Extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest (ECPR) is an emerging resuscitative therapy that has shown promising results for selected patients who may not otherwise survive. We sought to identify the characteristics of cardiac arrest patients presenting to our institution to begin assessing the feasibility of an ECPR program.

This retrospective health records review included patients aged 18–75 years old presenting to our academic teaching hospital campuses with refractory nontraumatic out-of-hospital or in-emergency department (ED) cardiac arrest over a 2-year period. Based on a scoping review of the literature, both “liberal” and “restrictive” ECPR criteria were defined and applied to our cohort.

A total of 179 patients met inclusion criteria. Median age was 60 years, and patients were predominantly male (72.6%). The initial rhythm was ventricular tachycardia/ventricular fibrillation in 49.2%. The majority of arrests were witnessed (69.3%), with immediate bystander CPR performed on 53.1% and an additional 12% receiving CPR within 10 minutes of collapse. Median prehospital time was 40 minutes (interquartile range, 31–53.3). Two-thirds of patients (65.9%) were identified as having a reversible cause of arrest and favorable premorbid status was identified in nearly three quarters (74.3%). Our two sets of ECPR inclusion criteria revealed that 33 and 5 patients (liberal and restrictive criteria, respectively), would have been candidates for ECPR.

At our institution, we estimate between 6% and 40% of ED refractory cardiac arrest patients would be candidates for ECPR. These findings suggest that the implementation of an ECPR program should be explored.

Quality improvement and patient safety (QIPS) competencies are increasingly important in emergency medicine (EM) and are now included in the CanMEDS framework. We conducted a survey aimed at determining the Canadian EM residents’ perspectives on the level of QIPS education and support available to them.

An electronic survey was distributed to all Canadian EM residents from the Royal College and Family Medicine training streams. The survey consisted of multiple-choice, Likert, and free-text entry questions aimed at understanding familiarity with QIPS, local opportunities for QIPS projects and mentorship, and the desire for further QIPS education and involvement.

Of 535 EM residents, 189 (35.3%) completed the survey, representing all 17 medical schools; 77.2% of respondents were from the Royal College stream; 17.5% of respondents reported that QIPS methodologies were formally taught in their residency program; 54.7% of respondents reported being “somewhat” or “very” familiar with QIPS; 47.2% and 51.5% of respondents reported either “not knowing” or “not having readily available” opportunities for QIPS projects and QIPS mentorship, respectively; 66.9% of respondents indicated a desire for increased QIPS teaching; and 70.4% were interested in becoming involved with QIPS training and initiatives.

Many Canadian EM residents perceive a lack of QIPS educational opportunities and support in their local setting. They are interested in receiving more QIPS education, as well as project and mentorship opportunities. Supporting residents with a robust QIPS educational and mentorship framework may build a cohort of providers who can enhance the local delivery of care.

Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.

An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.

Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.

A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

We 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.

Two 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.

Two 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).

There 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.

We conducted an environmental scan of quality improvement and patient safety (QIPS) infrastructure and activities in academic emergency medicine (EM) programs and departments across Canada.

We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee. “Survey 1” was sent by email to all 17 Canadian medical school affiliated EM department Chairs and Academic Hospitals department Chiefs; “Survey 2” to 12 identified QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey.

22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. Many described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per centre ranging from 1–10 over the past 5 years. Few respondents reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%).

This environmental scan provides a snapshot of QIPS activities in EM across academic centres in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals.

In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap.

Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity.

ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a “whole hospital” problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.