CJEM最新文献

Objectives: Point-of-care ultrasound (POCUS) is a rapidly evolving and clinically significant skill set that has potential for improving patient care for the approximately 7 million Canadians living in rural and under-resourced environments. A national appraisal of rural POCUS training and utilization is needed to understand barriers to funding and training for rural emergency physicians in Canada. The primary objective of this study was to determine the current level of training and types of POCUS utilization by rural emergency physicians in Canada. The secondary objective was to describe the barriers to POCUS use.

Methods: An online survey of POCUS education, training, and utilization was distributed, in English and French, to rural emergency physicians across Canada via the Canadian Association of Emergency Physicians, Society of Rural Physicians of Canada and College of Family Physicians of Canada listservs.

Results: One hundred and sixty-eight physicians completed the survey with a response rate of 10%. Most were family physicians registered with the College of Family Physicians of Canada (68%) and worked in rural communities with under 10,000 residents (64%). The majority of respondents (94%) used a POCUS device in their practice, with 40% always using POCUS and 84% having access to a high-quality device. POCUS was commonly used for abdominal aortic aneurysm, cardiac, and obstetrical exams. Key barriers to training were cost (62%), distance to the training center (48%), inability to take time off work (43%) and insufficient hospital administration support (21%). Eighty percent of respondents agreed that POCUS was valuable in rural and remote areas with limited access to diagnostic imaging and 78% agreed that institutions should fund POCUS training.

Conclusion: POCUS is used daily for patient care in rural Canadian emergency departments. Despite widespread access to POCUS, rural emergency physicians face significant barriers in training and utilization.

Background: Management of the adult airway is one of the most stressful and time-critical procedures in emergency medicine. In the Cowichan District Hospital, a rural hospital in British Columbia, Emergency Department (ED) staff were uncomfortable with acquiring the equipment needed for adult advanced airway management and the mean length of time to acquire the equipment was 319 s. The aim of this quality improvement (QI) project was to decrease the time to obtain the equipment needed for adult advanced airway management by nurses and physicians in the Cowichan District Hospital ED to less than 90 s by May 2023.

Methods: The Institute for Healthcare Improvement model of improvement was used to reduce the amount of time required to obtain the equipment for adult difficult airway management in the ED, which was measured using a standardised tabletop simulation every 2 weeks. Change ideas included using a colour-coded airway cart and employing translational simulation. Qualitative interviews with emergency department staff after intubations of patients in the ED captured process measures by examining provider comfort.

Results: From December 2022 to May 2023, the mean time to obtain equipment for adult advanced airway management decreased from an initial value of 319 s to 76 s, a 76% improvement from the baseline. Qualitative interviews obtained pre-intervention, mid-intervention and post-intervention reflected themes of initial discomfort, shifting discomfort to comfort and finally to comfort.

Conclusion: The change ideas of using a colour-coded airway cart and translational simulation were associated with a reduction in time to obtain equipment for management of the adult advanced airway as well as improved provider comfort with the procedure in a rural ED.

Despite awake tracheal intubation being considered the safest method of intubation for patients with predicted difficult airways, there is limited evidence and poor availability of training interventions to assist emergency medicine physicians achieve competency in this technique. Here, we describe a novel, cadaver-based course for emergency medicine physicians to acquire skills in awake tracheal intubation. A convenience sample of 15 emergency medicine physicians from across Canada participated in the pilot course. Questionnaire data regarding the course's usefulness and participants' confidence in awake tracheal intubation were collected. All 15 participants completed the course, and questionnaire data showed that participants found the course useful and practice-changing. Three physicians reported successfully performing awake tracheal intubation in the emergency department during the 3-6-month follow-up period. Expansion of similar courses could help emergency medicine physicians acquire the skills necessary to safely perform awake tracheal intubation. Future studies should focus on optimizing training protocols, with a focus on practical methods to improve long-term skill retention.

Objectives: Fundoscopy is crucial in the emergency department to identify or rule out serious ocular and neurological conditions. Despite its clinical importance, fundoscopy is often omitted due to the technical challenges associated with traditional direct ophthalmoscopy, particularly for non-ophthalmologists. This study examines emergency physicians' practices, confidence levels, and training related to various modalities of fundoscopy including traditional direct ophthalmoscopes, binocular indirect ophthalmoscopes, panoptic ophthalmoscopes, slit lamp fundoscopy and fundus cameras; and explores the potential role of alternative modalities, such as fundus cameras, in Canadian emergency departments.

Methods: A cross-sectional survey was distributed to approximately 1000 emergency physician members of the Canadian Association of Emergency Physicians between March 4 and April 10, 2024. The survey, developed with ophthalmology and emergency medicine experts, included Likert scales and multiple-choice questions addressing confidence, practices, training, and experience with various fundoscopy modalities. Demographic data and responses were analyzed using descriptive statistics. Surveys were anonymous and available in English and French.

Results: Seventy-four emergency physicians participated (mean experience 17.8 years), representing all Canadian provinces and territories. Most reported experience with traditional direct ophthalmoscopes (97.3%), slit lamp fundoscopy (82.2%) and panoptic ophthalmoscopes (58.9%). Only 1.4% had used binocular indirect ophthalmoscopes. No participant had experience with fundus cameras. Confidence in identifying fundus findings was low across all modalities, with only 13.7% reporting confidence using traditional ophthalmoscopes. Fundoscopy was performed frequently or always by 57.5% of the respondents, yet only 6.8% routinely used pupil dilation. Only 35.6% of the respondents felt their training in fundoscopy was adequate.

Conclusion: Emergency physicians in Canada report low confidence in fundoscopy despite its critical role in identifying vision- or life-threatening conditions. Traditional modalities are widely used but remain challenging for non-ophthalmologists. Fundus cameras, which offer ease of use and higher diagnostic accuracy, are underutilized.

Objectives: POCUS is a core emergency medicine skill and mainstay of early pregnancy assessment. The ultrasound competency assessment tool was developed as an entrustment-based assessment tool for use by content experts evaluating trainees performing multiple POCUS study types. The objective of this study was to evaluate the scoring and extrapolation inferences of the tool within Kane's validity framework when used to assess trainees performing an early pregnancy POCUS.

Methods: This was a multicentered study of emergency medicine residents participating in a POCUS assessment. After a background questionnaire, participants were read a case stem requesting a POCUS evaluation of an early pregnancy patient. Trainees were independently assessed by two fellowship-trained faculty. Descriptive statistics and two-way random, intraclass correlation coefficients, Cronbach's alpha were calculated on the merged data and used to assess all domains. Domain scores and an entrustment score for each participant were used to create a composite score. A one-way analysis of variance was performed.

Results: 36 trainees and 5 assessors completed the study. When used to assess trainee POCUS performance in early pregnancy, the tool demonstrated good to excellent interrater reliability for image acquisition, image generation, clinical integration, and entrustment (intraclass correlation coefficients 80-91 p < .001). The preparation domain had poor, but statistically significant interrater reliability (intraclass correlation coefficient 0.46 p = .04). An analysis of variance suggested the POCUS performance scores differed based on prior experience [F(2,32) = 3.74, p = .021).

Conclusion: This study adds further validity evidence relating to scoring and extrapolation of the ultrasound competency assessment tool when used to assess trainees performing a POCUS study in early pregnancy.