CJEM最新文献

{"title":"Discussions about goals of care in the emergency department: a qualitative study of emergency physicians' opinions using the normalization process theory.","authors":"Fannie Péloquin, Émile Marmen, Véronique Gélinas, Ariane Plaisance, Maude Linteau, Audrey Nolet, Nathalie Germain, Patrick M Archambault","doi":"10.1007/s43678-025-00911-8","DOIUrl":"https://doi.org/10.1007/s43678-025-00911-8","url":null,"abstract":"<p><strong>Purpose: </strong>We explored emergency department (ED) physicians' opinions about leading goals of care discussions in their daily practice. We contextualized our findings within the current landscape of ED goals of care.</p><p><strong>Methods: </strong>This qualitative study was based on the Normalization Process Theory. We conducted semi-structured interviews with a convenience sample of ten emergency physicians from one academic ED (Lévis, Canada) and aimed to reach data saturation. Using a mixed deductive and inductive thematic analysis, we codified the interviews under the four Normalization Process Theory constructs: coherence, cognitive participation, collective action, and reflexive monitoring.</p><p><strong>Results: </strong>We interviewed 10 emergency physicians. Fourteen themes were identified as factors influencing the feasibility of implementing goals of care discussions in the ED: (1) interpersonal communication, (2) efficiency of care, (3) anxiety generated by the discussion, (4) meeting between clinicians, patients and family, (5) importance of goals of care during handover, (6) deterioration catalyzing the goals of care discussions, (7) lack of training, (8) availability of protocols, (9) heterogeneous prioritization of goals of care discussions, (10) take action before the ED, (11) need for education, (12) legislation, (13) adapt the ED environment, and (14) requirement to lead goals of care discussions.</p><p><strong>Conclusion: </strong>Goals of care discussions are possible and essential with selected ED patients. Physicians identified outstanding needs to normalize goals of care discussions in their practice: education for both themselves and patients on the concept of goals of care discussions, legislative action for the systematization of goals of care discussions for patients, and proactive documentation of patients' preferences pre-ED. Patient, clinician and system-level policy-making efforts remain necessary to address these needs and ensure the normalization of goals of care discussions in emergency physicians' daily practice as suggested by clinical guidelines.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144251283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Socioeconomic and rural-urban inequalities in emergency department utilization during the perinatal period.","authors":"Ruben Ohanian, Jesus Serrano-Lomelin, Brian H Rowe, Susan Crawford, Susan Jelinski, Maria B Ospina","doi":"10.1007/s43678-025-00945-y","DOIUrl":"https://doi.org/10.1007/s43678-025-00945-y","url":null,"abstract":"<p><strong>Objective: </strong>To assess inequalities in emergency department utilization during the perinatal period across socioeconomic and rural-urban gradients in Alberta, Canada.</p><p><strong>Methods: </strong>We conducted a secondary analysis of a population-based cohort study of live-birth pregnancies in Alberta between 2011 and 2017. Emergency department visits during pregnancy and up to 1-year postpartum were analyzed. Socioeconomic position was assessed using 25 combined groups derived from quintiles of material and social deprivation. Rural-urban residence was categorized into seven geographic groups based on Alberta Health Services' classification. Concentration indexes quantified inequalities in emergency department utilization, categorized as low (≤ 0.05), medium (0.06-0.19), or high (≥ 0.20). Multilevel negative binomial regression models estimated adjusted rate ratios and 95% confidence intervals to measure differences in emergency department visit rates across socioeconomic and rural-urban groups, accounting for individual-level covariates.</p><p><strong>Results: </strong>Among 242,514 pregnancies, 366,241 emergency department visits were identified. Moderate inequality was observed across socioeconomic groups (concentration index = - 0.17, 95% confidence interval - 0.18 to - 0.16). Rates of emergency department visits were 1.7 times higher among the most deprived groups compared to the least deprived groups (adjusted rate ratio = 1.7; 95% confidence interval 1.6 to 1.8). Inequality across the rural-urban continuum was more pronounced (concentration index of - 0.31 (95% confidence interval - 0.32 to - 0.30), with rural residents experiencing significantly higher emergency department use. Compared to metropolitan areas, emergency department visits were nearly three times higher in rural centers (adjusted rate ratio = 2.9; 95% confidence interval 2.8 to 3.0) and near six times higher in rural remote areas (adjusted rate ratio = 5.5; 95% confidence interval 5.3 to 5.7).</p><p><strong>Conclusion: </strong>Significant inequalities in perinatal emergency department utilization are evident across both socioeconomic and urban-rural gradients. These findings highlight the need for targeted health-system interventions to improve access to appropriate, continuous perinatal care among disadvantaged and rural populations.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144217859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Paramedics and opioid use disorder: the case for a \"Lights and Sirens\" response.","authors":"Mark Froats, Michael A Austin","doi":"10.1007/s43678-025-00946-x","DOIUrl":"https://doi.org/10.1007/s43678-025-00946-x","url":null,"abstract":"","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144217858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health system utilization following medical advice from Alberta's Virtual MD: a descriptive analysis.","authors":"Richard Golonka, Mary V Modayil, Razieh Mansouri, Fayaz Kurji, Jane Q Huang, Wei Zhao, Denise Watt, Jake Hayward, Patricia Chambers, Carolyn Grolman, Judy Seidel, Robin L Walker","doi":"10.1007/s43678-025-00928-z","DOIUrl":"https://doi.org/10.1007/s43678-025-00928-z","url":null,"abstract":"<p><strong>Objectives: </strong>Alberta's Virtual MD program was established to enhance nurse tele-triage and divert low-acuity patients from the emergency department (ED). This study describes the use of Virtual MD and its impact on healthcare utilization.</p><p><strong>Methods: </strong>Demographic and clinical characteristics of Virtual MD patients were compared with Health Link 811 callers and the overall Alberta population between April 1, 2022, and March 31, 2023. Virtual MD recommendations included seeing a primary care provider, going to ED/urgent care, and self-management at home. Concordance with recommendations was determined using linked health administrative data.</p><p><strong>Results: </strong>Virtual MD patients (n = 19,312) had a mean age of 34.8 years and were mostly female (62.3%). Compared to Health Link 811 callers, Virtual MD patients were slightly older (≥ 55 years) (20.8% vs. 25.0%). Of patients who called within 4 h, 55.7% visited primary care within 14 days as advised, 60.0% visited ED within 2 days as advised and 52.5% of those advised to self-manage care at home did not use any healthcare within 14 days. Those advised to seek primary care had a higher odds [OR = 1.65 (95%CI: 1.24-2.21)] of family practice-sensitive conditions when they presented at ED compared to those advised to seek ED care. Hospitalization within 2 weeks was lower for patients advised to see primary care compared to those advised to see ED [4 h callback: OR = 0.33 (95%CI: 0.26 - 0.43), 24 h callback: OR = 0.15 (95%CI 0.08 - 0.28)].</p><p><strong>Conclusion: </strong>Virtual MD effectively triaged patients, with over half following through on recommendations to see primary care, see ED, or self-manage care at home. Patients referred to primary care, but instead choosing to visit ED, were more likely to present with family practice-sensitive conditions, demonstrating appropriateness of the initial primary care advice. Overall, the Virtual MD service enables patients to access more appropriate levels of care for their healthcare needs.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144217856","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multicenter review of antimicrobial stewardship in the emergency department through pharmacist-led culture review and follow-up programs in Alberta.","authors":"Ivy Nhan, Tracy Chin, Elissa Rennert-May, Thomas Brownlee, Micheal Guirguis, Irina Rajakumar","doi":"10.1007/s43678-025-00940-3","DOIUrl":"https://doi.org/10.1007/s43678-025-00940-3","url":null,"abstract":"<p><strong>Background: </strong>In some emergency departments (EDs), pharmacists review and follow-up on microbiological test results for recently discharged patients, intervening when empiric therapy is missing or inadequate to ensure appropriate antimicrobial use. Currently, this practice is not well described in Canada. Characterizing these ED pharmacist activities can help identify antimicrobial stewardship opportunities and allow for more tailored education and training.</p><p><strong>Objectives: </strong>The primary objective of this study was to describe culture review and follow-up pharmacy practice in terms of antimicrobial stewardship interventions. Secondary objectives included describing the types of cultures being managed and the antimicrobials prescribed empirically and post-culture review.</p><p><strong>Methods: </strong>A retrospective chart review was conducted using pharmacist workload tracking documentation to identify patients with eligible cultures from six EDs in Alberta.</p><p><strong>Results: </strong>Three hundred cultures were included in this study, and one hundred twenty-nine interventions (40.7% of all cultures reviewed) were performed by ED pharmacists. Initiation of therapy was the most common (33.3%), followed by tailoring therapy (21.7%). Urine cultures were predominant (55.7%), and the antibiotics most prescribed, empirically, and post-culture for urine, were cefixime (44%) and trimethoprim-sulfamethoxazole (34%), respectively. Five patients with asymptomatic bacteriuria were treated with antibiotics. Five patients with skin and soft tissue infections were treated with dual oral antibiotics when culture and sensitivity results indicated monotherapy would have been sufficient. Eight extra days of cefixime therapy were prescribed due to unaccounted doses administered in the ED.</p><p><strong>Conclusion: </strong>This study highlights the critical role of ED pharmacists in culture review and follow-up activities and their contributions to antimicrobial stewardship. By characterizing culture review and follow-up practices, several opportunities for minimizing unnecessary antimicrobial use were identified. These findings will help inform the development of targeted education and training programs to help strengthen the stewardship capabilities of ED pharmacists and prescribers.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144217857","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Are paramedics comfortable and confident in their ability to provide emergency healthcare to transgender and gender diverse populations? A cross-sectional survey.","authors":"Lyon Kengis, Michael Kruse, Robin Urquhart, Judah Goldstein","doi":"10.1007/s43678-025-00947-w","DOIUrl":"https://doi.org/10.1007/s43678-025-00947-w","url":null,"abstract":"<p><strong>Introduction: </strong>Transgender and gender diverse people report high rates of healthcare avoidance, yet they also access emergency departments at higher rates than the general population. Our research explores the paramedic perspective of providing care to transgender and gender diverse populations. The objectives were to assess paramedic comfort, confidence, and knowledge in providing healthcare to transgender and gender diverse communities.</p><p><strong>Methods: </strong>A descriptive, cross-sectional electronic survey was administered to paramedics licensed with the College of Paramedics of Nova Scotia (n = 1281) between April 9 and May 7, 2018. A 4-point Likert scale and open-ended questions about paramedic comfort, confidence, and knowledge were included. Descriptive statistics were used to describe respondent characteristics. Open-ended questions pertaining to paramedic knowledge needs were evaluated using constant comparative analyses employing open coding to identify themes.</p><p><strong>Results: </strong>The response rate for the survey was 30%, with 387 licensed paramedics participating. Most respondents (66.2%) reported providing care to a patient who identified as transgender and gender diverse. A few respondents (4.9%) felt very confident in their knowledge regarding transgender and gender diverse identities and only 26.6% felt very comfortable in providing optimal care. Of those surveyed, 74.7% had no formal education on transgender and gender diverse health. Close to half (41.9%) reported observing transphobia in the workplace. Most respondents (70%) were interested in obtaining formal education and believed that it should be included in formative education curricula. Paramedics identified four distinct barriers to delivering equitable healthcare to transgender and gender diverse populations: (1) systemic, (2) personal, (3) socio-cultural, and (4) educational barriers.</p><p><strong>Conclusion: </strong>Paramedics provide emergency healthcare to transgender and gender diverse patients. Comfort and confidence in providing this care were relatively low and identifiable barriers inhibit paramedic capacity to provide equitable healthcare. There was strong interest for education on transgender and gender diverse health and emergency presentations.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144210428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The increased mortality of older patients with moderate traumatic brain injury.","authors":"Chartelin Jean Isaac, Axel Benhamed, Valérie Boucher, Samuel Lauzon, Pierre-Gilles Blanchard, Christian Malo, Francis Bernard, Jean-Marc Chauny, Mélanie Bérubé, Eric Mercier, Amaury Gossiome, Myreille D'Astous, Marcel Émond","doi":"10.1007/s43678-025-00941-2","DOIUrl":"https://doi.org/10.1007/s43678-025-00941-2","url":null,"abstract":"<p><strong>Purpose: </strong>Higher mortality has been reported in older patients with moderate traumatic brain Injuries (TBI) compared to younger patients. To identify the risk factors associated with in-hospital mortality, complications and extended length of stay in moderate TBI patients.</p><p><strong>Methods: </strong>DESIGN: a multicentre observational cohort study using the Quebec Trauma Registry.</p><p><strong>Population: </strong>Hospitalized patients aged ≥ 16 with a moderate TBI (a head injury with an Abbreviated Injury Scale (AIS) ≥ 3, and a GCS score of 9-12).</p><p><strong>Outcomes: </strong>In-hospital mortality, complications and prolonged length of stay.</p><p><strong>Analyses: </strong>Multivariable logistic regression.</p><p><strong>Results: </strong>We included 1005 patients, 38.1% of whom were aged ≥ 65. The in-hospital mortality rate was 20.1%. Male sex (OR = 1.6 [95% CI:1.02-2.6], age (≥ 85 years old VS < 65 years) (OR = 18.7 [95% CI: 9.2-38.1]), ≥ 2 comorbidities (OR = 2.3 [95% CI: 1.3-4.0]), Injury Severity Score (OR = 1.04 [95% CI: 1.01-1.1]), presence of intraparenchymal hematoma (OR = 3.5 [95% CI: 2.2-5.5]) or other CT scan findings (cerebral edema, pneumocephalus, subpial hemorrhage, and pituitary injury) (OR = 1.9 [95% CI: 1.2-3.1]) were associated with increased odds of mortality. Male sex (OR = 1.8 [95% CI: 1.2-2.6]), age (65-74: OR = 1.7 [95% CI: 1.1-2.8] & 75-84: OR = 1.6 [95% CI: 1.03-2.6]), ≥ 2 comorbidities (OR = 2.9 [95% CI: 1.8-4.7]), thoraco-abdominal concomitant injury (OR = 2.0 [95% CI: 1.01-3.8]), and subarachnoid hemorrhage (OR = 7.6 [95% CI:1.5-38.5]) were associated with increased odds of complications. The number of comorbidities (≥ 2 OR = 1.7 [95% CI: 1.1-2.7]), spine injury (OR = 2.4 [95% CI: 1.4-4.1]), and delirium (OR = 3.1 [95% CI:1.8-5.2]) were associated with an increased odd of extended length of stay.</p><p><strong>Conclusions: </strong>This study identified risk factors of in-hospital mortality, complications and extended length of stay, most of which are quickly available in the Emergency Department (ED). These factors could help clinicians identify moderate TBI patients at high risk of in-hospital mortality and guide shared decision-making regarding goals of care.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":""},"PeriodicalIF":2.4,"publicationDate":"2025-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144201052","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Process mapping as a framework to define critical care delivery steps in massive transfusion in trauma.","authors":"Matthew A Bergens, Jessica D Guo, Bruce W Rogers, Ursula A Rogers, Jessica L Poisson, Emily C Sterrett, Zachary Ginsberg","doi":"10.1007/s43678-025-00898-2","DOIUrl":"10.1007/s43678-025-00898-2","url":null,"abstract":"<p><strong>Purpose: </strong>The purpose of this quality improvement initiative was to use process mapping to identify the critical process steps for executing massive transfusion in trauma patients with hemorrhagic shock in an academic emergency department. Understanding the relationships and complexity of care delivery steps in massive transfusion is needed to inform the development of performance metrics and improve care delivery.</p><p><strong>Methods: </strong>This process mapping exercise was conducted in the academic emergency department of a verified trauma center using the Institute for Healthcare Improvement framework. Interviews were conducted with emergency department staff members, including nurses, technicians, pharmacists, and blood bank staff. Data collection included structured stakeholder interviews and real-time observation of massive transfusion protocol deployment.</p><p><strong>Results: </strong>Seventeen interviews and real-time observations yielded 87 pages of interview text and 533 objects mapped. Two key clinical decision points were identified: the decision to transfuse and the decision to image. The process was segmented into initial protocol-based care and subsequent physician-driven care. High-level and mid-level process maps, incorporating swim lanes, were created to highlight the process steps to deliver of massive transfusion to trauma patient in our academic emergency department.</p><p><strong>Conclusion: </strong>Process mapping resulted in the creation of an agreed upon standard process that outlines critical steps and distinct phases of care in delivery of the massive transfusion protocol. These findings provide benchmarks for future improvement work and performance measurement efforts.</p>","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":"465-469"},"PeriodicalIF":2.4,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144031902","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Working towards consistency and clarity in pediatric blood culture management.","authors":"Seyara Shwetz, Lauren Roberts","doi":"10.1007/s43678-025-00942-1","DOIUrl":"https://doi.org/10.1007/s43678-025-00942-1","url":null,"abstract":"","PeriodicalId":93937,"journal":{"name":"CJEM","volume":"27 6","pages":"414-415"},"PeriodicalIF":2.4,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Opioid-induced neurotoxicity and delirium in the emergency department.","authors":"Lisa Fischer","doi":"10.1007/s43678-024-00816-y","DOIUrl":"10.1007/s43678-024-00816-y","url":null,"abstract":"","PeriodicalId":93937,"journal":{"name":"CJEM","volume":" ","pages":"435-437"},"PeriodicalIF":2.4,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144031777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}