CJEM最新文献

Background: Gender disparities in medicine are well documented, including in emergency medicine. These disparities are influenced by a variety of factors such as payment models, patient expectations, and time spent on different aspects of care, including documentation. While gender-based differences in patient care have been associated with better outcomes for patients treated by women physicians, the underlying reasons remain unclear. This study aims to quantify and compare time spent on patient care tasks, stratified by physician gender, in an academic emergency department (ED).

Methods: We conducted a prospective observational time-motion study from July to August 2022 in the ambulatory care area of a large tertiary academic ED. Research assistants shadowed physicians during daytime and evening shifts, timing eight predefined clinical tasks for each patient encounter while also collecting data on patient characteristics and provider demographics (gender, years of practice, training stream). Statistical analyses included Wilcoxon rank sum tests and linear regression to examine task durations and gender differences. Our sample size was determined by feasibility.

Results: Thirty-seven physicians (32.4% women, 67.6% men) were observed across 65 shifts involving 1204 patient encounters. Women physicians spent significantly more time per patient than men (mean 20.9 vs. 18.1 min, + 15.5%, p = 0.015), particularly on initial assessments (7.1 vs. 6.4 min, + 10.9%, p = 0.024) and charting (6.7 vs. 5.2 min, + 28.8%, p = 0.001). No significant gender differences were found in other tasks. The additional time spent by women was not fully explained by measured tasks, suggesting other unmeasured contributors such as interruptions or workflow inefficiencies.

Conclusion: Women emergency physicians spend more time per patient on assessments and documentation than men physicians. These findings raise important considerations for gender equity in clinical performance metrics and documentation burden.

Purpose: The landscape of the medico-legal risk in emergency medicine in Canada is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases in the emergency department (ED).

Methods: We conducted a descriptive analysis of closed medico-legal cases (hospital complaints, regulatory authority (i.e., College) complaints, and civil-legal actions) involving physicians practicing primarily emergency medicine in Canadian EDs. We used data from closed cases involving the Canadian Medical Protective Association from January 2018 until December 2022. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

Results: From 2018 until 2022, 37,046 cases were closed and 1,892 involved physicians practicing emergency medicine for which there was medico-legal information available for analysis. In all, 54% (1,019) were College complaints, 27% (516) were legal civil actions, and 19% (357) were hospital complaints. Out of these, 1,165 (62%) were subject to peer-expert criticism. More than half of the complaints (52%) resulted in an unfavorable medico-legal outcome for the physician. Analysis of the 1,165 cases with peer-expert criticism identified the most common factors contributing to medico-legal risk included clinical decision-making (64%), situational awareness (44%), and issues with provider's documentation (42%).

Conclusions: The most common diagnoses associated with medico-legal risk were injuries, infections, and disorders of the circulatory system. The three most common contributing factors were related to clinical decision-making, situational awareness, and issues with documentation.

Objectives: Emergency departments (EDs) have seen growing rates of pediatric mental health presentations, a trend exacerbated by the COVID-19 pandemic. Many of these patients will 'board', remaining in the ED for prolonged periods of time while awaiting transfer to an inpatient bed. Boarding disproportionately impacts mental health patients and is associated with worse patient health outcomes and healthcare system inefficiency. The objective of this scoping review is to synthesize the extent and nature of evidence relating to pediatric mental health boarding, and to identify knowledge gaps.

Methods: Searches were conducted in MEDLINE, Embase, PsycINFO, and CINAHL for peer-reviewed literature involving mental health patients boarding in hospital EDs. Studies underwent eligibility screening for pediatric populations and data extraction by two reviewers. Results are reported per PRISMA-ScR guidelines.

Results: Three thousand four hundred and fifty-eight studies were screened for title and abstract eligibility, 386 of which were assessed at full-text. Twenty-eight studies met inclusion criteria. Of these, 19 assessed variables impacting boarding, 18 quantified boarding duration or prevalence, 6 measured the impacts of boarding, 5 assessed interventions to mitigate boarding, and 4 provided consensus recommendations. Eighty-two percent of studies were published within the last 5 years and all are from the United States. Reported mean ED boarding times ranged from 5 to 54 h across 5 studies. Of 7 studies assessing the impact of COVID-19 on pediatric mental health boarding, all reported that COVID-19 was associated with increased boarding prevalence and/or duration.

Conclusions: An emerging body of literature on the burden and impacts of ED boarding among pediatric mental health patients suggests that boarding is a pressing concern in the delivery of pediatric emergency healthcare that has worsened since COVID-19. This is the most comprehensive evidence synthesis on pediatric mental health boarding to date, highlighting the impacts of boarding and the solutions studied to address this problem.

Objectives: Our primary objective was to determine whether the yield of pulmonary embolism imaging in the emergency department (ED) is different for patients presenting with "chest pain with cardiac features" than with other complaints. The yield of imaging was defined as the proportion of imaging tests that were positive for pulmonary embolism. Secondary objectives were to estimate the prevalence of pulmonary embolism, the use of imaging, and the yield of imaging for each presenting complaint category. Our hypothesis was that the presenting complaint influences the physician's threshold for requesting imaging.

Methods: We performed an observational health records review study including all adult patient visits between 2018 and 2019 in three EDs in Hamilton (Ontario), Canada. The primary outcome was the diagnostic yield of imaging (computed tomography pulmonary angiogram or ventilation/perfusion scan). We performed a multivariable regression analysis using a generalized linear model, adjusting for confounders.

Results: During the study period, 518,787 patients were assessed and 6,700 received imaging for pulmonary embolism. Among the 29,834 triaged as having chest pain with cardiac features, 1,440 (4.8%) received imaging. Among the 488,953 patients with any other presenting complaint, 5,260 (1.1%) received imaging. The diagnostic yield of imaging was 4.2% for patients with chest pain with cardiac features, 8.6% for those with other presenting complaints, with an adjusted odds ratio of 0.62 (95% confidence interval: 0.45-0.87). The prevalence of pulmonary embolism at 30 days was 0.20% in patients with chest pain with cardiac features and 0.10% for all other presenting complaints.

Conclusions: The lower yield despite a higher prevalence means that the threshold for ordering imaging in people presenting to the ED with chest pain with cardiac features was lower than in other patients. Clinicians should keep in mind this possible bias when assessing their patients.

Purpose: The COVID-19 pandemic and Canada's drug poisoning crisis placed exceptional demands on emergency departments (ED). We aimed to explore the impact of these intersecting crises from the perspectives of ED staff to understand how EDs can improve care and protect the health and well-being of patients who use opioids, ED staff, and healthcare providers.

Methods: We conducted a focused ethnographic study involving 29 semi-structured interviews with ED staff who cared for patients who use opioids during the pandemic. Interviews explored ED staff perspectives on how the pandemic impacted care for patients who use opioids and how EDs can better serve this population. We conducted latent content analysis and main theme generation was informed by the socioecological model.

Results: Four main themes emerged. First, there was a change in patient behaviors, which impacted provider-patient relationships. Second, hospital pandemic policies and resource limitations created new barriers to care. Third, community service alterations, including the shift to virtual care and uncertain availability of services, further complicated patient care. Finally, participants highlighted opportunities to strengthen systems of care, including enhanced hospital addiction resources, improved addiction care training, expanded harm reduction services, and more robust community services.

Conclusions: The COVID-19 pandemic highlighted significant changes in ED care delivery for patients who use opioids. Efforts to enhance EDs should include anticipating the needs of people who use substances and the healthcare providers who care for them to mitigate unintended harm and ensure a more resilient healthcare system.

Objectives: Timely diagnosis of neurological emergencies in the emergency department (ED) remains a critical skill for physicians. Errors in diagnosing neurological conditions can lead to severe patient harm, including permanent disability or death. Conversely, over-investigation may contribute to unnecessary imaging, increased healthcare costs, and reduced departmental efficiency. Understanding the nature and frequency of these diagnostic errors is essential to improving clinical practice and patient safety. The primary objective of this study was to describe the nature of diagnostic errors for neurologic emergencies in the ED.

Methods: This study conducted a five-year descriptive analysis of closed medicolegal cases from the Canadian Medical Protective Association (CMPA) database involving missed or delayed neurological diagnoses in Canadian EDs between January 2019 and December 2023. Cases were reviewed for patient demographics, primary neurological condition, provider type, patient-reported concerns, and expert reviewer commentary. Allegations and identified deficiencies were coded thematically and analyzed for common patterns and clinical pitfalls.

Results: A total of 143 cases met inclusion criteria. The most frequently missed diagnoses were cerebral infarcts (34%), traumatic intracranial injuries (22%), and central nervous system infections (15%). Cauda equina syndrome accounted for 8% of cases. Patient concerns frequently mirrored expert peer review findings, which identified deficient assessment, failure to consider key differential diagnoses, and inadequate diagnostic testing as the top contributing factors. Many cases involved atypical or non-specific presentations that may have led providers to prematurely rule out serious pathology.

Conclusion: Diagnostic errors in neurological emergencies remain an important contributor to patient harm and medico-legal risk in Canadian EDs. A better understanding of the factors that contribute to these diagnostic errors can support physicians in improving their clinical reasoning and documentation. These insights may ultimately empower Canadian emergency physicians to refine their diagnostic approach and enhance patient outcomes in both emergency and non-emergency settings.