Long-term care (LTC) patients are often sent to emergency departments (EDs) by ambulance. In this novel extended care paramedic (ECP) program, specially trained paramedics manage LTC patients on site. The objective of this pilot study was to describe the dispatch and disposition of LTC patients treated by ECPs and emergency paramedics.

Data were collected from consecutive calls to 15 participating LTC facilities for 3 months. Dispatch determinants, transport rates, and relapse rates were described for LTC patients attended by ECPs or emergency paramedics. ECP involvement in end-of-life care was identified.

Of 238 eligible calls, 140 (59%) were attended by an ECP and 98 (41%) by emergency paramedics. Although the top three determinants were the same in each group, the overall distribution of dispatch determinants and acuity differed. In the ECP cohort, 98 of 140 (70%) were treated and released, 33 of 140 (24%) had “facilitated transfer” arranged by an ECP, and 9 of 140 (6%) were immediately transported to the ED by ambulance. In the emergency paramedic cohort, 77 of 98 (79%) were immediately transported to the ED and 21 of 98 (21%) were not transported. In the ECP group, 6 of 98 (6%) patients not transported triggered a 911 call within 48 hours for a related clinical reason, although none of the patients not transported by emergency paramedics relapsed.

ECP involvement in LTC calls was found to reduce transports to the ED with a low rate of relapse. These pilot data generated hypotheses for future study, including determination of appropriate populations for ECP care and analysis of appropriate and safe nontransport.

Influenza assessment centres (IACs) were deployed to reduce emergency department (ED) volumes during the pH1N1 influenza outbreak in the Kingston, Frontenac, Lennox and Addington (KFL&A) public health region of Ontario, Canada, in the fall of 2009. We present a case study for the deployment of IACs to reduce ED visit volume during both periods of pandemic and seasonal communicable disease outbreak.

An emergency department syndromic surveillance system was used to trigger the deployment of eight geographically distributed IACs and to time their staggered closure 3 weeks later. We compared actual and expected ED visit volumes in the KFL&A region to neighbouring regions where no IACs operated by time series regression analysis before, during, and after IAC operation.

The deployment of IACs was triggered with a rise in overall ED volume at the hospitals in the KFL&A region to a level 10% above the 6-month running average. The IACs assessed 2,284 patients during 3 weeks of operation. Thirtythree patients were admitted directly to the hospital from the IACs, bypassing the EDs. During the operation of the IACs, the hospitals in the KFL&A region experienced a modest decrease in daily visits when compared to the 3 previous weeks. Overall ED visit volume in the hospitals in the neighbouring regions increased 105% during the period of IAC operation.

Operating stand-alone influenza IACs may reduce ED volumes during periods of increased demand, as observed during an anticipated pandemic situation.

Frequent emergency department (ED) users are inconsistently defined and poorly studied in Canada. The purpose of this study was to develop uniform definitions, quantify ED burden, and characterize adult frequent users of a suburban community ED.

We retrospectively reviewed the administrative database of the WestView ED in Alberta for patients ≥ 18 years of age presenting during the fiscal year of 2010. Adult frequent users and extreme frequent users were defined as patients with yearly visit numbers greater than the 95th and 99th percentiles, respectively. Demographic information including age, sex, ED length of stay, diagnoses, Canadian Triage and Acuity Scale (CTAS) level, and disposition were collected and stratified by ED frequency of use categories.

The study included 22,333 ED visits by 14,223 patients. Frequent users represented 3.1% of patients and 13.8% of visits. Extreme frequent users represented 0.8% of patients, 5.4% of visits, and 568,879 cumulative ED minutes (395 days). Nonfrequent users had one to four, frequent users had five or more, and extreme frequent users had eight or more visits over a 12-month period. Frequent users and extreme frequent users had a significantly longer ED length of stay overall and in most age categories. Alcohol-related behavioural disorders, anxiety, nausea/vomiting, and chronic obstructive pulmonary disease were prominent diagnoses, suggesting that psychiatric, somatic, and chronic illnesses may underlie recurrent visits. Admission rates were significantly higher for frequent compared to nonfrequent users.

We propose reproducible definitions for adult frequent and extreme frequent ED users and provide information on the characteristics and burden of care of these groups at a community Canadian suburban ED. Adoption of these definitions would allow comparison across centres in future research and facilitate targeted interventions for frequent and extreme frequent ED users.

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.

Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.

There was a higher level of agreement (κ = 0.73; 95% CI 0.68–0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ = 0.50; 95% CI 0.42–0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ = 0.80; 95% CI 0.76–0.84).

The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

This study sought to establish the current state of procedural skills training in Canadian Royal College emergency medicine (EM) residencies.

A national Web-based survey was administered to residents and program directors of all 13 Canadian-accredited Royal College EM residency programs. Programdirectors rated the importance and experience required for competence of 45 EM procedural skills. EM residents reported their experience and comfort in performing the same procedural skills.

Thirteen program directors and 86 residents responded to the survey (response rate of 100% and 37%, respectively). Thirty-two (70%) procedures were considered important by > 70% of program directors, including all resuscitation and lifesaving airway procedures. Four procedures deemed important by program directors, including cricothyroidotomy, pericardiocentesis, posterior nasal pack for epistaxis, and paraphimosis reduction, had never been performed by the majority of senior residents. Program director opinion was used to categorize each procedure based on performance frequency to achieve competence. Overall, procedural experience correlated positively with comfort levels as indicated by residents.

We established an updated needs assessment of procedural skills training for Canadian Royal College EM residency programs. This included program director opinion of important procedures and the performance frequency needed to achieve competence. However, we identified several important procedures that were never performed by most senior residents despite program director opinion regarding the experience needed for competence. Further study is required to better define objective measures for resident competence in procedural skills.