CJEM最新文献

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.

Objectives: Canada is a multicultural country. However, many frontline healthcare providers only speak English. Previous studies have shown that language barriers can impact care, but limited Canadian data exist. This study aims to determine the utilization of interpreter services and the impact of language barriers on Emergency Department (ED) patient care in a Canadian setting.

Methods: A health records review was conducted of ED patients' ≥ 18 years old with a documented preferred language, who presented to two Canadian tertiary care EDs between November 2019 and October 2020. The primary outcome was the impact of the language barrier on ED length of stay, investigations ordered, disposition, 30 day return ED visits, and use of interpreter services. Secondary outcomes included the type of interpreter services and their impact on the above ED care metrics. Statistical analysis was performed using a two-sided T-test, and chi-square tests with Bonferroni correction, and multivariable logistic regression.

Results: A total of 1266 patients were included, with 427, 434, and 405 patients identified as having a primary language of English, French, or Other, respectively. Language barriers were identified in 462 patients (36.5%) and only 52.2% utilized interpreter services. Comparing patients with and without language barriers, patients with language barriers had significantly longer ED length of stay (mean 406.9 vs. 342.4 min, p < 0.001), a higher proportion of investigations in the ED, hospitalizations, and return ED visits (blood work 68.8% vs. 52.5%, p < 0.001; imaging 53.9% vs. 47.4%, p = 0.026; hospitalized 19.7% vs. 12.3%, p < 0.001; return ED visits 23.6% vs. 15.6%, p < 0.001). Of those who received translation, 198 (82.2%) utilized a family member and only 12 (5%) used a professional translation service.

Conclusions: Our findings demonstrate underutilization of professional interpreter services despite available services in the ED. Furthermore, the results highlight that care inequities still exist and support the importance of continued advocacy for improved access to interpreter services and further investigations to mitigate the barriers in accessing these services.

Objectives: Emergency physicians have a core professional responsibility to provide expert consultative advice regarding emergency medical care, but it is unclear how their consultative role manifests in health systems and whether there is potential to expand those capacities. The purpose of this study is to identify, clarify, and map key concepts related to emergency physicians acting as consultants within health systems.

Methods: This scoping review searched MEDLINE, Embase, Cochrane, CINAHL, and grey literature. No date restrictions were used and only articles in English were included. Two authors conducted screening of titles and abstracts followed by full texts independently and in duplicate. Data were narratively synthesized.

Results: We screened 8744 articles and included 67 articles which included data from 15 countries and were published between 1974 and 2023. Emergency physicians were reported to assume three main consulting roles: (1) real-time support to other clinicians providing emergency care, (2) rapid critical medical response, and (3) response to direct referrals. The most common consultation modes were via telemedicine (56 studies), activation of hospital protocols (6 studies), and referrals to the emergency department (six studies). Few studies contextualized these roles in relation to health systems or access to emergency care.

Conclusions: Emergency physicians assume multiple consultative roles within health systems. We define "consultative emergency medicine" as a core competency of emergency physicians focused on the provision of advice to other care providers on individual patient care or health services for conditions that require rapid intervention to avert death or disability, or for which delays of minutes to hours render care less effective (i.e. emergency care). As emergency care develops globally, advancing "consultative emergency medicine" may be a tool to expand emergency care expertise to other providers requesting assistance with emergency care.