CJEM最新文献

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.

Purpose: This study aimed to examine how different learner arrangements affect the number of patients seen per hour by staff emergency physicians in ambulatory and non-ambulatory zones of two tertiary teaching hospitals in Ottawa, Canada.

Methods: This was a retrospective cohort study analyzing all emergency department (ED) shifts at the Civic and General Campus EDs of The Ottawa Hospital from April 2022 to March 2023. Data collected included shift type (ambulatory or non-ambulatory), learner arrangement, and number of patients seen per hour. Descriptive statistics and two-sample, two-tailed t tests to analyze the relationship between patients seen per hour and learner arrangements.

Results: We analyzed 8161 shifts over the study period, including 5233 in ambulatory care and 2928 in non-ambulatory care areas. Among ambulatory care shifts, the average number of patients seen per hour was 2.1 (95% CI 2.1-2.1) when working alone, 1.9 (1.9-2.0, p < 0.001) with a medical student, 2.1 (2.1-2.2, p = 0.20) with a junior resident, 2.6 (2.5-2.6, p < 0.001) with a senior resident, 2.1 (2.1-2.2, p = 0.33) with a junior resident and a medical student, and 2.6 (2.5-2.7, p < 0.001) with a senior resident and a medical student. In non-ambulatory care shifts, the average number of patients seen per hour was 1.4 (95% CI 1.3-1.5) when working alone (122 shifts, 4%), 1.4 (1.4-1.5, p = 0.63) with a medical student (85 shifts, 3%), 1.5 (1.5-1.5, p = 0.02) with a junior resident (1,013 shifts, 35%), 1.8 (1.7-1.8, p < 0.001) with a senior resident (682 shifts, 23%), 1.6 (1.5-1.6, p < 0.001) with a junior resident and a medical student (683 shifts, 23%), and 1.8 (1.7-1.8, p < 0.001) with a senior resident and a medical student (343 shifts, 12%).

Conclusion: This study highlights the significant impact that learner arrangements have on staff physician productivity in the ED. These findings underscore the importance of strategic scheduling to optimize patient throughput.

Purpose: This cohort study aimed to investigate resident physician productivity in an academic emergency department (ED) and assess the impact of longitudinal coaching relationships known as clinical coaching teams and co-learners (medical students) on resident productivity.

Methods: Data from patient visits to two academic EDs in Ottawa, Canada between April 2022 and March 2023 were analyzed. The attending physician schedule, learner arrangements, and patient ED treatment team information were collected. The presence or absence of clinical coaching teams was also recorded. Mean productivity, measured as patients per hour, was calculated for different shifts and learner arrangements. Linear regression and paired t tests were performed for analysis across ambulatory and non-ambulatory settings, with a focus on productivity differences across residents' training programs and level of training.

Results: A total of 142,386 ED visits were included in the analysis across 8161 attending physician shifts. Resident productivity increased with each year of training, with Royal College of Physicians and Surgeons of Canada emergency medicine residents being the most productive by year 5. There was no significant difference in productivity between residents on clinical coaching team shifts compared to non-clinical coaching team shifts. Productivity decreased slightly when residents worked with medical students as co-learners. There was no significant relationship between the difference in productivity on shifts with and without a medical student and year of training.

Conclusions: This study is the first of its kind to describe resident physician productivity in a Canadian emergency department. The results of this study demonstrate that resident physician productivity improves with seniority, and that co-learners and clinical coaching teams do not significantly impact productivity. This information will be useful to program directors and residents to help set realistic expectations around productivity and to ED physician leads in planning service delivery for patients in the context of a training program.

Purpose: A new limp or refusal to weight-bear are common symptoms in children presenting to the pediatric emergency department (ED). This poses a diagnostic challenge, particularly among toddlers and nonverbal patients. Point-of-care ultrasound (PoCUS) used by pediatric emergency medicine physicians may detect hip effusion, which dramatically aids diagnostic workup and management. There is limited literature regarding the accuracy of hip PoCUS conducted by pediatric emergency medicine physicians. This study aims to assess the diagnostic performance of pediatric emergency medicine physician-performed PoCUS in identifying hip effusion.

Methods: This prospective study was conducted in a single-center pediatric ED. Children presenting with limb pain or new limp were evaluated by pediatric emergency medicine physicians who also performed hip PoCUS and categorized findings as either "effusion" or "no effusion" based on standard sonographic definitions. Patients also underwent radiology department ultrasound reviewed by a pediatric radiologist. Diagnostic test characteristics with corresponding 95% confidence intervals (CI) were calculated using radiology department ultrasound findings as the reference standard.

Results: A total of 95 patients were enrolled by 8 pediatric emergency medicine physicians. Excellent agreement was observed between PoCUS performed by pediatric emergency medicine physicians and radiology department ultrasound for the presence or absence of hip effusion (kappa = 0.81 [95% CI 0.70-0.93]). Hip effusion was identified by PoCUS in 44 out of 49 effusion-positive patients, with a sensitivity of 89.8% (95% CI 77.7-96.6%), specificity of 91.3% (95% CI 79.2%-97.5%), positive likelihood ratio of 10.33 (95% CI 4.03-26.47), and negative likelihood ratio of 0.11 (95% CI 0.05-0.26).

Conclusion: PoCUS performed by pediatric emergency medicine physicians has reasonably high sensitivity and specificity for diagnosing hip effusion among pediatric patients presenting to the pediatric ED with a limp or leg pain. This practice may potentially expedite both diagnosis and treatment within this patient population.

Objective: Our meta-analysis aimed to evaluate the safety of procedural sedation and analgesia in pediatric emergency department (ED) settings by investigating the incidence of cardiac, respiratory, gastrointestinal, and neurological adverse events associated with different sedation medications.

Methods: In accordance with PRISMA guidelines, a comprehensive database search for randomized controlled trials was performed across ten databases from January 2005 to June 2024. Our inclusion criteria included randomized controlled trials involving children under 18 years old undergoing pediatric sedation and analgesia in the ED. Data on medication types, dosages, administration routes, and adverse events were extracted and analyzed. Primary endpoints included cardiac, respiratory, gastrointestinal, and neurological adverse events.

Results: Seventeen studies met the inclusion criteria, a total of 2,302 procedural sedations. The most common adverse events were vomiting, agitation, and hypoxia, which occurred in 104.9 [95% CI = 76.9-132.9], 37.5 [95% CI = 20.6-54.4], 38.3 [95% CI = 23.9-52.6] of each 1000 sedations, respectively. Other adverse events included apnea, hypotension, and the need for bag-valve mask ventilation, which occurred in 8.6 [95% CI: 3.5-13.6], 9.3 [95% CI: -1.4 to 20.1], and 13.5 [95% CI: 3.2-23.8] of each 1,000 sedations, respectively. Severe adverse events were rare, with no reported instances of intubation and only one case of laryngospasm. Subgroup analyses revealed varying incidence rates of adverse events across different sedation protocols, with ketamine and its combinations showing higher rates of specific respiratory complications.

Conclusions: Procedural sedation in pediatric EDs is generally safe, with a low incidence of adverse events, such as vomiting, agitation, and hypoxia. Life-threatening respiratory adverse events are extremely rare. Our findings thus support the careful selection and monitoring of sedation protocols to minimize risks.