CJEM最新文献

Background: Patients presenting to the emergency department (ED) with hip fractures are typically treated with opioids, which are associated with adverse events such as delirium and respiratory depression. The fascia iliaca compartment block (hereafter fascia iliaca block) is a regional analgesia technique which avoids these negative outcomes. We sought to increase the rate of use of this technique to 50% of all patients with hip fractures who presented to our EDs within an 18-month period.

Methods: We held three Plan-Do-Study-Act cycles designed in accordance with surveys sent to our physician group. The first cycle consisted of the dissemination of educational materials and standardization of equipment carts. Next, we held educational sessions for staff and trainee physicians. The third cycle consisted of additional education, Audit and Feedback methodology and incentives. Our outcome measure was the rate of fascia iliaca blocks performed. We tracked the number of unique physicians performing the fascia iliaca block as well as physician-reported comfort with the procedure for our process measures. Our balancing measure was the rate of adverse events.

Results: We went from a baseline rate of 2.0% to 22.6% of patients receiving fascia iliaca blocks. The number of physicians doing this increased from 6 pre-project to 35. Only one adverse event occurred (arterial puncture), which did not cause any significant patient harm. Our statistical process control chart revealed special cause variation in the form of a shift.

Conclusion: Although we did not meet our goal, we were able to significantly improve the rate of fascia iliaca blocks performed at our center. This was largely achieved through educational interventions. Our approach can be adapted by other centers looking to pursue a similar project.

Purpose: Higher mortality has been reported in older patients with moderate traumatic brain Injuries (TBI) compared to younger patients. To identify the risk factors associated with in-hospital mortality, complications and extended length of stay in moderate TBI patients.

Methods: DESIGN: a multicentre observational cohort study using the Quebec Trauma Registry.

Population: Hospitalized patients aged ≥ 16 with a moderate TBI (a head injury with an Abbreviated Injury Scale (AIS) ≥ 3, and a GCS score of 9-12).

Outcomes: In-hospital mortality, complications and prolonged length of stay.

Analyses: Multivariable logistic regression.

Results: We included 1005 patients, 38.1% of whom were aged ≥ 65. The in-hospital mortality rate was 20.1%. Male sex (OR = 1.6 [95% CI:1.02-2.6], age (≥ 85 years old VS < 65 years) (OR = 18.7 [95% CI: 9.2-38.1]), ≥ 2 comorbidities (OR = 2.3 [95% CI: 1.3-4.0]), Injury Severity Score (OR = 1.04 [95% CI: 1.01-1.1]), presence of intraparenchymal hematoma (OR = 3.5 [95% CI: 2.2-5.5]) or other CT scan findings (cerebral edema, pneumocephalus, subpial hemorrhage, and pituitary injury) (OR = 1.9 [95% CI: 1.2-3.1]) were associated with increased odds of mortality. Male sex (OR = 1.8 [95% CI: 1.2-2.6]), age (65-74: OR = 1.7 [95% CI: 1.1-2.8] & 75-84: OR = 1.6 [95% CI: 1.03-2.6]), ≥ 2 comorbidities (OR = 2.9 [95% CI: 1.8-4.7]), thoraco-abdominal concomitant injury (OR = 2.0 [95% CI: 1.01-3.8]), and subarachnoid hemorrhage (OR = 7.6 [95% CI:1.5-38.5]) were associated with increased odds of complications. The number of comorbidities (≥ 2 OR = 1.7 [95% CI: 1.1-2.7]), spine injury (OR = 2.4 [95% CI: 1.4-4.1]), and delirium (OR = 3.1 [95% CI:1.8-5.2]) were associated with an increased odd of extended length of stay.

Conclusions: This study identified risk factors of in-hospital mortality, complications and extended length of stay, most of which are quickly available in the Emergency Department (ED). These factors could help clinicians identify moderate TBI patients at high risk of in-hospital mortality and guide shared decision-making regarding goals of care.

Background: Measuring physician workload in the pediatric emergency department (ED) could help optimize staffing, improve department efficiency, and provide a metric to assess interventions aimed at improving pediatric ED flow. However, no accepted measure of physician workload exists. Billing codes, which reflect the perceived complexity of treating a patient, may serve as a surrogate for physician workload. Our objective was to evaluate whether billing codes are a valid surrogate for pediatric ED physician workload.

Methods: We conducted a health records review to determine if billing codes were associated with measures of pediatric ED physician work. Visit information was extracted for 150 pediatric ED visits. We used multivariable ordinal logistic regression models to assess the association between pediatric ED physician-assigned billing codes, with measures of visit complexity, and measures of pediatric ED physician work. We also completed a sensitivity analysis considering a billing auditors-assigned billing codes.

Results: Three measures of pediatric ED physician work were independently associated with increased physician-assigned billing codes: receiving labs (OR 5.6, 95% CI 2.2-15.4), ordering medications (OR 2.3, 95% CI 1.1-5.1), and having specialist consultation (OR 4.4, 95% CI 1.6-12.5). We did not find any statistically significant associations between physician-assigned billing codes and measures of physician work after adjusting for visit complexity, age, and sex. Visit acuity (PaedsCTAS 1-3) was associated with increased billing codes (aOR 5.1 95% CI 1.9-15.7). These results were largely consistent with our sensitivity analysis considering billing auditor-assigned codes.

Conclusions: Overall, we found limited evidence supporting the content validity of billing code as a surrogate of pediatric ED physician workload. These results, coupled with the potential value of tracking physician workload, highlight the necessity to develop a valid and reliable measure specifically considering pediatric ED physician workload.

Introduction: We evaluated how emergency department (ED) staff perceives the practice known as redirection, whereby triage nurses guide low-acuity patients to alternative care settings without evaluation by a physician. Our aim was to evaluate its use across Canada and to identify its key drivers and barriers to its implementation.

Methods: We conducted a cross-sectional survey of Canadian ED physicians, nurses and managers from September to December 2023. The survey tool was developed in French and English following a modified Dillman's tailored design method, including: (1) literature review to identify key themes on redirection; (2) semi-structured interviews with experts on redirection; (3) the development of a tool prototype; (4) scientific and linguistic revisions; and (5) pre-testing. The survey was distributed through the mailing list of the Canadian emergency medicine and nursing associations.

Results: Of the 719 respondents recruited, 47.0% were nurses, 44.2% were physicians and 5% were managers. The overall response rate was 10.2%. Most respondents endorsed redirection as safe, with this endorsement ranging from 75.5% in Ontario to 94.3% in Manitoba. Similarly, the view that first-line physicians can adequately manage redirected patients was supported by most respondents, with proportions ranging from 78.1% in Ontario to 92.1% in Québec. Redirection strategies reported by the majority of respondents were based on the Canadian Triage and Acuity Scale (65.2%). Insufficient opening hours of clinics (87.2%) and those with a CTAS score of 3 (62.7%) were identified as the main challenges. Professionals most suggested to receive redirected patients were family physicians (90.9%), nurse practitioners (86.4%), dentists (83.8%), social workers (71.9%), pharmacists (63.9%), and physiotherapists (58.0%).

Conclusions: In this pan-Canadian survey of ED personnel, the majority of respondents expressed support for redirecting low-acuity patients. These findings indicate an opportunity for further research on the development of redirection tools.