQ en assurant que les infrastructures universitaires et opérationnelles les alignent et les soutiennent. CONCLUSION: Six recommandations sont présentées pour aider la communauté de la médecine d'urgence canadienne à parvenir à une plus grande collaboration entre les chercheurs et les experts en AQ dans le but ultime d'améliorer les résultats des soins aux patients.