CJEM Articles: Michael J. Schull
Displaying 1-10 of 15 results
Effect of a brief emergency medicine education course on emergency department work intensity of family physiciansJanuary 2013 15 1Chad Leaver, Michael J. Schull, Samuel Vaillancourt, Susan E. Schultz, Thérèse A. Stukel
Recently, many Canadian emergency departments (EDs) have struggled with physician staffing shortages. In 2006, the Ontario Ministry of Health and Long-Term Care funded a brief “emergency medicine primer” (EMP) course for family physicians to upgrade or refresh skills, with the goal of increasing their ED work intensity. We sought to determine the effect of the EMP on the ED work intensity of family physicians.
A retrospective longitudinal study was conducted of the ED work of 239 family physicians in the 2 years before and after a minimum of 6 months and up to 2 years from completing an EMP course in 2006 to 2008 compared to non-EMP physicians. ED work intensity was defined as the number of ED shifts per month and the number of ED patients seen per month. We conducted two analyses: a before and after comparison of all EMP physicians and a matched cohort analysis matching each EMP physician to four non-EMP physicians on sex, year of medical school graduation, rurality, and pre-EMP ED work intensity.
Postcourse, EMP physicians worked 0.5 more ED shifts per month (13% increase, p = 0.027). Compared to their matched controls, EMP physicians worked 0.7 more shifts per month (13% increase, p = 0.0032) and saw 15 more patients per month (17% increase, p = 0.0008) compared to matched non-EMP physicians. The greatest increases were among EMP physicians who were younger, were urban, had previous ED experience, or worked in a high-volume ED. The effect of the EMP course was negligible for physicians with no previous ED experience or working in rural areas.
The EMP course is associated with modest increases in ED work intensity among some family physicians, in particular younger physicians in urban areas. No increase was seen among physicians without previous ED experience or working in rural areas.
Aklilu Azaj, Eric Letovsky, James Maskalyk, Megan Landes, Michael J. Schull, Sisay Teklu
Barriers and facilitators to the implementation of Ontario’s emergency department clinical decision unit pilot program: a qualitative studyNovember 2011 13 6Anne Sales, Astrid Guttmann, Brian H. Rowe, Chad A. Leaver, Erin Salkeld, Marian J. Vermeulen, Michael J. Schull
Objective: In Ontario, clinical decision units (CDUs) were implemented as a pilot project in 2008 by the Ministry of Health and Long-Term Care as part of its strategy to reduce emergency department (ED) waiting times. Our objective was to describe general characteristics of the program at each of the participating sites and to examine barriers and facilitators to integrating CDUs into practice.
Methods: On-site small-group interviews were conducted in two phases with ED and hospital staff at participating sites, first at 8 to 12 weeks and again at 12 months postimplementation. Interview data were analyzed using the framework approach. Unstructured field notes and CDU clinical care protocols and documentation were also reviewed.
Results: The qualitative analysis identified 10 key themes related to integrating CDUs into EDs: shift in clinical and operational practice; administrative aspects of implementation; team building and stakeholder involvement; use of clinical care protocols; physical or virtual model of care; responsive ancillary services; involvement of specialist services; coordination with hospital and community supports; appropriate use of the CDU; and ongoing evaluation and monitoring. Each theme represents an important insight from the perspective of clinical and administrative staff at participating sites.
Conclusion: The implementation of CDUs is a complex process, with no single preferred clinical care or operational model. This study identifies a number of key considerations relevant to the future implementation of CDUs.
Prioritizing performance measurement for emergency department care: consensus on evidencebased quality of care indicatorsSeptember 2011 13 5Astrid Guttmann, Brian H. Rowe, Caroline M. Hatcher, Chad A. Leaver, Geoffrey M. Anderson, Marian Vermeulen, Merrick Zwarenstein, Michael J. Schull
The evaluation of emergency department (ED) quality of care is hampered by the absence of consensus on appropriate measures. We sought to develop a consensus on a prioritized and parsimonious set of evidence-based quality of care indicators for EDs.
The process was led by a nationally representative steering committee and expert panel (representatives from hospital administration, emergency medicine, health information, government, and provincial quality councils). A comprehensive review of the scientific literature was conducted to identify candidate indicators. The expert panel reviewed candidate indicators in a modified Delphi panel process using electronic surveys; final decisions on inclusion of indicators were made by the steering committee in a guided nominal group process with facilitated discussion. Indicators in the final set were ranked based on their priority for measurement. A gap analysis identified areas where future indicator development is needed. A feasibility study of measuring the final set of indicators using current Canadian administrative databases was conducted.
A total of 170 candidate indicators were generated from the literature; these were assessed based on scientific soundness and their relevance or importance. Using predefined scoring criteria in two rounds of surveys, indicators were coded as “retained” (53), “discarded” (78), or “borderline” (39). A final set of 48 retained indicators was selected and grouped in nine categories (patient satisfaction, ED operations, patient safety, pain management, pediatrics, cardiac conditions, respiratory conditions, stroke, and sepsis or infection). Gap analysis suggested the need for new indicators in patient satisfaction, a healthy workplace, mental health and addiction, elder care, and community-hospital integration. Feasibility analysis found that 13 of 48 indicators (27%) can be measured using existing national administrative databases.
A broadly representative modified Delphi panel process resulted in a consensus on a set of 48 evidence-based quality of care indicators for EDs. Future work is required to generate technical definitions to enable the uptake of these indicators to support benchmarking, quality improvement, and accountability efforts.
Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patientsMarch 2011 13 2Clare L. Atzema, Jack V. Tu, Michael J. Schull, Peter C. Austin
Objective:The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time.
Methods:This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time.
Results:In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%.
Conclusions:Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.
Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provincesSeptember 2009 11 5Andrew Travers, Dug Andrusiek, Jack V. Tu, John Trickett, Linda Donovan, Lucy J. Boothroyd, Marian J. Vermeulen, Michael J. Schull, Samuel Vaillancourt, Sunil Sookram
Objective: Timely reperfusion therapy for ST-elevation myocardial infarction (STEMI) is an important determinant of outcome, yet targets for time to treatment are frequently unmet in North America. Prehospital strategies can reduce time to reperfusion. We sought to determine the extent to which emergency medical services (EMS) use these strategies in Canada.
Methods: We carried out a cross-sectional survey in 2007 of ground EMS operators in British Columbia, Alberta, Ontario, Quebec and Nova Scotia. We focused on the use of 4 prehospital strategies: 1) 12-lead electrocardiogram (ECG), 2) routine expedited emergency department (ED) transfer of STEMI patients (from a referring ED to a percutaneous coronary intervention [PCI] centre), 3) prehospital bypass (ambulance bypass of local EDs to transport patients directly to PCI centres) and 4) prehospital fibrinolysis.
Results: Ninety-seven ambulance operators were surveyed, representing 15 681 paramedics serving 97% of the combined provincial populations. Of the operators surveyed, 68% (95% confidence interval [CI] 59%-77%) had ambulances equipped with 12-lead ECGs, ranging from 40% in Quebec to 100% in Alberta and Nova Scotia. Overall, 47% (95% CI 46%-48%) of paramedics were trained in ECG acquisition and 40% (95% CI 39%-41%) were trained in ECG interpretation. Only 18% (95% CI 10%-25%) of operators had prehospital bypass protocols; 45% (95% CI 35%-55%) had protocols for expedited ED transfer. Prehospital fibrinolysis was available only in Alberta. All EMS operators in British Columbia, Alberta and Nova Scotia used at least 1 of the 4 prehospital strategies, and one-third of operators in Ontario and Quebec used 0 of 4. In major urban centres, at least 1 of the 3 prehospital strategies 12-lead ECG acquisition, bypass or expedited transfer was used, but there was considerable variation within and across provinces.
Conclusion: The implementation of widely recommended prehospital STEMI strategies varies substantially across the 5 provinces studied, and relatively simple existing technologies, such as prehospital ECGs, are underused in many regions. Substantial improvements in prehospital services and better integration with hospital-based care will be necessary in many regions of Canada if optimal times to reperfusion, and associated outcomes, are to be achieved.
Michael J. Schull
ALaRMED: adverse events in low-risk chest pain patients receiving continuous ECG monitoring in the emergency department: a survey of Canadian emergency physiciansSeptember 2008 10 5Clare L. Atzema, Michael J. Schull
Objective: Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We surveyed emergency physicians to determine their perception of current occupancy rates of CEM and to assess their attitudes toward prescribing monitors for low-risk chest pain patients in the ED.
Methods: We conducted a cross-sectional, self-administered Internet and mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians. Main outcome measures included the perceived frequency of fully occupied monitors in the ED and physicians' willingness to forgo CEM in certain chest pain patients.
Results: The response rate was 66% (199 respondents). The largest group of respondents (43%; 95% confidence interval [CI] 36%-50%) indicated that monitors were fully occupied 90%-100% of the time during their most recent ED shift. When asked how often they were forced to choose a patient for monitor removal because of the limited number of monitors, 52% (95% CI 45%-60%) of respondents selected 1-3 times per shift. Ninety percent (95% CI 84%-93%) of respondents indicated that they would forgo CEM in certain cardiac chest pain patients if there was good evidence that the risk of a monitor-detected adverse event was very low.
Conclusion: Emergency physicians report that monitors are often fully occupied in Canadian EDs, and most are willing to forgo CEM in certain chest pain patients. A large prospective study of CEM in low-risk chest pain patients is warranted.
Michael J. Schull, Sherry Kennedy, Wendy Young, Winston Isaac
Objective: In February 2007, the Health Council of Canada, in its third annual report, emphasized the need for pan-Canadian data on our health care system. To date, no studies have examined the strengths and weaknesses of emergency health services (EHS) administrative databases, as perceived by researchers. We undertook a qualitative study to determine, from a researcher's perspective, the strengths and weaknesses of EHS administrative databases. The study also elicited researchers' suggestions to improve these databases.
Methods: We conducted taped interviews with 4 Canadian health services researchers. The transcriptions were subsequently examined for common concepts, which were finalized after discussion with all the investigators.
Results: Five common themes emerged from the interviews: clinical detail, data quality, data linkage, data use and population coverage. Data use and data linkages were considered strengths. Clinical detail, data quality and population coverage were considered weaknesses.
Conclusion: The 5 themes that emerged from this study all serve to reinforce the call from the Health Council of Canada for national data on emergency services, which could be readily captured through a national EHS administrative database. We feel that key stakeholders involved in emergency services across Canada should work together to develop a strategy to implement an accurate, clinically detailed, integrated and comprehensive national EHS database.
Alison K. Macpherson, Michael J. Schull
Background: There is a paucity of population-based research on health service utilization related to penetrating trauma in Canada, even though such trauma can result in serious injury or death, and gunshot wounds have been labelled the "the new public health issue." Complete epidemiologic data, including emergency department (ED) visits and hospitalizations, for penetrating trauma is not available. The objective of this paper is to describe the epidemiology of ED visits for firearm-related and knife-related penetrating trauma in one Canadian province.
Methods: All EDs in the province of Ontario (pop. approx. 12 400 000 at the time of the study) submit data on ED visits to the National Ambulatory Care Reporting System. This database includes patients' demographic information (i.e., age, sex and geographic area of residence), the reason for the visit, disposition (i.e., admitted to hospital or sent home), and other diagnostic information. For visits related to injuries, the cause of injury is also reported (e-codes according to the Canadian Enhancement to the International Statistical Classification of Diseases and Related Health Problems, 10th rev [ICD-10-CA]). All patients seen in Ontario EDs for an injury related to a firearm, knife, or sharp object, were included in our study.
Results: Of the 1.2 million ED visits in 2002-03 for trauma in Ontario, 40 240 (3.4%) patients were treated for injuries relating to penetrating trauma. Most patients were male, and most were 15-24 years of age. Penetrating trauma was frequently a result of knives or sharp objects (39 654 visits or 98.5%); only 1.5% (n = 586) of these injuries were caused by firearms. Of those hospitalized, 151 were related to firearms and 1455 were related to knives/ sharp objects.
Conclusions: Analyzing administrative data provides an estimate of the impact of penetrating trauma on a population, thereby providing prevention programs with data upon which to design their strategies. Evidence-based prevention strategies are needed to reduce the burden of penetrating trauma. Monitoring ED and hospitalization data over time will help to assess trends and provide evidence for the effectiveness of such strategies.