Patient adherence with emergency department (ED) referral has not been well studied in Canada, and there are no Canadian studies assessing patient follow-up for evaluation of cardiovascular disease. Our primary objective was to determine the proportion of patients who adhered with an ED referral to a cardiac evaluation and risk assessment (CERA) clinic in Calgary, Alta. Secondary objectives included determining the final diagnoses and outcomes for patients attending CERA appointments. We also assessed the association between adherence and various system and patient factors.

A retrospective review of 385 patients who were referred to CERA from EDs in the study region between June 1, 2004, and Apr. 7, 2005, was performed. Hospital charts and the database at the medical examiner's office were reviewed for patients who did not attend their CERA appointment.

The majority of patients (345/385, 89.6%) followed through with their referral to CERA. No deaths were identified from hospital records or from the medical examiner's office for nonadherent patients. Of the 315 patients who completed their follow-up, 225 (71.4%) were diagnosed with noncardiac or low-risk cardiac disease, whereas 90 (28.6%) were diagnosed with cardiovascular disease. The referring hospital was the only variable significantly associated with adherence with the referral (p = 0.004).

The great majority of patients referred to CERA from Calgary EDs were adherent with the referral. Future studies may identify factors impairing adherence that are amenable to intervention. Implementation of a referral model similar to the one used by CERA may improve adherence with attendance at other outpatient clinics.

The SimpliRED ᴅ-dimer assay is commonly ordered by emergency physicians for suspected pulmonary embolus or deep venous thrombosis. A pretest probability (PTP) assessment is required for the results of this diagnostic test to be interpreted correctly and applied appropriately. Without this assessment, the physician may misinterpret the test results and proceed to unnecessary diagnostic imaging (DI) or inappropriate discharge. Our objectives were to measure the documentation rate of PTP for emergency department (ED) patients on whom a SimpliRED ᴅ-dimer assay was performed for suspected venous thromboembolism (VTE) and to determine if the clinical management decisions that followed were in keeping with current recommendations.

In this medical record review, we used a random number generator to select 100 charts from all 760 patients who had a SimpliRED ᴅ-dimer performed during a 3-month period at an academic tertiary care centre with 3 EDs. Trained data abstractors, blinded to the study hypothesis, abstracted explicitly defined data from each chart. An independent abstractor assessed the reliability of 15 of the charts that were randomly chosen.

Suspicion of VTE was documented in 97 of the 100 charts. There was no documentation of PTP assessment for 62 of the 97 cases. Ten had a positive ᴅ-dimer but 5 of these had no evidence of subsequent DI. Of the 97 charts reviewed, 24 documented decisions were in discordance with published clinical management recommendations for VTE.

In the majority of ED cases of suspected VTE, PTP assessment was not documented and approximately one-quarter of these documented decisions were in discordance with established recommendations for the given test results. This suggests that PTP assessments are not being conducted in a significant proportion of cases and the diagnostic test results are misinterpreted, applied incorrectly or both.

The emergency department (ED) environment requires physicians to focus on workflow efficiency (WFE) and manage ED throughput. We sought to determine whether an interactive workshop could be designed and favourably perceived by emergency physicians and residents as a means to improve their self-assessed WFE skills.

The authors designed a 4-station workshop to simulate key components of ED throughput. These included resource management in 1) acute care, 2) minor care, 3) charting and 4) communication skills and patient sign-overs. Anonymous surveys were completed after each workshop using 5-point Likert scales and qualitative responses. Qualitative data encompassed participants' past WFE training experiences and perspectives on the current workshop. Data were analyzed using descriptive statistics. The workshops were administered on 2 separate occasions to different groups of physicians. The first occasion was primarily for residents and the second session was only for practising physicians.

A total of 22 residents and 24 practising physicians participated. Evaluations were completed by 45 of 46 participants. Ratings of “definitely helpful” or “helpful” as noted for each station were received by 37 of 44 respondents for the sign-over and communication station, by 37 of 44 for the minor care station, by 41 of 44 for the acute care station and by 33 of 43 for the effective charting station. Among all participants, 42 of 45 reported that they felt the overall workshop experience was “helpful” or “definitely helpful.”

ED management “flow skills” are valued yet undertaught. A flow workshop designed to improve self-perceived WFE skills yields positive evaluations. Teaching this competency in a workshop setting is both feasible and appreciated by participants. Similar efforts should be considered for inclusion in both graduate and continuing medical education curricula.

We sought to determine the frequency with which fellows in accredited Canadian pediatric emergency medicine (PEM) fellowships perform specific procedures, the level of confidence fellows have in their abilities and whether there are differences in self-perceived success between first- and second-year fellows.

A national survey was developed that focused on 24 PEM procedural skills. The survey asked respondents how many times they had performed these procedures within the past 12 months and within the past 3 years. Respondents were then asked to rate their confidence in successfully performing each of the 24 procedures.

Of the 46 surveys sent to PEM fellows, 32 (70%) were returned. Most respondents were in their second year of training and the vast majority had previous training in pediatrics. In order of frequency, the most common procedures performed were closed reduction of fractures, peripheral intravenous insertion, complex laceration repair and endotracheal intubation. Of the surveyed skills, oropharyngeal/nasopharyngeal airway insertion was deemed the most successful (100% success rate for second-year fellows v. 92.5% success rate for first-year fellows, p = 0.01). Similarly, second-year fellows had a higher self-perceived success rate for intraosseous line insertion than did first-year fellows (95.0% v. 80.0% for second- and first-year fellows, respectively, p < 0.001).

In surveying PEM trainees across Canada, we have described the frequency and self-perceived success rate for 24 important procedures. This information may be helpful for program directors in evaluating future directions and opportunities for training of their PEM trainees.

A major role of admission interviews is to assess a candidate's suitability for a residency program. Structured interviews have greater reliability and validity than do unstructured ones. The development of content for a structured interview is typically based on the dimensions of performance that are perceived as important to succeed in a particular line of work. A formal job analysis is normally conducted to determine these dimensions. The dimensions essential to succeed as an emergency medicine (EM) resident have not yet been studied. We aimed to analyze the work of EM residents to determine these essential dimensions.

The “critical incident technique” was used to generate scenarios of poor and excellent resident performance. Two reviewers independently read each scenario and labelled the performance dimensions that were reflected in each. All labels assigned to a particular scenario were pooled and reviewed again until a consensus was reached.

Five faculty members (25% of our total faculty) comprised the subject experts. Fifty-one incidents were generated and 50 different labels were applied. Eleven dimensions of performance applied to at least 5 incidents. “Professionalism” was the most valued performance dimension, represented in 56% of the incidents, followed by “self-confidence” (22%), “experience” (20%) and “knowledge” (20%).

“Professionalism,” “self-confidence,” “experience” and “knowledge” were identified as the performance dimensions essential to succeed as an EM resident based on our formal job analysis using the critical incident technique. Performing a formal job analysis may assist training program directors with developing admission interviews.

La prise en charge optimale du sepsis grave dans les départements d'urgence a connu une évolution rapide. Le but des présentes lignes directrices est de revoir pour le bénéfice des médecins d'urgence canadiens les principes clés qui régissent la prise en charge du sepsis grave en se fondant sur un système de classification fondé sur des preuves.

Ce sont les membres du comité de l'ACMU pour les soins critiques, ou comité C4 (pour CAEP Critical Care Interest Group) qui ont déterminé les secteurs clés de la prise en charge des patients atteints de sepsis. Chaque membre du C4 avait pour tâche de répondre à une question qui lui avait été assignée après avoir fait un survol de la littérature établie selon le système de classification Oxford, après quoi, chaque secteur faisait l'objet d'une seconde révision par un autre membre du C4. D'autres experts de l'extérieur ont procédé à un troisième examen et les modifications ont été déterminées par voie de consensus. La classification reposait sur des publications révisées par des pairs uniquement, et là où les preuves étaient insuffisantes pour répondre à une question importante, le groupe a proposé un «point pratique».

Le projet a débuté en 2005 et a pris fin en décembre 2007. Les secteurs clés qui ont été passés en revue incluent la définition du terme sepsis, l'utilisation des interventions effractives, la réanimation liquidienne, l'utilisation d'agents vasopresseurs/inotropes, l'importance des prélèvements pour culture aux départements d'urgence, l'antibiothérapie et le contrôle des sources. Parmi les autres secteurs examinés, mentionnons l'utilisation des corticostéroïdes, la protéine C activée, les transfusions et la ventilation mécanique.

La prise en charge précoce du sepsis dans les départements d'urgence est extrêmement importante pour améliorer le pronostic des patients. L'énoncé de position du C4 sur le sepsis fournit un cadre de travail afin d'améliorer les soins prodigués à cette population de patients dans les départements d'urgence.