Introduction: ST-Elevation Myocardial Infarction (STEMI) represents irreversible necrosis of myocardial tissue. Prompt time-to-reperfusion in these patients is paramount in reducing morbidity and mortality. This concept, time-to-reperfusion, is the principle focus for improving STEMI care. Prioritizing diagnosis in patients with high-risk cardiac features through rapid electrocardiogram (ECG) is essential, with gold standard time-to-ECG benchmarked at 10-minutes. While substantial literature is established for pre-hospital ECG interventions, there is a paucity of intervention data for self-presenting patients. While evaluating these times within our department, we conducted a redesign of the triage process. These included nurses becoming the first contact and the addition of an extra triage nurse. These changes provided the opportunity to evaluate whether the redesign elements of the triage system meant to improve department flow could improve other patient-centered outcomes, namely time-to-ECG. Methods: The first fifty self-presenting patients designated as “cardiac chest pain” in the month preceding changes to the triage system were analyzed to create a baseline time-to-ECG value. Following the alteration to our triage system, three samples of the first 50 patient's time-to-ECG were collected at two, four and six months post-intervention and compared to pre-intervention via non-paired t-test. Data was further stratified into percentages of patients receiving an ECG within 10-minute intervals starting with 0-10 minutes. Proportions pre and post intervention were then compared using z-scores. Results: A baseline pre-intervention time-to-ECG value of 26.6 minutes was established. Average post-intervention time-to-ECG was significantly reduced at 15.6min with a mean difference of -11.0min ± 3.0 (95% CI -16.0 – (-5.0)). Interestingly, the proportion of ECGs performed under 20 minutes rose significantly from 58% to 81% (z=−3.2, p < 0.001) while the increase in proportion of ECGs performed under 10 minutes from 26% to 37% was not statistically significant (z=−1.4). Conclusion: The results of this analysis suggest that the addition of an extra triage nurse coupled with changing first point of ED contact from the business clerks to triage nurses significantly reduced mean time-to-ECG in self-presenting patients with chest pain deemed high risk for cardiac causes. Additionally, these changes significantly increased the proportion of ECGs performed within 20 minutes of ED arrival in these patients.
Innovation Concept: Canadian medical students completing their Emergency Medicine (EM) clerkship rotations must develop approaches to undifferentiated patients. Increasingly used in postgraduate EM education, Open Educational Resources (OERs) are a convenient and flexible solution to meeting medical student educational needs on their EM rotation. We hoped to supplement Canadian medical student EM education through the development of ‘ClerkCast’, a novel OER and podcast-based curriculum on CanadiEM.org. Methods: We utilized the Kern Six Step approach to curriculum development for ‘ClerkCast’. A general needs assessment involved a review of available OERs and identified a lack of effective EM OERs specific for medical students. A specific online needs assessment was used to determine which EM topics required further education for medical students. The survey was shared directly with key Canadian medical student and undergraduate medical educator stakeholder groups, and distributed globally through the CanadiEM social media networks. Results of the needs assessment highlighted shared perceptions of educational needs for medical students, with an emphasis on increased need for education on critical care and common EM presentations. We used the topics determined to be highest priority for the development of our first ten episodes of ‘ClerkCast’. Curriculum, Tool or Material: Podcast episodes are released from CanadiEM biweekly. Episodes are 30 to 45 min in length, and focus on cognitive approaches to a common EM presentation for medical students. Content is anchored on medical student interactions with a staff or resident EM co-host. Podcasts are supplemented by infographics and blog posts highlighting the key points from each episode. Learners are also encouraged to interact with the content through review quizzes on a provided question bank. Quality assurance of the content is provided by physician co-hosts who review episode scripts both prior to recording. Post-production feedback is elicited via comments on the curriculum's host website, CanadiEM.org, and through direct email correspondence to the ClerkCast address. Conclusion: With an ever increasing number of OERs in EM and critical care, the systematic development of new resources is important to avoid redundancies in content and medium while also addressing unmet learner needs. We describe the successful use of the Kern Six Steps for curriculum development for the creation of our novel EM OER for Canadian medical students, ‘ClerkCast’.
Introduction: For patients with ST-elevation myocardial infarction (STEMI), time is myocardium. The sooner STEMI patients receive a definitive intervention, the better their outcomes. The first point of contact with the healthcare system for STEMI patients is either via Emergency Medical Services (EMS), or self-transportation to an Emergency Department (ED). Despite a reduced time to definitive intervention, STEMI patients who use EMS have increased mortality compared to those who self-transport. In an effort to optimize STEMI care pathways, we characterized variations in modes of presentation of STEMI patients in our region. Methods: This study used a retrospective cohort design from a regional STEMI registry. Patients presenting to Hamilton Health Sciences between January 1, 2016, and December 31, 2018 meeting STEMI criteria were included in our analyses. Self-transport patients were analyzed from two academic EDs in Hamilton, Ontario. One hospital was PCI capable and the other, non-PCI capable. Patients transferred from other health regions were excluded from our analyses. Dichotomous variables were compared using χ2 tests. Group means were compared using the Student t-test. Results: Eight hundred and seventy-one patients were included in the analysis, including 675 EMS users, and 196 self-transporting to EDs. Patients self-transporting to EDs were younger (61.5 v. 64.6 y, p < 0.002) and more often male (82.6 v. 69.2%, p < 0.0002) compared to EMS users. There was a non-significant trend towards an increased rate of all STEMI patients self-transporting in the summer months compared to the winter (63 of 215 in summer v. 41 of 185 in winter, 29.3 v. 22.2%, p = 0.10). Comparative analysis between both hospitals yielded an increased rate of self-transportation to the PCI-capable hospital in the summer months compared to winter (46 v. 28, 23.2 v. 16.3%, p = 0.09), but not the other hospital (18 v. 13, 10.6 v. 8.3%, p = 0.57). The majority of self-transporting patients came from postal codes bordering each hospital, and the different rates of self-transportation between hospitals were not associated with recent specialist follow up at those sites. Conclusion: Seasonal trends in modes of presentation in STEMI patients may present an opportunity to optimize STEMI care pathways through resource utilization and patient education. A larger dataset and possible multicenter analysis should be done to determine if significance is obtained with larger sample size.
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