Purpose: Barriers to full disclosure and communication of complete and accurate health history from patients to their physicians can compromise patient care. Identification of barriers to communication between patients and their physicians, and assessing communication techniques to overcome putative barriers may improve medical training, quality patient care, and patient experience. Methods:The authors performed a cross-sectional study using a novel questionnaire at an urban, inner-city hospital in Toronto, Ontario between January 1, 2011 and January 1, 2012, in order to evaluate potential barriers to communication. Variables included physician age, gender, education, ethnicity, position, perceived sexual orientation, marital status, physical attractiveness and reason for appointment. All patients attending a gynaecology appointment received the paper-based, anonymous questionnaire. Analyses applied the statistical package, SAS Software, Version 9.2. Results:Responses for 286 completed questionnaires were analysed. The most common barriers to communication included having a male physician (40.9%) and having a history taken by a medical student (24.5%). Sensitivity to having a male provider was more frequently reported in women under the age of thirty (63.6%) and nulliparous women (49.6%), p<0.05. Communication was perceived to be improved when physicians acknowledged patient concerns (95.1%), sought to understand patient concerns (91.9%), and included the patient in decisionmaking (74.1%). Conclusions:Physician gender and education level are barriers to full disclosure and communication from patients. Physicians should strive to understand patient concerns and include patients in decision-making in order to encourage full disclosure. Awareness of these obstacles is vital to promoting patient-centered care and to effective physician training.

While video and audio recording (VAR) of patients is well described for clinical research, its application to quality improvement in the emergency department has thus far been limited and hindered by potential obstacles. We believe this technology holds promise to incite marked systems improvement but only if deployed in a thoughtful and principled manner. Experts in clinical, regulatory, legal, quality improvement, patient safety and ethical domains collaborated to articulate the salient considerations and challenges to implementation of a VAR programme. We describe this implementation using the lens of legislation and other principles specific to our current context. The landscape of ethical, legal and regulatory barriers and a case example of how a VAR programme has been implemented in an emergency department in Ontario, Canada are outlined. The potential to harness VAR data to drive quality and to improve safety is remarkable. Articulating the most contentious issues and illustrating how they can be addressed may guide others hoping to implement similar VAR programmes.

Introduction: Patient-centered care is a core principle of the Canadian healthcare system. In order to facilitate patient-centered care, the documentation of a patient's medical goals and expectations is important, especially in the event of acute decompensation when an informed conversation with the patient may not be possible. The 'Goals of Care Discussion Form (GCF)' at Kingston Health Sciences Centre (KHSC) documents goals of care discussions between patients and healthcare providers. All patients admitted to the Internal Medicine service are expected to have this form completed within 24 hours of admission. Formal measurement of form completion at our center has not previously been done, though anecdotally this form is often incomplete. The purpose of this study is to quantify the rate of completion and assess quality of documentation of the GCF at KHSC. Methods: This prospective chart review took place between August 25, 2018, and March 25, 2019. Charts were reviewed for the presence of a completed GCF, and the quality of notation was assessed, as appropriate. Given there are no existing tools for assessing the quality of a document such as the GCF, authors TC and JM created one de novo for this study. Extracted data included the amount of time elapsed between admission and completion of the GCF, whether the 'yes/no cardiopulmonary resuscitation (CPR)' order in the patient's chart aligned with their wishes as outlined on the GCF, and whether or not a patient's GCF was uploaded to the hospital's electronic medical record (EMR). Results: Two hundred sixteen charts were reviewed. Of these, 136 (63.0%) had a complete GCF. The mean GCF quality score was 3.4/7 (95% CI [3.2, 3.6]). The mean time elapsed from admission to the completion of the GCF was 1.5 days (95% CI [0.6, 2.4]). There were 130 charts with both a complete GCF and a 'yes/no CPR' order, and of these, 20 (15.4%) showed a discrepancy. Eighty-six (63.2%) of the completed GCFs were uploaded to the EMR. Discussion and conclusions: The rate of GCF completion at KHSC is noticeably higher than expected based on the previous literature. However, our assessment of the quality of completion indicates that there is room for improvement. Most concerning, discrepancies were found between the 'yes/no CPR' order in a patient's chart and their stated wishes on the GCF. Furthermore, less than two-thirds of completed GCFs were found to have been uploaded to the hospital's EMR. Given the emphasis on patient-centered care in the Canadian healthcare system, our findings suggest that improvement initiatives are needed with respect to documenting goals of care discussions with patients.

Objectives While quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal-to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities. Methods An expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms. Results The final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both. Conclusion Six recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes. Keywords Emergency medicine • Quality improvement • Research methods • Patient oriented Résumé Objectifs Bien que l'amélioration de la qualité (AQ) et la recherche clinique représentent deux approches scientifiques distinctes, elles ont le même but ultime: améliorer la santé et les résultats des soins aux patients. En tirant profit de leurs atouts respectifs, les chances d'obtenir et de soutenir des améliorations de santé sont plus élevées. Notre objectif était de créer des recommandations pour renforcer la collaboration entre les communautés d'AQ et de recherche clinique en médecine d'urgence canadienne. Méthodes Un groupe d'experts de huit cliniciens des services d'urgence dotés d'une expertise diversifiée en matière d'AQ et de recherche clinique a rédigé une liste de recommandations basées sur leur expertise professionnelle et un examen de la revue de littérature. Ces recommandations ont été affinées en consultation avec les parties prenantes nationales et examinées lors du Symposium académique virtuel de ACMU 2020, où des commentaires ont été reçus via plusieurs plateformes virtuelles. Résultats Les six recommandations finales incluent que tous les prestataires des services de médecine d'urgence devraient: (1) comprendre le rôle et l'application de la...

Objective: Evidence-based guidelines recommend promoting sleep in the Intensive Care Unit (ICU), yet many patients experience poor sleep quality. We sought to engage allied health staff and patient families to determine barriers to sleep promotion, to measure sleep quality for ICU patients, and to evaluate the improvement in sleep quality after implementation of nursing morning report protocol and a doorway poster. Design: The study followed an interrupted time-series framework of quality improvement. Qualitative diagnostics included focus groups and interviews with patients, families, and allied health care workers, analyzed by qualitative descriptive analysis. Quantitative diagnostics included direct observation of nurses and patients overnight. Analysis of primary outcome data used statistical process control methodology. Patients: Patients included were >18 years old, admitted overnight to a Canadian tertiary academic ICU, with a Richards Agitation Sedation Scale (RASS) ≥−2. Interventions: Sleep quality was measured using the Richards Campbell Sleep Questionnaire (RCSQ). Two interventions were developed: sleep quality in morning nursing report, and a doorway poster. Main results: A total of 2332 patient nights across 7 consecutive months were included for analysis. Baseline sleep in the ICU was poor (mean RCSQ 53.7/100). Root cause-analysis identified the most prominent sleep barriers as nurse stigma associated with less active management of patients and lack of physician engagement. No significant improvement occurred over the sleep quality improvement initiative (mean RCSQ 59.5/100). Sleep quality was better among non-delirious patients compared with delirious patients (mean RCSQ 62.7 vs 53.3). Conclusion: The intervention of a nursing morning report protocol and sleep posters did not improve the quality of ICU patient sleep in this study. Structured interviews revealed potential sleep barriers to be addressed such as nursing stigma and inappropriate awakenings. Nursing stigma has not been previously linked to sleep quality.

Objectives-Point-of-care ultrasound (POCUS) is a widely used diagnostic modality in the emergency physician's tool kit. The effect on health care costs is disputed. This study examined whether POCUS was associated with system-level cost savings. Secondary objectives included adverse patient outcomes and the association between POCUS use and diagnostic costs in specific patient groups.Methods-The Point-of-Care Ultrasound Use and Monetary Outcomes study was a single-center prospective observational study. A convenience sample of emergency medicine physicians working from July to October 2019 were included after using POCUS as part of their assessment. The cost of patient investigations was compared with those proposed by a control group of physicians simultaneously on shift, who were blinded to the POCUS findings. Ethical approval was obtained from the Queen'

ObjectivesTo describe the association between participant profession and the number and type of latent safety threats (LSTs) identified during in situ simulation (ISS). Secondary objectives were to describe the association between both (a) participants’ years of experience and LST identification and (b) type of scenario and number of identified LSTs.MethodsEmergency staff physicians (MDs), registered nurses (RNs) and respiratory therapists (RTs) participated in ISS sessions in the emergency department (ED) of a tertiary care teaching hospital. Adult and paediatric scenarios were designed to be high-acuity, low-occurrence resuscitation cases. Simulations were 10 min in duration. A written survey was administered to participants immediately postsimulation, collecting demographic data and perceived LSTs. Survey data was collated and LSTs were grouped using a previously described framework.ResultsThirteen simulation sessions were completed from July to November 2018, with 59 participants (12 MDs, 41 RNs, 6 RTs). Twenty-four unique LSTs were identified from survey data. RNs identified a median of 2 (IQR 1, 2.5) LSTs, significantly more than RTs (0.5 (IQR 0, 1.25), p=0.04). Within respective professions, MDs and RTs most commonly identified equipment issues, and RNs most commonly identified medication issues. Participants with ≤10 years of experience identified a median of 2 (IQR 1, 3) LSTs versus 1 (IQR 1, 2) LST in those with >10 years of experience (p=0.06). Adult and paediatric patient scenarios were associated with the identification of a median of 4 (IQR 3.0, 4.0) and 5 LSTs (IQR 3.5, 6.5), respectively (p=0.15).ConclusionsInclusion of a multidisciplinary team is important during ISS in order to gain a breadth of perspectives for the identification of LSTs. In our study, participants with ≤10 years of experience and simulations with paediatric scenarios were associated with a higher number of identified LSTs; however, the difference was not statistically significant.

Introduction: Point-of-care ultrasound (POCUS) is an integral tool in the modern emergency physician's toolkit. Evidence suggests many imaging and lab investigations are ordered without true medical indications; it is unknown how POCUS utilization impacts health care costs at a patient level. The purpose of this study was to assess whether POCUS use in the emergency department (ED) was associated with cost savings via decreased laboratory and radiographic testing. Methods: POCUMON is a single-center, prospective pilot study. The participants were a convenience sample of ED staff physicians and PGY-5 Emergency Medicine (EM) residents working in the ED from July-October 2019. Physicians who used POCUS as part of their assessment had the cost of their patient investigation plans compared with those proposed by a control group of ED physicians simultaneously on-shift. The control group was blinded to the POCUS findings but had access to the patient and medical record. The lab investigations and imaging studies ordered by both groups were recorded with respective costs. Data were analyzed using a paired T-test, with sub-group analyses. Ethics approval was obtained from the Queen's University HSREB (No.6026732). Results: 50 patient assessments using POCUS were captured in the study period. 76% of patient assessments were performed by EM staff physicians; 94% of control assessments were provided by EM staff physicians. Patient chief complaints included abdominal pain (7), chest pain/dyspnea (10), flank pain (3), pregnancy concerns (4), trauma (7), extremity complaints (4), back pain (3), and other (12). The POCUS group had a trend for lower number of laboratory tests (4.7 ± 0.44 vs 5.22 ± 0.39; p = 0.28) and imaging studies (0.94 ± 0.14 vs 1.1 ± 0.11; p = 0.33). Overall health care costs were similar in both groups, with a trend to cost savings in the POCUS group ($142.00 ± 15.44 vs $174.60 ± 17.00; p = 0.12). Subgrouping identified significant cost savings in the POCUS group for patients with a chief complaint of flank pain ($43.64 vs $248.82, p = 0.01). Conclusion: POCUS use was not associated with significant health care cost savings. ED POCUS usage did see a trend towards decreased laboratory and imaging investigations. Patients presenting with flank pain had significantly lower expenditures associated with their visit when POCUS was incorporated into their assessment. Large scale prospective studies are needed to investigate if POCUS is associated with cost-savings in ED patients.