The management of acute pain constitutes an essential skill of emergency department (ED) physicians. However, the accurate assessment of pain intensity and relief represents a clinically challenging undertaking. Some studies have proposed to define effective pain relief as the patient’s refusal for additional analgesic administration. The aim of this study was to verify whether such a refusal is effectively indicative of pain relief.

This prospective cohort study included ED patients who received single or multiple doses of pain medication for an acute pain problem. Patients were evaluated for pain relief using one Likert scale and two dichotomous questions: Is your pain relieved? and Do you want more analgesics? Non-relieved patients were further analysed using a checklist as to the reasons behind their refusal for supplemental pain medication.

We have recruited 378 adult patients with a mean age of 50.3 years (±19.1); 60% were women and had an initial mean pain level of 7.3 (±2.0) out of 10. We observed that 68 out of 244 patients who were adequately relieved from pain asked for more analgesics (28%), whereas 51 out of 134 patients who were not relieved from pain refused supplemental drugs (38%). Reasons for refusal included wanting to avoid side effects, feeling sufficiently relieved, and disliking the medication’s effects.

Over a third of ED patients in acute pain were not relieved but refused supplemental pain medication. Patients have reported legitimate reasons to decline further analgesics, and this refusal cannot be used as an indication of pain relief.

Vertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids.

To examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period.

Linked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days.

There were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97–6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43–1.97) compared to UTI patients who did not.

Patients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.

The aim of the study is to determine the performance of low-dose ketamine (LDK) as an analgesic for acute pain management in adult patients in the emergency department (ED).

We systematically reviewed electronic databases, grey literature, conference abstracts, and clinical trial registries. Two independent reviewers identified eligible studies. These selections were subsequently reviewed by one reviewer who identified the final eligible studies, using refined inclusion and exclusion criteria. Our outcome measures included the analgesic effect of LDK, need for rescue analgesia, and neuropsychological adverse events secondary to LDK use. We assessed inter-rater agreement using kappa statistics and proposed a treatment recommendation using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) software. Heterogeneity among studies precluded meta-analysis.

Our electronic search identified 1,408 records; 44 were selected for full evaluation (kappa=0.70), and 8 were included after the final review. All six randomized controlled trials and two observational studies were set in the ED where LDK was administered to adult patients ( >18 years old) exclusively for pain management. All studies had an overall low risk of bias. There was extensive variation in the dose and route of LDK used (0.1-0.7 mg/kg SC/IV/IM), administration protocols, and use of adjunct analgesia. Overall, most studies reported a significant analgesic effect of LDK with occasional need for rescue analgesia and mild-to-moderate adverse events (dizziness, dysphoria, and confusion).

There are moderate to low quality data supporting LDK as an alternative analgesic in the ED with the potential for minimal requirement of rescue analgesia and self-limited neuropsychological adverse events.

Rates of opioid-related deaths have reached the level of national public health crisis in Canada. Community-based opioid overdose education and naloxone distribution (OEND) programs distribute naloxone to people at risk, and the emergency department (ED) may be an underutilized setting to deliver naloxone to these people. The goal of this study was to identify Canadian emergency physicians’ attitudes and perceived barriers to the implementation of take-home naloxone programs.

This was an anonymous Web-based survey of members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals. Respondent demographics were collected, and Likert scales were used to assess attitudes and barriers to the prescription of naloxone from the ED.

A total of 459 physicians responded. The majority of respondents were male (64%), worked in urban tertiary centres (58.3%), and lived in Ontario (50.6%). Overall, attitudes to OEND were strongly positive; 86% identified a willingness to prescribe naloxone from the ED. Perceived barriers included support for patient education (57%), access to follow-up (44%), and inadequate time (37%). In addition to people at risk of overdose, 77% of respondents identified that friends and family members may also benefit.

Canadian emergency physicians are willing to distribute take-home naloxone, but thoughtful systems are required to facilitate opioid OEND implementation. These data will inform the development of these programs, with emphasis on multidisciplinary training and education.

No prior work exists examining the relation between the geographic distribution of out-of-hospital cardiac arrest (OHCA) in the city of Vancouver and surrounding areas that may exhibit a clustering of cases. The primary objective of this study was to describe the distribution of OHCA within the Vancouver Coastal Health region using a geographic information system (GIS) analysis and appropriate statistical analyses.

This study was a post-hoc GIS-based analysis of OHCA patients in the city of Vancouver and surrounding areas, using data collected by the Resuscitation Outcomes Consortium between September 2007 and December 2011. The kernel density techniques and regression tree analysis using binary recursive partitioning were used.

We examined 1617 cases of OHCA with a mortality rate of 86.5% (95% CI 84.8-88.2). The mean age of OHCA cases was 66.6 years (95% CI 65.7-67.5), and 33.6% (95% CI 31.3-35.9) were female. The proportion with an initial shockable rhythm (VF or pulseless VT) was 22.2% (95% CI 20.2-24.2); 42.3% (95% CI 39.9-44.7) of all cases received bystander CPR, and 49.7% (95% CI 47.3-52.1) were transported to the hospital by paramedics. The rate of survival to hospital discharge with favourable neurological status (FNS) Cerebral Performance Category (CPC) 1 or 2 was 10.4% (8.9-11.9). Distance of transport to the hospital (less than 2.7 km) was a significant predictor of survival with FNS, but income did not predict survival with FNS. Areas with higher proportions of commuters by car demonstrated lower rates of survival with FNS.

This is the first GIS-based study to examine OHCA in a single large Canadian centre. Clustering of OHCA consistent with areas of high population density was observed. Distance of transport was a significant predictor of survival with FNS for patients with OHCA. This may have important implications for future emergency medical services deployment and dispatch decision-making, and public policy initiatives.

Nurses and respiratory therapists are seldom allowed to use automated external defibrillators (AED) during in-hospital cardiac arrest. This can result in significant time delays before defibrillation occurs and lower survival for cardiac arrest victims. We sought to identify barriers and facilitators to AED use by nurses and respiratory therapists.

We conducted semi-structured qualitative interviews with a purposeful sample of nurses and respiratory therapists. We developed the interview guide based on the constructs of the theory of planned behaviour, which elicits salient attitudes, social influences, and control beliefs potentially influencing the intent to use an AED. Interviews were recorded, transcribed verbatim, and analysed until achieving data saturation. Two independent reviewers performed inductive analyses to identify emerging categories and themes, and ranked them by frequency of the number of participants stating the topic.

Demographics for the 24 interviewees include mean age 40.5, 79.2% female, 87.5% performed cardiopulmonary resuscitation (CPR), 29.2% defibrillated a patient. Identified attitudes pertained to the timeliness of defibrillation, patient survival, simplicity of AED use, accuracy of rhythm recognition, and harm to self or others. Social influences consisted of physician and hospital administration support of AED use. Control beliefs included training on AED use, policy allowing AED use, familiarity with AED, and task burden during resuscitation.

Most nurses and respiratory therapists intended to use an AED if permitted to do so by a medical directive. Successful implementation would require educational initiatives focusing on safety and efficacy of AEDs, support from physicians and hospital administrators, and additional training on AED use.

We aimed to explore whether a) step stool use is associated with improved cardiopulmonary resuscitation (CPR) quality; b) provider adjusted height is associated with improved CPR quality; and if associations exist, c) determine whether just-in-time (JIT) CPR training and/or CPR visual feedback attenuates the effect of height and/or step stool use on CPR quality.

We analysed data from a trial of simulated cardiac arrests with three study arms: No intervention; CPR visual feedback; and JIT CPR training. Step stool use was voluntary. We explored the association between 1) step stool use and CPR quality, and 2) provider adjusted height and CPR quality. Adjusted height was defined as provider height + 23 cm (if step stool was used). Below-average height participants were ≤ gender-specific average height; the remainder were above average height. We assessed for interaction between study arm and both adjusted height and step stool use.

One hundred twenty-four subjects participated; 1,230 30-second epochs of CPR were analysed. Step stool use was associated with improved compression depth in below-average (female, p=0.007; male, p<0.001) and above-average (female, p=0.001; male, p<0.001) height providers. There is an association between adjusted height and compression depth (p<0.001). Visual feedback attenuated the effect of height (p=0.025) on compression depth; JIT training did not (p=0.918). Visual feedback and JIT training attenuated the effect of step stool use (p<0.001) on compression depth.

Step stool use is associated with improved compression depth regardless of height. Increased provider height is associated with improved compression depth, with visual feedback attenuating the effects of height and step stool use.

The majority of children requiring emergency care are treated in general emergency departments (EDs) with variable levels of pediatric care expertise. The goal of the Translating Emergency Knowledge for Kids (TREKK) initiative is to implement the latest research in pediatric emergency medicine in general EDs to reduce clinical variation.

To determine national pediatric information needs, seeking behaviours, and preferences of health care professionals working in general EDs.

An electronic cross-sectional survey was conducted with health care professionals in 32 Canadian general EDs. Data were collected in the EDs using the iPad and in-person data collectors.

Total of 1,471 surveys were completed (57.1% response rate). Health care professionals sought information on children’s health care by talking to colleagues (n=1,208, 82.1%), visiting specific medical/health websites (n=994, 67.7%), and professional development opportunities (n=941, 64.4%). Preferred child health resources included protocols and accepted treatments for common conditions (n=969, 68%), clinical pathways and practice guidelines (n=951, 66%), and evidence-based information on new diagnoses and treatments (n=866, 61%). Additional pediatric clinical information is needed about multisystem trauma (n=693, 49%), severe head injury (n=615, 43%), and meningitis (n=559, 39%). Health care professionals preferred to receive child health information through professional development opportunities (n=1,131, 80%) and printed summaries (n=885, 63%).

By understanding health care professionals’ information seeking behaviour, information needs, and information preferences, knowledge synthesis and knowledge translation initiatives can be targeted to improve pediatric emergency care. The findings from this study will inform the following two phases of the TREKK initiative to bridge the research-practice gap in Canadian general EDs.

What is the risk of creating opioid dependence from an ED opioid prescription?

Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med 2017;376:663-73, doi:10.1056/NEJMsa1610524.

This study examined the risk of creating long-term opioid dependence from a prescription written in an opioid-naive patient in the ED.

Ontario established emergency department length-of-stay (EDLOS) targets but has difficulty achieving them. We sought to determine predictors of target time failure for discharged high acuity patients and intensive care unit (ICU) admissions.

This was a retrospective, observational study of 2012 Sunnybrook Hospital emergency department data. The main outcome measure was failing to meet government EDLOS targets for high acuity discharges and ICU emergency admissions. The secondary outcome measures examined factors for low acuity discharges and all admissions, as well as a run chart for 2015 – 2016 ICU admissions. Multiple logistic regression models were created for admissions, ICU admissions, and low and high acuity discharges. Predictor variables were at the patient level from emergency department registries.

For discharged high acuity patients, factors predicting EDLOS target failure were having physician initial assessment duration (PIAD)>2 hours (OR 5.63 [5.22-6.06]), consultation request (OR 10.23 [9.38-11.14]), magnetic resonance imaging (MRI) (OR 19.33 [12.94-28.87]), computed tomography (CT) (OR 4.24 [3.92-4.59]), and ultrasound (US) (OR 3.47 [3.13-3.83]). For ICU admissions, factors predicting EDLOS target failure were bed request duration (BRD)>6 hours (OR 364.27 [43.20-3071.30]) and access block (AB)>1 hour (OR 217.27 [30.62-1541.63]). For discharged low acuity patients, factors predicting failure for the 4-hour target were PIAD>2 hours (OR 15.80 [13.35-18.71]), consultation (OR 20.98 [14.10-31.22]), MRI (OR 31.68 [6.03-166.54]), CT (OR 16.48 [10.07-26.98]), and troponin I (OR 13.37 [6.30-28.37]).

Sunnybrook factors predicting failure of targets for high acuity discharges and ICU admissions were hospital-controlled. Hospitals should individualize their approach to shortening EDLOS by analysing its patient population and resource demands.

Quantitative research is one of the many research methods used to help educators advance their understanding of questions in medical education. However, little research has been done on how to succeed in publishing in this area.

We conducted a scoping review to identify key recommendations and reporting guidelines for quantitative educational research and scholarship.

Medline, ERIC, and Google Scholar were searched for English-language articles published between 2006 and January 2016 using the search terms, “research design,” “quantitative,” “quantitative methods,” and “medical education.” A hand search was completed for additional references during the full-text review. Titles/abstracts were reviewed by two authors (BT, PC) and included if they focused on quantitative research in medical education and outlined reporting guidelines, or provided recommendations on conducting quantitative research. One hundred articles were reviewed in parallel with the first 30 used for calibration and the subsequent 70 to calculate Cohen’s kappa coefficient. Two reviewers (BT, PC) conducted a full text review and extracted recommendations and reporting guidelines. A simple thematic analysis summarized the extracted recommendations.

Sixty-one articles were reviewed in full, and 157 recommendations were extracted. The thematic analysis identified 86 items, 14 categories, and 3 themes. Fourteen quality evaluation tools and reporting guidelines were found.

This paper provides guidance for junior researchers in the form of key quality markers and reporting guidelines. We hope that quantitative researchers in medical education will be informed by the results and that further work will be done to refine the list of recommendations.

Simulation-based education (SBE) is an important training strategy in emergency medicine (EM) postgraduate programs. This study sought to characterize the use of simulation in FRCPC-EM residency programs across Canada.

A national survey was administered to residents and knowledgeable program representatives (PRs) at all Canadian FRCPC-EM programs. Survey question themes included simulation program characteristics, the frequency of resident participation, the location and administration of SBE, institutional barriers, interprofessional involvement, content, assessment strategies, and attitudes about SBE.

Resident and PR response rates were 63% (203/321) and 100% (16/16), respectively. Residents reported a median of 20 (range 0–150) hours of annual simulation training, with 52% of residents indicating that the time dedicated to simulation training met their needs. PRs reported the frequency of SBE sessions ranging from weekly to every 6 months, with 15 (94%) programs having an established simulation curriculum. Two (13%) of the programs used simulation for resident assessment, although 15 (94%) of PRs indicated that they would be comfortable with simulation-based assessment. The most common PR-identified barriers to administering simulation were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Interprofessional involvement in simulation was strongly valued by both residents and PRs.

SBE is frequently used by Canadian FRCPC-EM residency programs. However, there exists considerable variability in the structure, frequency, and timing of simulation-based activities. As programs transition to competency-based medical education, national organizations and collaborations should consider the variability in how SBE is administered.