CJEM Articles: Andrew Worster

Clinical Question

Are surgical masks inferior to N95 respirators in reducing influenza infection in health care workers?

Article Chosen

Loeb M, Dafoe N, Mahony J, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA 2009;302:1865-71.

Objective

To evaluate the effectiveness of N95 respirators compared to standard surgical masks in reducing influenza infection in health care workers.

Objectives: Medical licensing bodies and professional colleges require their members to maintain a broad spectrum of knowledge, skills and attitudes, which, when taken together, define a competent emergency physician (EP). The objectives of this pilot study were: 1) to determine the resources used by academic EPs to maintain competence and 2) to determine academic EPs' learning priorities.

Methods: Using a modified Dillman method, we surveyed EPs from 2 Canadian academic tertiary health sciences centres.

Results: Thirty-seven (68.5%) of 54 EPs responded. Of those responding, 14 (37.8%) attended grand rounds 3 times or more annually, and 34 (91.7%) attended a medical conference or course at least once annually. Thirty-three (89.2%) respondents read journal articles at least once monthly, with 22 (59.5%) of those reading synopses of original articles. Twenty-three (62.1%) received clinical updates via email, and 11 (29.7%) subscribed to an audio journal or podcast of reviews of original research. Among the CanMEDS roles, Medical Expert, Scholar and Manager were selected as top professional development priorities by more than one-third of respondents. The topics that were not selected as priorities by respondents included patient communication and charting (Communicator); conflict resolution skills and teamwork abilities (Collaborator); advocate for patient and promote health in emergency department populations (Health Advocate) and ethical conflict resolution (Professional).

Conclusion: The results of this pilot study suggest that in order to maintain clinical competence in emergency medicine, traditional formats of professional development (e.g., grand rounds, print media and original research) are being substituted for independent study, online media and reviews of original research. This study also suggests a strong preference for Medical Expert topics, while Professional, Health Advocate, Collaborator and Communicator topics are not a reported priority for professional development.

Background: The SimpliRED D-dimer assay is commonly ordered by emergency physicians for suspected pulmonary embolus or deep venous thrombosis. A pretest probability (PTP) assessment is required for the results of this diagnostic test to be interpreted correctly and applied appropriately. Without this assessment, the physician may misinterpret the test results and proceed to unnecessary diagnostic imaging (DI) or inappropriate discharge. Our objectives were to measure the documentation rate of PTP for emergency department (ED) patients on whom a SimpliRED D-dimer assay was performed for suspected venous thromboembolism (VTE) and to determine if the clinical management decisions that followed were in keeping with current recommendations.

Methods: In this medical record review, we used a random number generator to select 100 charts from all 760 patients who had a SimpliRED D-dimer performed during a 3-month period at an academic tertiary care centre with 3 EDs. Trained data abstractors, blinded to the study hypothesis, abstracted explicitly defined data from each chart. An independent abstractor assessed the reliability of 15 of the charts that were randomly chosen.

Results: Suspicion of VTE was documented in 97 of the 100 charts. There was no documentation of PTP assessment for 62 of the 97 cases. Ten had a positive D-dimer but 5 of these had no evidence of subsequent DI. Of the 97 charts reviewed, 24 documented decisions were in discordance with published clinical management recommendations for VTE.

Conclusion: In the majority of ED cases of suspected VTE, PTP assessment was not documented and approximately one-quarter of these documented decisions were in discordance with established recommendations for the given test results. This suggests that PTP assessments are not being conducted in a significant proportion of cases and the diagnostic test results are misinterpreted, applied incorrectly or both.

Objective: We sought to determine the proportion of Canadian emergency departments (EDs) that have intimate partner violence (IPV) universal screening programs and intervention policies and procedures. Of the EDs with programs, we determined what proportion had made changes in their practices during the past 10 years and since the 2003 Canadian Task Force on Preventive Health Care recommendations.

Methods: Using the same sampling methods as a 1994 study, we mailed questionnaires to nurse managers of a stratified, random sample of 250 out of 638 (39%) Canadian EDs and followed up with a series of telephone calls.

Results: Of the 250 EDs initially contacted, 6 were excluded before the surveys were mailed. The response rate was 78.3% (191/244). Sixty-one (31.9%) of the studied EDs reported the existence of IPV policies and procedures. In this group, 26 (42.6%) applied universal screening and 13 (21.3%) implemented their screening policies after the 2003 national recommendations were published. When these results were compared with those of the 1994 study, there was no difference in the proportion of EDs with IPV policies and procedures or in the proportion of EDs that applied universal screening.

Conclusion: Despite increased research into IPV there was no significant change between 1994 and 2004 in the existence of IPV polices or universal screening in Canadian EDs. Policies and procedures that address appropriate responses to patients exposed to IPV should be a priority, with most emphasis directed toward developing effective interventions to which women can be referred.