3M™ Defib-Pads as a Reusable Alternative to Commercial Ultrasound Gel in Resource-Limited Settings.

INTRODUCTION: With point-of-care ultrasound (POCUS) use in austere environments comes the challenge of having an ever-available coupling medium for image generation. Commercial gel has numerous drawbacks that can limit its utility in these settings, and no studies have evaluated the potential for a reusable coupling medium. This study aimed to determine whether 3M™ Defib-Pads could be utilized as a reusable alternative to commercial gel for image generation in resource-limited settings. METHODS: A descriptive, cross-sectional survey of Canadian physicians with POCUS interest was conducted to evaluate the interpretability of various POCUS images in a blinded fashion. Three anatomic regions (cardiac, abdominal, and nerve) were utilized, and image generation from the commercial gel and 7 Defib-Pad conditions were evaluated. These included pads that were 1) newly opened, 2) dirtied then rinsed, 3) air dried, 4) rinsed after being air dried, 5) frozen then thawed, 6) used in double thickness, and 7) used with a probe cover. RESULTS: Compared to commercial gel, 3M™ Defib-Pads performed similarly, with adequate image interpretability of up to 100% in some conditions. The exception was pads that had prolonged air exposure, which produced images that were never interpretable. However, subsequent rinsing of these pads with water resulted in restored image generation. CONCLUSION: 3M™ Defib-Pads were found to produce interpretable POCUS images under multiple environmental stressors and with different modalities of use, suggesting that 3M™ Defib-Pads can perform as a reusable gel alternative in resource-limited settings.

Physician wellbeing and burnout in emergency medicine in Switzerland.

Emergency physicians are the most at-risk medical specialist group for burnout. Given its consequences for patient care and physician health and its resulting increased attrition rates, ensuring the wellbeing of emergency physicians is vital for preserving the integrity of the safety net for the healthcare system that is emergency medicine. In an effort to understand the current state of practicing physicians, this study reviews the results of the first national e-survey on physician wellbeing and burnout in emergency medicine in Switzerland. Addressed to all emergency physicians between March and April 2023, it received 611 complete responses. More than half of respondents met at least one criterion for burnout according to the Maslach Burnout Inventory - Human Services Survey (59.2%) and the Copenhagen Burnout Inventory (54.1%). In addition, more than half reported symptoms suggestive of mild to severe depression, with close to 20% screening positively for moderate to severe depression, nearly 4 times the incidence in the general population, according to the Patient Health Questionnaire-9. We found that 10.8% of respondents reported having considered suicide at some point in their career, with nearly half having considered this in the previous 12 months. The resulting high attrition rates (40.6% of respondents had considered leaving emergency medicine because of their working conditions) call into question the sustainability of the system. Coinciding with trends observed in other international studies on burnout in emergency medicine, this study reinforces the fact that certain factors associated with wellbeing are intrinsic to emergency medicine working conditions.

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study.

OBJECTIVES: This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia. METHODS: Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. RESULTS: There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. CONCLUSIONS: This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

ABSTRAIT: OBJECTIFS: Les objectifs de cette étude étaient de décrire les résultats des patients diabétiques présentant leur première visite aux urgences pour hyperglycémie, et d'identifier les prédicteurs des visites récurrentes aux urgences pour hyperglycémie. MéTHODES: À l'aide de bases de données couplées, nous avons mené une étude de cohorte basée sur la population de patients adultes et pédiatriques atteints de diabète de type 1 et 2 présentant une première visite aux urgences pour l'hyperglycémie d'avril 2010 à mars 2020 en Ontario, au Canada. Nous avons déterminé la proportion de patients présentant une visite récurrente à l'urgence pour hyperglycémie dans les 30 jours suivant la visite d'index. À l'aide d'une analyse de régression multivariée, nous avons examiné les prédicteurs cliniques et socioéconomiques des visites récurrentes. RéSULTATS: Il y avait 779 632 patients avec une première visite à l'urgence pour hyperglycémie. L'âge moyen (ET) était de 64,3 (15,2) ans; 47,7% étaient des femmes. 11,0 % avaient une visite récurrente pour hyperglycémie dans les 30 jours. Les prédicteurs statistiquement significatifs d'une visite récurrente comprenaient le sexe masculin, le diabète de type 1, les régions comptant moins de groupes de minorités visibles et ayant moins d'études ou d'emploi, une hémoglobine A1C plus élevée, plus de visites chez un médecin de famille ou un interniste au cours de la dernière année, être inscrit auprès d'un médecin de famille, consulter le service d'urgence au cours de la dernière année, être hospitalisé au cours des 14 derniers jours, avoir accès à des services de soins à domicile et avoir été confronté à une hyperglycémie au cours des 5 dernières années. L'alcoolisme et la dépression ou l'anxiété étaient des prédicteurs positifs pour le groupe des 18-65 ans. CONCLUSIONS: Cette étude au niveau de la population identifie des prédicteurs de visites récurrentes aux urgences pour l'hyperglycémie, y compris le sexe masculin, le diabète de type 1, les régions avec moins de groupes de minorités visibles et avec moins d'études ou d'emploi, plus d'hémoglobine A1C, l'utilisation antérieure plus élevée du système de soins de santé (visites aux urgences et hospitalisation) pour l'hyperglycémie, le fait d'être inscrit auprès d'un médecin de famille et l'accès aux services de soins à domicile. La connaissance de ces prédicteurs peut être utilisée pour élaborer des interventions ciblées afin d'améliorer les résultats pour les patients et de réduire les coûts du système de santé.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a pilot randomised controlled trial.

BACKGROUND: Current diabetic ketoacidosis (DKA) treatment guidelines recommend using normal saline (NS); however, NS may delay DKA resolution by causing more hyperchloremic metabolic acidosis compared with balanced crystalloids. This study's objective was to determine the feasibility of a future multicentred randomised controlled trial (RCT) comparing intravenous Ringer's lactate (RL) with NS in managing ED patients with DKA. METHODS: We conducted a parallel-arm, triple-blind, pilot RCT of adults (≥18 years) with DKA at a Canadian academic tertiary care ED. The primary feasibility outcome was recruitment rate (target ≥41.3% of eligible participants over the 1-year study period); the primary efficacy outcome was time elapsed from ED presentation to DKA resolution. The superiority margin for a clinically significant difference was chosen to be a 40% time reduction to DKA resolution. We also assessed the need to break allocation concealment and loss to follow-up. Patients with clinical suspicion for DKA were screened for inclusion and enrolled patients were randomised 1:1 to receive RL or NS. Patients, clinicians and outcome assessors were blinded to allocation. RESULTS: We enrolled 52 (25 RL, 27 NS) of 60 eligible patients (86.7%), exceeding our target recruitment rate. There were more patients in the NS group with type 1 diabetes, and more patients in the RL group had an admission co-diagnosis in addition to DKA. For the 44 participants with confirmed laboratory evidence of resolution, median (IQR) time to DKA resolution for RL versus NS was 15.7 (10.4-18.8) and 12.7 (7.9-19.2) hours, respectively. There were no cases where blinding was broken, and there was no loss to follow-up. CONCLUSIONS: This pilot trial demonstrated our protocol's feasibility by exceeding our target recruitment rate. Our results may be used to inform future multicentre trials to compare the safety and efficacy of RL and NS in managing DKA in the ED. TRIAL REGISTRATION NUMBER: NCT04926740.

Virtual Coaching and the Reduction of Radial Head Subluxation: A Case Series.

OBJECTIVES: After the establishment of the virtual pediatric emergency medicine clinic at our institution, we noted that several physicians independently began to instruct caregivers virtually on reducing a radial head subluxation. We thus conducted a case series to investigate the number, success, and follow-ups for the virtual reduction of radial head subluxation. METHODS: The electronic medical records at our institution were searched from the inception of the virtual clinic in May 2020 until August 2022 (inclusive), for visits and discharge diagnosis containing the word "elbow" or "arm." RESULTS: Fourteen charts were retrieved; however, 2 were excluded because they were not a suspected radial head subluxation. A virtual reduction was attempted for eight (66.7%) of the 12 patients. In 6 of 8 patients (75.0%), the reduction was deemed successful, and for 2 patients (25.0%), it was deemed unsuccessful. Of the latter, one was found to have a nondisplaced radial neck fracture. All 4 patients (33.3%) for whom a virtual reduction was not attempted were referred to the emergency department. CONCLUSIONS: Virtual video coaching of pulled elbow reduction was completed at our institution with overall good success rate. All the physicians involved noted the essential need and benefits of video conferencing for successfully reducing radial head subluxation. We note that a pediatric population may be more amenable to video-based appointments than other populations due to their caregivers' familiarity with digital technology. Finally, as nonphysician models of healthcare delivery for virtual urgent care visits expand, we propose a checklist based on our experience to ensure patient safety.

Balanced crystalloids (RInger's lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED): a protocol for a pilot randomized controlled trial.

BACKGROUND: Current guidelines for diabetic ketoacidosis (DKA) recommend treatment with normal saline (NS). However, NS, with its high chloride concentrations, may worsen acidosis and contribute to a hyperchloremic metabolic acidosis. Alternatives to NS are balanced crystalloids (e.g. Ringer's Lactate [RL]) which have chloride concentrations similar to human plasma; therefore, treatment with balanced crystalloids may lead to faster DKA resolution. A recent systematic review and meta-analysis by Catahay et al. (2022) demonstrated the need for more blinded, high-quality trials comparing NS versus RL in the treatment of DKA. METHODS: We describe a protocol for BRISK-ED (Balanced crystalloids [RInger's lactate] versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department). Our study is a single-centre, triple-blind, pilot randomized controlled trial (RCT) of adults (≥ 18 years) with DKA presenting to an academic tertiary care ED in London, Canada. Patients with clinical suspicion for DKA will be screened and those found to not meet DKA criteria or have euglycemic DKA will be excluded. We will aim to recruit 52 patients with DKA and will randomize them 1:1 to receive intravenous RL or NS. The primary feasibility outcome will be recruitment rate, and the primary efficacy outcome will be time elapsed from ED presentation to DKA resolution. Secondary outcomes include time to insulin infusion discontinuation, intensive care unit admission, in-hospital death, and major adverse kidney events within 30 days, defined as a composite of: i) death, ii) new renal replacement therapy, or iii) final serum creatinine ≥ 200% baseline at the earliest of hospital discharge or 30 days after ED presentation. Patients, clinicians, and outcome assessors will be blinded to allocation group. We will follow an intention-to-treat analysis. Gehan-Wilcoxon, Mann-Whitney U, or chi-square tests will be used to compare groups as appropriate. DISCUSSION: The results of this pilot study will inform the design and feasibility of a full-scale, multicentre RCT to assess fluid choice in adult ED patients with DKA. If proven to demonstrate faster resolution of DKA, administration of balanced crystalloids may replace NS in diabetes treatment guidelines and improve patient and health systems outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, Registration # NCT04926740; Registered June 15, 2021.

Provision of immobilization or ice by paramedics in Southwestern Ontario.

OBJECTIVES: Pain is the most common reason for prehospital transport. As emergency wait times increase, timely pain management is essential. In children, there is abundant evidence that prehospital pharmacologic analgesia is suboptimal, but little is known about non-pharmacologic therapies. We sought to characterize documentation by paramedics of non-pharmacologic (immobilization and ice) and pharmacologic analgesia in children with musculoskeletal injuries. METHODS: We reviewed all ambulance call reports for children 0-17 years transported to Southwestern Ontario regional hospitals from January 1, 2017, to December 31, 2019, with a musculoskeletal injury (Ontario Ministry of Health and Long-Term Care problem codes 66 and 67). Primary and secondary outcomes were documented immobilization or ice and pharmacologic analgesia, respectively. In a multivariable analysis, we explored the relationship between immobilization or ice and the following a priori covariates: age, sex, visible deformity, crew type, pain severity, and analgesia. RESULTS: Of 40,692 ambulance call reports reviewed, 4445 met inclusion criteria. There were 2584/4441 (58.2%) males, with a median (IQR) age of 14 (10, 16) years. In ambulance call reports with documented pain scores, 2106/3048 (69.1%) ambulance call reports reported "moderate or severe" pain. Immobilization or ice were documented in 1605/4445 (36.1%) and 385/4445 (8.7%) of ambulance call reports. Pharmacologic analgesia was documented in 275/1983 (13.9%) and 125/991 (12.6%) of ambulance call reports for primary care paramedics and advanced care paramedics, respectively. An increased odds of documented immobilization or ice was associated with moderate or severe pain [OR: 2.4; 95% CI 1.84-3.17; p < 0.01] and visible deformity [OR: 2.5; 95% CI 1.97-3.12; p < 0.01]. CONCLUSIONS: Documented immobilization and ice and pharmacologic analgesia to children by paramedics is suboptimal. Our findings underscore an important need for enhanced education surrounding the benefits of non-pharmacologic options for children with musculoskeletal injuries.

RéSUMé: OBJECTIFS: La douleur est le motif le plus fréquent de transport préhospitalier. À mesure que les temps d'attente aux urgences augmentent, la gestion de la douleur en temps opportun est essentielle. Chez les enfants, il existe de nombreuses preuves que l'analgésie pharmacologique préhospitalière est sous-optimale, mais on sait peu de choses sur les thérapies non pharmacologiques. Nous avons cherché à caractériser la documentation par les ambulanciers paramédicaux de l'analgésie non pharmacologique (immobilisation et glace) et pharmacologique chez les enfants souffrant de lésions musculo-squelettiques. MéTHODES: Nous avons examiné tous les rapports d'appels d'ambulance pour les enfants de 0 à 17 ans transportés vers les hôpitaux régionaux du Sud-Ouest de l'Ontario du 1er janvier 2017 au 31 décembre 2019, avec une blessure musculo-squelettique (codes de problèmes 66 et 67 du ministère de la Santé et des Soins de longue durée de l'Ontario). Les résultats primaires et secondaires étaient l'immobilisation documentée ou la glace et l'analgésie pharmacologique, respectivement. Dans une analyse multivariable, nous avons exploré la relation entre l'immobilisation ou la glace et les covariables a priori suivantes: âge, sexe, déformation visible, type d'équipage, intensité de la douleur et analgésie. RéSULTATS: Sur les 40 692 rapports d'appels d'ambulance examinés, 4 445 répondaient aux critères d'inclusion. Il y avait 2584/4441 (58,2 %) hommes, avec un âge médian (IQR) de 14 (10,16) ans. Dans les rapports d'appel d'ambulance avec des scores de douleur documentés, 2106/3048 (69,1 %) rapports d'appel d'ambulance ont signalé une douleur "modérée ou sévère". L'immobilisation ou la glace ont été documentées dans 1605/4445 (36,1 %) et 385/4445 (8,7 %) des rapports d'appel d'ambulance. L'analgésie pharmacologique a été documentée dans 275/1983 (13,9 %) et 125/991 (12,6 %) des rapports d'appel d'ambulance pour les ambulanciers de soins primaires et les ambulanciers de soins avancés, respectivement. Une probabilité accrue d'immobilisation documentée ou de glace était associée à une douleur modérée ou intense [OR: 2,4; IC à 95 %: 1,84-3,17; p < 0,01] et déformation visible [OR: 2,5; IC à 95 %: 1,97-3,12; p < 0,01]. CONCLUSIONS: L'immobilisation documentée et l'administration de glace et d'analgésie pharmacologique aux enfants par les ambulanciers est sous-optimale. Nos résultats soulignent le besoin important de renforcer l'éducation concernant les avantages des options non pharmacologiques pour les enfants souffrant de blessures musculo-squelettiques.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge.

BACKGROUND: While studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an emergency department (ED) presentation for hyperglycaemia. This study's objectives were to describe patient perspectives on their experience during and after an ED visit for hyperglycaemia and to identify factors that influence postdischarge adherence. METHODS: We conducted a qualitative description (QD) study of adult patients who had visited a Canadian ED for hyperglycaemia. Consistent with QD, purposive sampling was utilised, seeking diversity across age, gender and diabetes type. Participants took part in semistructured interviews and thematic analysis was used to identify and describe core themes. Frequent team meetings were held to review the analysis and to develop the final list of themes used to recode the data set. Analytic insights were tracked using reflective memos and an audit trail documented all steps and decisions. RESULTS: 22 patients with type 1 and 2 diabetes were interviewed from June to October 2019. Participants identified several factors that impacted their ability to adhere to discharge plans: communication of instructions, psychosocial factors (financial considerations, shame and guilt, stigma and mental health), access to follow-up care and paediatric to adult care transitions. CONCLUSIONS: This study describes the patient experience with the communication of discharge instructions, as well as factors affecting adherence post-ED discharge for hyperglycaemia. Our findings suggest four strategies that could improve the patient experience, improve adherence to discharge plans and potentially decrease the frequency of recurrent ED visits for hyperglycaemia.

Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial.

OBJECTIVES: Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners' rates of omission of tasks during simulated airway management scenarios. METHODS: Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey. RESULTS: The average percentage of omitted tasks over three scenarios was 45.7% in the control group (n = 25) and 13.5% in the checklist group (n = 29)-an absolute difference of 32.2% (95% CI 27.8, 36.6%). Time to definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI -18.0 to 98.0 respectively). CONCLUSIONS: In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management.

RéSUMé: OBJECTIFS: Des listes de contrôle ont été utilisées pour réduire les événements indésirables associés aux procédures médicales. La simulation offre un cadre sûr pour évaluer une nouvelle liste de contrôle. L'objectif de cette étude était de déterminer si l'utilisation d'une nouvelle liste de contrôle de péri-intubation permettrait de réduire les taux d'omission de tâches des praticiens lors de scénarios de gestion des voies aériennes simulés. MéTHODES: Cinquante-quatre praticiens de médecine d'urgence de deux centres universitaires ont été randomisés selon leur approche habituelle ou l'utilisation de notre liste de contrôle, puis ont réalisé trois scénarios de gestion des voies aériennes simulés. Un minimum de deux évaluateurs ont documenté le nombre de tâches omises et le délai avant la gestion définitive des voies respiratoires. Les divergences entre les évaluateurs ont été résolues par la revue vidéo d'un seul évaluateur. Les participants ont également rempli une enquête post-simulation. RéSULTATS: Le pourcentage moyen de tâches omises sur trois scénarios était de 45,7 % dans le groupe témoin (n = 25) et de 13,5 % dans le groupe liste de contrôle (n = 29) - une différence absolue de 32,2 % (IC à 95 %: 27,8 %, 36,6 %). Le délai de prise en charge définitive des voies respiratoires était plus long dans le groupe liste de contrôle dans les deux premiers des trois scénarios (différence de 110,0 s, IC à 95% : 55,0 à 167,0 ; 83,0 s, IC à 95 % : 35,0 à 128,0 ; et 36,0 s, IC à 95 % : -18,0 à 98,0 respectivement). CONCLUSIONS: Dans cet essai contrôlé randomisé à double centre, l'utilisation d'une liste de contrôle des voies respiratoires dans un environnement simulé a considérablement réduit le nombre de tâches importantes des voies respiratoires omises par les praticiens de médecine d'urgence, mais a prolongé le délai de prise en charge définitive des voies aérienne.

Seeking Care for Hyperglycemia in the Emergency Department: Through the Eyes of the Patient.

Health care systems often provide a range of options of care for patients with illnesses who do not require hospital admission. For individuals with diabetes, these options may include primary care providers, specialized diabetes clinics, and urgent care and walk-in clinics. We explored the reasons why patients choose the Emergency Department over other health care settings when seeking care for hyperglycemia.

Door-To-Triage Time in a Canadian Tertiary-Care Center.

BACKGROUND: The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional. OBJECTIVE: We sought to quantify door-to-triage time (DTT), an important factor in patient safety that has not yet been quantified in Canada. METHODS: Data were collected from all ambulatory patients presenting to a tertiary-care ED during a consecutive 7-day period. Demographic information, arrival time (door time), triage time, and Canadian Triage and Acuity Score (CTAS) were collected. DTT was compared across variables using Kruskal-Wallis one-way analysis of variance. RESULTS: Seven hundred and seventy-five patients were included in the study, representing 82.9% of ambulatory patients. DTT was variable (1-86 min) with a median of 12 min (interquartile range [IQR] 6-21 min). Patients in the 5th percentile with the longest DTT waited a median of 54 min (IQR 48-63 min). DTT varied across days of the week (p < 0.01); the longest wait was on Monday (median 22 [IQR 11-43] min) and the shortest on Sunday (median 8 [IQR 5-12] min). There was no relationship between DTT and CTAS (p = 0.12). CONCLUSIONS: DTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.

Do Adult Patients With Type 1 or 2 Diabetes Who Present to the Emergency Department With Hyperglycemia Have Improved Outcomes if They Have Access to Specialized Diabetes Care?

OBJECTIVES: Few studies have examined the effect of specialized care on patients with diabetes who present to the emergency department (ED) visits for acute hyperglycemia. The objective of this study was to characterize ED patients presenting with hyperglycemia and compare the 30-day outcomes of those followed by specialized diabetes clinics with those not followed. We hypothesized that patients followed by specialized clinics would have improved clinical outcomes compared with those who had no specialized follow up. METHODS: We conducted this single-centre retrospective cohort study of adults (≥18 years) with an ED visit for hyperglycemia over 1 year (January to December 2014). Data from ED visits were linked to specialized diabetes clinic records, which contained diabetes-specific clinical data not available in ED visit records. Descriptive statistics were summarized and comparisons between groups were performed, when appropriate. RESULTS: There were 456 patients (55.0% men; mean age, 47.7 years; 46.3% with type 1 diabetes) with 250 followed by the specialized diabetes clinics. The 206 patients who were not followed by the diabetes clinics (45%) were more likely to have a recurrent hyperglycemia ED visit (32.5% vs 9.6%, p<0.001) and to require hospitalization for hyperglycemia (14.1% vs 5.2%, p=0.001) within 30 days of initial presentation. CONCLUSIONS: Patients followed by specialized diabetes clinics had fewer recurrent ED visits and hospital admissions for hyperglycemia at 30 days compared with those not followed, suggesting that greater continuity of care between endocrinology and emergency medicine may help reduce these adverse outcomes for patients with diabetes.

Health research methodology education in Canadian emergency medicine residency programs: A national environmental scan.

OBJECTIVES: Our objective was to describe the variability of research methodology teaching among English-speaking Royal College of Physicians and Surgeons of Canada emergency medicine (RCPSC-EM) residency programs. We also aimed to identify barriers to teaching research methodology curricula. METHODS: An electronic survey was sent by email to program directors and residents of English-speaking RCPSC-EM training programs countrywide. Reminder emails were sent after two, four, and eight weeks. Quantitative, descriptive statistics were prepared, and qualitative data and themes were identified. RESULTS: We received a total of seven responses from the possible 12 program directors (response rate = 58.3%). Out of 354 potential resident respondents, 82 (23.2%) completed the survey. There was disparity between resident and program director responses with respect to the existence of curricula, preparation for Royal College exams, and usefulness for future practice. Barriers to teaching a research methodologies curriculum included lack of time, support, educated faculty, and finances. CONCLUSION: This survey demonstrates that Canadian EM residency programs vary with respect to research methodology curriculum, and discrepancies exist between residents' and program directors' perceptions of the curriculum. Given the lack of a standardized research methodology curriculum for these programs, there is an opportunity to improve training in research methodology.

OBJECTIFS: Notre objectif vise à décrire la variabilité de l'enseignement des méthodologies de la recherche entre les programmes anglophones de résidence en médecine d'urgence du Collège royal des médecins et chirurgiens du Canada (MU - CRMCC). Nous avions également pour but de déterminer les obstacles qui entravent l'enseignement des cursus de méthodologie de la recherche. MÉTHODES: On a transmis par courriel un sondage électronique aux directeurs de programme et résidents des programmes anglophones de formation MU - CRMCC dans tout le pays. Des courriels de rappel ont été envoyés après deux, quatre et huit semaines. On a ensuite préparé des statistiques descriptives quantitatives et identifié des données et thèmes qualitatifs. RÉSULTATS: Nous avons reçu un total de sept réponses des 12 directeurs de programme actuels (taux de réponse = 58,3 %). Quatre-vingt-deux des 354 résidents potentiels, soit 23,2 %, ont répondu au sondage. Nous avons relevé une disparité entre les réponses des résidents et celles des directeurs de programme en ce qui a trait à l'existence du cursus, la préparation en vue des examens du Collège royal et l'utilité dans la pratique future. Parmi les obstacles entravant l'enseignement des cursus de méthodologie de la recherche, on retrouvait le manque de temps, de soutien, de corps professoral qualifié et de fonds. CONCLUSION: Ce sondage démontre que les cursus de méthodologie de la recherche des programmes de résidence en médecine d'urgence varient dans l'ensemble du Canada et que des divergences existent entre le point de vue des résidents et celui des directeurs de programme sur ces cursus. Étant donné l'absence d'un cursus uniforme de méthodologie de la recherche pour ces programmes, ceci nous offre une occasion d'améliorer la formation en méthodologie de la recherche.

A national survey of burnout amongst Canadian Royal College of Physicians and Surgeons of Canada emergency medicine residents.

BACKGROUND: In recent years, there has been growing interest in the field of physician wellness and burnout. The prevalence of burnout is non-uniform between medical specialties and is most prevalent amongst emergency medicine physicians. Importantly, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. Despite ample studies in other populations, there is no national perspective of burnout amongst Canadian Royal College of Physicians and Surgeons of Canada (RCPSC)Emergency Medicine (EM) residents. METHODS: Our study surveyed Canadian residents undergoing EM training though the RCPSC via local program directors using an anonymous electronic form. Basic demographic characteristics and residents' contemplation of suicide were surveyed. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment). RESULTS: A total of 65 valid responses were collected from eight of 14 eligible institutions (response rate = 30%). Respondents are primarily male (58%) and in their postgraduate year (PGY) 1-3 (71%). Overall, 62% of residents met the threshold for burnout according to a widely cited definition of burnout using the MBI-HSS. Additionally, 14% contemplated suicide during their training. There was no statistical significance in burnout rates between male and female responders or between residents in different stages of training. CONCLUSION: Our results suggest significant burnout amongst Canadian EM residents. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout.

CONTEXTE: Ces dernières années, le bien-être et l'épuisement professionnel des médecins suscitent de plus en plus d'intérêt. La prévalence de l'épuisement professionnel n'est pas uniforme ente les spécialités médicales et est plus marquée chez les urgentologues. On peut observer l'épuisement professionnel tôt en carrière , incluant chez les étudiants en médecine et résidents. Malgré les études approfondies menées auprès d'autres populations, il n'existe aucune perspective nationale de l'épuisement professionnel chez les résidents en médecine d'urgence du Collège royal des médecins et chirurgiens du Canada (CRMCC). MÉTHODES: À l'aide d'un formulaire électronique anonyme, nous avons sondé les résidents canadiens des programmes du CRMCC enen médecine d'urgence par le biais des directeurs de programme. Le sondage a examiné les caractéristiques démographiques de base et les idées suicidaires chez les résidents. Nous nous sommes servis de Maslach Burnout Inventory ­ Human Services Survey (MBI-HSS) (MBI-HSS) à l'intention du personnel médical pour évaluer l'épuisement professionnel sur trois plans (épuisement émotionnel, dépersonnalisation et réalisation personnelle). RÉSULTATS: Nous avons recueilli 65 réponses valides de huit des 14 établissements admissibles (taux de réponse = 30%). Les répondants sont majoritairement des hommes (58%) qui font des études postdoctorales (R1 àR3 (71%). En général, 62% des résidents ont atteint le seuil d'épuisement selon une définition de l'épuisement couramment utilisée dans le MBI-HSS. De plus, 14% ont envisagé de se suicider durant leur formation. Les taux d'épuisement des hommes et ceux des femmes sondées ne présentaient pas de différence statistiquement significative, tout comme ceux entre les résidents à diverses étapes de leur formation. CONCLUSION: Nos résultats indiquent que l'épuisement professionnel est important chez les résidents en médecine d'urgence canadiens. Par conséquent, ils fournissent un excellent point de départ pour mieux soutenir ces résidents au cours de leur formation afin d'améliorer leur mieux-être et réduire leur épuisement professionnel.

Quality of abdominal ultrasound image acquisition by novice practitioners following a minimal training session on healthy volunteers.

BACKGROUND: Point of care ultrasound (POCUS) is an essential tool for physicians to guide treatment decisions in both hospital and prehospital settings. Despite the potential patient care and system utilization benefits of prehospital ultrasound, the financial burden of a "hands-on" training program for large numbers of paramedics remains a barrier to implementation. In this study, we conducted a prospective, observational, double-blinded study comparing paramedics to emergency physicians in their ability to generate usable abdominal ultrasound images after a 1-hour didactic training session. METHODS: Canadian aeromedical critical care paramedics were compared against emergency medicine physicians in their ability to generate adequate abdominal ultrasound images on five healthy volunteers. Quality of each scan was evaluated by a trained expert in POCUS who was blinded to the identity of the participant using a 5-point Likert scale and using the standardized QUICk Focused Assessment with Sonography in Trauma (FAST) assessment tool. RESULTS: Fourteen Critical care paramedics and four emergency department (ED) physicians were voluntarily recruited. Of paramedics, 57% had never used ultrasound before, 36% has used ultrasound without formal training, and 7% had previous training. Physicians had a higher proportion of usable scans compared with paramedics (100% v. 61.4%, Δ38.6%; 95% confidence interval, 19.3-50.28). CONCLUSIONS: Paramedics were not able to produce images of interpretable quality at the same frequency when compared with emergency medicine physicians. However, a 61.4% usable image rate for paramedics following a short 1-hour didactic training session is promising for future studies, which could incorporate a short hands-on tutorial while remaining cost-effective.

Abdominal ultrasound image acquisition and interpretation by novice practitioners after minimal training on a simulated patient model.

BACKGROUND: The Focused Assessment with Sonography in Trauma (FAST) exam is a rapid ultrasound test to identify evidence of hemorrhage within the abdomen. Few studies examine the accuracy of paramedic performed FAST examinations. The duration of an ultrasound training program remains controversial. This study's purpose was to assess the accuracy of paramedic FAST exam interpretation following a one hour didactic training session. METHODS: The interpretation of paramedic performed FAST exams was compared to the interpretation of physician performed FAST examinations on a mannequin model containing 300ml of free fluid following a one hour didactic training course. Results were compared using the Chi-square test. Differences in accuracy rate were deemed significant if p < 0.05. RESULTS: Fourteen critical care flight paramedics and four emergency physicians were voluntarily recruited. The critical care paramedics were mostly ultrasound-naive whereas the emergency physicians all had ultrasound training. The correct interpretation of FAST scans was comparable between the two groups with accuracy of 85.6% and 87.5% (∆1.79 95%CI -33.85 to 21.82, p = 0.90) for paramedics and emergency physicians respectively. CONCLUSIONS: This study determined that critical care paramedics were able to use ultrasound to detect free fluid on a simulated mannequin model and interpret the FAST exam with a similar accuracy as experienced emergency physicians following a one hour training course. This suggests the potential use of prehospital ultrasound to aid in the triage and transport decisions of trauma patients while limiting the financial and logistical burden of ultrasound training.

An environmental scan of wellness initiatives and programs at Canadian academic emergency medicine programs: How far have we come?

OBJECTIVES: We sought to conduct a major objective of the Canadian Association of Emergency Physicians (CAEP) Wellness Committee, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools. METHODS: An 89-question questionnaire was distributed to academic heads or wellness leads. The responses were verified by the lead author to ensure that the questions were answered completely and consistently. RESULTS: While formal wellness programs may exist in varying degrees across the 17 universities, most were found to exist only at local, divisional, or departmental levels. A broad variability of established leadership positions exists. Shift practices varied greatly. In day to day practice, availability for food and debriefing were high and childcare, sleep rooms, and follow-up following critical incidents were low. Sabbaticals existed in the majority of centers. Roughly 50% of departments have gender equity program and annual retreats. Centers report programs for the initiation of leaves (82%), onboarding (64%), and reorientation (94%). Support of health benefits (76%) and pensions (76%) depended on type of appointment and relationship to the university. Fiscal transparency was reported in 53% of programs. CONCLUSION: Wellness and burnout are critical issues for emergency medicine in Canada. This comprehensive review of wellness programs identifies areas of strength, but also allows identification of areas of improvement for future work. Individual centers can identify common options when developing or expanding their wellness programs.

Reducing unnecessary testing in the emergency department: The case for INR and aPTT.

OBJECTIVE: Routine coagulation testing is rarely indicated in the emergency department. Our goal is to determine the combined effects of uncoupling routine coagulation testing (i.e., international normalized ratio [INR]; activated partial thromboplastin time [aPTT]), disseminating an educational module, and implementing a clinical decision support system (CDSS) on coagulation testing rates in two academic emergency departments. METHODS: A prospective pre-post study of INR-aPTT uncoupling, educational module distribution, and CDSS implementation in two academic emergency departments. All patients ages 18 years and older undergoing evaluation and treatment during the period of August 1, 2015, to November 30, 2017, were included. Primary outcome was coagulation testing utilization during the emergency department encounter. Secondary outcomes included associated costs, frequency of downstream testing, and frequency of blood transfusions. RESULTS: Uncoupling INR-aPTT testing combined with educational module distribution and CDSS implementation resulted in significantly decreased coupled INR-aPTT testing, with significantly increased selective INR and aPTT testing. Overall, the aggregate rate of coagulation testing declined for both INR and aPTT testing (48 tests/100 patients/day to 26 tests/100 patients/day). There was a significant decrease in associated daily costs (median cost per day: $1048.32 v. $601.68), realizing estimated annual savings of $163,023 Canadian dollars (CAD). There was no signal of increased downstream testing or patient blood product requirements. CONCLUSION: Compared to baseline practice patterns, our multimodal initiative significantly decreased coagulation testing, with meaningful cost savings and without evidence of patient harm. Clinicians and administrators now have a growing toolkit to target the plethora of low-value tests and treatments in emergency medicine.

Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule.

BACKGROUND: Previous research has focused on creation and validation of a basic life support rule for termination of resuscitation (TOR) in nontraumatic out-of-hospital cardiac arrest (OHCA) to identify patients who will not be successfully resuscitated or will not have a favorable outcome. Although now widely implemented, translational research regarding in-field compliance with TOR criteria and barriers to use is scarce. OBJECTIVES: This project aimed to assess compliance rates, barriers to use, and effect on ambulance transport rates after implementing TOR criteria for OHCA. METHODS: Retrospective chart review of patients ≥ 18 years with OHCA. Data from regional Emergency Medical Services agencies were collected to determine TOR rule compliance for patients meeting criteria, barriers to use, and effect of a TOR rule on ambulance transport. RESULTS: There were 552 patients with OHCAs identified. Ninety-one patients met TOR criteria, with paramedics requesting TOR in 81 (89%) cases and physicians granting requests in 65 (80.2%) cases. Perceived barriers to TOR compliance included distraught families, nearby advanced-care paramedics, and unusual circumstances. Reasons for physician refusal of TOR requests included hospital proximity, patient not receiving epinephrine, and poor communication connection to paramedics. Total high priority transports decreased 15.6% after implementation of a TOR rule. CONCLUSIONS: The study found high compliance after implementation of a TOR rule and identified potentially addressable barriers to TOR use. Appropriate application of a TOR rule led to reduction in high-priority ambulance transports, potentially reducing futile use of health care resources and risk of ambulance motor vehicle collisions.