Pub Date : 2023-07-01DOI: 10.1007/s43678-023-00514-1
Yuan Tian, Nathaniel D Osgood, James Stempien, Vivian Onaemo, Adrienne Danyliw, Graham Fast, Beliz Acan Osman, Janet Reynolds, Jenny Basran
Objectives: Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times.
Methods: Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED.
Results: Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates.
Conclusions: A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.
{"title":"The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study.","authors":"Yuan Tian, Nathaniel D Osgood, James Stempien, Vivian Onaemo, Adrienne Danyliw, Graham Fast, Beliz Acan Osman, Janet Reynolds, Jenny Basran","doi":"10.1007/s43678-023-00514-1","DOIUrl":"https://doi.org/10.1007/s43678-023-00514-1","url":null,"abstract":"<p><strong>Objectives: </strong>Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times.</p><p><strong>Methods: </strong>Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED.</p><p><strong>Results: </strong>Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates.</p><p><strong>Conclusions: </strong>A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 7","pages":"608-616"},"PeriodicalIF":2.4,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9994670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-01DOI: 10.1007/s43678-023-00537-8
Hashim Kareemi, Ariel Hendin, Christian Vaillancourt
{"title":"Just the Facts: Management of return of spontaneous circulation after out-of-hospital cardiac arrest.","authors":"Hashim Kareemi, Ariel Hendin, Christian Vaillancourt","doi":"10.1007/s43678-023-00537-8","DOIUrl":"https://doi.org/10.1007/s43678-023-00537-8","url":null,"abstract":"","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 7","pages":"580-583"},"PeriodicalIF":2.4,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10367444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1007/s43678-023-00511-4
Conné Lategan, Amanda S Newton, Jennifer Thull-Freedman, Antonia Stang, Eddy Lang, Paul Arnold, Michael Stubbs, Stephen B Freedman
Objectives: We hypothesized that an association exists between satisfaction with ED mental health care delivery and patient and system characteristics. Primary: To evaluate overall satisfaction with ED mental health care delivery. Secondary: To explore aspects of ED mental health care delivery associated with general satisfaction, and patient and ED visit characteristic associated with total satisfaction scores and reported care experience themes.
Methods: We enrolled patients < 18 years of age presenting with a mental health concern between February 1, 2020 and January 31, 2021, to two pediatric EDs in Alberta, Canada. Satisfaction data were collected using the Service Satisfaction Scale, a measure of global satisfaction with mental health services. Association of general satisfaction with ED mental health care was evaluated using Pearson's correlation coefficient and variables associated with total satisfaction score was assessed using multivariable regression analyses. Inductive thematic analysis of qualitative feedback identified satisfaction and patient experience themes.
Results: 646 participants were enrolled. 71.2% were Caucasian and 56.3% female. Median age was 13 years (IQR 11-15). Parents/caregivers (n = 606) and adolescents (n = 40) were most satisfied with confidentiality and respect in the ED and least satisfied with how ED services helped reduce symptoms and/or problems. General satisfaction was associated with perceived amount of help received in the ED (r = 0.85) and total satisfaction with evaluation by a mental health team member (p = 0.004) and psychiatrist consultation (p = 0.05). Comments demonstrated satisfaction with ED provider attitudes and interpersonal skills and dissatisfaction with access to mental health and addictions care, wait time, and the impact of COVID-19.
Conclusions: There is a need to improve ED mental health care delivery, with a focus on timely access to ED mental health providers. Access to outpatient/community-based mental health care is needed to complement care received in the ED and to provide continuity of care for youth with mental health concerns.
{"title":"An evaluation of satisfaction with emergency department care in children and adolescents with mental health concerns.","authors":"Conné Lategan, Amanda S Newton, Jennifer Thull-Freedman, Antonia Stang, Eddy Lang, Paul Arnold, Michael Stubbs, Stephen B Freedman","doi":"10.1007/s43678-023-00511-4","DOIUrl":"https://doi.org/10.1007/s43678-023-00511-4","url":null,"abstract":"<p><strong>Objectives: </strong>We hypothesized that an association exists between satisfaction with ED mental health care delivery and patient and system characteristics. Primary: To evaluate overall satisfaction with ED mental health care delivery. Secondary: To explore aspects of ED mental health care delivery associated with general satisfaction, and patient and ED visit characteristic associated with total satisfaction scores and reported care experience themes.</p><p><strong>Methods: </strong>We enrolled patients < 18 years of age presenting with a mental health concern between February 1, 2020 and January 31, 2021, to two pediatric EDs in Alberta, Canada. Satisfaction data were collected using the Service Satisfaction Scale, a measure of global satisfaction with mental health services. Association of general satisfaction with ED mental health care was evaluated using Pearson's correlation coefficient and variables associated with total satisfaction score was assessed using multivariable regression analyses. Inductive thematic analysis of qualitative feedback identified satisfaction and patient experience themes.</p><p><strong>Results: </strong>646 participants were enrolled. 71.2% were Caucasian and 56.3% female. Median age was 13 years (IQR 11-15). Parents/caregivers (n = 606) and adolescents (n = 40) were most satisfied with confidentiality and respect in the ED and least satisfied with how ED services helped reduce symptoms and/or problems. General satisfaction was associated with perceived amount of help received in the ED (r = 0.85) and total satisfaction with evaluation by a mental health team member (p = 0.004) and psychiatrist consultation (p = 0.05). Comments demonstrated satisfaction with ED provider attitudes and interpersonal skills and dissatisfaction with access to mental health and addictions care, wait time, and the impact of COVID-19.</p><p><strong>Conclusions: </strong>There is a need to improve ED mental health care delivery, with a focus on timely access to ED mental health providers. Access to outpatient/community-based mental health care is needed to complement care received in the ED and to provide continuity of care for youth with mental health concerns.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"498-507"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10155139/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9630439","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1007/s43678-023-00505-2
Victoria Sanderson, Branka Vujcic, Sherry Coulson, Rodrick Lim
Purpose: This is the first study to take an in-depth qualitative approach to identify motivating factors for caregivers who chose the paediatric emergency virtual care option in Canada during the SARS-CoV-2 pandemic. The role that virtual care may play moving forward is also considered.
Methods: Between May 2020 and May 2021, 773 respondents attending the virtual clinic completed a follow-up survey with open-ended questions. For qualitative content analysis, comments were coded and analysed until thematic saturation was reached. Sub-codes were subsumed into major coding categories to identify themes.
Results: Three major themes, including safety, reassurance and convenience, and an overarching theme of satisfaction emerged from this analysis. Paediatric virtual clinic use was motivated in part by a desire to avoid the hospital environment. In-person Emergency Department visits were reported to be challenging and stressful, particularly due to perceived infection risk. Respondents appreciated that the clinic provided reassurance by assisting in navigating the healthcare system during a time of uncertainty and felt the virtual option allowed them to use healthcare resources responsibly. The convenience and ease of access to virtual care allowed for improved family-centred care in vulnerable populations. The overarching theme of satisfaction was emphasized by numerous comments for this service to be offered post-pandemic.
Conclusion: Our study indicates that virtual care was an attractive option for caregivers due to the safety, reassurance, and convenience provided. The strong patient desire for continued availability post-pandemic will be important considerations in this rapidly developing area of care.
{"title":"Qualitative analysis of values and motivation reported by families utilizing a paediatric virtual care emergency clinic launched during the SARS-CoV-2 pandemic.","authors":"Victoria Sanderson, Branka Vujcic, Sherry Coulson, Rodrick Lim","doi":"10.1007/s43678-023-00505-2","DOIUrl":"https://doi.org/10.1007/s43678-023-00505-2","url":null,"abstract":"<p><strong>Purpose: </strong>This is the first study to take an in-depth qualitative approach to identify motivating factors for caregivers who chose the paediatric emergency virtual care option in Canada during the SARS-CoV-2 pandemic. The role that virtual care may play moving forward is also considered.</p><p><strong>Methods: </strong>Between May 2020 and May 2021, 773 respondents attending the virtual clinic completed a follow-up survey with open-ended questions. For qualitative content analysis, comments were coded and analysed until thematic saturation was reached. Sub-codes were subsumed into major coding categories to identify themes.</p><p><strong>Results: </strong>Three major themes, including safety, reassurance and convenience, and an overarching theme of satisfaction emerged from this analysis. Paediatric virtual clinic use was motivated in part by a desire to avoid the hospital environment. In-person Emergency Department visits were reported to be challenging and stressful, particularly due to perceived infection risk. Respondents appreciated that the clinic provided reassurance by assisting in navigating the healthcare system during a time of uncertainty and felt the virtual option allowed them to use healthcare resources responsibly. The convenience and ease of access to virtual care allowed for improved family-centred care in vulnerable populations. The overarching theme of satisfaction was emphasized by numerous comments for this service to be offered post-pandemic.</p><p><strong>Conclusion: </strong>Our study indicates that virtual care was an attractive option for caregivers due to the safety, reassurance, and convenience provided. The strong patient desire for continued availability post-pandemic will be important considerations in this rapidly developing area of care.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"529-533"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10122871/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9633520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Residency training is associated with risks of burnout and impaired well-being. This may be due to multiple factors, including navigating various transitions. Chief among these is the transition to independent practice which, in Canada, involves a certification exam administered by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This qualitative study explored the experience of residents in their examination year, including residents impacted by pandemic-related examination postponment, to understand how these experiences may impact residents' well-being.
Methods: Qualitative description methodology was used for this study. Participants were residents and physicians in independent practice from McMaster University and the University of Toronto. In depth, semi-structured, one-on-one interviews were conducted by one of the investigators. Each was transcribed, reviewed, and coded by two members of the investigating team.
Results: Five themes were identified. Examinations were perceived to be a significant stressor, and the extent of preparation involved was viewed as a threat to one's physical and mental well-being. Participants identified a culture of fear surrounding the exam, as well as a perception that exam preparation requires significant sacrifice which can exacerbate the impacts of the exam year. Personal and professional supports were identified as important protective factors.
Conclusion: This study has identified unique challenges in the examination year, and its impact on the well-being of residents immediately before they enter independent practice. Residents also experienced significant learning and a sense of accomplishment through their preparation for the examination. The COVID-19 pandemic had a unique impact on one cohort of residents. This should prompt medical education institutions to examine the support provided to residents, the culture surrounding certification examinations, and mitigation strategies for future examination disruptions.
{"title":"Fear, health impacts, and life delays: residents' certification exam year experience.","authors":"Michelle Onlock, Laila Nasser, Tara Riddell, Natasha Snelgrove, Kaif Pardhan","doi":"10.1007/s43678-023-00485-3","DOIUrl":"https://doi.org/10.1007/s43678-023-00485-3","url":null,"abstract":"<p><strong>Background: </strong>Residency training is associated with risks of burnout and impaired well-being. This may be due to multiple factors, including navigating various transitions. Chief among these is the transition to independent practice which, in Canada, involves a certification exam administered by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This qualitative study explored the experience of residents in their examination year, including residents impacted by pandemic-related examination postponment, to understand how these experiences may impact residents' well-being.</p><p><strong>Methods: </strong>Qualitative description methodology was used for this study. Participants were residents and physicians in independent practice from McMaster University and the University of Toronto. In depth, semi-structured, one-on-one interviews were conducted by one of the investigators. Each was transcribed, reviewed, and coded by two members of the investigating team.</p><p><strong>Results: </strong>Five themes were identified. Examinations were perceived to be a significant stressor, and the extent of preparation involved was viewed as a threat to one's physical and mental well-being. Participants identified a culture of fear surrounding the exam, as well as a perception that exam preparation requires significant sacrifice which can exacerbate the impacts of the exam year. Personal and professional supports were identified as important protective factors.</p><p><strong>Conclusion: </strong>This study has identified unique challenges in the examination year, and its impact on the well-being of residents immediately before they enter independent practice. Residents also experienced significant learning and a sense of accomplishment through their preparation for the examination. The COVID-19 pandemic had a unique impact on one cohort of residents. This should prompt medical education institutions to examine the support provided to residents, the culture surrounding certification examinations, and mitigation strategies for future examination disruptions.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"468-474"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10040228/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9626708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1007/s43678-023-00507-0
Naveen Poonai, Christopher Creene, Ariel Dobrowlanski, Rishika Geda, Lisa Hartling, Samina Ali, Maala Bhatt, Evelyne D Trottier, Vikram Sabhaney, Katie O'Hearn, Rini Jain, Martin H Osmond
Objectives: The objective of this study was to synthesize indication-based evidence for N2O for distress and pain in children.
Study design: We included trials of N2O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N2O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively.
Results: We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N2O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I2 = 0%) and 50% N2O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I2 = 43%) were superior to EMLA. 50% N2O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I2 = 15%). For distress and pain during laceration repair, N2O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N2O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N2O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N2O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N2O plus EMLA was "favorable" versus N2O and EMLA alone. Common adverse effects of N2O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N2O alone (278/1147 (24.2%)) versus N2O plus midazolam (48/52 (92.3%)) and N2O plus fentanyl (123/201 (61.2%)).
Conclusions: There is sufficient evidence to recommend N2O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.
{"title":"Inhaled nitrous oxide for painful procedures in children and youth: a systematic review and meta-analysis.","authors":"Naveen Poonai, Christopher Creene, Ariel Dobrowlanski, Rishika Geda, Lisa Hartling, Samina Ali, Maala Bhatt, Evelyne D Trottier, Vikram Sabhaney, Katie O'Hearn, Rini Jain, Martin H Osmond","doi":"10.1007/s43678-023-00507-0","DOIUrl":"https://doi.org/10.1007/s43678-023-00507-0","url":null,"abstract":"<p><strong>Objectives: </strong>The objective of this study was to synthesize indication-based evidence for N<sub>2</sub>O for distress and pain in children.</p><p><strong>Study design: </strong>We included trials of N<sub>2</sub>O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of \"neutral\" (p ≥ 0.05), \"favorable,\" or \"unfavorable\" (p < 0.05, supporting N<sub>2</sub>O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively.</p><p><strong>Results: </strong>We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N<sub>2</sub>O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I<sup>2</sup> = 0%) and 50% N<sub>2</sub>O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I<sup>2</sup> = 43%) were superior to EMLA. 50% N<sub>2</sub>O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I<sup>2</sup> = 15%). For distress and pain during laceration repair, N<sub>2</sub>O was \"favorable\" versus each of SC lidocaine, oxygen, and oral midazolam but \"neutral\" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N<sub>2</sub>O was \"neutral\" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N<sub>2</sub>O was \"favorable\" versus oxygen. For distress and pain during urethral catheterization (one trial), N<sub>2</sub>O was \"neutral\" versus oral midazolam. For pain during intramuscular injection (one trial), N<sub>2</sub>O plus EMLA was \"favorable\" versus N<sub>2</sub>O and EMLA alone. Common adverse effects of N<sub>2</sub>O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N<sub>2</sub>O alone (278/1147 (24.2%)) versus N<sub>2</sub>O plus midazolam (48/52 (92.3%)) and N<sub>2</sub>O plus fentanyl (123/201 (61.2%)).</p><p><strong>Conclusions: </strong>There is sufficient evidence to recommend N<sub>2</sub>O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"508-528"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9629609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1007/s43678-023-00516-z
John Taylor, Recep Gezer, Vesna Ivkov, Mete Erdogan, Samar Hejazi, Robert Green, John M Tallon, Benjamin Tuyp, Jaimini Thakore, Paul T Engels, Alun Ackery, Andrew Beckett, Kelly Vogt, Neil Parry, Christopher Heyd, Angela Coates, Jacinthe Lampron, Iain MacPhail
Purpose: Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients.
Methods: Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL.
Results: Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated.
Conclusions: After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.
目的:创伤小组组长(TTLs)传统上是普通外科医生;然而,一些创伤中心采用混合护理模式,由外科医生和非外科医生(主要是急诊医生)担任这一角色。这项多中心研究的目的是提供一项强有力的研究,以确定TTL专业是否与重大创伤患者的死亡率相关。方法:从加拿大六个一级创伤中心的省级创伤登记处收集了10年的数据。我们纳入了触发最高水平创伤激活的成人创伤患者(年龄≥18岁)。主要结局是接受外科医生初始治疗的创伤患者与接受非外科医生TTL治疗的创伤患者经风险调整后的住院死亡率的差异。结果:共纳入12961例重大创伤患者。57.8% (n = 7513)的病例由外科医生TTL进行初始治疗,而42.2% (n = 5448)的患者由非外科医生TTL进行治疗。外科医生TTL组11.6%的患者发生未调整死亡率,非外科医生TTL组12.7%的患者发生未调整死亡率(OR 0.87, 95% CI 0.78-0.98, p = 0.02)。经风险调整的死亡率在接受外科医生和非外科医生ttl护理的患者之间无显著差异(OR 0.92, 95% CI 0.80-1.06, p = 0.23)。此外,我们没有观察到任何评估亚组的风险调整死亡率的差异。结论:经风险调整后,外科和非外科ttl治疗的创伤患者死亡率无差异。我们的研究支持急诊医生在一级创伤中心扮演TTL的角色。
{"title":"Do patient outcomes differ when the trauma team leader is a surgeon or non-surgeon? A multicentre cohort study.","authors":"John Taylor, Recep Gezer, Vesna Ivkov, Mete Erdogan, Samar Hejazi, Robert Green, John M Tallon, Benjamin Tuyp, Jaimini Thakore, Paul T Engels, Alun Ackery, Andrew Beckett, Kelly Vogt, Neil Parry, Christopher Heyd, Angela Coates, Jacinthe Lampron, Iain MacPhail","doi":"10.1007/s43678-023-00516-z","DOIUrl":"https://doi.org/10.1007/s43678-023-00516-z","url":null,"abstract":"<p><strong>Purpose: </strong>Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients.</p><p><strong>Methods: </strong>Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL.</p><p><strong>Results: </strong>Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated.</p><p><strong>Conclusions: </strong>After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"489-497"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9627743","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-06-01DOI: 10.1007/s43678-023-00532-z
{"title":"Global Research Highlights.","authors":"","doi":"10.1007/s43678-023-00532-z","DOIUrl":"https://doi.org/10.1007/s43678-023-00532-z","url":null,"abstract":"","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"537-541"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10241134/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9625034","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting.
Methods: This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value.
Results: Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days.
Conclusions: This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.
引言:在过去的二十年中,在加拿大和美国,严重的孕产妇发病率和与妊娠有关的死亡一直在稳步上升。改进的早期产科预警系统(MEOWS)是一种风险分层工具,旨在预测严重的孕产妇发病率和死亡率,并已被证实可用于产科病房。本研究的目的是确定MEOWS是否能准确识别急诊科环境中有严重孕产妇发病和死亡风险的患者。方法:这是对2020年5月至2022年3月期间,在一个学术三级保健中心(每年ED普查65,000例)分娩6周内出现产后投诉的患者进行的图表回顾。暴露是一个触发器的存在,定义为在急诊科就诊期间一次严重异常(红色)或两次轻度异常(黄色)的生理测量。通过计算敏感性、特异性、阳性预测值和阴性预测值,评估该工具对存在严重孕产妇发病或死亡风险患者的诊断准确性。结果:共纳入267例患者,其中21例(7.9%)符合重度孕产妇发病标准。没有产妇死亡。总体而言,MEOWS工具的敏感性为85.7% (95% CI 63.7 ~ 97.0%),特异性为67.9% (95% CI 61.7 ~ 73.7%),阳性预测值为18.6% (95% CI 15.1 ~ 22.7%),阴性预测值为98.2% (95% CI 95.1 ~ 99.4%)。重度先兆子痫和子痫是最常见的严重产妇发病的结局类别,占16例(76.2%)。大多数患者(86.5%)直接从急诊科出院,90.0%在30天内未返回。结论:本研究首次探讨了MEOWS在产后ED患者中的应用。在急诊科分诊或第一次急诊科护理评估时出现MEOWS触发与严重的产妇发病率相关。因此,MEOWS可能是一种有价值的工具,可以在急诊室就诊早期识别有严重后果风险的产后患者。
{"title":"Application of the Modified Early Obstetrical Warning System (MEOWS) in postpartum patients in the emergency department.","authors":"Jeeventh Kaur, Cameron Thompson, Shelley McLeod, Catherine Varner","doi":"10.1007/s43678-023-00500-7","DOIUrl":"https://doi.org/10.1007/s43678-023-00500-7","url":null,"abstract":"<p><strong>Introduction: </strong>Over the last two decades, there has been a steady rise in severe maternal morbidity and pregnancy-related deaths in Canada and the USA. The Modified Early Obstetric Warning System (MEOWS) is a risk stratification tool designed to predict severe maternal morbidity and mortality and has been validated for use in obstetrical wards. The objective of this study was to determine if MEOWS could accurately identify patients at risk of severe maternal morbidity and mortality in the ED setting.</p><p><strong>Methods: </strong>This was a chart review of patients presenting to an academic tertiary care centre (annual ED census 65,000) with a postpartum complaint within 6 weeks of delivery between May 2020 and March 2022. The exposure was the presence of a trigger, defined as one severely abnormal (red) or two mildly abnormal (yellow) physiological measurements during the ED visit. The diagnostic accuracy of the tool to identify patients at risk of severe maternal morbidity severe maternal morbidity or mortality was estimated by calculating the sensitivity, specificity, positive predictive value and negative predictive value.</p><p><strong>Results: </strong>Two hundred and sixty-seven patients were included, of which 21 (7.9%) met the criteria for severe maternal morbidity. There were no maternal deaths. Overall, the sensitivity of the MEOWS tool was 85.7% (95% CI 63.7-97.0%), specificity was 67.9% (95% CI 61.7-73.7%), positive predictive value was 18.6% (95% CI 15.1-22.7%), and negative predictive value was 98.2% (95% CI 95.1-99.4%). Severe preeclampsia and eclampsia were the most common outcome category of severe maternal morbidity, representing 16 (76.2%) cases. Most patients (86.5%) were discharged directly from the ED, and 90.0% did not return within 30 days.</p><p><strong>Conclusions: </strong>This study is the first to explore the utility of MEOWS in postpartum ED patients. The presence of a MEOWS trigger at ED triage or the first ED nursing assessment was associated with severe maternal morbidity. Thus, MEOWS may be a valuable tool to identify postpartum patients at risk of severe outcomes early in an ED visit.</p>","PeriodicalId":55286,"journal":{"name":"Canadian Journal of Emergency Medicine","volume":"25 6","pages":"481-488"},"PeriodicalIF":2.4,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9621588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}