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Shiftwork has numerous negative effects on workers, but it is an essential component of the demanding 24/7 practice of emergency medicine. We conducted a systematic literature review to characterize the effects of shiftwork on physician health, well-being and practice, and to describe rational strategies to mitigate its impact on Canadian emergency physicians.

CLINICIAN'S CAPSULE What is known about the topic? Goals of care discussions (GOC) are critical to reflecting patients' preferences in the provision of acute care, yet these discussions can be challenging to have in the emergency department (ED) setting. What did this study ask? What are emergency physicians' perspectives on barriers and facilitators to GOC discussions? What did this study find? In this survey of emergency medicine attending and resident physicians, the majority reported feeling comfortable and adequately trained to conduct GOC discussions. However, they identified time constraints, environmental factors, and patient expectations as barriers. Fifty-four percent of respondents believed that it was primarily the responsibility of admitting services to conduct GOC discussions. Why does this study matter to clinicians? This study suggests that dedicated ED resources for palliative care, such as a palliative care ED pathway, and addressing structural factors, such as a way to dedicate time and private space to GOC discussions, would be promising avenues for improvement. Training did not appear to be a barrier.

ED throughput for admitted medical patients improved with a quality improvement initiative involving education, goal setting and performance feedback.

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Objective: Postdischarge emergency department (ED) communication with family physicians is often suboptimal and negatively impacts patient care. We designed and piloted an online notification system that electronically alerts family physicians of patient ED visits and provides access to visitspecific laboratory and diagnostic information.Methods: Nine (of 10 invited) high-referring family physicians participated in this single ED pilot. A prepilot chart audit (30 patients from each family physician) determined the baseline rate of paper-based record transmission. A webbased communication portal was designed and piloted by the nine family physicians over 1 year. Participants provided usability feedback via focus groups and written surveys.Results: Review of 270 patient charts in the prepilot phase revealed a 13% baseline rate of handwritten chart and a 44% rate of any information transfer between the ED and family physician offices following discharge. During the pilot, participant family physicians accrued 880 patient visits. Seven and two family physicians accessed online records for 74% and 12% of visits, respectively, an overall 60.7% of visits, corresponding to an overall absolute increase in receipt of patient ED visit information of 17%. The postpilot survey found that 100% of family physicians reported that they were ''often'' or ''always'' aware of patient ED visits, used the portal ''always'' or ''regularly'' to access patients' health records online, and felt that the web portal contributed to improved actual and perceived continuity of patient care. Conclusion: Introduction of a web-based ED visit communication tool improved ED-family physician communication. The impact of this system on improved continuity of care, timeliness of follow-up, and reduced duplication of investigations and referrals requires additional study. RÉ SUMÉObjectif: La communication avec les mé decins de famille aprè s le renvoi des patients du service des urgences (SU) laisse souvent à dé sirer, et ce manque de relation a une incidence dé favorable sur les soins. Nous avons conç u et mis à l'essai un outil de communication en ligne, qui informe, par voie é lectronique, les mé decins de famille de la visite d'un de leurs patients au SU et qui leur donne accè s aux ré sultats d'examens de laboratoire ou de diagnostic.Mé thode: Neuf mé decins de famille (sur 10 invité s) ayant un nombre é levé de malades dirigé s ont participé à ce projet pilote mené dans un seul SU. Un examen des dossiers (30 patients pour chacun des mé decins de famille) durant la phase pré expé rimentale a permis de dé terminer le volume de base de transmission des dossiers sur papier. Les neuf mé decins de famille ont conç u un portail de communication sur le Web et l'ont mis à l'essai pendant un an. Les participants ont fait part de leurs observations sur la convivialité dans des groupes de ré flexion et dans des enquê tes é crites.Ré sultats: Une revue de 270 dossiers de patient durant la phase pré expé rimentale a ré vé lé un taux initial de dossier...

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Ontario is Canada's most populous province, with approximately 12 million people and 130 emergency departments (EDs). Canada has a national single-payer universal health care system, but provinces are responsible for administration. After years of problems and failed attempts to address chronic ED overcrowding, in April 2008 Ontario embarked on an ambitious program to improve system performance through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Supporting the program were requirements for hospitals to submit timely data and targets for length of stay (LOS) and annual improvements; results are publicly reported. The program has been continued this year. While not all our provincial level targets have been met as yet, major improvements have been made, especially in access to care and LOS in the ED for patients eventually discharged home. The greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the worst performance at baseline. This presentation will highlight some of the controversies and challenges and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble problem, but requires a system-level intervention.