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Warren BE, Bilbily A, Gichoya JW, Chartier LB, Fawzy A, Barragán C, Jaberi A, Mafeld S. An Introductory Guide to Artificial Intelligence in Interventional Radiology: Part 2: Implementation Considerations and Harms. Can Assoc Radiol J 2024:8465371241236377. [PMID: 38445517 DOI: 10.1177/08465371241236377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
The introduction of artificial intelligence (AI) in interventional radiology (IR) will bring about new challenges and opportunities for patients and clinicians. AI may comprise software as a medical device or AI-integrated hardware and will require a rigorous evaluation that should be guided based on the level of risk of the implementation. A hierarchy of risk of harm and possible harms are described herein. A checklist to guide deployment of an AI in a clinical IR environment is provided. As AI continues to evolve, regulation and evaluation of the AI medical devices will need to continue to evolve to keep pace and ensure patient safety.
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Affiliation(s)
- Blair Edward Warren
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Alexander Bilbily
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- 16 Bit Inc., Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Aly Fawzy
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Camilo Barragán
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Arash Jaberi
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
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2
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Hrymak C, Lim R, Trivedi S, Alvarez A, Purdy E, Belisle S, Thull-Freedman J, Leeies M, Lang E, Chartier LB. An Exploration of the Interplay Between Well-being and Quality and Safety. CAN J EMERG MED 2024; 26:148-155. [PMID: 38421518 DOI: 10.1007/s43678-024-00653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/11/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Quality improvement and patient safety (QIPS) and clinician well-being work are interconnected and impact each other. Well-being is of increased importance in the current state of workforce shortages and high levels of burnout. The Canadian Association of Emergency Physicians (CAEP) Academic Symposium sought to understand the interplay between QIPS and clinician well-being and to provide practical recommendations to clinicians and institutions on ensuring that clinician well-being is integrated into QIPS efforts. METHODS A team of emergency physicians with expertise in well-being and QIPS performed a literature review, drafted goals and recommendations, and presented at the CAEP Academic Symposium in 2023 for feedback. Goals and recommendations were then further refined. RESULTS Three goals and recommendations were developed as follows: QIPS leaders and practitioners must (1) understand the potential intersection of well-being and QIPS, (2) consider a well-being lens for all QIPS work, and (3) incorporate QIPS methodology in efforts to improve clinician well-being. CONCLUSION QIPS and clinician well-being are often closely linked. By incorporating these recommendations, QIPS strategies can enhance clinician well-being.
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Affiliation(s)
- Carmen Hrymak
- Department of Emergency Medicine and Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada.
| | - Rodrick Lim
- Departments of Paediatrics and Medicine, Western University, London, ON, Canada
| | - Sachin Trivedi
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Al'ai Alvarez
- Department of Emergency Medicine, Stanford University, Stanford, CA, USA
| | - Eve Purdy
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Gold Coast, Australia
| | - Sheena Belisle
- Departments of Paediatrics and Medicine, Western University, London, ON, Canada
| | - Jennifer Thull-Freedman
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine and Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University of Toronto, Toronto, ON, Canada
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McLaren JTT, Meyers HP, Smith SW, Chartier LB. Emergency department Code STEMI patients with initial electrocardiogram labeled "normal" by computer interpretation: A 7-year retrospective review. Acad Emerg Med 2024; 31:296-300. [PMID: 37620163 DOI: 10.1111/acem.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University Health Network, Toronto, Ontario, Canada
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, North Carolina, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University Health Network, Toronto, Ontario, Canada
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Couture V, Germain N, Côté É, Lavoie L, Robitaille J, Morin M, Chouinard J, Couturier Y, Légaré F, Hardy MS, Chartier LB, Brousseau AA, Sourial N, Mercier É, Dallaire C, Fleet R, Leblanc A, Melady D, Roy D, Sinha S, Sirois MJ, Witteman HO, Émond M, Rivard J, Pelletier I, Turcotte S, Samb R, Giguère R, Abrougui L, Smith PY, Archambault PM. Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments. BMC Geriatr 2024; 24:8. [PMID: 38172725 PMCID: PMC10763115 DOI: 10.1186/s12877-023-04482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.
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Affiliation(s)
- Vanessa Couture
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Nathalie Germain
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Medicine, Université Laval, Québec, Québec Canada
| | - Émilie Côté
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Lise Lavoie
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Joanie Robitaille
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Michèle Morin
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Medicine, Université Laval, Québec, Québec Canada
| | - Josée Chouinard
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Yves Couturier
- Department of Social Work, Université de Sherbrooke, Sherbrooke, Québec Canada
| | - France Légaré
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Québec Canada
- Centre de recherche du CHU de Québec - Université Laval, Axe santé des populations et pratiques optimales en santé, Université Laval, Québec, Québec Canada
| | - Marie-Soleil Hardy
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Lucas B. Chartier
- Department of Emergency Medicine, University Health Network, Toronto, ON Canada
| | | | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montréal, Québec Canada
| | - Éric Mercier
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- Centre de recherche du CHU de Québec - Université Laval, Axe santé des populations et pratiques optimales en santé, Université Laval, Québec, Québec Canada
| | - Clémence Dallaire
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Nursing Science, Université Laval, Québec, Québec Canada
| | - Richard Fleet
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
| | - Annie Leblanc
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
| | - Don Melady
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON Canada
| | - Denis Roy
- Commissaire à la santé et au bien-être (CSBE), Québec, Québec Canada
| | - Samir Sinha
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON Canada
| | - Marie-Josée Sirois
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- Département de réadaptation, Faculté de médecine, Université Laval, Québec, Québec Canada
| | - Holly O. Witteman
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
| | - Marcel Émond
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Québec Canada
| | - Josée Rivard
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Isabelle Pelletier
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Stéphane Turcotte
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Rawane Samb
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Raphaëlle Giguère
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Science and Engineering, Université Laval, Québec, Québec Canada
| | - Lyna Abrougui
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Science and Engineering, Université Laval, Québec, Québec Canada
| | - Pascal Y. Smith
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
| | - Patrick M. Archambault
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Québec Canada
- Faculty of Medicine, Université Laval, Québec, Québec Canada
- VITAM - Centre de recherche en santé durable, Québec, Québec Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Québec Canada
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McLaren JTT, El-Baba M, Sivashanmugathas V, Meyers HP, Smith SW, Chartier LB. Missing occlusions: Quality gaps for ED patients with occlusion MI. Am J Emerg Med 2023; 73:47-54. [PMID: 37611526 DOI: 10.1016/j.ajem.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND ST-elevation Myocardial Infarction (STEMI) guidelines encourage monitoring of false positives (Code STEMI without culprit) but ignore false negatives (non-STEMI with occlusion myocardial infarction [OMI]). We evaluated the hospital course of emergency department (ED) patients with acute coronary syndrome (ACS) using STEMI vs OMI paradigms. METHODS This retrospective chart review examined all ACS patients admitted through two academic EDs, from June 2021 to May 2022, categorized as 1) OMI (acute culprit lesion with TIMI 0-2 flow, or acute culprit lesion with TIMI 3 flow and peak troponin I >10,000 ng/L; or, if no angiogram, peak troponin >10,000 ng/L with new regional wall motion abnormality), 2) NOMI (Non-OMI, i.e. MI without OMI) or 3) MIRO (MI ruled out: no troponin elevation). Patients were stratified by admission for STEMI. Initial ECGs were reviewed for automated interpretation of "STEMI", and admission/discharge diagnoses were compared. RESULTS Among 382 patients, there were 141 OMIs, 181 NOMIs, and 60 MIROs. Only 40.4% of OMIs were admitted as STEMI: 60.0% had "STEMI" on ECG, and median door-to-cath time was 103 min (IQR 71-149). But 59.6% of OMIs were not admitted as STEMI: 1.3% had "STEMI" on ECG (p < 0.001) and median door-to-cath time was 1712 min (IQR 1043-3960; p < 0.001). While 13.9% of STEMIs were false positive and had a different discharge diagnosis, 32.0% of Non-STEMIs had OMI but were still discharged as "Non-STEMI." CONCLUSIONS STEMI criteria miss a majority of OMI, and discharge diagnoses highlight false positive STEMI but never false negative STEMI. The OMI paradigm reveals quality gaps and opportunities for improvement.
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Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Mazen El-Baba
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Grewal K, Atzema CL, Sutradhar R, Yu W, Chartier LB, Friedman SM, Landes M, Borgundvaag B, McLeod SL. Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study. CMAJ Open 2023; 11:E969-E981. [PMID: 37875312 PMCID: PMC10609908 DOI: 10.9778/cmajo.20230017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes. METHODS We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019). RESULTS Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period. INTERPRETATION The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.
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Affiliation(s)
- Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.
| | - Clare L Atzema
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Rinku Sutradhar
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Winnie Yu
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Lucas B Chartier
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Steven M Friedman
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Megan Landes
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute (Grewal, Borgundvaag, McLeod), Sinai Health; Division of Emergency Medicine, Department of Medicine (Grewal, Atzema, Chartier), Temerty Faculty of Medicine, University of Toronto; ICES (Grewal, Atzema, Sutradhar, Yu); Department of Emergency Services (Atzema), Sunnybrook Health Sciences Centre; Dalla Lana School of Public Health (Sutradhar), University of Toronto; Department of Emergency Medicine (Chartier, Friedman, Landes), University Health Network; Division of Emergency Medicine, Department of Family and Community Medicine (Friedman, Landes, Borgundvaag, McLeod), Temerty Faculty of Medicine, University of Toronto, Toronto, Ont
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McLaren JTT, Bhate TD, Taher AK, Chartier LB. Return visit audits, quality improvement infrastructure, and a culture of safety: a theoretical model and practical assessment tool. CAN J EMERG MED 2023; 25:649-652. [PMID: 37318705 PMCID: PMC10425292 DOI: 10.1007/s43678-023-00539-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/28/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Jesse T. T. McLaren
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
- Toronto General Hospital, Toronto, ON Canada
| | - Tahara D. Bhate
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Ahmed K. Taher
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Lucas B. Chartier
- Emergency Department, University Health Network, Toronto, ON Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
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8
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Wilson S, Chen KCJ, Chartier LB, Campbell SG, Dowling S, Upadhye S, Thiruganasambandamoorthy V. Revisiting Choosing Wisely recommendation #1: "Don't order CT head scan in adults and children who have suffered minor head injuries (unless positive for a validated clinical decision rule)". CAN J EMERG MED 2023:10.1007/s43678-023-00515-0. [PMID: 37253996 DOI: 10.1007/s43678-023-00515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/22/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Samuel Wilson
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
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9
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Hall JN, Chartier LB. Learning From a Regional Approach: Integration to Scale, Spread, and Sustain Virtual Urgent Care. Inquiry 2023; 60:469580221143273. [PMID: 36624685 PMCID: PMC9834925 DOI: 10.1177/00469580221143273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
While new offerings of virtual urgent care services from peer hospitals faltered after initial provincial pilot funding lapsed, our 3 regional academic health sciences centers decided to partner to enhance patient access, achieve efficiencies, and support long-term sustainability. Utilizing the Development Model for Integrated Care framework, we progressed through the 4 phases to ensure joint success and high-quality care: (1) initiative and design phase-individual parallel projects but with strong collaborations and broad stakeholder engagement; (2) experimental and execution phase-continuous quality improvement approach for governance, policies, and processes; (3) expansion and monitoring phase-weekly leadership touchpoints on key performance indicators; and (4) consolidation and transformation phase-sustainability through ongoing funding.
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Affiliation(s)
- Justin N. Hall
- Sunnybrook Health Sciences Centre,
Toronto, ON, Canada,University of Toronto, Toronto, ON,
Canada,Justin N. Hall, Department of Emergency
Services, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, C753, Toronto,
ON, M4N 3M5, Canada.
| | - Lucas B. Chartier
- University of Toronto, Toronto, ON,
Canada,University Health Network, Toronto, ON,
Canada
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10
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Taher A, Glazer P, Culligan C, Crump S, Guirguis S, Jones J, Dharamsi A, Chartier LB. Improving safety and communication for healthcare providers caring for SARS-COV-2 patients. Int J Emerg Med 2022; 15:62. [PMCID: PMC9652974 DOI: 10.1186/s12245-022-00464-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/23/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Decreasing healthcare provider (HCP) exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus in emergency departments (EDs) is crucial. Approaches include limiting the HCP presence and ensuring sealed isolation rooms, which can result in communication difficulties. This quality improvement (QI) initiative aimed to decrease by 50% duration of isolation room door opening and increasing HCP-perceived communication clarity by one point on a five-point Likert scale.
Methods
This was a prospective, multi-stage project with three Plan-Do-Study-Act (PDSA) cycles between May and July 2020: (1) an educational intervention, (2) the introduction of a novel transceiver communication device, and (3) utilizing a clinical champion. Statistical Process Control XbarR charts were used to assess for special cause variation, and two-tailed Mann-Whitney U tests were used for statistical significance between Likert survey means. Qualitative responses underwent thematic analysis.
Results
Observation of 174 patient encounters was completed over 33 days, with 95 meeting the inclusion criteria. Door opening decreased from baseline (n=40; mean 72.97%) to PDSA 3 (n=21; mean 1.58%; p<0.0001). HCP-perceived communication clarity improved from baseline (n=36; mean 3.36) to PDSA-3 (n=49; mean 4.21; p<0.001). Survey themes included positive effects on communication and workflow, with some challenges on the integration of the new device into the clinical workflow. HCP-perceived errors, workarounds, and workflow pauses showed significant improvements.
Conclusion
This QI initiative with a novel transceiver showed significant decreases in isolation room door opening and increases in communication clarity. Future work will expand to operating rooms and intensive care units.
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11
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McLaren JTT, Chartier LB. In Reply to Berger and Yiadom. J Emerg Med 2022; 63:134-135. [PMID: 35940979 DOI: 10.1016/j.jemermed.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jesse T T McLaren
- Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada
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12
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Chartier LB. What's in a name? "Return visits" in the emergency department. Acad Emerg Med 2022; 29:914-915. [PMID: 35297532 DOI: 10.1111/acem.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Lucas B. Chartier
- Division of Emergency Medicine, Division of Medicine University of Toronto Toronto Ontario Canada
- Department of Emergency Medicine University Health Network Toronto Ontario Canada
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13
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Affiliation(s)
- Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada. .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jennifer Thull-Freedman
- Departments of Pediatrics and Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute, Calgary, AB, Canada
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14
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Chartier LB, Masood S, Choi J, McGovern B, Casey S, Friedman SM, Porplycia D, Tosoni S, Sabbah S. A blueprint for building an emergency department quality improvement and patient safety committee. CAN J EMERG MED 2022; 24:195-205. [PMID: 35107806 PMCID: PMC8808466 DOI: 10.1007/s43678-021-00252-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, “Leading Change.” Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a “burning platform,” select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.
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Affiliation(s)
- Lucas B Chartier
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada. .,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
| | - Sameer Masood
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Joseph Choi
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Barb McGovern
- Ryerson University, Daphne Cockwell School of Nursing, Toronto, ON, Canada.,Emergency Department, Trillium Health Partners, Mississauga, ON, Canada
| | - Stephen Casey
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada
| | - Steven Marc Friedman
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Porplycia
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada
| | - Sarah Tosoni
- University Health Network, Quality, Safety & Clinical Adoption, Toronto, ON, Canada
| | - Sam Sabbah
- Department of Emergency Medicine, University Health Network, 200 Elizabeth St., RFE-GS-480, Toronto, ON, M5G 2C4, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
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15
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Lee DD, Hacker Teper M, Chartier LB, Crump S, Ma M, Parotto M, Perri P, Chin KJ, Nirmalanathan K, Sabbah S, Taher AK. Experiences of healthcare providers with a novel emergency response intubation team during COVID-19. CAN J EMERG MED 2022; 24:185-194. [PMID: 35041201 PMCID: PMC8764172 DOI: 10.1007/s43678-021-00248-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/06/2021] [Indexed: 11/27/2022]
Abstract
Objectives In the early stages of the COVID-19 pandemic, there were significant concerns about the infectious risks of intubation to healthcare providers. In response, a dedicated emergency response intubation team (ERIT) consisting of anesthesiologists and allied health providers was instituted for our emergency department (ED). Given the high-risk nature of intubations and the new interprofessional team dynamics, we sought to assess health-care provider experiences and potential areas of improvement. Methods Surveys were distributed to healthcare providers at the University Health Network, a quaternary healthcare centre in Toronto, Canada, which includes two urban EDs seeing over 128,000 patients per year. Participants included ED physicians and nurses, anesthesiologists, anesthesia assistants, and operating room nurses. The survey included free-text questions. Responses underwent thematic analysis using grounded theory and were independently coded by two authors to generate descriptive themes. Discrepancies were resolved with a third author. Descriptive themes were distilled through an inductive, iterative process until fewer main themes emerged. Results A total of 178 surveys were collected (68.2% response rate). Of these, 123 (69%) participated in one or more ERIT activations. Positive aspects included increased numbers of staff to assist, increased intubation expertise, improved safety, and good team dynamics within the ERIT team. Challenges included a loss of scope (primarily ED physicians and nurses) and unfamiliar workflows, perceived delays to ERIT team arrival or patient intubation, role confusion, handover concerns, and communication challenges between ED and ERIT teams. Perceived opportunities for improvement included interprofessional training, developing clear guidelines on activation, inter-team role clarification, and guidelines on handover processes post-intubation. Conclusions Healthcare providers perceived that a novel interprofessional collaboration for intubations of COVID-19 patients presented both benefits and challenges. Opportunities for improvement centred around interprofessional training, shared decision making between teams, and structured handoff processes.
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Affiliation(s)
- Daniel D Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | | | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Stephanie Crump
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Martin Ma
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Matteo Parotto
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Pauline Perri
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Konika Nirmalanathan
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
| | - Sam Sabbah
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ahmed K Taher
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
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16
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Chen KCJ, Thiruganasambandamoorthy V, Campbell SG, Upadhye S, Dowling S, Chartier LB. Choosing Wisely Canada: scratching the 7-year itch. CAN J EMERG MED 2022; 24:569-573. [PMID: 35819640 PMCID: PMC9273920 DOI: 10.1007/s43678-022-00349-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/15/2022] [Indexed: 02/08/2023]
Affiliation(s)
| | | | - Samuel G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Suneel Upadhye
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, University Health Network, Toronto, ON, Canada
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17
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McLaren JTT, Meyers HP, Smith SW, Chartier LB. From STEMI to occlusion MI: paradigm shift and ED quality improvement. CAN J EMERG MED 2021; 24:250-255. [PMID: 34967919 PMCID: PMC9001399 DOI: 10.1007/s43678-021-00255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Jesse T T McLaren
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. .,Emergency Department, University Health Network, Toronto, ON, Canada. .,Toronto General Hospital, 200 Elizabeth Street, R. Fraser Elliott Building, Ground Floor, Room 480, Toronto, ON, M5G 2C4, Canada.
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Centre and University of Minnesota, Minneapolis, MN, USA
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, ON, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
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18
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Choi J, Young TL, Chartier LB. Recurrent acute pancreatitis during a ketogenic diet-a case report and literature review. Int J Emerg Med 2021; 14:52. [PMID: 34525949 PMCID: PMC8444592 DOI: 10.1186/s12245-021-00374-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ketogenic ("keto") diet has been gaining more attention lately in the medical literature and the lay media as a potentially effective method for weight control and management of type 2 diabetes. Though rare, there have been case reports of serious side effects. Here, we present a peculiar case of pancreatitis presumably associated with the ketogenic diet. CASE PRESENTATION A 35-year-old man on a calorie-restricted ketogenic diet presented to the emergency department with weekly abdominal pain on Monday mornings, each time after dietary indiscretions ("cheat days") on the weekend. It was found that he had a clinical presentation consistent with acute pancreatitis with no associated alcohol use, hypertriglyceridemia, pancreatic obstruction, or other anatomic abnormalities. The patient's symptoms resolved with conservative management and progressive reintroduction of a standard diet. CONCLUSION This case indicates that the ketogenic diet could lower the threshold for acute pancreatitis, and that an episodic stressor may trigger an acute attack in the absence of traditional risk factors.
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Affiliation(s)
- Joseph Choi
- Emergency Department, University Health Network, 200 Elizabeth Street, RFE – Ground Floor, 480, Toronto, Ontario M5G 2C4 Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, C. David Naylor Building, 6 Queen’s Park Crescent West, Third Floor, Toronto, Ontario M5S 3H2 Canada
| | - Tayler L. Young
- Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada
| | - Lucas B. Chartier
- Emergency Department, University Health Network, 200 Elizabeth Street, RFE – Ground Floor, 480, Toronto, Ontario M5G 2C4 Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, C. David Naylor Building, 6 Queen’s Park Crescent West, Third Floor, Toronto, Ontario M5S 3H2 Canada
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19
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Lee DD, Jung H, Lou W, Rauchwerger D, Chartier LB, Masood S, Sathiaseelan S, Taher AK. The Impact of COVID-19 on a Large, Canadian Community Emergency Department. West J Emerg Med 2021; 22:572-579. [PMID: 34125029 PMCID: PMC8202991 DOI: 10.5811/westjem.2021.1.50123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/26/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION As the COVID-19 pandemic unfolded, emergency departments (EDs) across the world braced for surges in volume and demand. However, many EDs experienced decreased demand even for higher acuity illnesses. In this study we sought to examine the change in utilization at a large Canadian community ED, including changes in patient demographics and presentations, as well as structural and administrative changes made in response to the pandemic. METHODS This retrospective observational study took place in Ontario, Canada, from March 17-June 30, 2020, during province-wide lockdowns in response to COVID-19. We used a control period of March 17-June 30 in 2018-2019. Differences between observed and expected values were calculated for total visits, Canadian Triage and Acuity Scale (CTAS) groups, and age groups using Fisher's exact test. Length of stay (LOS), physician initial assessment time (PIA), and top primary and admission diagnoses were also examined. RESULTS Patient visits fell to 66.3% of expected volume in the exposure period (20,901 vs 31,525, P<0.0001). CTAS-1 (highest acuity) patient volumes dropped to 86.8% of expected (P = 0.1964) while CTAS-5 (lowest acuity) patient volumes dropped to 32.4% of expected (P <0.0001). Youth (0-17), adult (18-64), and senior (65+) visits all decreased to 37.4%, 71.7%, and 72.9% of expected volumes, respectively (P <0.0001). Median PIA and median ED LOS both decreased (1.1 to 0.6 hours and 3.3 to 3.0 hours, respectively). The most common primary diagnosis in both periods was "other chest pain." Viral syndromes were more prevalent in the exposure period. The top admission diagnoses were congestive heart failure in the control period (4.8%) and COVID-19 in the study period (3.5%). CONCLUSION ED utilization changed drastically during COVID-19. Our ED responded with wide stakeholder engagement, spatial reorganization, and human resources changes informed by real-time data. Our experiences can help prepare for potential subsequent "waves" of COVID-19 and future pandemics.
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Affiliation(s)
- Daniel Dongjoo Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - Hyejung Jung
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - David Rauchwerger
- Mackenzie Health, Department of Emergency Medicine, Richmond Hill, Ontario, Canada
| | - Lucas B Chartier
- University of Toronto, Department of Medicine, Division of Emergency Medicine, Toronto, Ontario, Canada.,University Health Network, Department of Emergency Medicine, Toronto, Ontario, Canada
| | - Sameer Masood
- University of Toronto, Department of Medicine, Division of Emergency Medicine, Toronto, Ontario, Canada.,University Health Network, Department of Emergency Medicine, Toronto, Ontario, Canada
| | - Seyon Sathiaseelan
- Mackenzie Health, Department of Emergency Medicine, Richmond Hill, Ontario, Canada.,University of Toronto, Department of Medicine, Division of Emergency Medicine, Toronto, Ontario, Canada.,McMaster University, Department of Family Medicine, Hamilton, Ontario, Canada
| | - Ahmed Khaled Taher
- Mackenzie Health, Department of Emergency Medicine, Richmond Hill, Ontario, Canada.,University of Toronto, Department of Medicine, Division of Emergency Medicine, Toronto, Ontario, Canada.,University Health Network, Department of Emergency Medicine, Toronto, Ontario, Canada
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20
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Chartier LB, Jalali H, Seaton MB, Ovens H, Borgundvaag B, McLeod SL, Dainty KN, Ostrow O. Qualitative evaluation of a mandatory provincial programme auditing emergency department return visits. BMJ Open 2021; 11:e044218. [PMID: 33827836 PMCID: PMC8031058 DOI: 10.1136/bmjopen-2020-044218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The objective of this qualitative study was to evaluate the perceived impact and value of the Return Visit Quality Programme (RVQP), a mandatory province-wide emergency department audit programme. DESIGN We employed an interpretive descriptive qualitative approach with maximum variation sampling to ensure diverse representation across several geographical and institutional factors. RVQP programme leads were invited to participate in semistructured interviews and snowball sampling was used to reach non-lead physicians to capture the perspectives of those working within the programme. SETTING In Ontario's RVQP, participating emergency departments must audit their return visits resulting in admission to identify issues that can be addressed through quality improvement initiatives. PARTICIPANTS Between June and August 2018, we interviewed 32 participants (local programme leads and non-lead physicians) from 23 out of the 86 participating centres. RESULTS Participants' perceived impact and value of the programme was associated with the existence (or absence) and nature of the local quality improvement culture, the implementation approach of the programme within their emergency departments, and key aspects of the programme pertaining to medicolegal concerns and resource availability. CONCLUSIONS This study of an innovative, large-scale programme aimed at promoting continuous quality improvement in emergency departments showed that while its perceived impact has been meaningful, there are key structural and operational elements that support and hinder this aim. Healthcare leaders should consider these findings when looking to implement large-scale audit or quality improvement programmes.
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Affiliation(s)
- Lucas B Chartier
- Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Hanna Jalali
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - M Bianca Seaton
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Howard Ovens
- Department of Emergency Medicine, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Bjug Borgundvaag
- Department of Emergency Medicine, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Katie N Dainty
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Olivia Ostrow
- Department of Pediatrics, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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21
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McLaren JTT, Taher AK, Kapoor M, Yi SL, Chartier LB. Sharing and Teaching Electrocardiograms to Minimize Infarction (STEMI): reducing diagnostic time for acute coronary occlusion in the emergency department. Am J Emerg Med 2021; 48:18-32. [PMID: 33838470 DOI: 10.1016/j.ajem.2021.03.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/19/2021] [Accepted: 03/21/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Limits to ST-Elevation Myocardial Infarction (STEMI) criteria may lead to prolonged diagnostic time for acute coronary occlusion. We aimed to reduce ECG-to-Activation (ETA) time through audit and feedback on STEMI-equivalents and subtle occlusions, without increasing Code STEMIs without culprit lesions. METHODS This multi-centre, quality improvement initiative reviewed all Code STEMI patients from the emergency department (ED) over a one-year baseline and one-year intervention period. We measured ETA time, from the first ED ECG to the time a Code STEMI was activated. Our intervention strategy involved a grand rounds presentation and an internal website presenting weekly local challenging cases, along with literature on STEMI-equivalents and subtle occlusions. Our outcome measure was ETA time for culprit lesions, our process measure was website views/visits, and our balancing measure was the percentage of Code STEMIs without culprit lesions. RESULTS There were 51 culprit lesions in the baseline period, and 64 in the intervention period. Median ETA declined from 28.0 min (95% confidence interval [CI] 15.0-45.0) to 8.0 min (95%CI 6.0-15.0). The website garnered 70.4 views/week and 27.7 visitors/week in a group of 80 physicians. There was no change in percentage of Code STEMIs without culprit lesions: 28.2% (95%CI 17.8-38.6) to 20.0% (95%CI 11.2-28.8%). Conclusions Our novel weekly web-based feedback to all emergency physicians was associated with a reduction in ETA time by 20 min, without increasing Code STEMIs without culprit lesions. Local ECG audit and feedback, guided by ETA as a quality metric for acute coronary occlusion, could be replicated in other settings to improve care.
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Affiliation(s)
- Jesse T T McLaren
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Ahmed K Taher
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monika Kapoor
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
| | - Soojin L Yi
- Emergency Department, University Health Network, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, ON, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Gray A, Chartier LB, Pavenski K, McGowan M, Lebovic G, Petrosoniak A. The clock is ticking: using in situ simulation to improve time to blood administration for bleeding trauma patients. CAN J EMERG MED 2021; 23:54-62. [PMID: 33683613 DOI: 10.1007/s43678-020-00011-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/25/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Massive hemorrhage protocols are widely used to facilitate the administration of blood components to bleeding trauma patients. Delays in this process are associated with worse patient outcomes. We used in situ simulation as a novel and iterative quality improvement technique to reduce the mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations. METHODS We completed monthly, risk-informed unannounced in situ trauma simulations at a Canadian Level 1 trauma centre. We identified three major latent safety threats: (1) massive hemorrhage protocol activation; (2) transport of blood components; and (3) situational awareness of team members. Process improvements for each latent safety threats were tested and implemented during subsequent in situ simulation sessions. We evaluated the effect of this simulation-based intervention on the care of patients before, during and after the intervention. Demographic, clinical and massive hemorrhage protocol data were collected. The primary outcome was mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations as analyzed using a two-sample t test. RESULTS Each group was similar in demographic and injury characteristics. The time from massive hemorrhage protocol activation to blood administration decreased from 11.6 min pre-intervention to 9.1 min post-intervention. This represented a significant reduction (2.5 min, 95% confidence interval, 0.03-5.08) following the in situ simulation-based quality improvement intervention. CONCLUSIONS A comprehensive, in situ simulation-based quality improvement project was associated with a significant reduction in the mean time between massive hemorrhage protocol activation and blood administration among injured patients. In situ simulation represents a novel approach to the identification and mitigation of latent safety threats during massive hemorrhage protocol activation.
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Affiliation(s)
- Alice Gray
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada.,Department of Emergency Medicine, University Health Network, Toronto, Canada.,Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lucas B Chartier
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada.,Department of Emergency Medicine, University Health Network, Toronto, Canada
| | - Katerina Pavenski
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Melissa McGowan
- Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Gerald Lebovic
- Applied Health Research Centre, St. Michael's Hospital, Toronto, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - Andrew Petrosoniak
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada. .,Department of Emergency Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Karin A, Kulasingam V, Chartier LB, Ejumudo A, Wolff T, Brinc D. Recurring Critical Results and Their Impact on the Volume of Critical Calls at a Tertiary Care Center. J Appl Lab Med 2021; 6:962-968. [PMID: 33582795 DOI: 10.1093/jalm/jfab001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND When a test result is critically abnormal, laboratories notify the responsible caregivers immediately, usually with a phone call. If the same test was ordered repeatedly, our institution has a policy of not notifying the caregiver if the previous result was also critical and within 24 h. We compared our policy with those of several different laboratories in North America and estimated the impact of changing our current policy to calling for all critical results, regardless of the time interval. METHODS Several North American laboratories (n = 15) were surveyed regarding their critical result notification policy. For our institution, we performed a retrospective analysis focusing on critical values in a 5-month period for common chemistry tests. We estimated the effect on volume of calls and the impact on workload with regard to changing the critical result notification policy and critical thresholds. RESULTS A majority of surveyed laboratories had some form of restriction for calling about recurring critical results. In our institution, removing the restrictions would increase the average number of daily calls by 11%-155%, depending on the analyte. The choice of critical thresholds also has an effect on the number of calls, and the effect depends on the analyte and the threshold chosen. CONCLUSIONS Guidelines do not specify how recurring critical results should be communicated. Depending on the institutional resources, some laboratories call only the first critical result for one or more tests if certain criteria are met. Modification of these policies can lead to significant changes in the volume of calls made by the laboratory and can have numerous impacts related to workload, logistics, and patient care.
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Affiliation(s)
- Amir Karin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Vathany Kulasingam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Canada
| | - Angela Ejumudo
- Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Talya Wolff
- Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Davor Brinc
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Clinical Biochemistry, University Health Network, Toronto, Canada
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McLaren JT, Kapoor M, Yi SL, Chartier LB. Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion. J Emerg Med 2021; 60:25-34. [DOI: 10.1016/j.jemermed.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/24/2020] [Accepted: 09/12/2020] [Indexed: 12/27/2022]
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Chartier LB, Ovens H, Hayes E, Davis B, Calder L, Schull M, Dreyer J, Ostrow O. Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program. Ann Emerg Med 2020; 77:193-202. [PMID: 33199045 DOI: 10.1016/j.annemergmed.2020.09.449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/31/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.
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Affiliation(s)
- Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Howard Ovens
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Sinai Health System, Toronto, Ontario, Canada
| | - Emily Hayes
- Health Quality Ontario, Toronto, Ontario, Canada
| | | | - Lisa Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Schull
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada; ICES and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan Dreyer
- London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Olivia Ostrow
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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Mikhaeil JS, Jalali H, Orchanian-Cheff A, Chartier LB. Quality Assurance Processes Ensuring Appropriate Follow-up of Test Results Pending at Discharge in Emergency Departments: A Systematic Review. Ann Emerg Med 2020; 76:659-674. [DOI: 10.1016/j.annemergmed.2020.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/20/2020] [Accepted: 04/28/2020] [Indexed: 11/16/2022]
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Woolner V, Ahluwalia R, Lum H, Beane K, Avelino J, Chartier LB. Improving timely analgesia administration for musculoskeletal pain in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000797. [PMID: 31986116 PMCID: PMC7011892 DOI: 10.1136/bmjoq-2019-000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/05/2019] [Accepted: 12/10/2019] [Indexed: 12/23/2022] Open
Abstract
Delays to adequate analgesia result in worse patient care, decreased patient and provider satisfaction and increased patient complaints. The leading presenting symptom to emergency departments (EDs) is pain, with approximately 34 000 such patients per year in our academic hospital ED and 3300 visits specific for musculoskeletal (MSK) injuries. Our aim was to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 min) in 9 months' time (May 2018). Our outcome measures included mean TTA and ED length of stay (LOS). Process measures included rates of analgesia administration and of use of medical directives. We obtained weekly data capture for Statistical Process Control (SPC) charts, as well as Mann-Whitney U tests for before-and-after evaluation. We performed wide stakeholder engagement, root cause analyses and created a Pareto Diagram to inform Plan-Do-Study-Act (PDSA) cycles, which included: (1) nurse-initiated analgesia at triage; (2) a new triage documentation aid for medication administration; (3) a quick reference medical directive badge for nurses; and (4) weekly targeted feedback of the project's progress at clinical team huddle. TTA decreased from 129 min (n=153) to 100 min (22.5%; n=87, p<0.05). Special cause variation was identified on the ED LOS SPC chart with nine values below the midline after the first PDSA. The number of patients that received any analgesia increased from 42% (n=372) to 47% (n=192; p=0.13) and those that received them via medical directives increased from 22% (n=154) to 44% (n=87; p<0.001). We achieved a significant reduction of TTA and an increased use of medical directives through front-line focused improvements.
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Affiliation(s)
- Victoria Woolner
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Reena Ahluwalia
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Hilary Lum
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kevin Beane
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jackie Avelino
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
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28
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Taher A, Magcalas FW, Woolner V, Casey S, Davies D, Chartier LB. Quality improvement initiative for improved patient communication in an ED rapid assessment zone. Emerg Med J 2020; 37:811-818. [PMID: 32816897 DOI: 10.1136/emermed-2019-209124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 06/06/2020] [Accepted: 06/16/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patient-clinician communication in the Emergency Department (ED) faces challenges of time and interruptions, resulting in negative effects on patient satisfaction with communication and failure to relieve anxiety. Our aim was to improve patient satisfaction with communication and to decrease related patient anxiety. METHODS A multistage quality improvement (QI) initiative was conducted in the ED of Toronto General Hospital, a quaternary care centre in Ontario, Canada, from January to May 2018. We engaged stakeholders widely including clinicians, allied health and patients. We developed a 5-point Likert scale survey to measure patient and clinician rating of their communication experience, along with open-ended questions, and a patient focus group. Inductive analyses yielded interventions that were introduced through three Plan-Do-Study-Act (PDSA) cycles: (1) a clinician communication tool called Acknowledge-Empathize-Inform; (2) patient information pamphlets; and (3) a multimedia solution displaying patient-directed material. Our primary outcome was to improve patient satisfaction with communication and decrease anxiety by at least one Likert scale point over 6 months. Our secondary outcome was clinician-perceived interruptions by patients. We used statistical process control (SPC) charts to identify special cause variation and two-tailed Mann-Whitney U tests to compare means (statistical significance p<0.05). RESULTS A total of 232 patients and 104 clinicians were surveyed over baseline and three PDSA cycles. Communication about wait times, ED process, timing of next steps and directions to patient areas were the most frequently identified gaps, which informed our interventions. Measurements at baseline and during PDSA 3 showed: patient satisfaction increased from 3.28 (5 being best; n=65) to 4.15 (n=59, p<0.0001). Patient anxiety decreased from 2.96 (1 being best; n=65) to 2.31 (n=59, p<0.001). Clinician-perceived interruptions by patients changed from 4.33 (5 being highest; n=30) to 4.18 (n=11, p=0.98) and did not meet significance. SPC charts showed special cause variation temporally associated with our interventions. CONCLUSIONS Our pragmatic low-cost QI initiative led to statistically significant improvement in patient satisfaction with communication and decreased patient anxiety while narrowly missing our a priori improvement aim of one full Likert scale point.
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Affiliation(s)
- Ahmed Taher
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Emergency Department, University Health Network, Toronto, Ontario, Canada
| | | | - Victoria Woolner
- Emergency Department, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Casey
- Emergency Department, University Health Network, Toronto, Ontario, Canada
| | - Debra Davies
- Emergency Department, University Health Network, Toronto, Ontario, Canada
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Emergency Department, University Health Network, Toronto, Ontario, Canada
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29
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Dharamsi A, Hayman K, Yi S, Chow R, Yee C, Gaylord E, Tawadrous D, Chartier LB, Landes M. Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. J Hosp Infect 2020; 105:604-607. [PMID: 32540462 PMCID: PMC7292952 DOI: 10.1016/j.jhin.2020.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/10/2020] [Indexed: 01/25/2023]
Abstract
In response to coronavirus disease 2019 (COVID-19), a rapid-cycle in-situ simulation (ISS) programme was developed to facilitate identification and resolution of systems-based latent safety threats. The simulation involved a possible COVID-19 case in respiratory failure, using a mannequin modified to aerosolize phosphorescent secretions. Thirty-six individuals participated in five ISS sessions over 6 weeks, and a further 20 individuals observed these sessions. Debriefing identified latent safety threats from four domains: personnel, personal protective equipment, supply/environment and communication. These threats were addressed and resolved in later iterations. Ninety-four percent of participants felt more prepared to care for a potential case of COVID-19 after the ISS.
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Affiliation(s)
- A Dharamsi
- Emergency Department, University Health Network, Toronto, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada.
| | - K Hayman
- Emergency Department, University Health Network, Toronto, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | - S Yi
- Emergency Department, University Health Network, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - R Chow
- The Michener Institute of Education at University Health Network, Toronto, Canada
| | - C Yee
- Emergency Department, University Health Network, Toronto, Canada
| | - E Gaylord
- Emergency Department, University Health Network, Toronto, Canada
| | - D Tawadrous
- Emergency Department, University Health Network, Toronto, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | - L B Chartier
- Emergency Department, University Health Network, Toronto, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | - M Landes
- Emergency Department, University Health Network, Toronto, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
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Hansen K, Boyle A, Holroyd B, Phillips G, Benger J, Chartier LB, Lecky F, Vaillancourt S, Cameron P, Waligora G, Kurland L, Truesdale M. Updated framework on quality and safety in emergency medicine. Emerg Med J 2020; 37:437-442. [PMID: 32404345 PMCID: PMC7413575 DOI: 10.1136/emermed-2019-209290] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Quality and safety of emergency care is critical. Patients rely on emergency medicine (EM) for accessible, timely and high-quality care in addition to providing a 'safety-net' function. Demand is increasing, creating resource challenges in all settings. Where EM is well established, this is recognised through the implementation of quality standards and staff training for patient safety. In settings where EM is developing, immense system and patient pressures exist, thereby necessitating the availability of tiered standards appropriate to the local context. METHODS The original quality framework arose from expert consensus at the International Federation of Emergency Medicine (IFEM) Symposium for Quality and Safety in Emergency Care (UK, 2011). The IFEM Quality and Safety Special Interest Group members have subsequently refined it to achieve a consensus in 2018. RESULTS Patients should expect EDs to provide effective acute care. To do this, trained emergency personnel should make patient-centred, timely and expert decisions to provide care, supported by systems, processes, diagnostics, appropriate equipment and facilities. Enablers to high-quality care include appropriate staff, access to care (including financial), coordinated emergency care through the whole patient journey and monitoring of outcomes. Crowding directly impacts on patient quality of care, morbidity and mortality. Quality indicators should be pragmatic, measurable and prioritised as components of an improvement strategy which should be developed, tailored and implemented in each setting. CONCLUSION EDs globally have a remit to deliver the best care possible. IFEM has defined and updated an international consensus framework for quality and safety.
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Affiliation(s)
- Kim Hansen
- Emergency Department, Prince Charles Hospital, Chermside, Queensland, Australia .,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adrian Boyle
- Emergency Department, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Brian Holroyd
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Emergency Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Georgina Phillips
- Emergency Department, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jonathan Benger
- Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lucas B Chartier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Emergency Department, University Health Network, Toronto, Ontario, Canada
| | - Fiona Lecky
- Health Services Research, University of Sheffield, Sheffield, UK.,Emergency Department /TARN, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | | | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Emergency Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Grzegorz Waligora
- Emergency Department, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
| | - Lisa Kurland
- Medical Sciences, Orebro Universitet, Orebro, Sweden
| | - Melinda Truesdale
- Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Emergency Department, Royal Women's Hospital, Parkville, Victoria, Australia
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Masood S, Woolner V, Yoon JH, Chartier LB. Checklist for Head Injury Management Evaluation Study (CHIMES): a quality improvement initiative to reduce imaging utilisation for head injuries in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000811. [PMID: 32019751 PMCID: PMC7011890 DOI: 10.1136/bmjoq-2019-000811] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/06/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
Over 90% of patients with head trauma seen in emergency departments (EDs) are diagnosed with minor head injuries. Over-utilisation of CT scans results in unnecessary exposure to radiation and increases healthcare utilisation. Using recommendations from the Choosing Wisely Canada (CWC) campaign and quality improvement (QI) methodology, we aimed to reduce the CT scan rate for head injuries by 10% over a 6-month period. Baseline CT scan rates were determined through a 27-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and Plan-Do-Study-Act (PDSA) cycles, which included (1) improving provider knowledge about the CWC campaign recommendations; (2) testing, refining and implementing a modified Canadian CT Head Rule checklist; (3) developing CWC-themed head injury–specific patient handouts; and (4) feedback on CT scan group ordering rates to providers. Our primary outcome measure was the number of CT scans performed for patients with head injuries. Process measures included the number of checklists completed and ED length of stay (LOS). Our balancing measure was return ED visits within 72 hours (with or without admission). Baseline CT scan rates prior to our interventions was 46.1%. Our QI initiative resulted in a ‘shift’ in the Statistical Process Control chart of the weekly CT scan rates, associated with the first and second PDSA cycles, resulting in a 13.9% reduction in CT rates during the initial 3 months, and a sustained reduction of 8% at 16 months (p<0.05). Mean ED LOS for all patients with head injuries decreased by 1.5 min (p=0.74). 33% of checklists were completed. 72-hour return visits did not change significantly (p=0.68). Through provider and patient education, and the creation of a user-friendly evidence-based tool, our local QI initiative was successful in achieving long-term reduction in CT rates for patients presenting to EDs with head injuries.
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Affiliation(s)
- Sameer Masood
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Woolner
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joo Hyung Yoon
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Taher A, Bunker E, Chartier LB, Ostrow O, Ovens H, Davis B, Schull MJ. Application of the Informatics Stack framework to describe a population-level emergency department return visit continuous quality improvement program. Int J Med Inform 2019; 133:103937. [PMID: 31739223 DOI: 10.1016/j.ijmedinf.2019.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Population health programs are increasingly reliant on Health Information Technology (HIT). Program HIT architecture description is a necessary step prior to evaluation. Several sociotechnical frameworks have been used previously with HIT programs. The Informatics Stack is a novel framework that provides a thorough description of HIT program architecture. The Emergency Department Return Visit Quality Program (EDRVQP) is a population-level continuous quality improvement (QI) program connecting EDs across Ontario. The objectives of the study were to utilize the Informatics Stack to provide a description of the EDRVQP HIT architecture and to delineate population health program factors that are enablers or barriers. MATERIALS AND METHODS The Informatics Stack was used to describe the HIT architecture. A qualitative study was completed with semi-structured interviews of key informants across stakeholder organizations. Emergency departments were selected randomly. Purposive sampling identified key informants. Interviews were conducted until saturation. An inductive qualitative analysis using grounded theory was completed. A literature review of peer-reviewed background literature, and stakeholder organization reports was also conducted. RESULTS 23 business actors from 15 organizations were interviewed. The EDRVQP architecture description is presented across the Informatics Stack levels. The levels from most comprehensive to most basic are world, organization, perspectives/roles, goals/functions, workflow/behaviour/adoption, information systems, modules, data/information/knowledge/wisdom/algorithms, and technology. Enabling factors were the high rate of electronic health record adoption, legislative mandate for data collection, use of functional data standards, implementation flexibility, leveraging validated algorithms, and leveraging existing local health networks. Barriers were privacy legislation and a high turn-around time. DISCUSSION The Informatics Stack provides a robust approach to thoroughly describe the HIT architecture of population health programs prior to program replication. The EDRVQP is a population health program that illustrates the pragmatic use of continuous QI methodology across a population (provincial) level.
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Affiliation(s)
- Ahmed Taher
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States.
| | - Edward Bunker
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Lucas B Chartier
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada; University Health Network, Toronto, Canada
| | - Olivia Ostrow
- Division of Pediatric Emergency Medicine, Department of Paediatrics, University of Toronto, Toronto, Canada; The Hospital for Sick Children, Toronto, Canada
| | - Howard Ovens
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada; Sinai Health System, Toronto, Canada
| | | | - Michael J Schull
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Canada; ICES, Toronto, Canada
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Chartier LB, Helman A. Development, improvement and funding of the emergency medicine cases open-access podcast. Int J Med Educ 2016; 7:340-341. [PMID: 27771630 PMCID: PMC5116366 DOI: 10.5116/ijme.57f8.c1b4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 10/08/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Lucas B. Chartier
- Emergency Department, University Health Network, Toronto, ON, Canada
| | - Anton Helman
- Emergency Department, North York General Hospital, Toronto, ON, Canada
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Chartier LB, Bonnycastle MJ. Improving the Quality of Auscultation for Individuals with Cachexia. J Am Geriatr Soc 2015; 63:2441. [PMID: 26603083 DOI: 10.1111/jgs.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Bonnycastle
- Division of Geriatrics, St. Mary's Hospital, Montreal, Quebec, Canada.,Division of Geriatric Medicine, McGill University, Montreal, Quebec, Canada
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