Our study objective was to describe the Canadian emergency medicine (EM) research community landscape prior to the initiation of a nationwide network.

A two-phase electronic survey was sent to 17 Canadian medical schools. The Phase 1 Environmental Scan was administered to department chairs/hospital EM chiefs, to identify EM physicians conducting clinical or educational research. The Phase 2 Survey was sent to the identified EM researchers to assess four themes: 1) geographic distribution, 2) training/career satisfaction, 3) time/financial compensation, and 4) research facilitators/barriers. Descriptive analyses were conducted, and results were stratified by Canadian regions.

A total of 92 EM researchers were identified in Phase 1; 67 (73%) responded to the Phase 2 Survey. Of those, 42 (63%) reported being clinical researchers, and 19 (45%) had a graduate degree. Three provinces encompassed most of the researchers (n = 35). Of the respondents, 61% had a research degree, 66% felt adequately trained for their research career, 73% had financial support, 83% had access to office spaces, 52% had no mentor during their first years of their career, 69% felt satisfied with their research career, and 82% suggested that they will still be conducting research in 5 years.

EM researchers reported being adequately trained, even though only a little over half had a graduate degree. Only two-thirds had financial support, and mentorship was lacking in one-third of the participants. Not all respondents had a form of infrastructure, but most felt optimistic about their careers. The Canadian EM research environment could be improved to ensure better research capacity.

Opioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.

We conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.

We enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.

The majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.

Opioid-related deaths are increasing at alarming rates in Canada, with a 34% increase from 2016 to 2017. Patients with opioid use disorder often visit emergency departments (ED), presenting an opportunity to engage patients in treatment. Buprenorphine-naloxone is first-line treatment for opioid use disorder, but current management in the ED is unknown. This study aimed to characterize opioid use disorder management in the ED.

We conducted a cross-sectional study of emergency physicians across Canada. A survey was circulated electronically to the Canadian Association of Emergency Physicians members. Participants were asked about their current management practices, satisfaction, and helpfulness of resources. SAS (version 9.4) was used for statistical analysis. We dichotomized Likert-scale responses to approximate relative risk ratios via a log binomial analysis.

The survey was completed by 179 participants for a response rate of 11.1%; 143 (79.9%) physicians treated patients with opioid use disorder more than once a week. Only 7% (n = 13) of respondents always/often gave buprenorphine in the ED. Referral to an addiction clinic where patients were seen quickly was deemed the most helpful (90.5%, n = 162). Physicians who reported satisfaction with opioid use disorder management were four times more likely to prescribe buprenorphine in the ED or as an outpatient script (RR = 4.41, CI = 2.33–8.33, p < 0.01; RR = 4.51, CI = 2.21–9.22, p < 0.01).

This study found that buprenorphine is not frequently prescribed in the ED setting, which is incongruent with the 2018 guidelines. Care coordination and on-site support were helpful to ED physicians. Hospitals should use knowledge translation strategies to improve the care of patients with an opioid use disorder.

Regional anesthesia has many applications in the emergency department (ED). It has been shown to reduce general anesthetic dose, requirement for post-procedural opioids, and recovery time. We sought to characterize the use of regional anesthesia by Canadian emergency physicians, including practices, perspectives and barriers to use in the ED.

A cross-sectional survey was administered to members of the Canadian Association of Emergency Physicians (CAEP), consisting of sixteen multiple choice and numerical response questions. Responses were summarized descriptively as percentages and as the median and inter quartile range (IQR) for quantitative variables.

The survey was completed by 149/1144 staff emergency physicians, with a response rate of 13%. Respondents used regional anesthesia a median of 2 (IQR 0–4) times in the past ten shifts. The most broadly used applications were soft tissue repair (84.5% of respondents, n = 126), fracture pain management (79.2%, n = 118) and orthopedic reduction (72.5%, n = 108). Respondents agreed that regional anesthesia is safe to use in the ED (98.7%) and were interested in using it more frequently (78.5%). Almost all (98.0%) respondents had point of care ultrasound available, however less than half (49.0%) felt comfortable using it for RA. Respondents indicated that they required more training (76.5%), a departmental protocol (47.0%), and nursing assistance (30.2%) to increase their use of RA.

Canadian emergency physicians use regional anesthesia infrequently but express an interest in expanding their use. While equipment is available, additional training, protocols, and increased support from nursing staff are modifiable factors that could facilitate uptake.

Older patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.

This systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.

Of 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.

Various interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.

The Maximizing Aging Using Volunteer Engagement in the Emergency Department (MAUVE + ED) program connects specially trained volunteers with older patients whose personal and social needs are not always met within the busy ED environment. The objective of this study was to describe the development and implementation of the MAUVE + ED program.

Volunteers were trained to identify and approach older patients at risk for adverse outcomes, including poor patient experience, and invite such patients to participate in the program. The program is available to all patients >65 years, and those with confusion, patients who were alone, those with mobility issues, and patients with increased length of stay in the ED. Volunteers documented their activities after each patient encounter using a standardized paper-based data collection form.

Over the program's initial 6-month period, the MAUVE + ED volunteers reported a total of 896 encounters with 718 unique patients. The median time (interquartile range [IQR]) a MAUVE volunteer spent with a patient was 10 minutes (IQR = 5, 20), with a range of 1 to 130 minutes. The median number of patients seen per shift was 7 (IQR = 6, 9), with a range of 1 to 16 patients per shift. The most common activities the volunteer assisted with were therapeutic activities/social visits (n = 859; 95.9%), orientation activities (n = 501; 55.9%), and hydration assistance (n = 231; 25.8%). The least common were mobility assistance (n = 36; 4.0%), and vision/hearing assistance (n = 13; 1.5%).

Preliminary data suggest the MAUVE + ED volunteers were able to provide additional care to older adults and their families/carers in the ED.

Cricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.

Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.

Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).

We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

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.

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.

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.

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.

Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region.

We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups.

A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners.

This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.