CAEP 2015 Academic Symposium: Leadership within the emergency medicine academic community and beyond.

OBJECTIVES: A panel of emergency medicine (EM) leaders endeavoured to define the key elements of leadership and its models, as well as to formulate consensus recommendations to build and strengthen academic leadership in the Canadian EM community in the areas of mentorship, education, and resources. METHODS: The expert panel comprised EM leaders from across Canada and met regularly by teleconference over the course of 9 months. From the breadth of backgrounds and experience, as well as a literature review and the development of a leadership video series, broad themes for recommendations around the building and strengthening of EM leadership were presented at the CAEP 2015 Academic Symposium held in Edmonton, Alberta. Feedback from the attendees (about 80 emergency physicians interested in leadership) was sought. Subsequently, draft recommendations were developed by the panel through attendee feedback, further review of the leadership video series, and expert opinion. The recommendations were distributed to the CAEP Academic Section for further feedback and updated by consensus of the expert panel. RESULTS: The methods informed the panel who framed recommendations around four themes: 1) leadership preparation and training, 2) self-reflection/emotional intelligence, 3) academic leadership skills, and 4) gender balance in academic EM leadership. The recommendations aimed to support and nurture the next generation of academic EM leaders in Canada and included leadership mentors, availability of formal educational courses/programs in leadership, self-directed education of aspiring leaders, creation of a Canadian subgroup with the AACEM/SAEM Chair Development Program, and gender balance in leadership roles. CONCLUSIONS: These recommendations serve as a roadmap for all EM leaders (and aspiring leaders) to build on their success, inspire their colleagues, and foster the next generation of Canadian EM academic leaders.

Increased uptake of guideline-recommended oral antiplatelet therapy: insights from the Canadian acute coronary syndrome reflective.

Current guideline-based recommendations for oral dual-antiplatelet therapy in an acute coronary syndrome (ACS) include the use of newer adenosine diphosphate receptor inhibitor (ADPri) regimens and agents. The Canadian ACS Reflective Program is a multicenter observational quality-enhancement project that compared the use of ADPri therapy in 2 phases (November 2011-March 2013 and April 2013-November 2013) and also compared ADPri use with previous national data from the Canadian Global Registry of Acute Coronary Events (2000-2008). Of 3099 patients with ACS, 30.6% had ST-segment elevation myocardial infarction (STEMI), 52.3% had non-STEMI, and 17% had unstable angina. There was high use of dual-antiplatelet therapy for ≤ 24 hours, with important increases noted when compared with previous national experience (P for trend, < 0.0001). Clopidogrel was the most commonly used ADPri (82.2%), with lower use of the newer agents ticagrelor (9.0%) and prasugrel (3.1%). Ticagrelor and prasugrel use was most frequent in patients with STEMI undergoing percutaneous coronary intervention PCI (34.3%). There was relatively lower use of ADPri therapy at discharge; it was given mainly to patients who did not undergo PCI (68.2%) and to those with non-ST-elevation ACS (82%). When comparing the 2 consecutive phases of data collection in the ACS Reflective, there was an approximate 3- and 2-fold increase in the early and discharge use of the newer ADPri agents, respectively. In conclusion, there has been a temporal increase in ADPri use compared with previous national experience and an increased uptake of newer ADPri agents. Additional work is needed to identify and address barriers limiting optimal implementation of these newer guideline-recommended agents into routine Canadian practice.

Practice patterns of graduates of a CCFP(EM) residency program: a survey.

OBJECTIVE: To determine the practice settings of graduates of a residency program that leads to a Certificate of Special Competence in Emergency Medicine (CCFP[EM]). DESIGN: Web-based survey using standard Dillman methodology. SETTING: Canada. PARTICIPANTS: All graduates of the CCFP(EM) residency training program at the University of Toronto (U of T) in Ontario between 1982 and 2009. MAIN OUTCOME MEASURES: Practice type and location, job satisfaction, and nonclinical EM activities of graduates of a CCFP(EM) residency program. RESULTS: Of 146 graduates surveyed, 88 responded (response rate of 60.3%). All of the respondents indicated that they had practised EM at some point after completing the CCFP(EM) program at U of T. At survey completion, 76.7% were practising EM. Of the EM-practising cohort, 93.9% worked in urban or suburban hospitals as opposed to rural settings. Those practising EM expressed high levels of job satisfaction, with 83.3% reporting a score of 8 or higher on a 10-point satisfaction scale. Most (57.0%) of the graduates of the CCFP(EM) residency program at U of T had participated in leadership activities in EM on local, provincial, or national levels. CONCLUSION: Most graduates of the CCFP(EM) residency program continue to practise EM, and most of them practise in urban and suburban environments. The low attrition rate of CCFP(EM) graduates should be regarded as a success of the CCFP(EM) program, and the geographic distribution of all physicians, including EM providers, warrants further study to help plan future physician resources in Canada.

A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments.

BACKGROUND: The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments. METHODS: We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head. RESULTS: Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the "before" period (62.8%) to the "after" period (76.2%) (difference +13.3%, 95% CI 9.7%-17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%-10.8%). The change in mean imaging rates from the "before" period to the "after" period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes. INTERPRETATION: Our knowledge-translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252).

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.

OBJECTIVE: To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments. DESIGN: Matched pair cluster randomised trial. SETTING: University and community emergency departments in Canada. Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals. INTERVENTIONS: Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites. MAIN OUTCOME MEASURE: Diagnostic imaging rate of the cervical spine during two 12 month before and after periods. RESULTS: Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred. CONCLUSIONS: Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide. TRIAL REGISTRATION: Clinical trials NCT00290875.

Non ST segment elevation acute coronary syndromes: A simplified risk-orientated algorithm.

Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.