CJEM最新文献

Introduction: There are many limitations to utilizing on-duty emergency department (ED) physicians as Base Hospital Physicians for paramedic telephone consultations. We aimed to examine the impact of a specialized and centralized Online Medical Consultation program for paramedic consultations on system-relevant performance.

Methods: This is a before-after study with concurrent control using health record review of audio recordings over a 6-month period before and after implementation of the Online Medical Consultation program. The primary outcome was the duration of paramedic consultation calls. The secondary outcomes included number of calls with orders that contradicted existing medical directives, number of calls with orders outside of paramedic scope of practice, number of calls with Base Hospital Physician requiring clarification on medical directives, and number of calls with Base Hospital Physician interrupting the paramedic during the call.

Results: We included 220 consultation calls. The patients' mean age was 54.5 years. Most consultation calls (70.5%) were for mandatory consultations and 22.7% were voluntary. Most consultations were related to cardiac arrest (43.6%), combative patients (15.0%), and analgesia (13.6%). Before-after comparisons for total call duration showed that mean call duration decreased in Ottawa from 4:28 to 4:05 min (p = 0.77) and decreased in Kingston from 4:50 to 4:13 min (p = 0.49). There were no significant differences in our secondary outcomes.

Conclusions: The Online Medical Consultation program was implemented and removed the responsibility of responding to online medical consultations for on-duty emergency physicians in Ottawa. The total call duration was not significantly different between groups. Additional time intervals and adherence to protocol benefits were also not statistically significant due to low baseline incidence.

Introduction: Little is known about how patients are managed after a suspected cancer diagnosis through the emergency department. The objective of this study was to examine the ED management, specifically referral practices, for ten suspected cancer diagnoses by emergency physicians across Ontario and to explore variability in management by cancer-type and centre.

Methods: An electronic survey was distributed to emergency physicians across Ontario, asking about referral practices for patients who could be discharged from the ED with one of ten suspected cancer diagnoses. Options for referral included: in-ED consult, outpatient medical or surgical specialists, surgical or medical oncology, and specialized cancer clinics. Data were described using frequencies and proportions. Variance partition coefficients were calculated to determine variation in responses attributed to differences between hospitals, with physicians nested within hospitals.

Results: 262 physicians from 54 EDs responded. Across most cancers, emergency physicians would refer to surgical specialists for further work-up; however, this ranged from 30.2% for lung cancer to 69.5% for head and neck cancer. For patients with an unknown primary malignancy, most physicians would refer to internal medicine clinic (34.3%) or obtain an in-ED consult (25.0%). Few physicians would refer directly to surgical or medical oncology from the ED. Comments suggest this may be due to oncologists requiring tissue confirmation of malignancy. Most referrals to specialized clinics were for suspected lung (30.2%) or breast cancer (19.5%); however, these appear to only be available at some centres. Variance in referrals between hospitals was lowest for breast cancer (variance partition coefficient = 8.6%) and highest for unknown primary malignancies (variance partition coefficient = 29.8%).

Interpretation: Physician management of new suspected cancer varies between EDs and is specific to cancer type. Strategies to standardize access to cancer care in a timely and equitable way for patients with newly suspected cancer in the ED are needed.

Objective: Although point of care ultrasound (POCUS) use has become prevalent in medicine, clinicians may not be familiar with the evidence supporting its utility in patient care. The objective of this study is to identify the top five most influential papers published on the use of cardiac POCUS and lung POCUS in adult patients.

Methods: A 14-member expert panel from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative used a modified Delphi process. Panel members are ultrasound fellowship trained or equivalent, are engaged in POCUS scholarship, and are leaders in POCUS locally and nationally in Canada. The modified Delphi process consisted of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers on cardiac POCUS and lung POCUS.

Results: A total of 66 relevant papers on cardiac POCUS and 68 relevant papers on lung POCUS were nominated by the panel. There was 100% participation by the panel members in all three rounds of the modified Delphi process. At the end of this process, we identified the top five most influential papers on cardiac POCUS and lung POCUS. Papers include studies supporting the use of POCUS for accurately assessing left ventricular systolic function, diagnosing pericardial effusion, clarifying its test characteristics for pulmonary embolism, identifying pulmonary edema and pneumonia, as well as consensus statements on the use of cardiac and lung POCUS in clinical practice.

Conclusion: We have created a list of the top five influential papers on cardiac POCUS and lung POCUS as an evidence-based resource for trainees, clinicians, and researchers. This will help trainees and clinicians better understand how to use POCUS when scanning the heart and lungs, and it will also help researchers better understand where to direct their scholarly efforts with future research.