We evaluated how emergency department (ED) staff perceives the practice known as redirection, whereby triage nurses guide low-acuity patients to alternative care settings without evaluation by a physician. Our aim was to evaluate its use across Canada and to identify its key drivers and barriers to its implementation. We conducted a cross-sectional survey of Canadian ED physicians, nurses and managers from September to December 2023. The survey tool was developed in French and English following a modified Dillman's tailored design method, including: (1) literature review to identify key themes on redirection; (2) semi-structured interviews with experts on redirection; (3) the development of a tool prototype; (4) scientific and linguistic revisions; and (5) pre-testing. The survey was distributed through the mailing list of the Canadian emergency medicine and nursing associations. Of the 719 respondents recruited, 47.0% were nurses, 44.2% were physicians and 5% were managers. The overall response rate was 10.2%. Most respondents endorsed redirection as safe, with this endorsement ranging from 75.5% in Ontario to 94.3% in Manitoba. Similarly, the view that first-line physicians can adequately manage redirected patients was supported by most respondents, with proportions ranging from 78.1% in Ontario to 92.1% in Québec. Redirection strategies reported by the majority of respondents were based on the Canadian Triage and Acuity Scale (65.2%). Insufficient opening hours of clinics (87.2%) and those with a CTAS score of 3 (62.7%) were identified as the main challenges. Professionals most suggested to receive redirected patients were family physicians (90.9%), nurse practitioners (86.4%), dentists (83.8%), social workers (71.9%), pharmacists (63.9%), and physiotherapists (58.0%). In this pan-Canadian survey of ED personnel, the majority of respondents expressed support for redirecting low-acuity patients. These findings indicate an opportunity for further research on the development of redirection tools.

Gender disparities in medicine are well documented, including in emergency medicine. These disparities are influenced by a variety of factors such as payment models, patient expectations, and time spent on different aspects of care, including documentation. While gender-based differences in patient care have been associated with better outcomes for patients treated by women physicians, the underlying reasons remain unclear. This study aims to quantify and compare time spent on patient care tasks, stratified by physician gender, in an academic emergency department (ED). We conducted a prospective observational time-motion study from July to August 2022 in the ambulatory care area of a large tertiary academic ED. Research assistants shadowed physicians during daytime and evening shifts, timing eight predefined clinical tasks for each patient encounter while also collecting data on patient characteristics and provider demographics (gender, years of practice, training stream). Statistical analyses included Wilcoxon rank sum tests and linear regression to examine task durations and gender differences. Our sample size was determined by feasibility. Thirty-seven physicians (32.4% women, 67.6% men) were observed across 65 shifts involving 1204 patient encounters. Women physicians spent significantly more time per patient than men (mean 20.9 vs. 18.1min, + 15.5%, p = 0.015), particularly on initial assessments (7.1 vs. 6.4min, + 10.9%, p = 0.024) and charting (6.7 vs. 5.2min, + 28.8%, p = 0.001). No significant gender differences were found in other tasks. The additional time spent by women was not fully explained by measured tasks, suggesting other unmeasured contributors such as interruptions or workflow inefficiencies. Women emergency physicians spend more time per patient on assessments and documentation than men physicians. These findings raise important considerations for gender equity in clinical performance metrics and documentation burden.

The landscape of the medico-legal risk in emergency medicine in Canada is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases in the emergency department (ED). We conducted a descriptive analysis of closed medico-legal cases (hospital complaints, regulatory authority (i.e., College) complaints, and civil-legal actions) involving physicians practicing primarily emergency medicine in Canadian EDs. We used data from closed cases involving the Canadian Medical Protective Association from January 2018 until December 2022. We abstracted descriptive factors of the cases and used a framework for contributing factors classification. From 2018 until 2022, 37,046 cases were closed and 1,892 involved physicians practicing emergency medicine for which there was medico-legal information available for analysis. In all, 54% (1,019) were College complaints, 27% (516) were legal civil actions, and 19% (357) were hospital complaints. Out of these, 1,165 (62%) were subject to peer-expert criticism. More than half of the complaints (52%) resulted in an unfavorable medico-legal outcome for the physician. Analysis of the 1,165 cases with peer-expert criticism identified the most common factors contributing to medico-legal risk included clinical decision-making (64%), situational awareness (44%), and issues with provider's documentation (42%). The most common diagnoses associated with medico-legal risk were injuries, infections, and disorders of the circulatory system. The three most common contributing factors were related to clinical decision-making, situational awareness, and issues with documentation.

Emergency departments (EDs) have seen growing rates of pediatric mental health presentations, a trend exacerbated by the COVID-19 pandemic. Many of these patients will 'board', remaining in the ED for prolonged periods of time while awaiting transfer to an inpatient bed. Boarding disproportionately impacts mental health patients and is associated with worse patient health outcomes and healthcare system inefficiency. The objective of this scoping review is to synthesize the extent and nature of evidence relating to pediatric mental health boarding, and to identify knowledge gaps. Searches were conducted in MEDLINE, Embase, PsycINFO, and CINAHL for peer-reviewed literature involving mental health patients boarding in hospital EDs. Studies underwent eligibility screening for pediatric populations and data extraction by two reviewers.Results are reported per PRISMA-ScR guidelines. Three thousand four hundred and fifty-eight studies were screened for title and abstract eligibility, 386 of which were assessed at full-text. Twenty-eight studies met inclusion criteria. Of these, 19 assessed variables impacting boarding, 18 quantified boarding duration or prevalence, 6 measured the impacts of boarding, 5 assessed interventions to mitigate boarding, and 4 provided consensus recommendations. Eighty-two percent of studies were published within the last 5years and all are from the United States. Reported mean ED boarding times ranged from 5 to 54h across 5 studies. Of 7 studies assessing the impact of COVID-19 on pediatric mental health boarding, all reported that COVID-19 was associated with increased boarding prevalence and/or duration. An emerging body of literature on the burden and impacts of ED boarding among pediatric mental health patients suggests that boarding is a pressing concern in the delivery of pediatric emergency healthcare that has worsened since COVID-19. This is the most comprehensive evidence synthesis on pediatric mental health boarding to date, highlighting the impacts of boarding and the solutions studied to address this problem.

Our primary objective was to determine whether the yield of pulmonary embolism imaging in the emergency department (ED) is different for patients presenting with "chest pain with cardiac features" than with other complaints. The yield of imaging was defined as the proportion of imaging tests that were positive for pulmonary embolism. Secondary objectives were to estimate the prevalence of pulmonary embolism, the use of imaging, and the yield of imaging for each presenting complaint category. Our hypothesis was that the presenting complaint influences the physician's threshold for requesting imaging. We performed an observational health records review study including all adult patient visits between 2018 and 2019 in three EDs in Hamilton (Ontario), Canada. The primary outcome was the diagnostic yield of imaging (computed tomography pulmonary angiogram or ventilation/perfusion scan). We performed a multivariable regression analysis using a generalized linear model, adjusting for confounders. During the study period, 518,787 patients were assessed and 6,700 received imaging for pulmonary embolism. Among the 29,834 triaged as having chest pain with cardiac features, 1,440 (4.8%) received imaging. Among the 488,953 patients with any other presenting complaint, 5,260 (1.1%) received imaging. The diagnostic yield of imaging was 4.2% for patients with chest pain with cardiac features, 8.6% for those with other presenting complaints, with an adjusted odds ratio of 0.62 (95% confidence interval: 0.45-0.87). The prevalence of pulmonary embolism at 30 days was 0.20% in patients with chest pain with cardiac features and 0.10% for all other presenting complaints. The lower yield despite a higher prevalence means that the threshold for ordering imaging in people presenting to the ED with chest pain with cardiac features was lower than in other patients. Clinicians should keep in mind this possible bias when assessing their patients.

D-dimer testing can reduce imaging utilization in the workup of pulmonary embolism, but the optimal cutoff remains unclear. The conventional D-dimer cutoff is < 500µg/L Fibrinogen Equivalent Units, while the age-adjusted cutoff in patients over 50 is age × 10. Newer probability-adjusted strategies-the YEARS criteria and PEGeD algorithm-allow a higher threshold (D-dimer < 1000µg/L) for select low-risk patients. We aimed to retrospectively compare the diagnostic accuracy of four evidence-based pathways to exclude pulmonary embolism without imaging among our emergency department patients who were imaged. A historical patient cohort was generated including all adults who received computed tomography pulmonary angiography or ventilation-perfusion scans after D-dimer testing in three emergency departments in a large urban Canadian center. Electronic medical records were reviewed to retrospectively compare the test performance of four D-dimer pathways: (i) conventional, (ii) age-adjusted, (iii) YEARS, and (iv) PEGeD. Of 1092 patients, 129 had pulmonary embolism. Conventional and age-adjusted cutoffs were both 100% sensitive (95% CI, 97.1-100.0), with specificities of 3.5% (2.5-4.9) and 6.4% (5.1-8.2). YEARS was 93.8% sensitive (88.2-96.8) and 30.4% specific (27.6-33.4), with PPV of 15.3% (13.0-18.0) and NPV of 97.3% (94.8-98.6). PEGeD was the least sensitive (92.2%, 86.3-95.7), but most specific (39.1%, 36.1-42.3), with PPV of 16.9% (14.3-19.8) and NPV of 97.4% (95.3-98.6). PEGeD would have resulted in the most patients managed without imaging (35.4%), followed by YEARS (27.6%), age-adjusted (5.7%), and the conventional cutoff (3.1%). While implementation of a probability-adjusted D-dimer pathway, such as YEARS or PEGeD, would have substantially reduced imaging utilization, these strategies may miss some cases of pulmonary embolism detectable by both age-adjusted and conventional cutoffs. We add to the heterogeneity of safety data, suggesting that adjustment of D-dimer to clinical probability represents a trade-off between sensitivity and imaging utilization.

The COVID-19 pandemic and Canada's drug poisoning crisis placed exceptional demands on emergency departments (ED). We aimed to explore the impact of these intersecting crises from the perspectives of ED staff to understand how EDs can improve care and protect the health and well-being of patients who use opioids, ED staff, and healthcare providers. We conducted a focused ethnographic study involving 29 semi-structured interviews with ED staff who cared for patients who use opioids during the pandemic. Interviews explored ED staff perspectives on how the pandemic impacted care for patients who use opioids and how EDs can better serve this population. We conducted latent content analysis and main theme generation was informed by the socioecological model. Four main themes emerged. First, there was a change in patient behaviors, which impacted provider-patient relationships. Second, hospital pandemic policies and resource limitations created new barriers to care. Third, community service alterations, including the shift to virtual care and uncertain availability of services, further complicated patient care. Finally, participants highlighted opportunities to strengthen systems of care, including enhanced hospital addiction resources, improved addiction care training, expanded harm reduction services, and more robust community services. The COVID-19 pandemic highlighted significant changes in ED care delivery for patients who use opioids. Efforts to enhance EDs should include anticipating the needs of people who use substances and the healthcare providers who care for them to mitigate unintended harm and ensure a more resilient healthcare system.