CJEM最新文献

Objectives: Social and structural factors strongly influence health outcomes but are inconsistently addressed in emergency care. This study used a mixed methods approach to assess the knowledge, attitudes, and practices of emergency department staff regarding social determinants of health, and to explore barriers and enablers to their integration into clinical care.

Methods: We conducted a mixed methods study in a single urban emergency department in Atlantic Canada. A 23-item electronic survey was distributed to 306 clinical staff between May and August 2023. Descriptive statistics with 95% confidence intervals were used to summarize responses. A subsequent qualitative component involved semi-structured interviews with a purposeful sample of staff. Interview transcripts were analyzed using inductive thematic analysis with iterative coding and theme development.

Results: Seventy staff members responded to the survey (23% response rate). Most respondents (93%) reported at least moderate understanding of the term "social determinants of health" and 86% correctly identified the Public Health Agency of Canada definition. However, only 23% reported routinely considering social determinants of health in clinical decision-making. Fewer than one in four respondents routinely inquired about social support or ability to afford medications. Most staff (93%) reported difficulty accessing information on community resources. Qualitative interviews revealed strong support for addressing social determinants of health in principle, but described time pressures, staffing shortages, and unclear referral pathways as key barriers.

Conclusions: Emergency department staff are aware of the impact of social determinants of health and support their integration into care, but consistent implementation is limited by practical and structural constraints. Enhancing access to resources, developing standardized screening tools, and clarifying system-supported referral pathways may help bridge the gap between awareness and action.

Introduction: Teaching hospitals are vital for training future physicians, yet there is concern that the presence of learners may increase unscheduled emergency department (ED) return visits. Previous studies of this phenomenon are limited to a sample of EDs in a region. Our study aimed to address this gap using a comprehensive regional dataset and multiple academic years of routinely collected electronic medical record data. Our objective was to determine whether ED patients seen by supervised learners had higher rates of unscheduled return visits within 72 hours compared to those seen by attending physicians alone. Secondary outcomes were return visits resulting in hospital admission and the impact of learner training level.

Methods: We conducted a cohort study of over 1 million ED discharges across nine linked hospitals in a large Canadian health region between July 1, 2015, and June 30, 2018. The primary outcome was the rate of unscheduled return visits within 72 hours. Secondary outcomes included return visits with hospital admission and critical care admission. Logistic regression models were adjusted for patient demographics, acuity, and site characteristics.

Results: Among 1,033,026 patient visits, 7.4% returned within 72 hours. There was no statistically significant difference in unscheduled return visits between supervised learners and attending physicians alone (adjusted RR 0.98, 95% CI 0.96-1.00, p = 0.054). Return visit admissions were slightly higher among patients seen by learners (adjusted RR 1.06, 95% CI 1.01-1.13), primarily those seen by medical students and off-service residents. Emergency medicine residents in mid-training had lower return visit rates than attendings.

Conclusions: Patients seen by supervised learners in a regional ED network did not have increased rates of unscheduled return visits. Further research is warranted to explore factors underlying return visit admissions in learner-involved care.

Objectives: Feedback is a cornerstone of competency-based medical education and critical for learner development in emergency medicine. Despite its importance, feedback conversations are often inconsistent, incomplete, or avoided-particularly when addressing areas for improvement. Anecdotal evidence suggests that clinical teachers may withhold constructive feedback due to fear of retaliation or negative consequences, yet this phenomenon remains underexplored in the literature.

Methods: We conducted a cross-sectional, multi-site, descriptive survey-based study of EM clinical teachers and trainees across three academic hospitals affiliated with McGill University. Using DeVellis' framework, we developed a survey tool exploring participant perceptions of daily feedback conversations, with emphasis on barriers, facilitators, and the influence of fear of retaliation. Surveys were distributed from April to June 2023 and analyzed using descriptive statistics and qualitative content analysis.

Results: Of 193 eligible participants, 87 (45%) completed the survey (39 clinical teachers, 48 residents). Both groups described daily feedback as a key learning tool, particularly for procedural skills, communication, and professionalism. Positive feedback was seen as motivating and growth-promoting. However, 25% of clinical teachers reported avoiding or softening difficult feedback due to concerns over resident defensiveness, being perceived as mistreating learners, or fear of negative evaluations. Structural barriers such as time constraints, lack of privacy, and the burdensome process of formal failure further limited constructive feedback delivery. Trainees, in contrast, rarely reported interpreting constructive feedback as punitive and instead expressed a desire for more honest, specific feedback. Time pressure, limited privacy, and unclear expectations were additional barriers described by both participant groups.

Conclusion: Daily feedback conversations in EM are shaped by complex interpersonal and contextual factors. While learners and teachers recognize feedback as essential, fear of retaliation and systemic inefficiencies contribute to hesitancy in delivering constructive feedback. Addressing these barriers through faculty development, learner training in feedback literacy, and clear differentiation between mistreatment and feedback may foster safer, more effective learning environments.

Background: Providing guideline-based care for patients with skin and soft tissue infections improves patient outcomes. The Canadian Emergency Department Best Practices Checklist for skin and soft tissue infections was recently developed for use by emergency physicians.

Objectives: To identify barriers and facilitators to using the skin and soft tissue infection checklist by emergency physicians.

Methods: An interview guide was developed based on the theoretical domains framework and piloted on two interview subjects. Following minimal refinements to the interview guide to decrease repetitiveness and improve clarity, from August to December 2024 we conducted semi-structured interviews with Canadian emergency physicians. The transcripts were anonymized and independently coded using direct content analysis, and specific beliefs were generated by grouping similar responses. A saliency analysis was conducted to identify relevant domains.

Results: Fifteen interviews were conducted involving emergency physicians across eight Canadian provinces. Six theoretical domains framework domains were identified as relevant: knowledge, beliefs about consequences, intentions, memory/attention/decision processes, environmental context/resources, and behavioral regulation. Competing demands (busy environment, many decision tools) were identified as potential barriers, whereas using technology (e.g., electronic health record integration) and the presence of learners were identified as facilitators to using the skin and soft tissue infection checklist.

Conclusion: This qualitative study using the theoretical domains framework identified barriers and facilitators to using the skin and soft tissue infection checklist by emergency physicians. Our findings form a basis for developing strategies to improve evidence-based care of skin and soft tissue infections in the emergency department.

Objectives: Despite an increase in interhospital transfers and the safety risks they represent for patients, little is known about the quality of clinical practices in this field. This study aimed to characterize interhospital transfers by ambulance from the Emergency Departments (ED) of a university hospital and clinicians' perceptions on barriers and facilitators to quality interhospital transfers.

Methods: This single-center, prospective descriptive study used a convergent mixed-methods design and was conducted in two phases between May and December 2023. The study was informed by the Donabedian Model for quality improvement and its structure, process and outcomes domains. Quantitative data were collected from the medical records of transferred ED patients and qualitative data from semi-structured interviews with multidisciplinary clinicians involved in interhospital transfers. Descriptive statistics (quantitative) and content analysis (qualitative) were conducted.

Results: Characteristics: a total of 72 interhospital transfers were evaluated, with 86.1% carried out for specialized treatment. A nurse accompanied 68.1% of the transfers and respiratory and intravenous equipment was used in about 40% of them. Mean total transfer time was 64.8 (± 20.4) minutes and medication adjustments were performed in 20% of transports supervised by nurses. Among the 57 transfers with complete data, 37 (64.9%) adverse events were observed; 49.1% clinical, 12.3% logistical and 3.5% technical. The 11 interviewed clinicians identified several barriers impacting the quality of interhospital transfers including: equipment issues, insufficient organizational resources, insufficiently prepared patients, and the overall complexity of the transfer process. To address these challenges, they proposed developing specialized expertise, enhancing standardization, establishing multidisciplinary transfer teams dedicated to transfers and integrating paramedics more effectively into the process.

Conclusions: This study characterized ED interhospital transfers and the key barriers and facilitators to quality care as perceived by clinicians. Logistical and organizational challenges were highlighted. These findings can inform future quality improvement initiatives targeting interhospital transfer practices.

Objectives: Efforts to implement evidence-based guidelines for sepsis care (Surviving Sepsis, CAEP guideline) have met with limited success and mortality from sepsis remains high. We sought to understand barriers and facilitators from the frontline perspective of emergency nurses, physicians, and paramedics.

Methods: In an explanatory sequential mixed methods approach, a 55-question survey was developed using the Theoretical Domains Framework (TDF) and scoping review (reported separately) and distributed via Canadian emergency, nurse, physician, and paramedic organizations in English and French. Purposeful recruiting of interviewees followed, using an interview guide informed by the scoping review and survey. Recordings were transcribed, and audit trails were maintained. A coding tree was developed and findings from the thematic analysis were mapped to TDF constructs, triangulating findings from all data sources.

Results: Data consisted of 545 surveys from paramedics (37%), nurses (20%), and physicians (27%), spanning all provinces and the territories in Canada, and 15 interviews (4 nurses, 6 physicians, 5 paramedics).Six themes emerged: access block, recognition by the public, resources (human, physical), leveraging scopes of practice (paramedics, nurses), recognition by healthcare, and the importance of communication. Many of these map to the TDF domain of Environment, Context, and Resources. There was support for guidelines (88% physician/93% paramedic/89% nurse), but interprofessional differences include awareness/understanding the guidelines (92% physician/72% paramedic/84% nurse) and trust in the evidence behind the guidelines (70% physician/85% paramedic/94% nurse). Reinforcement strategies at the point of care were more highly supported (74%/76%/81%) than education (physician 59%, paramedic 85%, nurse 78%).

Conclusion: The themes of this work confirm many of the issues known from previous publications, but also added key insights such as access block and recognition by the public. It also reinforces that raising awareness/more education is not a strong facilitator for physicians or nurses.The frontline perspective adds key insights that can improve sepsis care by overcoming key barriers and leveraging facilitators that have been highlighted as important in the complex healthcare implementation environment that is the ED.