P055: Canadian emergency physician attitudes toward endotracheal intubation for aspiration prophylaxis

Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS < 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.

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P071: Emergency physician attitudes and perceived barriers to take-home naloxone programs in Canadian emergency departments

CJEM ◽

10.1017/cem.2016.247 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S102-S102

Author(s):

L. Lacroix ◽

I.G. Stiell ◽

L. Thurgur ◽

A. Orkin

Keyword(s):

At Risk ◽

Emergency Physician ◽

Emergency Departments ◽

Allied Health ◽

Physician Attitudes ◽

Perceived Barriers ◽

Opioid Overdose ◽

Emergency Physicians ◽

Canadian Association ◽

Health Support

Introduction: Unintentional overdose is the leading cause of injurious death among Americans aged 25-64 years. A similar epidemic is underway in Canada. Community-based opioid overdose education and naloxone distribution (OOEND) programs distribute take-home naloxone kits to people at risk of overdose in several cities across Canada. Due to the high rate of drug-related visits, recurrent opioid prescribing, and routine encounters with opioid overdose, Emergency Departments (ED) may represent an under-utilized setting to deliver naloxone to people at risk of opioid overdose or likely to witness overdose. The goal of this study was to identify Canadian emergency physician attitudes and perceived barriers to the implementation of take-home naloxone programs. Methods: This was an anonymous web-based survey of physician and trainee members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals, per the modified Dillman method. Respondent demographics were collected and Likert scales used to assess attitudes and barriers to the prescription of naloxone from the ED. Results: A total of 347/1658 CAEP members responded (20.9%). Of the respondents, 62.1% were male and residents made up 15.6%. The majority (48.2%) worked in Ontario and 55.7% worked in an urban tertiary centre. Overall attitudes to OOEND were strongly positive: 86.6% of respondents identified a willingness to prescribe naloxone from the ED. Perceived barriers included allied health support for patient education (56.4%), access to follow-up (40.3%), and inadequate time in the clinical encounter (37.7%). In addition to people at risk of overdose, 78% of respondents identified that friends and family members may benefit from OOEND programs. Conclusion: Canadian emergency physicians are willing to prescribe take-home naloxone to at-risk patients, but better systems and tools are required to facilitate opioid overdose education and naloxone distribution implementation. This data will inform the development of these programs, with emphasis on allied health support, training and education.

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Physician Attitudes About Prehospital 12-Lead ECGs in Chest Pain Patients

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00000091 ◽

2002 ◽

Vol 17 (1) ◽

pp. 33-37 ◽

Cited By ~ 2

Author(s):

Andrew H. Brainard ◽

Philip Froman ◽

Maria E. Alarcon ◽

Bill Raynovich ◽

Dan Tandberg

Keyword(s):

Chest Pain ◽

Confidence Intervals ◽

Standard Of Care ◽

Physician Attitudes ◽

Emergency Physicians ◽

Hypothesis Tests ◽

Electrocardiogram Ecg ◽

Pain Patients

AbstractIntroduction:The prehospital 12-lead electrocardiogram (ECG) has become a standard of care. For the prehospital 12-lead ECG to be useful clinically, however, cardiologists and emergency physicians (EP) must view the test as useful. This study measured physician attitudes about the prehospital 12-lead ECG.Hypothesis:This study tested the hypothesis that physicians had “no opinion” regarding the prehospital 12-lead ECG.Methods:An anonymous survey was conducted to measure EP and cardiologist attitudes toward prehospital 12-lead ECGs. Hypothesis tests against “no opinion” (VAS = 50 mm) were made with 95% confidence intervals (CIs), and intergroup comparisons were made with the Student-t-test.Results:Seventy-one of 87 (81.6%) surveys were returned. Twenty-five (67.6%) cardiologists responded and 45 (90%) EPs responded. Both groups of physicians viewed prehospital 12-lead ECGs as beneficial (mean = 69 mm; 95% CI = 65–74mm). All physicians perceived that ECGs positively influence preparation of staff (mean = 63 mm; 95% CI = 60–72mm) and that ECGs transmitted to hospitals would be beneficial (mean = 66 mm; 95% CI = 60–72mm). Cardiologists had more favorable opinions than did EPs. The ability of paramedics to interpret ECGs was not seen as important (mean = 50 mm; 95% CI = 43–56mm). The justifiable increase in field time was perceived to be 3.2 minutes (95% CI = 2.7–3.8 minutes), with 23 (32.8%) preferring that it be done on scene, 46 (65.7%) during transport, and one (1.4%) not at all.Conclusions:Prehospital 12-lead ECGs generally are perceived as worthwhile by cardiologists and EPs. Cardiologists have a higher opinion of the value and utility of field ECGs. Since the reduction in mortality from the 12-lead ECG is small, it is likely that positive physician attitudes are attributable to other factors.

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Emergency Department Management of Heart Failure and COPD: A National Survey of Attitudes and Practice

CJEM ◽

10.1017/cem.2016.24 ◽

2016 ◽

Vol 18 (6) ◽

pp. 429-436 ◽

Cited By ~ 3

Author(s):

Michael K.P. Hale ◽

Ian G. Stiell ◽

Catherine M. Clement

Keyword(s):

Heart Failure ◽

Outcome Measures ◽

Physician Attitudes ◽

Secondary Outcome ◽

Emergency Physicians ◽

Medical Risk ◽

Canadian Association ◽

Emergency Department Management ◽

Physician Rating ◽

Risk Scale

AbstractObjectivesThe Ottawa Heart Failure Risk Scale (OHFRS) and the Ottawa COPD Risk Scale (OCRS) were developed in order to estimate medical risk and to help guide disposition decisions for patients presenting to the ED with acute exacerbations of heart failure (HF) and COPD. We sought to determine physician attitudes towards these two new risk scales and to identify potential barriers to their ED implementation.MethodsTwo self-administered online surveys were distributed to the Canadian Association of Emergency Physicians. The surveys each consisted of 16 questions relating to the OHFRS and OCRS. The primary outcome measures were the overall physician rating of the two risk scales. Secondary outcome measures assessed the likelihood of risk scale implementation into Canadian EDs, as well as the perceived barriers to such implementation. Descriptive statistics were used.ResultsFor the OHFRS survey, we received responses from 195 emergency physicians (35.7%). Overall, 74.4% approved of the risk scale based on a Likert rating of 4 or 5 and 66.7% believed that the risk scale would be implemented at their hospital. For the OCRS survey, we received responses from 208 emergency physicians (38.1%). Overall, 76.9% approved of the risk scale based on a Likert rating of 4 or 5 and 70.2% believed that the risk scale would be implemented at their hospital.ConclusionsCanadian emergency physicians are very supportive of the new OHFRS and OCRS. We believe these risk scales will assist physicians with making safe and efficient disposition decisions and improve outcomes for patients suffering from HF and COPD.

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LO067: Emergency department management of diabetic ketoacidosis and hyperosmolar hyperglycemic state: national survey of attitudes and practice

CJEM ◽

10.1017/cem.2016.104 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S53-S53

Author(s):

A. Hamelin ◽

J. Yan ◽

I.G. Stiell

Keyword(s):

Emergency Department ◽

Diabetic Ketoacidosis ◽

Diabetes Education ◽

Guideline Implementation ◽

Physician Attitudes ◽

Future Research ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Canadian Association ◽

Hyperosmolar Hyperglycemic State

Introduction: The 2011 Canadian Diabetes Association (CDA) Clinical Practice Guidelines were developed in order to help physicians manage hyperglycemic emergencies in the emergency department (ED), including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The goal of this study was to determine physician attitudes towards these guidelines and to identify potential barriers to their implementation in the ED. Methods: We distributed an online, cross sectional survey to 500 randomly selected members of the Canadian Association of Emergency Physicians (CAEP) who were currently practicing physicians. A total of 3 email notifications were distributed on days 1, 7 and 14. The survey consisted of 23 questions relating to physician management of DKA and HHS in the ED. The primary outcome was overall physician familiarity and usage of the guidelines using a 7-point Likert scale. Secondary outcomes included physician attitudes towards the guidelines as well as any perceived barriers to their implementation in the ED. Simple descriptive statistics were used to illustrate the survey results. Results: The survey response rate was 62.2% (311/500) with the following participant characteristics: male (62.6%), CCFP(EM) training (46.1%) and working in major academic centers (50.5%). The overall awareness rate of the CDA guidelines was 22.9% (95% CI = 18.3%, 27.5%). 58.9% (95% CI = 53.3%, 64.3%) reported the CDA guidelines being useful. The most frequently reported barriers to CDA guideline implementation were concerns about education issues (56.0%), lack of time and disruption of flow (23.9%), staffing and human resource issues (26.7%) and poor policy adherence (25.5%). Physician’s ideal changes to optimize the management of these patients included improved coordination for follow-up with family physicians (79.9%), increased diabetes education for patients (73.9%) and increased availability to diabetes specialists (47.5%). Conclusion: In this study, although Canadian ED physicians were generally supportive of the CDA guidelines, many were unaware that these guidelines existed and barriers to their implementation were reported. Future research should focus on strategies to standardize DKA and HHS management by ensuring physician awareness and education to ensure the highest quality of patient care.

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Recommendations for patient engagement in patient-oriented emergency medicine research

CJEM ◽

10.1017/cem.2018.370 ◽

2018 ◽

Vol 20 (3) ◽

pp. 435-442 ◽

Cited By ~ 6

Author(s):

Patrick M. Archambault ◽

Colleen McGavin ◽

Katie N. Dainty ◽

Shelley L. McLeod ◽

Christian Vaillancourt ◽

...

Keyword(s):

Emergency Medicine ◽

Literature Review ◽

Patient Engagement ◽

Qualitative Interviews ◽

Future Research ◽

Translation Strategies ◽

Medicine Research ◽

Canadian Association ◽

Knowledge Translation Strategies ◽

National Patient

AbstractObjectiveTo make pragmatic recommendations on best practices for the engagement of patients in emergency medicine (EM) research.MethodsWe created a panel of expert Canadian EM researchers, physicians, and a patient partner to develop our recommendations. We used mixed methods consisting of 1) a literature review; 2) a survey of Canadian EM researchers; 3) qualitative interviews with key informants; and 4) feedback during the 2017 Canadian Association of Emergency Physicians (CAEP) Academic Symposium.ResultsWe synthesized our literature review into categories including identification and engagement, patients’ roles, perceived benefits, harms, and barriers to patient engagement; 40/75 (53% response rate) invited researchers completed our survey. Among respondents, 58% had engaged patients in research, and 83% intended to engage patients in future research. However, 95% stated that they need further guidance to engage patients. Our qualitative interviews revealed barriers to patient engagement, including the need for training and patient partner recruitment.Our panel recommends 1) an overarching positive recommendation to support patient engagement in EM research; 2) seven policy-level recommendations for CAEP to support the creation of a national patient council, to develop, adopt and adapt training material, guidelines, and tools for patient engagement, and to support increased patient engagement in EM research; and 3) nine pragmatic recommendations about engaging patients in the preparatory, execution, and translational phases of EM research.ConclusionPatient engagement can improve EM research by helping researchers select meaningful outcomes, increase social acceptability of studies, and design knowledge translation strategies that target patients’ needs.

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Emergency physicians’ attitudes and perceived barriers to the implementation of take-home naloxone programs in Canadian emergency departments

CJEM ◽

10.1017/cem.2017.390 ◽

2017 ◽

Vol 20 (1) ◽

pp. 46-52 ◽

Cited By ~ 10

Author(s):

Lauren Lacroix ◽

Lisa Thurgur ◽

Aaron M. Orkin ◽

Jeffrey J. Perry ◽

Ian G. Stiell

Keyword(s):

At Risk ◽

Perceived Barriers ◽

Face Validity ◽

Opioid Overdose ◽

Emergency Physicians ◽

Web Based ◽

Health Crisis ◽

Canadian Association ◽

National Public Health

AbstractObjectivesRates of opioid-related deaths have reached the level of national public health crisis in Canada. Community-based opioid overdose education and naloxone distribution (OEND) programs distribute naloxone to people at risk, and the emergency department (ED) may be an underutilized setting to deliver naloxone to these people. The goal of this study was to identify Canadian emergency physicians’ attitudes and perceived barriers to the implementation of take-home naloxone programs.MethodsThis was an anonymous Web-based survey of members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals. Respondent demographics were collected, and Likert scales were used to assess attitudes and barriers to the prescription of naloxone from the ED.ResultsA total of 459 physicians responded. The majority of respondents were male (64%), worked in urban tertiary centres (58.3%), and lived in Ontario (50.6%). Overall, attitudes to OEND were strongly positive; 86% identified a willingness to prescribe naloxone from the ED. Perceived barriers included support for patient education (57%), access to follow-up (44%), and inadequate time (37%). In addition to people at risk of overdose, 77% of respondents identified that friends and family members may also benefit.ConclusionsCanadian emergency physicians are willing to distribute take-home naloxone, but thoughtful systems are required to facilitate opioid OEND implementation. These data will inform the development of these programs, with emphasis on multidisciplinary training and education.

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149 Virtual Care: A Quality Improvement Project on the Experience of Paediatricians during the COVID-19 Pandemic

Paediatrics & Child Health ◽

10.1093/pch/pxab061.117 ◽

2021 ◽

Vol 26 (Supplement_1) ◽

pp. e102-e104

Author(s):

Emma McCrady ◽

Julie Strychowsky ◽

Jessica Woolfson

Keyword(s):

Quality Improvement ◽

Online Survey ◽

Local Level ◽

Standard Of Care ◽

Subject Area ◽

Future Research ◽

Improvement Project ◽

Diagnostic Uncertainty ◽

Virtual Care ◽

Practice Efficiency

Abstract Primary Subject area Practice/Office Management Background Prior to the COVID-19 pandemic, in-person visits were the standard of care for paediatricians at our centre. With the pandemic onset, virtual care (VC) was adopted at an unprecedented scale and pace. Studies have reported positive patient VC experience; however, few have explored physician experience. This quality improvement (QI) initiative sought to qualify the VC experience of local paediatricians during the pandemic, with the intention of implementing VC clinical practice changes at the department level. Objectives To determine key factors that have supported and challenged the adoption of, and that will support integration of, VC in the future. Design/Methods The Donabedian model for healthcare QI was used to evaluate VC experience through an online survey with a focus on structure, process, and outcome measures. All physicians affiliated with the Department of Paediatrics (generalists and subspecialists in medicine and surgery) were invited to participate via email. Three reminder emails were sent at 2-week intervals. Descriptive statistics were reported. Results The response rate was 32.3% (63 of 195 physicians). The majority of respondents were subspecialists (84.1%), and at academic centres (87.5%) (Table 1). Pre-pandemic, only 30.1% used VC and saw <10% of patients virtually. During March-May 2020, 93.8% transitioned to VC, with > 50% seeing over 75% of patients virtually. By summer 2020, VC use declined, but remained higher than pre-pandemic (53.6% seeing < 25% of patients). OTN and telephone were platforms most used (32.8% and 28.6%, respectively). Most conducted visits from their work location (55.2%) versus home (44.8%). VC experience was considered positive by most physicians (73.6%), and only 18.8% found VC difficult to use despite technical difficulties reported by 41.5% (Figure 1). Physicians with ≤ 5 years in practice were most likely to find VC convenient (93.8%). Challenges with VC included lack of physical exam, diagnostic uncertainty, lower patient volumes, and poor patient VC etiquette. Regardless of practice location, specialty, years in practice, and prior experience, 96% would continue VC to 25% of patients, ideally for patients who live far away (26.4%) and for follow-ups of patients with established diagnoses (21.4%). Conclusion A rapid transition to VC during the COVID-19 pandemic was associated with challenges but also positive experiences. Willingness to continue VC was high. VC experience could be improved with greater patient education and focus on select patient populations. Future research is needed to improve practice efficiency and to inform regulatory guidelines for VC at a local level.

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An Industrial Accident

Legal and Ethical Issues in Emergency Medicine ◽

10.1093/med/9780190066420.003.0024 ◽

2020 ◽

pp. 175-180

Author(s):

Chadd K. Kraus

Keyword(s):

Public Health ◽

Emergency Physician ◽

Standard Of Care ◽

Professional Autonomy ◽

Standards Of Care ◽

Emergency Physicians ◽

Scarce Resources ◽

Public Health Emergencies ◽

Public Health Functions ◽

Critical Public Health

Emergency physicians and emergency departments serve critical public health functions at all times and particularly during public health emergencies or disasters. Public health emergencies and disasters transform standards of care into crisis standards of care. In addition to traditional tenets of bioethics, during events requiring crisis standards of care, the emergency physician faces the dilemmas of balancing responsibilities of how to allocate scarce resources to individual patients with obligations to the community and with personal and professional autonomy. Crisis standards of care permit emergency physicians to allocate scarce resources to provide necessary treatments to patients most likely to benefit. In crisis standard-of-care situations, emergency physicians must adhere to ethical and professional norms. The emergency physician should focus on how to best use the available resources with the recognition that not all patients might be able to be treated.

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Building and strengthening relationships between academic departments/divisions of emergency medicine and rural and regional emergency departments

CJEM ◽

10.1017/cem.2019.359 ◽

2019 ◽

Vol 21 (5) ◽

pp. 595-599 ◽

Cited By ~ 1

Author(s):

Aaron Johnston ◽

Kylie Booth ◽

Jim Christenson ◽

David Fu ◽

Shirley Lee ◽

...

Keyword(s):

Emergency Medicine ◽

Emergency Departments ◽

Academic Departments ◽

List Type ◽

Emergency Physicians ◽

Common Value ◽

Rural And Urban ◽

Canadian Association ◽

Rural Physicians ◽

Training Opportunities

ABSTRACTObjectivesMake recommendations on approaches to building and strengthening relationships between academic departments or divisions of Emergency Medicine and rural and regional emergency departments.MethodsA panel of leaders from both rural and urban/academic practice environments met over 8 months. Draft recommendations were developed from panel expertise as well as survey data and presented at the 2018 Canadian Association of Emergency Physicians (CAEP) Academic Symposium. Symposium feedback was incorporated into final recommendations.ResultsSeven recommendations emerged and are summarized below: 1)CAEP should ensure engagement with other rural stakeholder organizations such as the College of Family Physicians of Canada and the Society of Rural Physicians of Canada.2)Engagement efforts require adequate financial and manpower resources.3)Training opportunities should be promoted.4)The current operational interface between the academic department of Emergency Medicine and the emergency departments in the catchment area must be examined and gaps addressed as part of building and strengthening relationships.5)Initial engagement efforts should be around projects with common value.6)Academic Departments should partner with and support rural scholars.7)Academic departments seeking to build or strengthen relationships should consider successful examples from elsewhere in the country as well as considering local culture and challenges.ConclusionThese recommendations serve as guidance for building and strengthening mutually beneficial relationships between academic departments or divisions of Emergency Medicine and rural and regional emergency departments.

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P072: Exploring definitions of “unnecessary care” in emergency medicine: a qualitative analysis of physician survey responses

CJEM ◽

10.1017/cem.2017.274 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S102-S103

Author(s):

L. Krebs ◽

L. Gaudet ◽

L.B. Chartier ◽

B.R. Holroyd ◽

S. Dowling ◽

...

Keyword(s):

Qualitative Analysis ◽

System Level ◽

Free Text ◽

Emergency Physicians ◽

System Failures ◽

Canadian Association ◽

Urgent Patient ◽

Definition Of ◽

Evidenced Based ◽

Survey Responses

Introduction: Recently, campaigns placing considerable emphasis on improving emergency department (ED) care by reducing unnecessary tests, treatments, and/or procedures have been initiated. This study explored how Canadian emergency physicians (EPs) conceptualize unnecessary care in the ED. Methods: An online 60-question survey was distributed to EP-members of the Canadian Association of Emergency Physicians (CAEP) with valid emails. The survey explored respondents awareness/support for initiatives to improve ED care (i.e., reduce unnecessary tests, treatments and/or procedures) and asked respondents to define “unnecessary care” in the ED. Thematic qualitative analysis was performed on these responses to identify key themes and sub-themes and explore variation among EPs definitions of unnecessary care. Results: A total of 324 surveys were completed (response rate: 18%); 300 provided free-text definitions of unnecessary care. Most commonly, unnecessary ED care was defined as: 1) performing tests, treatments, procedures, and/or consults that were not indicated or potentially harmful (n=169) and/or 2) care that should have been provided within a non-emergent context for a non-urgent patient (n=143). Emergency physicians highlighted the role of system-level factors and system failures that result in ED presentations as definitions of unnecessary care (n=69). They also noted a distinction between providing necessary care for a non-urgent patient and performing inappropriate/non-evidenced based care. Finally, a tension emerged in their description of frustration with patient expectations (n=17) and/or non-ED referrals (n=24) for specific tests, treatments, and/or procedures. These frustrations were juxtaposed by participants who asserted that “in a patient-centred care environment, no care is unnecessary” (Participant 50; n=12). Conclusion: Variation in the definition of unnecessary ED care is evident among EPs and illustrates that EPs’ conceptualization of unnecessary care is more nuanced than current campaigns addressing ED care improvements represent. This may contribute to a perceived lack of uptake or support for these initiatives. Further exploring EPs perceptions of these campaigns has the potential to improve EP engagement and influence the language utilized by these programs.

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