Concordance between 8-1-1 HealthLink BC Emergency iDoctor-in-assistance (HEiDi) virtual physician advice and subsequent health service utilization for callers to a nurse-managed provincial health information telephone service.

BACKGROUND: British Columbia 8-1-1 callers who are advised by a nurse to seek urgent medical care can be referred to virtual physicians (VPs) for supplemental assessment and advice. Prior research indicates callers' subsequent health service use may diverge from VP advice. We sought to 1) estimate concordance between VP advice and subsequent health service use, and 2) identify factors associated with concordance to understand potential drivers of discordant cases. METHODS: We linked relevant provincial administrative databases to obtain inpatient, outpatient, and emergency service use by callers. We developed operational definitions of concordance collaboratively with researcher, patient, VP, and management perspectives. We used Kaplan-Meier curves to describe health service use post-VP consultation and Cox regression to estimate the association of caller factors (rurality, demography, attachment to primary care) and call factors (reason, triage level, time of day) with concordance as hazard ratios. RESULTS: We analyzed 17,188 calls from November 16, 2020 to April 30, 2021. Callers advised to attend an emergency department (ED) immediately were the most concordant (73%) while concordance was lowest for those advised to seek Family Physician (FP) care either immediately (41%) or within 7 days (47%). Callers unattached to FPs were less likely to schedule an FP visit (hazard ratio = 0.76 [95%CI: 0.68-0.85]). Rural callers were less likely to attend an ED within 48 h when advised to go immediately (0.53 [95%CI:0.46-0.61]) compared to urban callers. Rural callers advised to see an FP, either immediately (1.28 [95%CI:1.01-1.62]) or within 7 days (1.23 [95%CI: 1.11-1.37]), were more likely to do so than urban callers. INTERPRETATION: Concordance between VP advice and subsequent caller health service use varies substantially by category of advice and caller rurality. Concordance with advice to "Go to ED" is high overall but to access primary care is below 50%, suggesting potential issues with timely access to FP care. Future research from a patient/caller centered perspective may reveal additional barriers and facilitators to concordance.

Reasons and outcomes for patients receiving ICS/LABA agents prior to, and one month after, emergency department presentations for acute asthma.

Objective: Asthma is a common emergency department (ED) presentation. This study examined factors associated with inhaled corticosteroids/long-acting beta-agonist (ICS/LABA) use; and management and outcomes before and after ED presentation. Methods: Secondary analysis of a prospective cohort study; adults treated for acute asthma in Canadian EDs underwent a structured interview before discharge and were followed-up four weeks later. Patients received oral corticosteroids (OCS) at discharge and, at physician discretion, most received ICS or ICS/LABA inhaled agents. Analyses focused on ICS/LABA vs "other" treatment groups at ED presentation. Results: Of 807 enrolled patients, 33% reported receiving ICS/LABA at ED presentation; 62% were female, median age was 31 years. Factors independently associated with ICS/LABA treatment prior to ED presentation were: having an asthma action plan; using an asthma diary/peak flow meter; influenza immunization; not using the ED as usual site for prescriptions; ever using OCS and currently using ICS. Patients were treated similarly in the ED and at discharge; however, relapse was higher in the ICS/LABA group, even after adjustment. Conclusion: One-third of patients presenting to the ED with acute asthma were already receiving ICS/LABA agents; this treatment was independently associated with preventive measures. While ICS/LABA management improves control of chronic asthma, patients using these agents who develop acute asthma reflect higher severity and increased risk of future relapse.

Process and findings informing the development of a provincial emergency medicine network.

We describe the process undertaken to inform the development of the recently launched British Columbia (BC) Emergency Medicine Network (EM Network). Five methods were undertaken: (1) a scoping literature review, (2) a survey of BC emergency practitioners and EM residents, (3) key informant interviews, (4) focus groups in sites across BC, and (5) establishment of a brand identity. There were 208 survey respondents: 84% reported consulting Internet resources once or more per emergency department shift; however, 26% reported feeling neutral, somewhat unsatisfied, or very unsatisfied with searching for information on the Internet to support their practice. Enthusiasm was expressed for envisioned EM Network resources, and the key informant interviews and focus group results helped identify and refine key desired components of the EM Network. In describing this, we provide guidance and lessons learned for health leaders and others who aspire to establish similar clinical networks, whether in EM or other medical disciplines.

A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management.

OBJECTIVE: To comparatively evaluate hypertonic sodium (HTS) and mannitol in patients following acute traumatic brain injury (TBI) on the outcomes of all-cause mortality, neurological disability, intracranial pressure (ICP) change from baseline, ICP treatment failure, and serious adverse events. DATA SOURCES: PubMed, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and WHO ICTRP (World Health Organization International Clinical Trials Registry Platform) were searched (inception to November 2015) using hypertonic saline solutions, sodium chloride, mannitol, osmotic diuretic, traumatic brain injury, brain injuries, and head injury. Searches were limited to humans. Clinical practice guidelines and bibliographies were reviewed. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized trials comparing HTS and mannitol in adults (≥16 years) with severe TBI (Glasgow Coma Scale score ≤8) and elevated ICP were included. ICP elevation, ICP reduction, and treatment failure were defined using study definitions. DATA SYNTHESIS: Of 326 articles screened, 7 trials enrolling a total of 191 patients met inclusion criteria. Studies were underpowered to detect a significant difference in mortality or neurological outcomes. Due to significant heterogeneity and differences in reporting ICP change from baseline, this outcome was not meta-analyzed. No difference between HTS and mannitol was observed for mean ICP reduction; however, risk of ICP treatment failure favored HTS (risk ratio [RR] = 0.39; 95% CI = 0.18-0.81). Serious adverse events were not reported. CONCLUSIONS: Based on limited data, clinically important differences in mortality, neurological outcomes, and ICP reduction were not observed between HTS or mannitol in the management of severe TBI. HTS appears to lead to fewer ICP treatment failures.

Effect of a Multi-Diagnosis Observation Unit on Emergency Department Length of Stay and Inpatient Admission Rate at Two Canadian Hospitals.

BACKGROUND: Observation units (OUs) have been shown to reduce emergency department (ED) lengths of stay (LOS) and admissions. Most published studies have been on OUs managing single complaints. OBJECTIVE: Our aim was to determine whether an OU reduces ED LOS and hospital admission rates for adults with a variety of presenting complaints. METHODS: We comparatively evaluated two hospitals in British Columbia, Canada (hereafter ED A and ED B) using a pre-post design. Data were extracted from administrative databases. The post-OU cohort included all adults presenting 6 months after OU implementation. The pre-OU cohort included all adults presenting in the same 6-month period 1 year before OU implementation. RESULTS: There were 109,625 patient visits during the study period. Of the 56,832 visits during the post-OU period (27,512 to ED A and 29,318 to ED B), 1.9% were managed in the OU in ED A and 1.4% in ED B. Implementation was associated with an increase in the median ED LOS at ED A (179.0 min pre vs. 192.0 min post [+13.0 min]; p < 0.001; mean difference -12.5 min, 95% confidence interval [CI] -15.2 to -9.9 min), but no change at ED B (182.0 min pre vs. 182.0 min post; p = 0.55; mean difference +2.0 min, 95% CI -0.7 to +4.7 min). Implementation significantly decreased the hospital admission rate for ED A (17.8% pre to 17.0% post [-0.8%], 95% CI -0.18% to 0.15%; p < 0.05) and did not significantly change the hospital admission rate at ED B (18.9% pre to 18.3% post [-0.6%], 95% CI -1.19% to -0.09%; p = 0.09). CONCLUSIONS: A multi-diagnosis OU can reduce hospital admission rate in a site-specific manner. In contrast to previous studies, we did not find that an OU reduced ED LOS. Further research is needed to determine whether OUs can reduce ED overcrowding.

Hyperbaric Oxygen Post Established Stroke.

BACKGROUND AND PURPOSE: Hyperbaric oxygen therapy (HBOT) has been reported to improve neurological function in the chronic phase of stroke in a single trial having significant limitations, including a lack of a sham control. METHODS: We conducted a single-center, parallel-group, randomized trial to determine the effectiveness of HBOT compared with a sham control in adults who were 6 to 36 months post-ischemic stroke. The treatment group received 40 sessions of HBOT at the Vancouver General Hospital Hyperbaric Unit. The control group received 40 sessions of sham treatment designed to replicate an HBOT experience. Due to recruitment challenges and timeline/feasibility tracking by the research team, the control arm was altered after 20 months to a waitlist in the hope of increasing participation. In the second phase, participants were randomized to receive HBOT immediately or following an eight-week observation period. The primary outcome was the post-treatment Stroke Impact Scale-16 (SIS-16). Secondary outcomes included the National Institute of Health Stroke Scale, Berg Balance Test, Digit Symbol Substitution Test, 5-Metre Walk Test, 6-Minute Walk Test, Grip Strength, Montreal Cognitive Assessment, Box/Block Test, and Center for Epidemiological Studies - Depression and Short Form-36. Based on detecting a clinically important between-group difference of 10 on the SIS-16 score, our target sample size was 68 participants per arm.  Results: From January 5, 2016 to October 9, 2018, 34 participants were enrolled in the trial, 27 during the first phase and seven in the second phase. The study was stopped after 36 months, and prior to meeting the sample size target, due to low recruitment. At the end of treatment, the difference in the SIS-16 between groups was 5.5 (95% CI: 1.3 to 9.7, p = 0.01) in favor of the sham group. CONCLUSIONS: Our results exclude a clinically important benefit of HBOT on the primary outcome of the SIS-16. These findings do not support the use of HBOT in chronic stroke survivors.

A Global Survey of Emergency Care Clinical Networks: Discussion and Implications for Canadian Learning Health Systems.

Clinical networks (CNs) can promote innovation and collaboration across providers and stakeholders. However, little is known about the structure and operations of CNs, particularly in emergency care. As Canada advances learning health systems (LHSs), foundational research is essential to enable future comparisons across CNs to identify those that contribute to positive system change. Drawing from the results of our international survey, we provide a description of 32 emergency care CNs worldwide, including their structure, operations and sustainability. Future research should consider the context of such networks, how they may contribute to an LHS and how they impact patient outcomes.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial.

STUDY OBJECTIVE: We determine whether a 1:1 mixture of ketamine and propofol (ketofol) for emergency department (ED) procedural sedation results in a 13% or more absolute reduction in adverse respiratory events compared with propofol alone. METHODS: Participants were randomized to receive either ketofol or propofol in a double-blind fashion. Inclusion criteria were aged 14 years or older and American Society of Anesthesiology class 1 to 3 status. The primary outcome was the number and proportion of patients experiencing an adverse respiratory event as defined by the Quebec Criteria. Secondary outcomes were sedation consistency, efficacy, and time; induction time; and adverse events. RESULTS: A total of 284 patients were enrolled, 142 per group. Forty-three (30%) patients experienced an adverse respiratory event in the ketofol group compared with 46 (32%) in the propofol group (difference 2%; 95% confidence interval -9% to 13%; P=.80). Three ketofol patients and 1 propofol patient received bag-valve-mask ventilation. Sixty-five (46%) patients receiving ketofol and 93 (65%) patients receiving propofol required repeated medication dosing or progressed to a Ramsay Sedation Score of 4 or less during their procedure (difference 19%; 95% confidence interval 8% to 31%; P=.001). Six patients receiving ketofol were treated for recovery agitation. Other secondary outcomes were similar between the groups. Patients and staff were highly satisfied with both agents. CONCLUSION: Ketofol for ED procedural sedation does not result in a reduced incidence of adverse respiratory events compared with propofol alone. Induction time, efficacy, and sedation time were similar; however, sedation depth appeared to be more consistent with ketofol.

College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017.

BACKGROUND: An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA). METHODS: We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians. RESULTS: Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism. INTERPRETATION: Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.

Outcomes of emergency department patients presenting with adverse drug events.

STUDY OBJECTIVE: Our objectives are to describe the outcomes of patients presenting to the emergency department (ED) because of an adverse drug event and to compare them with outcomes of patients presenting for other reasons. METHODS: This prospective observational study was conducted at Vancouver General Hospital, a 955-bed tertiary care hospital. We prospectively enrolled adults presenting to the ED between March and June 2006, using a systematic sampling algorithm. Pharmacists and physicians independently evaluated patients for adverse drug events. An independent committee reviewed and adjudicated cases in which assessments were discordant or uncertain. Data from the index visit were linked to vital statistics, administrative health services utilization, and cost of care data. RESULTS: Of 1,000 patients, 122 (12.2%; 95% confidence interval [CI] 10.3% to 14.4%) presented to the ED because of an adverse drug event. Of these, 48 presented because of an adverse drug reaction (one type of adverse drug event defined as an unintended response that occurred despite use of an appropriate drug dosage). We found no difference in mortality among patients presenting with and without adverse drug reactions (14.6% versus 5.9%; hazard ratio 1.57; 95% CI 0.70 to 3.52). After adjustment, patients with adverse drug events had a higher risk of spending additional days in the hospital per month (6.3% versus 3.4%; odds ratio 1.52; 95% CI 1.43 to 1.62) and higher rate of outpatient health care encounters (1.73 versus 1.22; rate ratio 1.20; 95% CI 1.03 to 1.40). The adjusted median monthly cost of care was 1.90 times higher (Can $325 versus $96; 95% CI 1.18 to 3.08). CONCLUSION: ED patients presenting with an adverse drug event incurred greater health services utilization and costs during a 6-month follow-up period compared with patients presenting for other reasons.

Integration of virtual physician visits into a provincial 8-1-1 health information telephone service during the COVID-19 pandemic: a descriptive study of HealthLink BC Emergency iDoctor-in-assistance (HEiDi).

BACKGROUND: British Columbia, like many jurisdictions, has a health information telephone service (8-1-1) to provide callers with information by registered nurses and help them decide whether to attend an emergency department or primary care clinic, or manage their concern at home. We describe a new service, HealthLink BC Emergency iDoctor-in-assistance (HEiDi), that partnered physicians available by videoconferencing with 8-1-1 registered nurses to support callers. METHODS: From Apr. 6 to Aug. 2, 2020, all callers to the 8-1-1 telephone service (available to anyone in BC) categorized as "seek care within 24 hours" by registered nurses were eligible for referral to HEiDi. HEiDi physicians ("virtual physicians") connected directly with callers via desktop videoconferencing software, assessed their health complaint, provided advice and suggested care disposition. We conducted a descriptive study and collected demographic characteristics, health concern and disposition determined by the virtual physician. RESULTS: HEiDi virtual physicians provided 7687 consultations. Most patients (n = 4439, 57.8%) were in the 20-64 age range, and 4814 (62.9%) were female. Common health concerns were related to gastroenterology (n = 1275, 16.6%), respiratory (n = 877, 11.4%) and dermatology (n = 874, 11.4%). From the 7531 calls with available data, 2548 (33.8%) callers were advised to attempt home treatment, 2885 (38.3%) to contact a primary care physician within 1 week, 1131 (15.0%) to attend an emergency department immediately and 538 (7.1%) to attend their primary provider now. INTERPRETATION: We found that virtual physicians were able to advise nearly 3 out of 4 (72.1%) patients away from in-person emergency or clinic assessment and 1 in 7 (15.0%) to seek immediate emergency department care. Virtual physicians can provide an effective complement to a provincial health telephone system.

Do emergency physicians attribute drug-related emergency department visits to medication-related problems?

STUDY OBJECTIVE: Adverse drug events represent the most common cause of preventable nonsurgical adverse events in medicine but may remain undetected. Our objective is to determine the proportion of drug-related visits emergency physicians attribute to medication-related problems. METHODS: This prospective observational study enrolled adults presenting to a tertiary care emergency department (ED) during 12 weeks. Drug-related visits were defined as ED visits caused by adverse drug events. The definition of adverse drug event was varied to examine both narrow and broad adverse drug event classification systems. Clinical pharmacists evaluated all patients for drug-related visits, using standardized assessment algorithms, and then followed patients until hospital discharge. Interrater agreement for the clinical pharmacist diagnosis of drug-related visit was assessed. Emergency physicians, blinded to the clinical pharmacist opinion, were interviewed at the end of each shift to determine whether they attributed the visit to a medication-related problem. An independent committee reviewed and adjudicated all cases in which the emergency physicians' and clinical pharmacists' assessments were discordant, or either the emergency physician or clinical pharmacist was uncertain. The primary outcome was the proportion of drug-related visits attributed to a medication-related problem by emergency physicians. RESULTS: Nine hundred forty-four patients were enrolled, of whom 44 patients received a diagnosis of the narrowest definition of an adverse drug event, an adverse drug reaction (4.7%; 95% confidence interval [CI] 3.5% to 6.2%). Twenty-seven of these were categorized as medication-related by emergency physicians (61.4%; 95% CI 46.5% to 74.3%), 10 were categorized as uncertain (22.7%; 95% CI 12.9% to 37.1%), and 7 categorized as a non-medication-related problem (15.9%; 95% CI 8.0% to 29.5%). Seventy-eight patients (8.3%; 95% CI 6.7% to 10.2%) received a diagnosis of an adverse drug event caused by an adverse drug reaction, a drug interaction, drug withdrawal, a medication error, or noncompliance. Emergency physicians attributed 49 of these to a medication-related problem (62.8%; 95% CI 51.7% to 72.7%), were uncertain about 15 (19.2%; 95% CI 12.0% to 29.4%), and attributed 14 to non-medication-related problems (17.9%; 95% CI 11.0% to 27.9%). Twenty-five of 29 (86.2%; 95% CI 69.3% to 94.4%) adverse drug events not considered medication related by emergency physicians were rated at least moderate in severity. CONCLUSION: A significant proportion of drug-related visits are not deemed medication related by emergency physicians. Drug-related visits not attributed to medication-related problems by emergency physicians may be missed in ongoing outpatient adverse drug event surveillance programs intended to develop strategies to enhance drug safety. Further research is needed to determine what the effect may be of not attributing adverse drug events to medication-related problems.

Patterns of death among avalanche fatalities: a 21-year review.

BACKGROUND: Avalanches are a significant cause of winter recreational fatalities in mountain regions. The purpose of this study was to determine the relative contributions of trauma and asphyxia to avalanche deaths. METHODS: We reviewed all avalanche fatalities between 1984 and 2005 that had been investigated by the offices of the British Columbia Coroners Service and the Chief Medical Examiner of Alberta. In addition, we searched the database of the Canadian Avalanche Centre for fatal avalanche details. We calculated injury severity scores for all victims who underwent autopsy. RESULTS: There were 204 avalanche fatalities with mortality information over the 21-year study period. Of these, 117 victims underwent autopsy, and 87 underwent forensic external examination. Asphyxia caused 154 (75%) deaths. Trauma caused 48 (24%) deaths, with the rate of death from trauma ranging from 9% (4/44) for snowmobilers to 42% (5/12) for ice climbers. In addition, 13% (12/92) of the asphyxia victims who underwent autopsy had major trauma, defined as an injury severity score of greater than 15. Only 48% (23/48) of victims for whom trauma was the primary cause of death had been completely buried. INTERPRETATION: Asphyxia and severe trauma caused most avalanche fatalities in western Canada. The relative rates differed between snowmobilers and those engaged in other mountain activities. Our findings should guide recommendations for safety devices, safety measures and resuscitation.

The bougie and first-pass success in the emergency department: Journal Club review.

CLINICAL QUESTION: Is bougie use associated with increased first-pass success in emergency department (ED) intubations?Article chosen: Driver et al. The Bougie and First-Pass Success in the Emergency Department. Annals of Emerg Med 2017;70(4):473-478. OBJECTIVE: To compare data and assess whether bougie use is independently associated with first-pass success in ED intubations.

Application of quality improvement analytic methodology in emergency medicine research: A comparative evaluation.

OBJECTIVE: Quality improvement (QI) analytic methodology is rarely encountered in the emergency medicine literature. We sought to comparatively apply QI design and analysis techniques to an existing data set, and discuss these techniques as an alternative to standard research methodology for evaluating a change in a process of care. METHODS: We used data from a previously published randomized controlled trial on triage-nurse initiated radiography using the Ottawa ankle rules (OAR). QI analytic tools were applied to the data set from this study and evaluated comparatively against the original standard research methodology. RESULTS: The original study concluded that triage nurse-initiated radiographs led to a statistically significant decrease in mean emergency department length of stay. Using QI analytic methodology, we applied control charts and interpreted the results using established methods that preserved the time sequence of the data. This analysis found a compelling signal of a positive treatment effect that would have been identified after the enrolment of 58% of the original study sample, and in the 6th month of this 11-month study. CONCLUSIONS: Our comparative analysis demonstrates some of the potential benefits of QI analytic methodology. We found that had this approach been used in the original study, insights regarding the benefits of nurse-initiated radiography using the OAR would have been achieved earlier, and thus potentially at a lower cost. In situations where the overarching aim is to accelerate implementation of practice improvement to benefit future patients, we believe that increased consideration should be given to the use of QI analytic methodology.

Epinephrine in cardiac arrest: The PARAMEDIC2 trial.

Link:http://www.nejm.org/doi/10.1056/NEJMoa1806842Full citation: Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med 2018; epub, NEJMoa1806842.Article type: TherapyRatings: Methods - 4/5 Usefulness - 3.5/5.

Use of personal mobile devices to record patient data by Canadian emergency physicians and residents.

OBJECTIVE: Use of personal mobile devices to record patient data appears to be increasing, but remains poorly studied. We sought to determine the extent and reasons that Canadian emergency physicians (EPs) and emergency medicine residents use personal mobile devices to record patient data in the emergency department (ED). METHODS: A national survey was distributed to Canadian EPs and residents between 27/02/17 and 23/03/17. This captured demographics, frequency, and purpose of personal mobile device use to record patient data in the ED. It also asked about obtaining consent, security of information, implications for patient care, and knowledge of relevant regulations. RESULTS: The response rate was 23.1% (406 participants). A third (31.5%) reported using personal mobile devices to record patient data. Most (78.1%) did so more than once a month, and 7.0% did so every shift. Reasons cited included beliefs that using personal mobile devices to record patient data improves care by consultants (36.7%), expedites care (31.3%), and advances medical education (32.8%). Consent was rarely or never documented and a minority of participants (10.9%) indicated they did not obtain consent. More than half of participants (53.2%) reported being unaware of applicable regulations. CONCLUSIONS: This is the first Canadian study on the use of personal mobile devices to record patient data in the ED. Our findings demonstrate current practice may risk privacy breaches. Personal mobile device use to record patient data in the ED is common and Canadian EPs and residents believe that this practice enhances patient care.

OBJECTIF: L'utilisation des appareils mobiles personnels (AMP) pour l'enregistrement de données sur les malades semble de plus en plus fréquente, mais elle a été peu examinée jusqu'à maintenant. Aussi l'étude visait-elle à déterminer l'étendue de la pratique et les raisons pour lesquelles les médecins d'urgence (MU) et les résidents dans le domaine, au Canada, utilisent les AMP pour enregistrer des données sur les malades au service des urgences (SU). MÉTHODE: Un questionnaire d'enquête nationale a été envoyé au MU et aux résidents en la matière, au Canada, entre le 2 février 2017 et le 23 mars 2017. On a ainsi recueilli des données démographiques, de même que des renseignements sur la fréquence de la pratique et les raisons motivant l'utilisation des AMP pour la collecte de données sur les malades au SU. Des questions portaient aussi sur l'obtention du consentement, la sécurité de l'information, la portée de l'acte sur les soins aux malades et la connaissance de la réglementation applicable. RÉSULTATS: Le taux de réponse a atteint 23,1% (406 participants). Un tiers (31,5%) des répondants ont indiqué faire usage d'AMP pour enregistrer des données sur les malades. La plupart (78,1%) les utilisaient plus d'une fois par mois et 7,0%, à toutes les périodes de travail. Les raisons invoquées le plus souvent comprenaient l'opinion selon laquelle l'utilisation des AMP pour l'enregistrement de données sur les malades améliorait les soins par les consultants (36,7%), accélérait la prestation de soins (31,3%) et faisait progresser la formation médicale (32,8%). Le consentement était rarement documenté, voire jamais, et une minorité de répondants (10,9%) ont indiqué ne pas avoir obtenu le consentement des patients. Plus de la moitié des participants (53,2%) ont déclaré ne pas être courant de l'existence de règlements applicables. CONCLUSION: Il s'agit là de la première étude sur l'utilisation des AMP au Canada pour l'enregistrement de données sur les malades au SU. D'après les résultats de l'enquête, la pratique pourrait comporter des risques d'atteinte à la vie privée. L'usage des AMP pour l'enregistrement de données sur les malades au SU est courant, et les MU comme les résidents sont d'avis que la pratique améliore les soins aux malades.