CJEM最新文献

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.

Objectives: To evaluate the impact of introducing a regional advanced care paramedic program on clinical outcomes for patients with out-of-hospital cardiac arrest transported to hospital by emergency medical services (EMS).

Methods: We conducted a health records review of adult out-of-hospital cardiac arrest patients transported by emergency medicine services (EMS) to a Canadian tertiary care hospital between 2010 and 2014 (pre-implementation) and 2016 and 2019 (post-implementation) of a regional advanced care paramedic program. The transition year (2015) was excluded due to a phased rollout. Eligible patients were 18 years of age or older who experienced an out-of-hospital cardiac arrest. Patients with traumatic or overdose-related arrests were excluded. Primary outcomes were sustained return of spontaneous circulation, survival to hospital admission, and survival to hospital discharge. Multivariable logistic regression adjusted for witnessed arrest, bystander CPR, initial rhythm, and epinephrine administration.

Results: A total of 390 patients met inclusion criteria, with 228 in the pre-implementation group and 162 in the post-implementation group. Survival to hospital admission increased from 14.9 to 24.7% (adjusted odds ratio [aOR] 2.1, 95% confidence interval [CI] 1.2-3.7) and survival to hospital discharge increased from 3.1 to 11.1% (aOR 5.0, 95% CI 2.0-12.3). Return of spontaneous circulation occurred more frequently with borderline statistical significance after adjustment (aOR 1.5, 95% CI 1.0-2.4). No other changes in prehospital protocols or hospital-based cardiac arrest care occurred during the study period.

Conclusions: The implementation of an advanced care paramedic program was associated with significantly improved survival among out-of-hospital cardiac arrest patients transported to hospital by EMS. EMS systems with developing airway management, vascular access, and resuscitation capabilities may achieve meaningful outcome gains through strategic integration of advanced care paramedic providers into cardiac arrest response frameworks.

Objective: Patients labeled as "community emergency" are older adults who present to the emergency department (ED) with no apparent acute medical cause for their visit but rather, social, functional, or safety concerns that prevent them from staying in their existing living situations. Acute illness can sometimes be disguised due to non-specific complaints, atypical presentations, or insufficient time to manifest. These patients often remain in the ED for days or weeks awaiting a more appropriate care arrangement. While previous research has identified the difficulties associated with diagnosis and treatment in this population, there is limited qualitative research examining the experience of physicians managing this patient population in ED settings. Our study aimed to address this gap.

Methods: We interviewed nine ED physicians practicing at different hospitals in Newfoundland and Labrador to examine the experience of managing patients labeled as "community emergency." Interviews were transcribed verbatim and analyzed based on principles of grounded theory, including constant comparison and an iterative coding process.

Results: We identified three main themes: First, while there are multiple labels for this patient population, the concept of "community emergency" is universally understood among ED physicians. Second, there are numerous barriers to supporting these patients in EDs, such as a lack of appropriate infrastructure and limited access to allied health professionals. Finally, there is inconsistency in how these patients are managed in rural and urban EDs, leading to disparities in care for this population.

Conclusion: Physicians felt that the ED was not an appropriate place to care for patients labeled as "community emergency" for extended periods of time while they await alternative care arrangements or diagnostic clarity. These findings suggest a need for improved policies that address the clinical and social needs of this population.