CJEM最新文献

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.

Purpose: The landscape of the medico-legal risk in emergency medicine in Canada is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases in the emergency department (ED).

Methods: We conducted a descriptive analysis of closed medico-legal cases (hospital complaints, regulatory authority (i.e., College) complaints, and civil-legal actions) involving physicians practicing primarily emergency medicine in Canadian EDs. We used data from closed cases involving the Canadian Medical Protective Association from January 2018 until December 2022. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

Results: From 2018 until 2022, 37,046 cases were closed and 1,892 involved physicians practicing emergency medicine for which there was medico-legal information available for analysis. In all, 54% (1,019) were College complaints, 27% (516) were legal civil actions, and 19% (357) were hospital complaints. Out of these, 1,165 (62%) were subject to peer-expert criticism. More than half of the complaints (52%) resulted in an unfavorable medico-legal outcome for the physician. Analysis of the 1,165 cases with peer-expert criticism identified the most common factors contributing to medico-legal risk included clinical decision-making (64%), situational awareness (44%), and issues with provider's documentation (42%).

Conclusions: The most common diagnoses associated with medico-legal risk were injuries, infections, and disorders of the circulatory system. The three most common contributing factors were related to clinical decision-making, situational awareness, and issues with documentation.

Objectives: Emergency departments (EDs) have seen growing rates of pediatric mental health presentations, a trend exacerbated by the COVID-19 pandemic. Many of these patients will 'board', remaining in the ED for prolonged periods of time while awaiting transfer to an inpatient bed. Boarding disproportionately impacts mental health patients and is associated with worse patient health outcomes and healthcare system inefficiency. The objective of this scoping review is to synthesize the extent and nature of evidence relating to pediatric mental health boarding, and to identify knowledge gaps.

Methods: Searches were conducted in MEDLINE, Embase, PsycINFO, and CINAHL for peer-reviewed literature involving mental health patients boarding in hospital EDs. Studies underwent eligibility screening for pediatric populations and data extraction by two reviewers. Results are reported per PRISMA-ScR guidelines.

Results: Three thousand four hundred and fifty-eight studies were screened for title and abstract eligibility, 386 of which were assessed at full-text. Twenty-eight studies met inclusion criteria. Of these, 19 assessed variables impacting boarding, 18 quantified boarding duration or prevalence, 6 measured the impacts of boarding, 5 assessed interventions to mitigate boarding, and 4 provided consensus recommendations. Eighty-two percent of studies were published within the last 5 years and all are from the United States. Reported mean ED boarding times ranged from 5 to 54 h across 5 studies. Of 7 studies assessing the impact of COVID-19 on pediatric mental health boarding, all reported that COVID-19 was associated with increased boarding prevalence and/or duration.

Conclusions: An emerging body of literature on the burden and impacts of ED boarding among pediatric mental health patients suggests that boarding is a pressing concern in the delivery of pediatric emergency healthcare that has worsened since COVID-19. This is the most comprehensive evidence synthesis on pediatric mental health boarding to date, highlighting the impacts of boarding and the solutions studied to address this problem.

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.