CJEM最新文献

Introduction: Esophageal button battery impactions represent a life-threatening medical emergency in children. There are established clinical benchmarks to help reduce the risk of injury. Our objective was to describe the care pathways of children presenting with esophageal button battery impactions in the four main pediatric centers in Ontario.

Methods: A multi-institutional health records review of button battery ingestion cases in children from 2012 to 2023 at four large-volume tertiary pediatric hospitals was conducted. Participants included children under 18 years who underwent esophagoscopy for battery removal.

Results: Eighty-six children with button battery impactions were identified. The median age was 2.6 years. Fifteen children presented directly to a tertiary institution, while 71 (82.6%) were transferred from a community hospital. The median total distance traveled was 44.6 km. The median time from button battery diagnosis to removal was 7.9 h. Honey or sucralfate was administered in < 5% of cases. The median hospital stay was 3.1 days. Complications included esophageal perforation (2.3%), esophageal stricture (8.5%), tracheoesophageal fistula (1.2%), and vascular injury (1.2%), with one death reported. No cases met the benchmark of button battery removal within 2 h of ingestion, with significant delays occurring at every management stage.

Conclusion: Despite efforts to increase awareness and rapid management of button battery ingestion, significant delays, poor adherence to mitigation strategies, and serious complications persist. These findings emphasize the need for prevention and the development of regional and institution-specific protocols to provide timely and streamlined care.

Purpose: Aortic dissection is a life-threatening emergency and delayed or missed diagnoses can result in significant morbidity and mortality for patients.

Methods: We conducted a quantitative and qualitative analysis of medico-legal cases from a national repository involving thoracic aortic dissection seen in the emergency department during a 10-year period. We thematically analyzed peer expert criticism of the care in these cases, including provider, team, and systems factors related to diagnostic issues. We also applied two clinical decision tools to explore whether use of these tools could have affected the diagnostic process.

Results: Of 3,531 medico-legal cases in the emergency department during our study period, just 43 were related to aortic dissection. Patients were primarily male (68.2%), presented for care at large urban centers (65.1%), and were triaged as urgent or emergent (72.1%). Thirty-six patients died of their aortic dissection. A thematic analysis identified atypical presentations, diagnostic anchoring, misinterpretation or misuse of tests, communication breakdowns, and resource limitations as common in these cases.

Conclusions: Missed diagnoses of aortic dissection in the ED often result from a combination of cognitive, communication, and system-level factors. Understanding these contributors can inform evidence-based, systems-level supports and strategies to enhance diagnostic accuracy and reduce patient harm.

The McGill Healthcare-Management Case Competition was developed to increase exposure and understanding of medical learners to operations management and quality improvement. The case competition was designed and implemented based on Kern's curriculum development framework focusing on experiential learning and case-based gamification. Informed by the Medical Council of Canada's objectives, it enabled participants to critically analyze real-world healthcare operations and associated challenges. Evaluation of the effectiveness of case competition using Kirkpatrick's model (level 1 and 2) demonstrated significant improvements in participants' perceived knowledge, comfort, and confidence addressing quality improvement issues and management of flow and overcrowding. The McGill Healthcare-Management Case Competition is an educational innovation that represents a curricular tool for integrating healthcare operations management and quality improvement education into medical training.

Purpose: Emergency department (ED) care often requires the collaboration of team members who are recruited in ad hoc ways to preserve the lives of rapidly deteriorating patients. These moments are described as "high stakes" for their time-sensitive, complex, stressful, and emotional nature. The purpose of this manuscript is to describe how exemplary ED leaders and team members perceive optimal clinical leadership in high stakes moments.

Methods: Semi-structured interviews were completed with 15 exemplary emergency department staff (Eight physicians, seven team members), as identified by their colleagues. The participants were asked to describe their perspectives on effective leadership in high stakes clinical moments and to explore strategies that leaders can perform to optimize team function. Data were analyzed via a qualitative descriptive approach with thematic analysis.

Results: Exemplary ED leaders and team members jointly identified seven strategies that may be used in high stakes clinical ED care: (1) identifying and organizing resuscitation resources in anticipation of high stress moments, (2) declaring a single resuscitation leader, (3) checking in with team to gather input and feedback, (4) delegating tasks in manageable ways that reflect team member preference and competency, (5) maintaining a quiet room while exuding calm and confident energy, (6) adapting leadership strategies to fit the needs of the team, and (7) anticipating future directions while maintaining broad perspectives.

Conclusion: Strategies identified in this manuscript provide detailed descriptions of how exemplary leaders can optimize team function during high stakes clinical ED patient care. The analysis also uncovers nuanced differences between leader expectations and team member preferences that should be considered in future high stakes clinical moments. The lessons learned may be relevant to informing the ongoing training of current and future ED personnel who wish to improve their clinical and resuscitative leadership.

Objectives: Managing constant interruptions is an intrinsic aspect of emergency medicine practice; however, effective physician responses to mitigate their impact remain unclear. Although interruptions are exceedingly common and closely linked to adverse patient outcomes, the approaches for managing such disruptions have yet to be established. In this study, we aimed to identify how emergency physicians and residents respond to interruptions and the factors influencing their responses.

Methods: We conducted a scoping review to identify how emergency physicians and residents manage interruptions in the emergency department, searching the following databases using controlled vocabulary: Medline, APA PsycInfo, SCOPUS, and PubMed. Data extraction was conducted using the Covidence platform through a standardized and structured process.

Results: The scoping review identified 18 relevant articles, the majority of which (12/18) employed observational methods, involving a total of 417 emergency physicians. These observations, amounting to 778.6 h, were conducted across 25 emergency departments in 4 countries. Physicians responded to interruptions through task switching, multitasking, deferral, acknowledgment, and rejection. Their responses were influenced by the nature of the interrupted activity, cognitive load management, use of telecommunications, physicians' perceptions, and the work environment.

Conclusion: Emergency departments are inherently fast-paced and prone to interruptions; therefore, it is important to better understand how emergency physicians and residents navigate these disruptions. This study explores how physicians respond to interruptions and provides insights to support clinicians in identifying and developing effective management strategies.