CJEM最新文献

Objectives: Alberta's Virtual MD program was established to enhance nurse tele-triage and divert low-acuity patients from the emergency department (ED). This study describes the use of Virtual MD and its impact on healthcare utilization.

Methods: Demographic and clinical characteristics of Virtual MD patients were compared with Health Link 811 callers and the overall Alberta population between April 1, 2022, and March 31, 2023. Virtual MD recommendations included seeing a primary care provider, going to ED/urgent care, and self-management at home. Concordance with recommendations was determined using linked health administrative data.

Results: Virtual MD patients (n = 19,312) had a mean age of 34.8 years and were mostly female (62.3%). Compared to Health Link 811 callers, Virtual MD patients were slightly older (≥ 55 years) (20.8% vs. 25.0%). Of patients called within 4 h, 55.7% visited primary care within 14 days as advised, 60.0% visited ED within 2 days as advised and 52.5% of those advised to self-manage care at home did not use any healthcare within 14 days. Those advised to seek primary care had a higher odds [OR = 1.65 (95%CI: 1.24-2.21)] of family practice-sensitive conditions when they presented at ED compared to those advised to seek ED care. Hospitalization within 2 weeks was lower for patients advised to see primary care compared to those advised to see ED [4 h callback: OR = 0.33 (95%CI: 0.26 - 0.43), 24 h callback: OR = 0.15 (95%CI 0.08 - 0.28)].

Conclusion: Virtual MD effectively triaged patients, with over half following through on recommendations to see primary care, see ED, or self-manage care at home. Patients referred to primary care, but instead choosing to visit ED, were more likely to present with family practice-sensitive conditions, demonstrating appropriateness of the initial primary care advice. Overall, the Virtual MD service enables patients to access more appropriate levels of care for their healthcare needs.

Objectives: D-dimer testing can reduce imaging utilization in the workup of pulmonary embolism, but the optimal cutoff remains unclear. The conventional D-dimer cutoff is < 500 µg/L Fibrinogen Equivalent Units, while the age-adjusted cutoff in patients over 50 is age × 10. Newer probability-adjusted strategies-the YEARS criteria and PEGeD algorithm-allow a higher threshold (D-dimer < 1000 µg/L) for select low-risk patients. We aimed to retrospectively compare the diagnostic accuracy of four evidence-based pathways to exclude pulmonary embolism without imaging among our emergency department patients who were imaged.

Methods: A historical patient cohort was generated including all adults who received computed tomography pulmonary angiography or ventilation-perfusion scans after D-dimer testing in three emergency departments in a large urban Canadian center. Electronic medical records were reviewed to retrospectively compare the test performance of four D-dimer pathways: (i) conventional, (ii) age-adjusted, (iii) YEARS, and (iv) PEGeD.

Results: Of 1092 patients, 129 had pulmonary embolism. Conventional and age-adjusted cutoffs were both 100% sensitive (95% CI, 97.1-100.0), with specificities of 3.5% (2.5-4.9) and 6.4% (5.1-8.2). YEARS was 93.8% sensitive (88.2-96.8) and 30.4% specific (27.6-33.4), with PPV of 15.3% (13.0-18.0) and NPV of 97.3% (94.8-98.6). PEGeD was the least sensitive (92.2%, 86.3-95.7), but most specific (39.1%, 36.1-42.3), with PPV of 16.9% (14.3-19.8) and NPV of 97.4% (95.3-98.6). PEGeD would have resulted in the most patients managed without imaging (35.4%), followed by YEARS (27.6%), age-adjusted (5.7%), and the conventional cutoff (3.1%).

Conclusion: While implementation of a probability-adjusted D-dimer pathway, such as YEARS or PEGeD, would have substantially reduced imaging utilization, these strategies may miss some cases of pulmonary embolism detectable by both age-adjusted and conventional cutoffs. We add to the heterogeneity of safety data, suggesting that adjustment of D-dimer to clinical probability represents a trade-off between sensitivity and imaging utilization.

Background and aim: Predicting the need for urgent urological care in Emergency Department (ED) patients with suspected renal colic remains challenging, with no validated strategy available at initial presentation. We aimed to develop a prediction model and a clinical score combining point-of-care ultrasound (POCUS) and clinical findings to identify patients at low risk of requiring urgent urological care.

Methods: We conducted a multicenter prospective study between December 2022 and June 2023 in three French EDs. Adult patients with suspected uncomplicated acute renal colic underwent POCUS examination to assess hydronephrosis severity and identify potential complications. The primary outcome was urgent urological care within 30 days, defined as inhospital admission, urological procedure within 24 h after ED admission, or new ED admission within 30 days leading to urgent urological procedure within 24 h.

Results: Among 168 patients (mean 46.1 years old, 49% female), 25 (15%) required urgent urological care within 30 days, including 8 (5%) urgent decompressions after initial ED admission and 6 (4%) following new ED admission within 30 days. Three independent predictors were identified: age over 65 years (adjusted OR, 3.7; 95% CI, 1.4-9.9), moderate to severe hydronephrosis (adjusted OR, 4.8; 95% CI, 2.1-11.8) and persistent pain 4 h after analgesic administration (adjusted OR, 12.5; 95% CI, 4.6-35). The derived ECOLIC score (range, 0-6) showed that a score ≤ 1 was associated with a 98% negative predictive value for urgent urological care.

Conclusion: The ECOLIC score combines POCUS findings (absence of moderate/severe hydronephrosis), clinical features (age < 65 years), and treatment response (pain relief 4 h after analgesia) to identify patients at low risk of requiring urgent urological care at 30 days. This tool may help emergency physicians safely discharge low-risk patients without immediate CT imaging or urgent urological referral but require external validation before clinical implementation.

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.