A reliable emergency department (ED) workload measurement tool would provide a method of quantifying clinical productivity for performance evaluation and physician incentive programs; it would enable health administrators to measure ED outputs; and it could provide the basis for an equitable formula to estimate ED physician staffing requirements. Our objectives were to identify predictors that correlate with physician time needed to treat patients and to develop a multivariable model to predict physician workload.

During 31 day, evening, night and weekend shifts, a research assistant (RA) shadowed 20 emergency physicians, documenting time spent performing clinical and non-clinical functions for 585 patient visits. The RA recorded key predictors including patient gender, age, vital signs and Glasgow Coma Scale (GCS) score, and the mode of arrival, triage level assigned, comorbidity and procedures performed. Multiple linear regression was used to describe the associations between predictor variables and total physician time per patient visit (TPPV), and to derive an equation for physician workload. Model derivation was based on 16 shifts and 314 patient visits; model validation was based on 15 shifts and 271 additional patient visits.

The strongest predictor variables were: procedure required, triage level, arrival by ambulance, GCS, age, any comorbidity, and number of prior visits. The derived regression equation is: TPPV = 29.7 + 8.6 (procedure required [Yes]) – 3.8 (triage level [1–5]) + 7.1 (ambulance arrival) – 1.1 (GCS [3–15]) + 0.1 (age in years) – 0.05 (n of previous visits) + 3.1 (any comorbidity). This model predicted 31.3% of the variance in physician TPPV (F [12, 29] = 13.2; p < 0.0001).

This study clarifies important determinants of emergency physician workload. If validated in other settings, the predictive formula derived and internally validated here is a potential alternative to current simplistic models based solely on patient volume and perceived acuity. An evidence-based workload estimation tool like that described here could facilitate ED productivity measurement, benchmarking, physician performance evaluation, and provide the substrate for an equitable formula to estimate ED physician staffing requirements.

To assess patient comprehension of emergency department discharge instructions and to describe other predictors of patient compliance with discharge instructions.

Patients departing from the emergency department of an inner-city teaching hospital were invited to undergo a structured interview and reading test, and to participate in a follow-up telephone interview 2 weeks later. Two physicians, blinded to the other's data, scored patient comprehension of discharge information and compliance with discharge instructions. Inter-rater reliability was assessed using a kappa-weighted statistic, and correlations were assessed using Spearman's rank correlation coefficient and Fisher's exact test.

Of 106 patients approached, 88 (83%) were enrolled. The inter-rater reliability of physician rating scores was high (kappa = 0.66). Approximately 60% of subjects demonstrated reading ability at or below a Grade 7 level. Comprehension was positively associated with reading ability (r = 0.29, p = 0.01) and English as first language (r = 0.27, p = 0.01). Reading ability was positively associated with years of education (r = 0.43, p < 0.0001) and first language (r = 0.24, p = 0.03), and inversely associated with age (r = -0.21, p = 0.05). Non-English first language and need for translaor were associated with poorer comprehension of discharge instructions but not related to compliance. Compliance with discharge instructions was correlated with comprehension (r = 0.31, p = 0.01) but not associated with age, language, education, years in anglophone country, reading ability, format of discharge instructions, follow-up modality or association with a family physician.

Emergency department patients demonstrated poor reading skills. Comprehension was the only factor significantly related to compliance; therefore, future interventions to improve compliance with emergency department instructions will be most effective if they focus on improving comprehension.

Dog bites are a common problem. The purpose of this study was to determine the characteristics of dog bites and their emergency department management in a Canadian pediatric population, and to provide treatment and prevention recommendations.

The charts of all children ≤ 16 years of age presenting with a dog bite to either of the 2 tertiary emergency departments in Edmonton, Alberta, between 1998 and 2002 were retrospectively reviewed.

Overall, 287 cases were reviewed; 145 boys (50.5%) and 142 girls (49.5%). The mean age was 7.4 years. The patient's face was the most frequently bitten site (58.5%, n = 168), followed by an extremity (35.5%, n = 102). Most bites required sutures (54.5%, n = 155), and 72 (25.1%) were classified as severe, based on suture number (>10 sutures, n = 69), associated fractures (n = 4), operating room repair (n = 21) or fatality (n = 1). The mean age of children with severe bites was significantly lower than children with mild bites (6.3 v. 7.8 yr, p < 0.01). Most patients were treated solely in the emergency department (84.7%, n = 243); however 44 (15.3%) were admitted to hospital and required a total of 144 days of inpatient care. Signs of infection were described in 16 cases (5.6%); of these 8 had received 2 or more prior doses of antibiotics. Public health or police notification was documented in 56 cases (19.5%), and safety or preventive discussion was documented in 3 cases (1.0%).

Dog bites in Canadian children are common, often serious or even lethal, and not always managed ideally. Preventive discussion and public health contact is infrequently documented and likely seldom occurs. In addition to medical care, emergency department staff should provide and document preventive guidance and ensure involvement of public health or police when indicated.

To identify the rate of treatment failure in emergency department patients with cellulitis.

This prospective observational convenience study enrolled adult patients with uncomplicated cellulitis. Physicians performed a standardized assessment prior to treatment. To calculate the interrater reliability of the assessment, duplicate data collection forms were completed on a small subsample of patients. Treatment failure was defined as the occurrence of any one of the following events after the initial emergency department visit: incision and drainage of abscess; change in antibiotics (not due to allergy/intolerance); specialist consultation; or, hospital admission. Comparison of means and proportions between the 2 groups was performed with univariate associations, using parametric or non-parametric tests where appropriate.

Seventy-five patients were enrolled; 57% were male, the mean age was 48 (standard deviation 19), 71 (95%) patients had extremity cellulitis and 10 (13%) had abscess with cellulitis. Fourteen episodes (18.7%, 95% confidence interval [CI] 11%–28%) were classified as treatment failures, with an oral antibiotic failure rate of 6.8% (95% CI 2%–22%) and an emergency department-based intravenous antibiotic failure rate of 26.1% (95% CI 16%–40%). Patients with treatment failure were older (mean age 59 yr v. 46 yr, p = 0.02) and more likely to have been taking oral antibiotics at enrolment (50% v. 16.4%, p = 0.01). Patients with a larger surface area of infection were also more likely to fail treatment (465.1 cm2 v. 101.5 cm2, p < 0.01). Interrater agreement was high for the presence of fever (kappa 1.0) and the size of surface area of infection (intraclass correlation coefficient 0.98), but low for assessments of both severity (kappa 0.35) and need for admission (kappa 0.46).

The treatment of cellulitis with daily emergency department–based intravenous antibiotics has a failure rate of more than 25% in our centre. Cellulitis patients with a larger surface area of infection and previous (failed) oral therapy are more likely to fail treatment. Further research should focus on defining eligibility for treatment with emergency department-based intravenous antibiotics.

To explore the public's expectations of emergency department care and to compare these with emergency department staff perceptions of patient expectations.

Focus groups were conducted with the residents of Calgary, Alta., and with emergency department staff in the Calgary Health Region. Both recent users of the emergency department and people who had not used the emergency department in the past 3 years were included in this study. An experienced moderator conducted the focus groups, which were taped and then transcribed. A well established method of qualitative analysis identified common themes.

The focus groups identified common expectations of emergency department care. Public expectations were categorized into 6 thematic areas: staff communication with patients, appropriate waiting times, the triage process, information management, quality of care, and improvements to existing services. Those who had recently used the emergency department had similar expectations to those who had not. Emergency department care providers understand some, but not all, of the public's expectations.

Public expectations of emergency department care were identified by this study. The findings are important for quality improvement initiatives and were used to develop a quantitative questionnaire.

Our primary objective was to survey the graduates of one residency program with respect to anticipated versus actual medical practice.

Using a modified Dillman technique, we surveyed all 83 physicians who had completed one year of residency training that led to certification of special competency in Emergency Medicine (CCFP-EM) at the University of Western Ontario (UWO) from 1982–2004. Respondents were asked what type of medicine they had thought they would practise before beginning their emergency medicine training. They were then asked to describe their employment from graduation to present time. Additional demographic information was collected. Correlation between demographic factors and other selected factors of influence upon career decisions was analyzed.

Our response rate was 87% (72/83), with 71% (51/72) respondents being male. At the start of their CCFP-EM residency training, 50% of respondents intended to practise emergency medicine exclusively and 47% intended to blend family and emergency medicine. For each of the respondents' first 4 positions of employment, the greatest percentage were practising emergency medicine only (ranging from 72% in position 1 to 53% in position 4), while the number engaging in a blended family/emergency medicine practice never exceeded 20%. No demographic factors surveyed had significant correlation with intended or actual practice. In all positions of employment, “type of practice” was ranked as the most influential factor in choosing that position.

Most graduates of the UWO CCFP-EM program practise in emergency medicine only positions. Less than 20% are engaged in a blended family/emergency medicine practice. At training onset, one-half of the residents intended to practise emergency medicine exclusively. None of the demographic factors surveyed significantly correlated with intended or actual practice. Further examination of the practice patterns of all emergency medicine residency program graduates is an essential part of future planning for the specialty of Emergency Medicine in Canada.

Traditionally, patients have to wait until assessed by a physician for opioid analgesia to be administered, which contributes to delays to analgesia. Western Hospital developed a protocol enabling nurses to initiate opioid analgesia prior to medical assessment for selected conditions. The aim of this study was to determine the impact of this protocol on time to first opioid dose in patients presenting to the emergency department (ED) with renal or biliary colic.

This was an explicit medical record review of all adult patients with an ED discharge diagnosis of renal or biliary colic presenting to a metropolitan teaching hospital ED. Patients were identified via the ED data management system. Data collected included demographics, condition, triage category, time of presentation, whether analgesia was nurse-initiated or not, and interval from arrival to first opioid analgesic dose. The narcotic drug register for the relevant period was also searched to cross-check whether opiates were doctor- or nurse-initiated.

There were 58 presentations in the nurse-initiated opioid analgesia group and 99 in the non-nurse-initiated analgesia group. Groups were reasonably well matched for gender, triage category and time of presentation, but there was a higher proportion of biliary colic in the non-nurse-initiated analgesia group. Median time to first analgesic dose was 31 minutes in the nurse-initiated group and 57 minutes in the non-nurse-initiated analgesia group (effect size, 26 minutes; 95% confidence interval 16-36 min; p < 0.0001]. There were no major adverse events in either group.

A nurse-initiated opioid analgesia protocol reduces delays to opioid analgesia for patients with renal and biliary colic.

To maintain continuity of care when a patient's care is transferred between physicians, continuity of patient information is required. This survey determined how, and how well, Ontario emergency departments (EDs) communicate patient information to physicians in the community.

We surveyed Ontario ED chiefs to determine the most common media and methods used for disseminating information. We measured the perceived quality of their system, which was regressed against the hospital teaching status and community size using generalized logits modelling. Finally, we elicited the components of an ideal communication system for the ED.

One hundred and forty-three (85.6%) Ontario ED chiefs participated. The ED record of treatment was the most commonly used medium (95%). Postal service was the most common (55%) method of disseminating information. Thirty-three chiefs (23%) perceived the quality of communicating patient information from their ED as unsatisfactory or inadequate. This perception was significantly more prevalent in larger communities (excellent v. unsatisfactory [odds ratio (OR) 44.9, 95% confidence interval (CI) 13.9-140] and satisfactory v. unsatisfactory [OR 2.9, 95% CI 1.6-5.1]) and in teaching hospitals (satisfactory v. unsatisfactory [OR 9.7, 95% CI 4.7-20.3]). Seventy-eight percent of responding chiefs felt that patient information should be disseminated using electronic means, either through email or server access.

To communicate patient information to community physicians, Ontario ED chiefs report that a copy of the ED record of treatment is sent by postal service. More than one-fifth of ED chiefs perceived communication from their department as unsatisfactory or inadequate. Studies that assess the completeness and accuracy of the record of treatment are required as a first step for measuring the quality of patient information communication in the Ontario ED system.

There is no set of prospectively validated criteria to identify the emergency department (ED) patients with renal colic who are most likely to eventually have to undergo an intervention. This study prospectively assessed predictors of intervention in this patient population.

This prospective cohort study included adult patients with renal colic who presented to 2 tertiary care hospital EDs. Patients had an 18-variable data form completed by an emergency physician and a radiological study to confirm urolithiasis. After discharge, patients were followed at 1 and 4 weeks to assess for intervention. The outcome criteria included the patient having had at least 1 of the following procedures performed: extracorporeal shockwave lithotripsy (ESWL), ureteroscopy, percutaneous nephrostomy or open surgery. Data were analyzed using appropriate univariate techniques, and those variables associated with intervention were combined using logistic regression analysis.

Over an 8-month period, 245 patients with confirmed urolithiasis were followed; 20% (95% confidence interval [CI] 15%–25%) eventually had a procedure to remove their calculi. Three variables were significantly correlated with having a procedure: i) size of calculus ≥ 6 mm (odds ratio [OR] 10.7, 95% CI 4.6–24.8), ii) location of calculus above mid-ureter (OR 6.9, 95% CI 3.0–15.9), and iii) Visual Analogue Scale score for pain at discharge from the ED ≥ 2 cm (OR 2.6, 95% CI 1.0–6.8). The area under receiver operating characteristic curve was 0.77 (95% C I 0.70–0.84) (p < 0.001). If all variables were present there was a 90% probability of the patient having an intervention performed within 4 weeks of discharge from the ED. Conversely, if none of the variables were present there was only a 4% probability of an intervention. Overall, the model had a sensitivity of 92% (95% CI 89%–96%) and a specificity of 63% (95% CI 57%–69%).

This study has identified variables that could potentially be used to identify those renal colic patients who require an intervention after ED evaluation. Future studies will prospectively validate this model.

To determine influenza vaccination rates and attitudes toward vaccination among emergency department health care workers at 4 Ontario teaching hospitals.

During the influenza season of 1999–2000 a confidential 28-item survey was distributed to emergency physicians and residents, nurses, respiratory therapists, and other allied health care workers at the emergency departments of 4 London, Ontario teaching hospitals.

Of 426 surveys distributed, 343 were returned, for an overall response rate of 80.5%. The mean age of respondents was 38.5 years (standard deviation = 8.3), 74.3% were female, and 86.6% were non-smokers. The overall vaccination rate was 37.0% (95% confidence interval, 31.9%–42.4%). Vaccination rates were 45.9% for respiratory therapists, 35.3% for emergency physicians and residents, 34.5% for nurses and 27.1% for other allied health care workers (p = 0.083). Multivariate logistic regression analysis revealed that age ≥41 and a chronic medical condition were positively associated with influenza vaccination (p < 0.05). Close to one-third of respondents (28.3%) believed that adverse affects were common, 51.6% believed vaccination was effective, 52% would support a program to improve vaccination rates among emergency department staff, and 24.4% would support mandatory vaccination for this population. Only 26.8% believed that patients were at increased risk of contracting influenza from emergency department staff, but 58.3% perceived that emergency department staff were at increased risk of contracting influenza through exposure to patients.

In this study, only 37% of emergency department health care workers were immunized against influenza, with chronic illness and older age being the only 2 significant correlates. Strategies to improve emergency department health care worker attitudes toward influenza vaccination for themselves and to increase vaccination rates for this population should be developed.

Faculty development initiatives to improve emergency department (ED) teaching are compromised by the paucity of information about what behaviours and characteristics are desirable in an emergency medicine (EM) teacher.

To design and evaluate a learner-centred, interactive faculty development workshop based on original ED teaching research.

Registrants for a university-based faculty development workshop on ED teaching completed a needs assessment and pre-workshop self-reflection exercise. Responses were grouped into 3 themes derived from the ambulatory teaching literature and a recent survey of expert clinical EM teachers and learners. Participants underwent a half-day workshop consisting of 1 large group interactive session and 3 small group sessions using role playing, practice reflection, real time review of hard copy resources, and brainstorming. Evaluation included a post-event ordinal scale questionnaire and a 4-month follow-up short answer survey, both measuring participants' perceptions of workshop effectiveness.

Fifteen faculty participated. The needs assessment identified “Common mistakes,” “Teaching efficiently” and “Dealing with the difficult learner” as themes. All 15 completed evaluations, rating the workshop as relevant (4.6/5), specific to their needs (4.4/5) and useful (4.5/5). At 4 months, 10 out of 10 respondents reported success at implementing new techniques and 8 reported greater confidence in teaching. The most common new techniques were: setting better learning objectives, giving better feedback, actively seeking teaching opportunities, and identifying a teaching point.

Learner-centred faculty development meets perceived needs of faculty and can result in participants trying new teaching strategies.