Communication between consultants providing advice and referring physicians: a scoping review

OBJECTIVE

Communication during consultations between referring and consultant physicians is often cited as a source of adverse events, medical error and professional incivility. While existing literature focuses on the role of referring physicians, few studies acknowledge the role of consultant physicians in enhancing communication during consultations. This scoping review aims to identify and synthesise available recommendations to enhance the communication practices of consultants during real-time consultations.

DESIGN

A scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

DATA SOURCES

Medline, EMBASE and PsycINFO databases were searched from inception to August 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English-language publications which describe recommendations, strategies or frameworks to improve the communication practices of consultant physicians during real-time consultations with referring physicians.

DATA EXTRACTION AND SYNTHESIS

The search strategy included the following concepts: consultation, physician, communication, interprofessional relations and best practice. Two authors independently performed each phase of title and abstract screening, full-text review and data extraction. Discrepancies were resolved by a third author. Extracted data were iteratively analysed and summarised thematically.

RESULTS

Sixteen publications met the inclusion criteria. Synthesis of available recommendations identified organisation, expertise and interpersonal skills as three overarching and interconnected dimensions of communication demonstrated by consultants during effective consultations. Twelve studies identified interpersonal skills as being critical in alleviating the widespread professional incivility that is reported during consultations. Existing recommendations to improve the communication practices of consultants are limited as they lack standardised interventions and fail to comprehensively address all three elements identified in this review.

CONCLUSION

This scoping review synthesises available recommendations to improve the communication practices of consultant physicians during real-time consultations. An opportunity exists to develop communication tools or educational interventions based on the findings of this review to enhance interphysician consultation encounters.

Call to action: equity, diversity, and inclusion in emergency medicine resident physician selection

OBJECTIVES

This call to action seeks to improve emergency care in Canada for equity-deserving communities, enabled by equitable representation among emergency physicians nationally. Specifically, this work describes current resident selection processes and makes recommendations to enhance the equity, diversity, and inclusion (EDI) of resident physician selection in Canadian emergency medicine (EM) residency programs.

METHODS

A diverse panel of EM residency program directors, attending and resident physicians, medical students, and community representatives met monthly from September 2021 to May 2022 via videoconference to coordinate a scoping literature review, two surveys, and structured interviews. This work informed the development of recommendations for incorporating EDI into Canadian EM resident physician selection. At the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, these recommendations were presented to symposium attendees composed of national EM community leaders, members, and learners. Attendees were divided into small working groups to discuss the recommendations and address three conversation-facilitating questions.

RESULTS

Symposium feedback informed a final set of eight recommendations to promote EDI practices during the resident selection process that address recruitment, retention, mitigating inequities and biases, and education. Each recommendation is accompanied by specific, actionable sub-items to guide programs toward a more equitable selection process. The small working groups also described perceived barriers to the implementation of these recommendations and outlined strategies for success that are incorporated into the recommendations.

CONCLUSION

We call on Canadian EM training programs to implement these eight recommendations to strengthen EDI practices in EM resident physician selection and, in doing so, help to improve the care that patients from equity-deserving groups receive in Canada's emergency departments (EDs).

"We're drowning and we're alone": a qualitative study of the lived experience of people experiencing persistent post-COVID-19 symptoms

BACKGROUND

The "long tail" of the COVID-19 pandemic will be reflected in disabling symptoms that persist, fluctuate or recur for extended periods for an estimated 20%-30% of those who had a SARS-CoV-2 infection; development of effective interventions to address these symptoms must account for the realities faced by these patients. We sought to describe the lived experience of patients living with persistent post-COVID-19 symptoms.

METHODS

We conducted a qualitative study, using interpretive description, of the lived experiences of adults experiencing persistent post-COVID-19 symptoms. We collected data from in-depth, semistructured virtual focus groups in February and March 2022. We used thematic analysis to analyze the data and met with several participants twice for respondent validation.

RESULTS

The study included 41 participants (28 females) from across Canada with a mean age of 47.9 years and mean time since initial SARS-CoV-2 infection of 15.8 months. Four overarching themes were identified: the unique burdens of living with persistent post-COVID-19 symptoms; the complex nature of patient work in managing symptoms and seeking treatment during recovery; erosion of trust in the health care system; and the process of adaptation, which included taking charge and transformed self-identity.

INTERPRETATION

Living with persistent post-COVID-19 symptoms within a health care system ill-equipped to provide needed resources profoundly challenges the ability of survivors to restore their well-being. Whereas policy and practice increasingly emphasize the importance of self-management within the context of post-COVID-19 symptoms, new investments that enhance services and support patient capacity are required to promote better outcomes for patients, the health care system and society.

Strength in the gap: A rapid review of principles and practices for urgent care centres

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Epidemiology and outcomes for level 1 and 2 traumas during the first wave of COVID19 in a Canadian centre

To determine if lockdown measures imposed during the first wave of the COVID19 pandemic affected trauma patterns, volumes, and outcomes in a western Canadian level 1 trauma center, we performed a retrospective cohort study assessing level 1 and 2 trauma patients presenting to our center during the initial COVID19 "lockdown" period (March 15-June 14, 2020) compared to a similar cohort of patients presenting during a "control" period 1 year prior (March 15-June 14, 2019). Overall, we saw a 7.8% reduction in trauma volumes during the lockdown period, and this was associated with a shorter average ED length of stay (6.2 ± 4.7 h vs. 9.7 ± 11.8 h, p = 0.003), reduced time to computed tomography (88.5 ± 68.2 min vs. 105.1 ± 65.5 min, p < 0.001), a reduction in intensive care unit admissions (11.0 ± 4.9% vs. 20.0 ± 15.5%, p = 0.001), and higher injury severity score (6.5 ± 7.6 vs. 6.2 ± 9.5, p = 0.04). Our findings suggest that lockdown measures imposed during the first wave of the COVID19 pandemic had a significant impact on trauma patients.

Unidentified patients in the emergency department: a historical cohort study

OBJECTIVES

To characterize unidentified patients presenting to a single, urban emergency department (ED) in Canada. We report their demographics, ED course, post-ED discharge outcomes, and mode of identification.

METHODS

We performed a retrospective chart review using descriptive analyses to assess unidentified patients admitted to Royal University Hospital and St. Paul's Hospital EDs between May 1, 2018, and April 30, 2019, in Saskatoon, Saskatchewan, Canada. We assessed demographic data, clinical presentation, mode of identification, discharge information, and major clinical outcomes.

RESULTS

Unidentified patients were disproportionately male (64.9%), and mostly presented as Canadian Triage and Acuity Scale (CTAS) 1 (41.6%) and CTAS 2 (44.2%). Most patients arrived via emergency medical services (80.7%). The most common presenting complaints were substance misuse (33.3%) and trauma (24.6%). The average ED length of stay was 8.7 h (SD 18.6). Many patients received an inpatient consult (58.8%), and 22.3% received support services (e.g., social work). The 30-day mortality of all patients was 13.2%. Of those patients who survived to ED discharge, common dispositions included: home (36.0%), police services (3.5%), or emergency shelters (3.5%). Four (3.5%) patients returned to the hospital unidentified within the study period, and 6.7% of patients discharged from the ED returned within 48 hours.

CONCLUSION

Unidentified patients are a high-needs demographic that present mostly with substance misuse or trauma. Repeat ED attendance, sometimes as unidentified patients again, calls for initiatives that facilitate prompt identification, better discharge planning, and linkage to social supports.

Prevalence of Cigarette Smoking Among Adult Emergency Department Patients in Canada

Introduction

Tobacco smoking is a priority public health concern, and a leading cause of death and disability globally. While the daily smoking prevalence in Canada is approximately 9.7%, the proportion of smokers among emergency department (ED) patients has been found to be significantly higher. The purpose of this survey study was to determine the smoking prevalence of adult ED patients presenting to three urban Canadian hospitals, and to determine whether there was an increased prevalence compared to the general public.

Methods

A verbal questionnaire was administered to adult patients aged 18 years and older presenting to Royal University Hospital, St. Paul’s Hospital, and Saskatoon City Hospital in Saskatoon, Saskatchewan. We compared patients’ smoking habits to Fagerström tobacco dependence scores, readiness to quit smoking, chief complaints, Canadian Triage Acuity Scale scores, and willingness to partake in ED-specific cessation interventions.

Results

A total of 1190 eligible patients were approached, and 1078 completed the questionnaire. Adult Saskatoon ED patients demonstrated a cigarette smoking prevalence of 19.6%, which is significantly higher than the adult Saskatchewan public at 14.65% (P<0.0001). Out of the smoking cohort, 51.4% indicated they wanted to quit smoking and would partake in ED-specific cessation counselling, if available. Of the proposed interventions, ED cessation counselling was most popular among patients (62.4%), followed by receiving a pamphlet (56.2%), and referral to a smokers’ quit line (49.5%).

Conclusion

The higher smoking prevalence demonstrated among ED patients highlights the need for a targeted intervention program that is feasible for the fast-paced ED environment. Training ED staff to conduct brief cessation counselling and referral to community supports for follow-up could provide an initial point of contact for smokers not otherwise receiving cessation assistance.

Extensive Upper Airway Hematoma Secondary to Supratherapeutic Warfarin Anticoagulation

Case Presentation

A 63-year-old female presented to the emergency department complaining of cough, neck swelling, dysphagia, and dysphonia for two days, with a past medical history of atrial fibrillation managed with warfarin. Investigations revealed a supratherapeutic international normalised ratio (greater than 10). Imaging and endoscopic examination showed an extensive retropharyngeal hematoma with significant mass effect on the airway.

Discussion

A rare but potentially fatal complication of warfarin anticoagulation is upper airway hematoma, with violent coughing described as an inciting cause. Signs of airway compromise necessitate specialist consultation and definitive airway management, while mild cases without airway concerns can be managed conservatively with medical anticoagulation reversal.