CJEM最新文献

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.

Purpose: This study aimed to understand current prehospital trauma air-ambulance policies and triage guidelines across Canada. The research question centered on understanding the guidelines used by provinces and territories and identifying potential regional variations in air-ambulance triage.

Methods: We conducted a cross-sectional survey from November 2022 to May 2023, involving trauma leaders from Canada's 13 provinces and territories. Participants were identified via the Trauma Association of Canada and professional networks. The survey, developed with expert input and pilot tested for clarity, focused on prehospital trauma-triage guidelines, level of adoption of Center for Disease Control and Prevention (CDC) triage guidelines, and auto-launch air-ambulance policies. Data were collected using an 18-item electronic survey. Potential response bias was considered, and confidentiality was maintained. A cross-sectional qualitative analysis was used to evaluate the guidelines' adoption and variations, with responses compared across regions.

Results: The analysis revealed a nationwide adoption (11 of 11 respondents) of the CDC guidelines, indicating a standardized approach to patient transportation. Notably, many provinces and territories (5 of 11) endorse auto-launch protocols for air ambulances in specific scenarios. These policies offer advantages in geographically vast regions weighed against the cost of over-triage and inefficient resource allocation. Each province and territory tailors its approach based on factors such as geographic areas served, and available resources.

Conclusion: This study provides a snapshot of the current state of prehospital trauma-triage guidelines in Canada. With some differences in nomenclature, Canadian provinces and territories widely apply the CDC guidelines to serve their populations. There is some regional variation on how transport is initiated within their borders. The findings underscore the delicate balance required for optimizing air-ambulance policies, considering factors such as timely access, resource allocation, and the local application of guidelines.

Objectives: The objective of this study was to better understand caregiver perspectives on educational materials relating to paediatric community-acquired pneumonia and antibiotic stewardship in the emergency department setting.

Methods: This was a phenomenologically informed qualitative study. Caregivers of young children in Hamilton, Ontario were presented with four educational materials (animated video, physician led lecture-style video, caregiver led testimony-style video, and a printed brochure) providing information relating to treatment strategies for community-acquired pneumonia. Caregivers were then asked open-ended questions about how they felt about the effectiveness of the media used. The principles of conventional content analysis guided the coding and synthesis of the transcribed interviews.

Results: Eleven caregivers were interviewed. Most caregivers preferred the animated video and brochure to the lecture-style physician video and caregiver testimonial video. Common themes for effective educational materials included visually attention-grabbing graphics, accessible language, and formats they could reference following their visit (e.g. brochure).

Conclusions: The busy nature of the emergency department setting can impede effective communication between clinicians and parents. Employing educational materials may allow for more informed parent-provider communication on care decision making. Caregivers in our study prioritized the simplest information formats for education around community-acquired pneumonia and antimicrobial stewardship which could be referenced following discharge. This was best accomplished by short, animated videos and brochures. Results from this study can inform development of future educational materials used in paediatric emergency department settings to optimize caregiver education and corresponding care plan adherence.