CJEM Articles: Michael J. Schull
Displaying 1-10 of 13 results
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November
2011
13
6
Anne 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. -
September
2011
13
5
Astrid Guttmann, Brian H. Rowe, Caroline M. Hatcher, Chad A. Leaver, Geoffrey M. Anderson, Marian Vermeulen, Merrick Zwarenstein, Michael J. Schull
Background:
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.
Methods:
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.
Results:
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.
Discussion:
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.
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March
2011
13
2
Clare 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. -
September
2009
11
5
Andrew 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. -
March
2009
11
2
Michael J. Schull
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September
2008
10
5
Clare 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. -
March
2008
10
2
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. -
January
2007
9
1
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. -
July
2005
7
4
Chris A. Altmayer, Graham L. Woodward, Michael J. Schull, Sten Ardal
The purpose of this report is to examine Ontario's geographic variation in emergency department (ED) visits for conditions that may be treated in alternative primary care settings. We studied all visits to Ontario EDs in 2002/03 and calculated county-specific age-standardized rates. Overall in Ontario, there were 3174 ED visits per 100 000 population aged 1-74 for conditions that could be treated in alternate primary care settings, but rates varied widely across counties. They were higher in rural counties with rates up to 7-fold higher than the provincial average. Urban counties had lower rates, some were less than one-third of the provincial average. Further research is needed to determine the relationship between ED utilization and primary care capacity.
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March
2005
7
2
Marian Vermeulen, Michael J. Schull
Background: Difficulty maintaining physician staffing in emergency departments (EDs) prompted the government of Ontario to offer alternate funding arrangements (AFAs) to replace fee-for-service remuneration for physicians working in EDs.
Objective: To analyze the effect of AFAs on physician staffing and practice patterns.
Methods: We obtained Ontario Health Insurance Program fee-for-service and shadow-billing records for all physician services provided in EDs one year before and one year after implementation of an ED AFA. Only sites with reliable billing data were retained. Physicians were assigned to small/rural, community or teaching hospital groups based on their billing claims. For each hospital type, and all hospitals combined, we compared the pre- and post-AFA periods in terms of the number of physicians working regularly in the ED and their workload. As a possible unintended consequence of AFAs, we also compared physicians' involvement in primary care.
Results: Overall, 76.2% of eligible hospitals adopted an ED AFA, of which 49 (42.6%) were included in our study (16 small/rural, 27 community and 6 teaching hospitals). In the post-AFA period, the number of physicians working in EDs increased by 7, from 674 to 681, representing a 1.0% increase overall in the workforce (p = 0.84). The change varied by hospital type, from a 5.8% increase in teaching hospitals to a 2.2% decrease in community hospitals, though none was significant. In the post-AFA period, the number of physicians working a moderate number of days per month increased from 190 to 214, representing a 3.2% absolute increase (p = 0.39), and the number working few (<5) or many (>10) days per month decreased. Post-AFA, the number of physicians working in EDs who also provided primary care services decreased by 1.7%, from 544 to 535 (p = 0.10).
Conclusion: Emergency department AFAs have been widely adopted in Ontario, but have not been associated with substantial changes in the overall physician workforce in EDs. However, trends toward increased physician numbers were seen in small/rural and teaching hospitals. There was little evidence of any adverse effects on the provision of primary care services by physicians.
