The diagnosis of concussion is a critical step in the appropriate management of patients following minor head trauma. The authors hypothesized that wide practice variation exists among pediatric emergency medicine physicians in the application of physical and cognitive rest recommendations following an acute concussion.

The authors developed a 35-item questionnaire incorporating case vignettes to examine pediatric emergency physician knowledge of concussion diagnosis, understanding of initial management using return-to-play/school/work guidelines, use of existing concussion protocols, and perceived barriers to protocol use. Using a modified Dillman technique, the authors distributed an online survey to members of Pediatric Emergency Research Canada, a national association of pediatric emergency physicians.

Of 176 potential participants, 115 (65%) responded to the questionnaire, 89% (95% confidence interval [CI]: 0.81, 0.93) of whom reported having diagnosed 20 or more concussions annually. Although 90% (95% CI: 0.83, 0.94) of respondents adequately diagnosed concussion, only 64% (95% CI: 0.54, 0.72) correctly applied graduated return-to-play guidelines. Cognitive rest recommendations were also frequently limited: 40% (95% CI: 0.31, 0.49) did not recommend school absence, 30% (95% CI: 0.22, 0.39) did not recommend schoolwork reduction, and 35% (95% CI: 0.27, 0.45) did not recommend limiting screen time. Eighty percent (95% CI: 0.72, 0.87) of respondents reported having used guidelines frequently or always to guide clinical decisions regarding concussion.

Despite a proficiency in the diagnosis of concussion, pediatric emergency physicians exhibit wide variation in recommending the graduated return to play and cognitive rest following concussion.

To examine sociodemographic variations among children <18 years in (1) rates of self-harm visits to emergency departments (EDs) and (2) physician follow-up after the self-harm visit in Alberta.

A retrospective, population-based cohort (2002–2011) of ED visits for self-harm by individuals <18 years was conducted using administrative databases from Alberta, Canada. Individuals were grouped by First Nations status or type of health care premium subsidy (family receipt of government subsidy, human services program subsidy, no subsidy received). Visits from 104 EDs were summarized by crude and directly standardized visit rates (DSVRs) per 100,000 individuals. Kaplan-Meier estimates for median estimated time to physician follow-up were calculated with 95% confidence intervals (CIs).

During the study period, visit rates decreased with the exception of children from families receiving government-sponsored program subsidy (DSVRs 163/100,000 to 250/100,000; p=0.032). First Nations children had disproportionately fewer follow-up visits compared to other children. The median time to follow-up for First Nations children was 39 days (95% CI: 32, 48) compared to 16 days for children from families receiving no subsidy (95% CI: 14, 19), who had the shortest follow-up time after an ED visit.

Sociodemographic differences were evident in ED visit rates as well as the number of and time to physician follow-up visit. The disparities experienced by First Nations children in the follow-up period highlight an opportunity for culturally-grounded risk and needs assessment in the ED to determine and facilitate timely and appropriate follow-up care.

Outcome feedback is the process of learning patient outcomes after their care within the emergency department. We conducted a national survey of Canadian Royal College emergency medicine (EM) residents and program directors to determine the extent to which active outcome feedback and follow-up occurred. We also compared the perceived educational value of outcome feedback between residents and program directors.

We distributed surveys to all Royal College-accredited adult and pediatric EM training programs using a modified Dillman method. We analyzed the data using student’s t-test for continuous variables and Fisher’s exact test for categorical variables.

We received 210 completed surveys from 260 eligible residents (80.8%) and 21 of 24 program directors (87.5%) (overall 81.3%). Mandatory active outcome feedback was not present in any EM training program for admitted or discharged patients (0/21). Follow-up was performed electively by 89.4% of residents for patients admitted to the hospital, and by 44.2% of residents for patients discharged home. A majority of residents (76.9%) believed that patient follow-up should be mandatory compared to 42.9% of program directors (p=0.002). The perceived educational value of outcome feedback was 5.8/7 for residents and 5.1/7 for program directors (difference 0.7; p=0.002) based on a seven-point Likert scale (1=not important; 7=very important).

While Canadian EM training programs do not mandate follow-up, it is performed electively by the majority of residents surveyed. Residents place a significantly greater educational value on outcome feedback than their program directors, and believe that follow-up should be a mandatory component of EM residencies.

A cardiac source is often implicated in strokes where the deficit includes aphasia. However, less is known about the etiology of isolated aphasia during transient ischemic attack (TIA). Our objective was to determine whether patients with isolated aphasia are likely to have a cardioembolic etiology for their TIA.

We prospectively studied a cohort of TIA patients in eight tertiary-care emergency departments. Patients with isolated aphasia were identified by the treating physician at the time of emergency department presentation. Patients with dysarthria (i.e., a phonation disturbance) were not included. Potential cardiac sources for embolism were defined as atrial fibrillation on history, electrocardiogram, Holter monitor, atrial fibrillation on echocardiography, or thrombus on echocardiography.

Of the 2,360 TIA patients identified, 1,155 had neurological deficits at the time of the emergency physician assessment and were included in this analysis, and 41 had isolated aphasia as their only neurological deficit. Patients with isolated aphasia were older (73.9±10.0 v. 67.2±14.5 years; p=0.003), more likely to have a history of heart failure (9.8% v. 2.6%; p=0.027), and were twice as likely to have any cardiac source of embolism (22.0% v. 10.6%; p=0.037).

Isolated aphasia is associated with a high rate of cardioembolic sources of embolism after TIA. Emergency patients with isolated aphasia diagnosed with a TIA warrant a rapid and thorough assessment for a cardioembolic source.

One of the many challenges facing emergency departments (EDs) across North America is timely access to emergency radiology services. Academic institutions, which are typically also regional referral centres, frequently require cross-sectional studies to be performed 24 hours a day with expedited final reports to accelerate patient care and ED flow.

The purpose of this study was to determine if the presence of an in-house radiologist, in addition to a radiology resident dedicated to the ED, had a significant impact on report turnaround time.

Preliminary and final report turnaround times, provided by the radiology resident and staff, respectively, for patients undergoing computed tomography or ultrasonography of their abdomen/pelvis in 2008 (before the implementation of emergency radiology in-house staff service) were compared to those performed during the same time frame in 2009 and 2010 (after staffing protocols were changed).

A total of 1,624 reports were reviewed. Overall, there was no statistically significant decrease in the preliminary report turnaround times between 2008 and 2009 (p = 0.1102), 2009 and 2010 (p = 0.6232), or 2008 and 2010 (p = 0.0890), although times consistently decreased from a median of 2.40 hours to 2.08 hours to 2.05 hours (2008 to 2009 to 2010). There was a statistically significant decrease in final report turnaround times between 2008 and 2009 (p < 0.0001), 2009 and 2010 (p < 0.0011), and 2008 and 2010 (p < 0.0001). Median final report times decreased from 5.00 hours to 3.08 hours to 2.75 hours in 2008, 2009, and 2010, respectively. There was also a significant decrease in the time interval between preliminary and final reports between 2008 and 2009 (p < 0.0001) and 2008 and 2010 (p < 0.0001) but no significant change between 2009 and 2010 (p = 0.4144).

Our results indicate that the presence of a dedicated ED radiologist significantly reduces final report turnaround time and thus may positively impact the time to ED patient disposition. Patient care is improved when attending radiologists are immediately available to read complex films, both in terms of health care outcomes and regarding the need for repeat testing. Providing emergency physicians with accurate imaging findings as rapidly as possible facilitates effective and timely management and thus optimizes patient care.

As an aging population continues to place strain on the health care system, many older adults are living with unmet social and medical needs. In response, Emergency Medical Services (EMS) have initiated programs that encourage paramedics to refer patients in need to community based support services. This qualitative study explores frontline paramedic experiences with referral programs to identify opportunities and challenges in their practice.

This study used an intepretivist qualitative study design involving interviews of frontline paramedics employed in a region where referral programs were in place. Interviews were semi-structured and one-on-one. Data were transcribed verbatim and analyzed using inductive open coding throughout, then grouped to identify themes. Data collection and analysis were conducted simultaneously and flexibly until saturation.

Twenty-three interviews were conducted representing 6 regions. When participating with referral programs the data revealed that frontline paramedics appear to experience (a) role confusion, (b) an inadequate knowledge base, (c) inadequate feedback, (d) undefined accountability, and (e) strong patient advocacy.

In a strained health care system, EMS and paramedics have an opportunity to better serve patients by initiating referrals for patients they encounter with unmet social and medical needs. However, referral programs face a number of challenges that, if left poorly addressed, may threaten the success of such programs.

To determine the outcomes of patients discharged from the emergency department (ED) with a bloodstream infection (BSI) and how these outcomes are influenced by antibiotic treatment.

We identified every BSI in adult patients discharged from our ED to the community between July 1, 2002, and March 31, 2011. The medical records of all cases were reviewed to determine antibiotic treatment in the ED and at discharge. Microorganism sensitivities were used to determine whether antibiotics were appropriate. These data were linked to population-based administrative data to determine specific patient outcomes within the subsequent 2-week period: death, urgent hospitalization, or an unplanned return to the ED.

A total of 480 adults with BSI were identified (1.49 cases per 1,000 adults discharged from the department). Compared to controls (321,048 patients), BSI patients had a significantly higher risk of urgent hospitalization (adjusted OR 2.1 [95% CI 1.6–2.8]) and unplanned return to the ED (adjusted OR 4.1 [95% CI 3.3–4.9]). Outcome risk was significantly lowered in BSI patients who received appropriate antibiotics in the ED and at discharge. In elderly patients, the risk of urgent hospitalization increased significantly as the time to appropriate antibiotics was delayed.

BSI patients discharged from the ED have a significantly increased risk of urgent hospitalization and unplanned return to the ED in the subsequent 2 weeks. These risks decrease significantly with the timely provision of appropriate antibiotics. Our results support the aggressive use of measures ensuring that such patients receive appropriate antibiotics as soon as possible.

Under-treatment of children’s pain in the emergency department (ED) can have many detrimental effects. Emergency medicine (EM) residents often manage pediatric pain, but their educational needs and perspectives have not been studied.

A novel online survey was administered from May to June 2013 to 122 EM residents at three Canadian universities using a modified Dillman methodology. The survey instrument captured information on training received in pediatric acute pain management, approach to common painful presentations, level of comfort, perceived facilitators, and barriers and attitudes towards pediatric pain.

56 residents participated (46%), 25 of whom (45%) indicated they had not received any training in pediatric pain assessment. All levels of residents reported they were uncomfortable with pain assessment in 0-2 year olds (p=0.07); level of comfort with assessment increased with years of training for patients aged 2-12 years (p=0.02). When assessing children with disabilities, 83% of respondents (45/54) indicated they were ‘extremely’ or ‘somewhat’ uncomfortable. Sixty-nine percent (38/55) had received training on how to treat pediatric pain. All residents reported they were more comfortable using pain medication for a 9 year old, as compared to a 1 year old (oral oxycodone p<0.001, oral morphine p<0.001, IV morphine p=0.004). The preferred methods to learn about children’s pain management were role-modeling (61%) and lectures (57%). The top challenges in pain management were with non-verbal, younger, or developmentally delayed patients.

Canadian EM residents report receiving inadequate training in pediatric pain management, and are particularly uneasy with younger or developmentally disabled children. Post-graduate curricula should be adjusted to correct these self-identified weaknesses in children’s pain management.

Collaborative writing applications (CWAs), such as the Google DocsTM platform, can improve skill acquisition, knowledge retention, and collaboration in medical education. Using CWAs to support the training of residents offers many advantages, but stimulating them to contribute remains challenging. The purpose of this study was to identify emergency medicine (EM) residents’ beliefs about their intention to contribute summaries of landmark articles to a Google DocsTM slideshow while studying for their Royal College of Physicians and Surgeons of Canada (RCPSC) certification exam.

Using the Theory of Planned Behavior, the authors interviewed graduating RCPSC EM residents about contributing to a slideshow. Residents were asked about behavioral beliefs (advantages/disadvantages), normative beliefs (positive/negative referents), and control beliefs (barriers/facilitators). Two reviewers independently performed qualitative content analysis of interview transcripts to identify salient beliefs in relation to the defined behaviors.

Of 150 eligible EM residents, 25 participated. The main reported advantage of contributing to the online slideshow was learning consolidation (n=15); the main reported disadvantage was information overload (n=3). The most frequently reported favorable referents were graduating EM residents writing the certification exam (n=16). Few participants (n=3) perceived any negative referents. The most frequently reported facilitator was peer-reviewed high-quality scientific information (n=9); and the most frequently reported barrier was time constraints (n=22).

Salient beliefs exist regarding EM residents’ intention to contribute content to an online collaborative writing project using a Google DocsTM slideshow. Overall, participants perceived more advantages than disadvantages to contributing and believed that this initiative would receive wide support. However, participants reported several barriers that need to be addressed to increase contributions. Our intention is for the beliefs identified in this study to contribute to the design of a theory-based questionnaire to explore determinants of residents' intentions to contribute to an online collaborative writing project. This will help develop implementation strategies for increasing contributions to other CWAs in medical education.

Determining which patients with ureterolithiasis are likely to require urologic intervention is a common challenge in the emergency department (ED). The objective was to determine if normal renal sonogram could identify low-risk renal colic patients, who were defined as not requiring urologic intervention within 90 days of their initial ED visit and can be managed conservatively.

This was a prospective cohort study involving adult patients presenting to the EDs of a tertiary care centre with suspected renal colic over a 20-month period. Renal ultrasonography (US) was performed in the diagnostic imaging department by trained ultrasonographers, and the results were categorized into four mutually exclusive groups: normal, suggestive of ureterolithiasis, visualized ureteric stone, or findings unrelated to urolithiasis. Electronic medical records were reviewed to determine if patients received urologic intervention within 90 days of their ED visit.

Of 610 patients enrolled, 341 (55.9%) had US for suspected renal colic. Of those, 105 (30.8%) were classified as normal; none of these patients underwent urologic intervention within 90 days of their ED visit. Ninety (26.4%) US results were classified as suggestive, and nine (10%) patients received urologic intervention. A total of 139 (40.8%) US results were classified as visualized ureteric stone, and 34 (24.5%) patients had urologic intervention. Seven (2.1%) US results were classified as findings unrelated to urolithiasis, and none of these patients required urologic intervention. The rate of urologic intervention was significantly lower in those with normal US results (p<0.001) than in those with abnormal findings.

A normal renal sonogram predicts a low likelihood for urologic intervention within 90 days for adult ED patients with suspected renal colic.

To evaluate the accuracy of physician estimates of the probability of intracranial injury in children with minor head trauma.

This is a subanalysis of a large prospective multicentre cohort study performed from July 2001 to November 2005. During data collection for the derivation of a clinical prediction rule for children with minor head trauma, physicians indicated their estimate of the probability of brain injury visible on computed tomography (P-Injury) and the probability of injury requiring intervention (P-Intervention) by choosing one of the following options: 0%, 1%, 2%, 3%, 4%, 5%, 10%, 20%, 30%, 40%, 50%, 75%, 90%, and 100%. We compared observed frequencies to expected frequencies of injury using Pearson’s χ2-test in analyses stratified by the level of each type of predicted probability and by year of age.

In 3771 eligible subjects, the mean predicted risk was 4.6% (P-Injury) and 1.4% (P-Intervention). The observed frequency of injury was 4.1% (any injury) and 0.6% (intervention). For all levels of P-Injury from 1% to 40%, the observed frequency of injury was consistent with the expected frequency. The observed frequencies for the 50%, 75%, and 90% levels were lower than expected (p<0.05). For estimates of P-Intervention, the observed frequency was consistently higher than the expected frequency. Physicians underestimated risk for infants (mean P-Intervention 6.2%, actual risk 12.3%, p<0.001).

Physician estimates of probability of any brain injury in children were collectively accurate for children with low and moderate degrees of predicted risk. Risk was underestimated in infants.