Requests for specialty consultation are common in emergency departments (EDs) and often contribute to delays in throughput. Our objectives were to describe the contribution of the consultation process to total ED length of stay (LOS) through novel metrics and illustrate causes of delay.

We conducted a prospective cross-sectional study at three Canadian tertiary care centres. Adult ED patients with requested medical/surgical consultations were enrolled. We created original metric intervals: total consultation time (TCT) defined as the interval from the initial consultation request to the disposition decision, consult response time (CRT) from the request to the consultant arrival, and decision-making interval (DMI) from arrival to the disposition decision. The consultation impact index (CII) was defined as the percentage of ED LOS consumed by the TCT. Reasons for delay were documented if time stamps exceeded preset benchmarks.

The median TCT for 285 patients was 138 minutes (interquartile range [IQR]: 82–239 minutes), whereas the median total ED LOS was 778 minutes (IQR 485–1,274 minutes). The median CRT was 55 minutes (IQR 21–115 minutes), and the median DMI was 58 minutes (IQR 25–126 minutes). The CII measured 26% (95% CI 23–28). Major contributors to consultation delay included urgent ward issues, simultaneous ED consultations, and the need for additional laboratory or radiographic investigations.

The consultation process is highly variable and has an important impact on ED LOS. We describe novel measures related to consultation performance and provide an analysis of what causes delays. These results can be used to seek improvements in the consulting process.

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors.

This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists’ recommendations.

A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5–3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32–4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54–9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18–4.14).

Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

Despite evidence that patients suffering major traumatic injuries have improved outcomes when cared for within an organized system, the extent of trauma system development in Canada is limited. We sought to compile a detailed inventory of trauma systems in Canada as a first step toward identifying opportunities for improving access to trauma care.

We distributed a nationwide online and mail survey to stakeholders intended to evaluate the extent of implementation of specific trauma system components. Targeted stakeholders included emergency physicians, trauma surgeons, trauma program medical directors and program managers, prehospital providers, and decision makers at the regional and provincial levels. A “snowball” approach was used to expand the sample base of the survey. Descriptive statistics were generated to quantify the nature and extent of trauma system development by region.

The overall response rate was 38.7%, and all levels of stakeholders and all provinces/territories were represented. All provinces were found to have designated trauma centres; however, only 60% were found to have been accredited within the past 10 years. Components present in 50% or fewer provinces included an inclusive trauma system model, interfacility transfer agreements, and a mechanism to track bed availability within the system.

There is significant variability in the extent of trauma system development in Canada. Although all provinces have designated trauma centres, opportunities exist in many systems to implement additional components to improve the inclusiveness of care. In future work, we intend to quantify the strength of the relationship between different trauma system components and access to definitive trauma care.

Blood glucose can be lowered via insulin and/or fluid administration. Insulin, although efficacious, can cause hypoglycemia and hypokalemia. Fluids do not cause hypoglycemia or hypokalemia, but the most effective route of fluid administration has not been well described. This study compared the efficacy and safety of oral versus intravenous fluids for reducing blood glucose in patients with hyperglycemia.

We conducted a prospective, nonblinded, randomized, controlled trial. Inclusion criteria were blood glucose > 13.9 mmol/L, age > 18 years, and ability to tolerate oral fluids. Subjects were excluded for critical illness, contraindication to fluids, and/or hyperglycemia therapy prior to enrolment. Subjects were randomized to receive oral bottled water or intravenous normal saline (maximum 2 L) over 2 hours. The primary outcome of interest was a change in blood glucose at 2 hours across treatment arms.

The 48 subjects were randomized. Baseline blood glucose levels and total amount of fluid received were similar between the two groups. The mean decrease in blood glucose at 2 hours was similar for both treatment arms: a mean decrease of 3.4 mmol/L (20.2 mmol/L to 16.8 mmol/L) in the oral fluid group versus a mean decrease of 4.0 mmol/L (19.7 mmol/L to 15.7 mmol/L) in the intravenous fluid group. The mean difference between groups was −0.6 mmol/L (95% confidence interval −2.3–1.2; p = 0.51). No adverse events were observed in either group.

In this unblinded randomized trial, oral and intravenous fluids were equally efficacious in lowering blood glucose levels in stable hyperglycemic patients and no adverse events were noted. Physicians should be mindful that, although similar, the reduction in blood glucose was modest in both groups.

Emergency department (ED) overcrowding in Canada is an ongoing problem resulting in prolonged wait times, service declines, increased patient suffering, and adverse patient outcomes. We explored the relationship between socioeconomic status (SES) and ED use in Canada's universal health care system to improve our understanding of the nature of ED users to both improve health care to the most deprived populations and reduce ED patient input.

This retrospective study took information from the National Ambulatory Care Reporting System (NACRS) database for all ED visits in Ontario between April 1, 2003, and March 31, 2010. As there is no direct measure of SES available from ED visit records, a proxy measure of SES was used, namely a deprivation index (DI) developed from material and social factors from the 2006 Canadian census using the patient's residential neighbourhood. DI scores were assigned to ED visit records using Statistics Canada's Postal Code Conversion File, which links postal and census geography.

A total of 36,765,189 visits occurred during the study period. A cross-province trend was found wherein the most deprived population used EDs disproportionately more than the least deprived population (relative risk: 1.971 95% confidence interval 1.969–1.973, p < 0.0001). This trend was stable across the entire study period, although the divergence is attenuating.

Social determinants of health clearly impact ED use patterns. People of the lowest SES use ED services disproportionately more than other socioeconomic groups. Focused health system planning and policy development directed at optimizing health services for the lowest SES populations are essential to changing ED use patterns and may be one method of decreasing ED overcrowding.

The lifetime prevalence of ureterolithiasis is approximately 13% for men and 7% for women in the United States. Tamsulosin, an α-antagonist, has been used as therapy to facilitate the expulsion of lithiasis. Whether it is a good treatment for distal lithiasis remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of tamsulosin on the passage of distal ureterolithiasis.

A systematic search was conducted using MEDLINE, EMBASE, and Cochrane Central. Trial eligibility was evaluated by two investigators. All randomized controlled trials (RCTs) comparing tamsulosin to standard therapy or placebo for the treatment of a single distal ureterolithiasis ≤ 10 mm in adult patients with renal colic confirmed by radiographic imaging were included. Data extraction was conducted in duplicate. Primary outcome was the expulsion rate, and secondary outcomes were the mean time for ureterolithiasis expulsion, analgesic requirements, and side effects. Mantel-Haenszel random effect models were used, and heterogeneity was assessed using I2 statistics. Data were presented with relative risks (RRs).

The search strategy identified 685 articles, of which 22 studies were included. Combined results suggested a benefit for the expulsion of ureterolithiasis (≥ 10 mm) when tamsulosin was used compared to a standard treatment (RR 1.50 [95% CI 1.31–1.71], I2 = 70%). A decrease in the average time of expulsion of the ureterolithiasis of 3.33 days in favour of tamsulosin was observed (95% CI −4.23, −2.44], I2 = 67%).

Tamsulosin increases the rate of spontaneous passage of distal ureterolithiasis (≤ 10 mm).