Objective: We examined the records of patients presenting to the emergency department (ED) with low-impact pelvic fractures. We describe frequency, demographics, management and patient outcomes in terms of ambulatory ability, living independence and mortality. Methods: Patients treated for a pelvic fracture over a 2-year period in Kingston, Ont., were identified. We performed a retrospective hospital record review to distinguish high- versus low-impact injury mechanisms, and to characterize the injury event, ED management and outcomes for patients with low-impact fractures. Results: Of 132 pelvic fractures identified, 77 were low-impact fractures. Patients were predominantly women (82%) with a mean age of 81 years; 96% had some pre-existing medical comorbidity. The pubic rami were most commonly involved (86%). The median length of stay in the ED was 9.4 hours. Twenty-five patients (32%) were admitted to hospital. Ten patients had surgical stabilization, mostly of the acetabulum. Five patients died in hospital, 4 from pneumonia and 1 from myocardial infarction. Eight additional patients died within 1 year of injury. At discharge, only 18% lived independently and 16% walked without aids versus 42% and 38%, respectively, before injury. Conclusion: Low-impact pelvic fractures affect predominantly elderly women with pre-existing comorbidities. A substantial amount of time and resources in the ED are used during the workup of these patients and while awaiting their disposition from the ED. These injuries are important because they affect independence and seem associated with an increased risk of death.
Background Professional culture is a powerful influence in emergency departments, but incompletely understood. Disasters magnify cultural realities, and as such the COVID-19 pandemic offered a unique opportunity to better understand emergency medicine (EM) values, practices, and beliefs. Methods We conducted a collaborative ethnography at a tertiary care center during the acute phase of the response to the threat of COVID-19 (March–May 2020). Collaborative ethnography is a method that partners directly with communities during design, data gathering, and analysis to study culture. An ED-based research team gathered data including field notes from 300 h of participant observation and informal interviews, 42 semi-structured interviews, and 57 departmental documents. Data were deductively coded using a previously generated framework for understanding EM culture. Results Each of seven core values from the original framework were identified in the dataset and further contextualized understanding of EM culture. COVID-19 exacerbated pre-existing tensions and threats to the core values of EM. For example, the desire to provide patient-centered care was impeded by strict visitor restrictions; the ability to treat life-threatening illness was impaired by new resuscitation room layouts and infection control procedures; and subtle changes in protocols had downstream impact on flow and the ability to balance needs and resources at a system level. The cultural values related to teams were protective and strengthened during this time. The pandemic exposed problems with the status quo, underscored inherent tensions between ED values, and highlighted threats to self-identity. Conclusion COVID-19 has highlighted and compounded existing tensions and threats to the core values of EM, underscoring a critical mismatch between values and practice. Realignment of the realities of ED work with staff values is urgently needed.
Background Advanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians’ burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD). Objectives To compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs. Methods This trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time. Discussion MSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD. Trial registration ClinicalTrials.govNCT05545917. Registered on September 19, 2022
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