bluuebunny/crossref_metadata_2025_split huggingface dataset:
Understanding hospital and emergency department congestion: an examination of inpatient admission trends and bed resources
Authors: Wong Hannah J. , Morra Dante , Caesar Michael , Carter Michael W. , Abrams Howard 
Published: July 2016

ABSTRACTObjective:Patients in the emergency department (ED) who have been admitted to hospital (inpatient “boarders”) are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitting services at our teaching institution.Methods:We used hospital databases from Jan. 1, 2004, to Dec. 31, 2007, to analyze ED visits that resulted in admission to hospital.Results:During the study period, 21 986 ED patients were admitted to hospital. The percentage of cancer-related admissions to the oncology admitting service decreased from 48% in 2004 to 24% in 2007, and admissions to general internal medicine (GIM) increased nearly 2-fold, from 28% in 2004 to 54% in 2007. In addition, GIM admitted about 10% more myocardial infarction and heart failure patients than did cardiology. General internal medicine constituted the majority of ED boarders and had a median boarding length of stay of approximately 15 hours. Inpatient beds on oncology and cardiology services remained static.Conclusion:Without bed capacity to admit more patients, our specialty services relied on GIM to serve as a safety net. At the same time, GIM was cited as a main source of ED congestion as their patients occupied more ED beds for longer periods than any other admitting service. The data presented in this study has helped effect positive change within our institution. Other hospitals running at or near capacity and faced with similar ED congestion may apply the methods we used in this study to analyze the cause and nature of their situation.
The effectiveness of training with an emergency department simulator on medical student performance in a simulated disaster
Authors: Franc-Law Jeffrey Michael , Ingrassia Pier Luigi , Ragazzoni Luca , Corte Francesco Della 
Published: July 2016

ABSTRACT

Objective:
Training in practical aspects of disaster medicine is often impossible, and simulation may offer an educational opportunity superior to traditional didactic methods. We sought to determine whether exposure to an electronic simulation tool would improve the ability of medical students to manage a simulated disaster.

Methods:
We stratified 22 students by year of education and randomly assigned 50% from each category to form the intervention group, with the remaining 50% forming the control group. Both groups received the same didactic training sessions. The intervention group received additional disaster medicine training on a patient simulator (disastermed.ca), and the control group spent equal time on the simulator in a nondisaster setting. We compared markers of patient flow during a simulated disaster, including mean differences in time and number of patients to reach triage, bed assignment, patient assessment and disposition. In addition, we compared triage accuracy and scores on a structured command-and-control instrument. We collected data on the students' evaluations of the course for secondary purposes.

Results:
Participants in the intervention group triaged their patients more quickly than participants in the control group (mean difference 43 s, 99.5% confidence interval [CI] 12 to 75 s). The score of performance indicators on a standardized scale was also significantly higher in the intervention group (18/18) when compared with the control group (8/18) (p &lt; 0.001). All students indicated that they preferred the simulation-based curriculum to a lecture-based curriculum. When asked to rate the exercise overall, both groups gave a median score of 8 on a 10-point modified Likert scale.

Conclusion:
Participation in an electronic disaster simulation using the disastermed.ca software package appears to increase the speed at which medical students triage simulated patients and increase their score on a structured command-and-control performance indicator instrument. Participants indicated that the simulation-based curriculum in disaster medicine is preferable to a lecture-based curriculum. Overall student satisfaction with the simulation-based curriculum was high.
Out-of-hospital cardiac arrest surveillance in Canada: a survey of national resources
Authors: Vaillancourt Christian , Charette Manya , Stiell Ian G. , Phillips Karin R. , Wells George A. 
Published: July 2016

ABSTRACT

Objective:
The general objective of this study was to explore the challenges of establishing an out-of-hospital cardiac arrest (OOHCA) surveillance program in Canada. More specifically, we attempted to determine the organizational structure of the delivery of emergency medical services (EMS) in Canada, describe the cardiac arrest data collection infrastructure in each province and determine which OOHCA variables are being collected.

Methods:
We conducted a national survey of 82 independent EMS health authorities in Canada. Methodology experts developed the survey and distribution using a modified Dillman technique. We distributed 67 surveys electronically (84%) and the rest by regular mail. We weighted each survey response by the population of the catchment area represented by the responding health authority (2004 census). Descriptive statistics are reported.

Results:
We received 60 completed surveys, representing a 73% response rate. The responding health authorities' catchment areas represented 80% of the Canadian population (territories excluded). Our survey results highlight a lack of common OOHCA data definitions used among health authorities, sporadic use of data quality assurance procedures, rare linkages to in-hospital survival outcomes and potential confidentiality issues. Other challenges raised by respondents included determining warehousing location and finding financial resources for a national OOHCA registry.

Conclusion:
Results from this survey demonstrate that, although it is challenging, it is possible to collect OOHCA data and access in-hospital survival outcomes. Collaborative efforts with the Resuscitation Outcomes Consortium and other potential provincial partners should be explored.
Door-to-antibiotic time for pneumonia in a rural emergency department
Authors: Anstett Danielle , Smallfield Audra , Vlahaki Dean , Milne W. Ken 
Published: July 2016

ABSTRACTObjective:The Joint Commission on Accreditation of Healthcare Organizations recommends that patients admitted to hospital with pneumonia receive their first dose of antibiotics within 6 hours of presenting to the emergency department (ED). Previous research in the United States indicates that rural hospitals may be better at achieving this benchmark than urban centres. This particular quality indicator has not yet been evaluated in Canada. The purpose of this study was to determine whether the target door-to-antibiotic (DTA) time of 6 hours or less could be met in a rural ED.Methods:We conducted a retrospective chart review of patients admitted to hospital with a diagnosis of pneumonia. Descriptive data for each case was collected, including demographic and timeline information. We analyzed DTA time, antibiotic type, route of administration, hospital length of stay and disposition at discharge.Results:We reviewed a total of 320 charts from Apr. 1, 2003, to Mar. 31, 2008. The final sample consisted of 143 patients (50.3% women) whose median age was 79 years. The median DTA time was 151 minutes and 81.8% of patients received their first dose of antibiotics within 6 hours. Patients received antibiotics either orally (47.6%), intravenously (47.6%) or both (4.8%). Single-agent respiratory fluoroquinolones were used 71.4% of the time. Median length of hospital stay was 4 days; most patients were discharged home (79.7%), 11 died, 11 were transferred and 7 were discharged to a nursing home.Conclusion:A DTA time of 6 hours or less is achievable in a rural ED.
A new emergency medicine clerkship program: students' perceptions of what works
Authors: Yeung Marianne , Beecker Jennifer , Marks Meridith , Nuth Janet , Weitzman Brian , Lee A. Curtis , Frank Jason R. 
Published: July 2016

ABSTRACT

Objective:
Emergency medicine is an evolving discipline in Canadian medical schools. Little has been published regarding student preferences for emergency medicine training during the clerkship phase of MD programs. We assessed medical students' perceptions of a newly developed emergency medicine clerkship rotation involving multiple learning modalities. The evaluation process included assessment of the rotation's instructional elements and overall educational value.

Methods:
The first cohort of medical students to complete this new emergency medicine clerkship was invited to answer a questionnaire just before graduation. Students rated their preferences for components of the rotation using paired comparisons. Open-ended questions explored students' satisfaction with the emergency medicine clerkship as well as perceptions of the rotation's impact on career development.

Results:
Of the 94 students in the first clerkship cohort, 81 (86%) responded to the survey. Students found the emergency medicine clerkship highly valuable, citing the broad range of cases seen, close supervision, and opportunities to develop clinical assessment, decision-making and procedural skills. Students' curricular preferences were for advanced cardiac life support (ACLS) (26.4%), clinical shifts (20.6%), supervised clinical shifts (17.8%), procedural skills laboratories (14.8%), tutorials (10.8%) and preceptor-assisted learning sessions (9.8%).

Conclusion:
This new emergency medicine clerkship program incorporated multiple learning methods within a 4-week rotation and was highly rated by students. Although clinical shifts and ACLS were generally preferred activities, students had varying individual preferences for specific learning activities. Multiple learning methods allowed all students to benefit from the rotation. This study makes a compelling case for including an emergency medicine rotation with multiple learning modalities as a core element of clerkship at every medical school.
Development of the Canadian Emergency Department Diagnosis Shortlist
Authors: Unger Bernard , Afilalo Marc , Boivin Jean François , Bullard Michael , Grafstein Eric , Schull Michael , Lang Eddy , Colacone Antoinette , Soucy Nathalie , Xue Xiaoqing , Segal Eli 
Published: July 2016

ABSTRACTObjective:Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).Methods:Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the ED-specific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.Results:Of the 83 reviewers, 76% were emergency medicine (EM)–trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n= 292), followed by gastrointestinal (n= 59), musculoskeletal (n= 55) and infectious disease (n= 42). Chapters with the lowest number retained were neoplasm (n= 18) and pregnancy (n= 12).Conclusion:We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.
Noncompletion of referrals to outpatient specialty clinics among patients discharged from the emergency department: a prospective cohort study
Authors: Friedman Steven Marc , de Dios Jennifer Vergel , Hanneman Kate 
Published: July 2016

ABSTRACTObjective:We sought to characterize patients who are referred from the emergency department (ED) to specialty clinics but do not complete the referral, and to identify reasons for their failure to follow up.Methods:A prospective cohort study was carried out over 3 months of patients who were discharged from the ED of a teaching hospital with referral to internal medicine, cardiology or neurology clinics, but who did not complete the referral. Information on demographics, barriers to care and reasons for not completing the referral was obtained through a standardized telephone interview.Results:Of 171 ED referrals, 42 (24.6%) were not completed. Interviews were completed for 71.4% (30 patients). Of the nonattenders, 80% were functional in English and most had high school (73.1%) or university (60.7%) education. Virtually all (93.0%) interviewees could get to hospital by themselves or have someone take them. Only 42.9% (12 patients) understood why the emergency physician (EP) requested consultation, and 42.9% (12 patients) described EP instructions as poor or fair. Primary reasons for noncompletion of consult were patient choice (46.7%, 95% confidence interval [CI] 27.1%–66.2%), physical or social barriers (13.3%, 95% CI 0.0%–27.2%), communication failure (20%, 95% CI 4.0%–36.0%) and consultant's refusal of the consultation (20% [95% CI 4.0%–36.0%]). All consultant refusals were from one internal medicine clinic, representing 42% (8/19) of ED referrals to that clinic. None of the 6 patients interviewed who were declined consultation was aware that their consultation had been refused.Conclusion:Patients discharged by the EP with referral to specialty clinics frequently do not complete the consultation. Causes for failure to follow up relate to patient decision, inadequate or poorly understood discharge information, and system factors. Institutional audits of patients who fail to complete follow-up may reveal unanticipated barriers to care.
Incorporating simulation into a residency curriculum
Authors: Takayesu James K. , Nadel Eric S. , Bhatia Kriti , Walls Ron M. 
Published: July 2016

ABSTRACT
The integration of simulation into a medical postgraduate curriculum requires informed implementation in ways that take advantage of simulation's unique ability to facilitate guided application of new knowledge. It requires review of all objectives of the training program to ensure that each of these is mapped to the best possible learning method. To take maximum advantage of the training enhancements made possible by medical simulation, it must be integrated into the learning environment, not simply added on. This requires extensive reorganization of the resident didactic schedule.
Simulation planning is supported by clear learning objectives that define the goals of the session, promote learner investment in active participation and allow for structured feedback for individual growth. Teaching to specific objectives using simulation requires an increased time commitment from teaching faculty and careful logistical planning to facilitate flow of learners through a series of simulations in ways that maximize learning. When applied appropriately, simulation offers a unique opportunity for learners to acquire and apply new knowledge under direct supervision in ways that complement the rest of the educational curriculum. In addition, simulation can improve the learning environment and morale of residents, provide additional methods of resident evaluation, and facilitate the introduction of new technologies and procedures into the clinical environment.
Profound metabolic acidosis from pyroglutamic acidemia: an underappreciated cause of high anion gap metabolic acidosis
Authors: Green Thomas J. , Bijlsma Jan Jaap , Sweet David D. 
Published: July 2016

ABSTRACTThe workup of the emergency patient with a raised anion gap metabolic acidosis includes assessment of the components of “MUDPILES” (methanol; uremia; diabetic ketoacidosis; paraldehyde; isoniazid, iron or inborn errors of metabolism; lactic acid; ethylene glycol; salicylates). This approach is usually sufficient for the majority of cases in the emergency department; however, there are many other etiologies not addressed in this mnemonic. Organic acids including 5-oxoproline (pyroglutamic acid) are rare but important causes of anion gap metabolic acidosis. We present the case of a patient with profound metabolic acidosis with raised anion gap, due to pyroglutamic acid in the setting of malnutrition and chronic ingestion of acetaminophen.
Low-impact pelvic fractures in the emergency department
Authors: Dodge Greg , Brison Rob 
Published: July 2016

ABSTRACT

Objective:
We examined the records of patients presenting to the emergency department (ED) with low-impact pelvic fractures. We describe frequency, demographics, management and patient outcomes in terms of ambulatory ability, living independence and mortality.

Methods:
Patients treated for a pelvic fracture over a 2-year period in Kingston, Ont., were identified. We performed a retrospective hospital record review to distinguish high- versus low-impact injury mechanisms, and to characterize the injury event, ED management and outcomes for patients with low-impact fractures.

Results:
Of 132 pelvic fractures identified, 77 were low-impact fractures. Patients were predominantly women (82%) with a mean age of 81 years; 96% had some pre-existing medical comorbidity. The pubic rami were most commonly involved (86%). The median length of stay in the ED was 9.4 hours. Twenty-five patients (32%) were admitted to hospital. Ten patients had surgical stabilization, mostly of the acetabulum. Five patients died in hospital, 4 from pneumonia and 1 from myocardial infarction. Eight additional patients died within 1 year of injury. At discharge, only 18% lived independently and 16% walked without aids versus 42% and 38%, respectively, before injury.

Conclusion:
Low-impact pelvic fractures affect predominantly elderly women with pre-existing comorbidities. A substantial amount of time and resources in the ED are used during the workup of these patients and while awaiting their disposition from the ED. These injuries are important because they affect independence and seem associated with an increased risk of death.
Emergency department discharge instructions comprehension and compliance study
Authors: Clarke Collin , Friedman Steven Marc , Shi Kevin , Arenovich Tamara , Monzon Jose , Culligan Christopher 
Published: July 2016

ABSTRACT

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

Methods:
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.

Results:
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 &lt; 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.

Conclusions:
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.
Emergency medicine teaching faculty perceptions about formal academic sessions: “What’s in it for us?”
Authors: Bandiera Glen W. , Morrison Laurie 
Published: July 2016

ABSTRACTBackground:Little is known about factors affecting emergency physician attendance at formal academic teaching sessions or what emergency physicians believe to be the benefits derived from attending these activities.Objectives:To determine what factors influence emergency medicine faculty attendance at formal academic rounds, what benefits they derive from attendance, and what differences in perceptions there are between full-time clinical and part-time clinical academic faculty.Methods:A survey was sent to all emergency physicians with academic appointments at one institution. Responses were tabulated dichotomously (yes/no) for checklist answers and analyzed using a 2-person grounded theory approach for open answers based on an a priori analysis plan. Differences between full-time and part-time faculty were compared using the chi-squared test for significance.Results:Response rate was 73.8% (48/65). Significant impediments to attendance included clinical responsibilities (75%), professional responsibilities (52.1%), personal responsibilities (33.3%), location (31.2%) and time (27.1%). Perceived benefits of attending rounds were: continuing medical education, social interaction, teaching opportunities, interaction with residents, comparing one's practice with peers, improving teaching techniques, and enjoyment of the format. There were no statistically significant differences between groups' responses.Conclusions:Emergency physicians in our study attend formal teaching sessions infrequently, suggesting that the perceived benefits do not outweigh impediments to attendance. The single main impediment, competing responsibilities, is difficult to modify for emergency physicians. Strategies to increase faculty attendance should focus on enhancing the main perceived benefits: continuing medical education, social interaction and educational development. Faculty learn from themselves and from residents during formal teaching sessions.
Acute pneumoperitoneum following coitus
Authors: Manchanda Ranjit , Refaie Ashraf 
Published: July 2016

ABSTRACTVaginal rupture leading to pneumoperitoneum is well documented to occur after hysterectomy or surgery. However, it is extremely rare in a young woman following conventional intercourse. We report one such case. A 16-year-old woman presented to the accident and emergency department with a clinical picture of an acute abdomen. Results of radiography showed gas under the diaphragm, suggesting the possibility of bowel perforation. A detailed sexual history pointed toward the possibility of vaginal trauma. Diagnosis was confirmed on examination under anesthesia, and the tear repaired. A concomitant laparoscopy ruled out any other intra-abdominal injury. This case reminds us that acute peritoneum can occur after sexual intercourse and also reiterates the importance of a detailed sexual history and vaginal examination in young women presenting with an acute abdomen.