A systematic review of the literature was conducted to determine if the administration of methylene blue in humans improves hemodynamic status and/or outcome in patients with septic shock. Studies were identified from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials database. The review included human studies of patients with septic shock treated with methylene blue in which hemodynamic variables or mortality rates were reported. An electronic form was used to extract items including study design, population characteristics, intervention details, and outcomes. No meta-analysis was performed. Methylene blue administration in patients with septic shock increases mean arterial pressure and systemic vascular resistance while decreasing vasopressor requirements. Increased pulmonary vascular resistance has been reported with bolus administration but might be avoided by continuous infusion. No other ill effects were reported. Effects on mortality have not been adequately evaluated in the literature.

Objectives: The objective of this study was to determine the feasibility and acceptability of a structured morbidity and mortality (M&M) rounds model through an innovative educational intervention. Methods:The authors engaged the Departments of Emergency Medicine (EM) and Trauma Services at a tertiary care teaching hospital. A needs assessment was performed; the Ottawa M&M rounds model was developed, implemented, and then evaluated as a four-part intervention. This consisted of: 1) physician training on case selection and analysis, 2) engaging interprofessional members, 3) disseminating lessons learned, and 4) creating an administrative pathway for acting on issues identified through the M&M rounds. The measures of intervention feasibility included the proportion of sessions adherent to the new model and M&M rounds attendance. Pre-and postintervention surveys of presenters and attendees were used to determine intervention acceptability. M&M presentation content was reviewed to determine the most frequently adopted components of the model. Results:Nine of 14 (64.3%) sessions were adherent to three of four components of the Ottawa M&M Model. Of those M&M attendees who responded to the survey (796 of 912, 87.2%), improvements were found in M&M rounds attendance as well as perceived effect on clinical practice at both individual and departmental levels. Thirty-seven case presentations were analyzed and improvements postintervention were found in appropriate case selection and recognition of cognitive and system issues. Conclusions:The Ottawa M&M Model was a feasible intervention that was perceived to be effective by both presenters and attendees. The authors believe that this could be readily applied to any hospital department seeking to enhance quality of care and patient safety.ACADEMIC EMERGENCY MEDICINE 2014; 21:314-321

BackgroundDizziness is a common presenting symptom in the emergency department (ED). The HINTS exam, a battery of bedside clinical tests, has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo. The present study sought to assess practice patterns in the assessment of patients in the ED with peripherally-originating vertigo with respect to utilization of HINTS and neuroimaging.MethodsA retrospective cohort study was performed using data pertaining to 500 randomly selected ED visits at a tertiary care centre with a final diagnostic code related to peripherally-originating vertigo between January 1, 2010 - December 31, 2014.ResultsA total of 380 patients met inclusion criteria. Of patients presenting to the ED with dizziness and vertigo and a final diagnosis of non-central vertigo, 139 (36.6%) received neuroimaging in the form of CT, CT angiography, or MRI. Of patients who did not undergo neuroimaging, 17 (7.1%) had a bedside HINTS exam performed. Almost half (44%) of documented HINTS interpretations consisted of the ambiguous usage of “HINTS negative” as opposed to the terminology suggested in the literature (“HINTS central” or “HINTS peripheral”).ConclusionsIn this single-centre retrospective review, we have demonstrated that the HINTS exam is under-utilized in the ED as compared to neuroimaging in the assessment of patients with peripheral vertigo. This finding suggests that there is room for improvement in ED physicians’ application and interpretation of the HINTS exam.

Objectives: Overcrowding is a serious and ongoing challenge in Canadian hospital emergency departments (EDs) that has been shown to have negative consequences for patient outcomes. The American College of Emergency Physicians recommends observation/short-stay units as a possible solution to alleviate this problem. However, the most recent systematic review assessing short-stay units shows that there is limited synthesized evidence to support this recommendation; it is over a decade old and has important methodologic limitations. The aim of this study was to conduct a more methodologically rigorous systematic review to update the evidence on the effectiveness and safety of short-stay units, compared with usual care, on hospital and patient outcomes.Methods: A literature search was conducted using MEDLINE, the Cochrane Library, Embase, ABI/ INFOM, and EconLit databases and gray literature sources. Randomized controlled trials of ED shortstay units (stay of 72 hours or less) were compared with usual care (i.e., not provided in a short-stay unit), for adult patients. Risk-of-bias assessments were conducted. Important decision-making (gradable) outcomes were patient outcomes, quality of care, utilization of and access to services, resource use, health system-related outcomes, economic outcomes, and adverse events.Results: Ten reports of five studies were included, all of which compared short-stay units with inpatient care. Studies had small sample sizes and were collectively at a moderate risk of bias. Most outcomes were only reported by one study and the remaining outcomes were reported by two to four studies. No deaths were reported. Three of the four included studies reporting length of stay found a significant reduction among short-stay unit patients, and one of the two studies reporting readmission rates found a significantly lower rate for short-stay unit patients. All four economic evaluations indicated that shortstay units were a cost-saving intervention compared to inpatient care from both hospital and health care system perspectives. Results were mixed for outcomes related to quality of care and patient satisfaction.Conclusions: Insufficient evidence exists to make conclusions regarding the effectiveness and safety of short-stay units, compared with inpatient care.ACADEMIC EMERGENCY MEDICINE 2015;22:893-907 © 2015 by the Society for Academic Emergency Medicine T he increasing demand for emergency services in Canada has created circumstances in which overcrowding in emergency departments (EDs) is becoming commonplace. A 2014 systematic review found that ED crowding is a major patient safety concern associated with poor patient outcomes, concluding that interventions and policies are needed to address this growing issue.1 Other studies have demonstrated

Implementation of a structured model enhanced the quality of M&M rounds with demonstrable policy improvements hospital wide. The OM3 can be feasibly implemented at other hospitals to effectively improve quality of M&M rounds across different specialties.

Background: The rise of free open-access medical education (FOAM) has led to a wide range of online resources in emergency medicine. Canadian physicians have been active contributors to FOAM.Objectives: We aimed to create a virtual community of practice that would serve as a national platform for collaboration, learning, and knowledge dissemination.Methods: CanadiEM was formed in 2016 from the merger of two Canadian websites and a podcast. Using a community-of-practice model, we introduced two training programs to support junior community members in becoming core editorial team members and employed asynchronous Web technologies to facilitate collaboration. We also introduced a coached peer review process and formed strategic alliances that aim to ensure a high quality of publication.Results: CanadiEM has become a portal for readers to access a broad range of FOAM content. The website has published 782 articles. Of these, 71 have undergone a coached peer review process. The website has received over 2.5 million page views from 217 countries, and the associated CRACKCast podcast has been downloaded over 750,000 times.Conclusions: CanadiEM has succeeded in building a national multi-interface dissemination network that fosters collaboration and knowledge sharing in emergency medicine while fostering junior digital scholars. The construction of a community of practice has been facilitated by quality assurance, training programs, and the use of asynchronous Web technologies. Ongoing challenges in sustainability include a volunteer workforce with high turnover.

ObjectivesWe sought to identify emergency department interventions that lead to improvement in door-to-electrocardiogram (ECG) times for adults presenting with symptoms suggestive of acute coronary syndrome.MethodsTwo reviewers searched Medline, Embase, CINAHL, and Cochrane CENTRAL from inception to April 2018 for studies in adult emergency departments with an identifiable intervention to reduce median door-to-ECG times when compared with the institution's baseline. Quality was assessed using the Quality Improvement Minimum Quality Criteria Set critical appraisal tool. The primary outcome was the absolute median reduction in door-to-ECG times as calculated by the difference between the post-intervention time and pre-intervention time.ResultsTwo reviewers identified 809 unique articles, yielding 11 before-after quality improvement studies that met eligibility criteria (N = 15,622 patients). The majority of studies (10/11) reported bundled interventions, and most (10/11) showed statistical improvement in door-to-ECG times. The most common interventions were having a dedicated ECG machine and technician in triage (5/11); improved triage education (4/11); improved triage disposition (2/11); and data feedback mechanisms (2/11).ConclusionsThere are multiple interventions that show potential for reducing emergency department door-to-ECG times. Effective bundled interventions include having a dedicated ECG technician, triage education, and better triage disposition. These changes can help institutions attain best practice guidelines. Emergency departments must first understand their local context before adopting any single or group of interventions.

Background Under the pandemic conditions created by the novel coronavirus of 2019 (COVID-19), physicians have faced difficult choices allocating scarce resources, including but not limited to critical care beds and ventilators. Past experiences with severe acute respiratory syndrome (SARS) and current reports suggest that making these decisions carries a heavy emotional toll for physicians around the world. We sought to explore Canadian physicians’ preparedness and attitudes regarding resource allocation decisions. Methods From April 3 to April 13, 2020, we conducted an 8-question online survey of physicians practicing in the region of Ottawa, Ontario, Canada, organized around 4 themes: physician preparedness for resource rationing, physician preparedness to offer palliative care, attitudes towards resource allocation policy, and approaches to resource allocation decision-making. Results We collected 219 responses, of which 165 were used for analysis. The majority (78%) of respondents felt "somewhat" or "a little prepared" to make resource allocation decisions, and 13% felt “not at all prepared.” A majority of respondents (63%) expected the provision of palliative care to be “very” or “somewhat difficult.” Most respondents (83%) either strongly or somewhat agreed that there should be policy to guide resource allocation. Physicians overwhelmingly agreed on certain factors that would be important in resource allocation, including whether patients were likely to survive, and whether they had dementia and other significant comorbidities. Respondents generally did not feel confident that they would have the social support they needed at the time of making resource allocation decisions. Interpretation This rapidly implemented survey suggests that a sample of Canadian physicians feel underprepared to make resource allocation decisions, and desire both more emotional support and clear, transparent, evidence-based policy.