clinical practice

WTBS 6 Measuring Quality – The Value of Health Care Metrics

A New York Times article titled “How Measurement Fails Doctors and Teachers” went viral on social media in January and caused a lot of chatter in medical circles. Its author, a professor of medicine at the University of California, gave voice to a wide sense of frustration, and while I understand that feeling and think it’s justified, I don’t agree with labelling measurement as the culprit. As I expressed in my first WTBS blog post, “Why Recording Time to Initial Assessment is Worthwhile,” I believe my job as an administrator is to make the job of my staff easier, and measurements can help us maintain standards of care and understand where gaps in the system may exist—when such data are collected and used appropriately. In this guest blog, Dr. Lucas Chartier, an emergency physician in Toronto with a background in quality improvement, expands on the subject of how we’ve gone off course in our zeal for measurement and helps us try to find the path back to our intended goals.

By Dr. Howard Ovens|2016-10-17T11:48:28-04:00February 29th, 2016|Categories: Clinical Practice, Emergency Medicine, Medical Specialty, Waiting to be Seen|Tags: heatlh care metrics, Howard Ovens, LEAN, Lucas Chartier, QI, quality improvement|0 Comments

Episode 75 Decision Making in EM – Cognitive Debiasing, Situational Awareness & Preferred Error

While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients. Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets...

By Anton Helman|2021-03-30T14:58:06-04:00January 12th, 2016|Categories: Clinical Practice, Emergency Medicine, Episodes, Medical Specialty|Tags: anticipatory guidance, Chris Hicks, David Dushenski, decision fatigue, mental rehearsal, preferred error, risk tolerance, situational awareness, stress inoculation training, Walter HImmel|4 Comments

Episode 74 Opioid Misuse in Emergency Medicine

Pain leads to suffering. Opioid misuse leads to suffering. We strive to avoid both for our patients. On the one hand, treating pain is one of the most important things we do in emergency medicine to help our patients and we need to be aggressive in getting our patients' pain under control in a timely, effective, sustained and safe fashion. This was the emphasis 10-20 years ago after studies showed that we were poor at managing pain and our patients were suffering. On the other hand, opioid dependence, addiction, abuse and misuse are an enormous public health issue. Opioid misuse in Emergency Medicine has become a major problem in North America over the past 10 years at least partly as a reaction to the years that we were being told that we were failing at pain management. As Dr. Reuben Strayer said in his SMACC talk on the topic: “Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.” So how do we strike a balance between managing [...]

By Anton Helman|2021-03-30T14:59:01-04:00December 15th, 2015|Categories: Clinical Practice, Emergency Medicine, Episodes, Medical Specialty, Psychiatry, Special Populations, Toxicology|Tags: analgesia, David Juurlink, drug abuse, ketamine, malingerer, opiates, pain management, Reuben Strayer|7 Comments

WTBS 5 Emergency Physician Speed Part 2 – Solutions to Physician Productivity

In Emergency Physician Speed How Fast is Fast Enough – Part I, Dr. David Petrie addressed the issue of physician productivity (patients per hour, or PPH), the many factors that influence how quickly emergency physicians can process patients, and some of the tradeoffs between speed and quality. He also discussed the processing rate of the entire ED and introduced the concepts of surge capacity and the effect of crowding on safety if the ED can’t keep up. In this follow-up blog, Dr. Petrie expands on the departmental aspects of throughput and safety, and calls on policy-makers to recognize the need to include surge capacity in planning efforts. He also makes some powerful arguments about the related issues of so-called 'inappropriate visits' and the changing role of the ED. In this post - Emergency Physician Speed Part 2 - Solutions to Physician Productivity , he also brilliantly dismantles some common myths about ED visits — and drivers of costs.

By Anton Helman|2020-05-31T23:20:58-04:00November 17th, 2015|Categories: Clinical Practice, Emergency Medicine, Medical Specialty, Waiting to be Seen|Tags: David Petrie, patient safety, physician productivity, physician scheduling|6 Comments

Best Case Ever 41 Opiate Misuse and Physician Compassion

Opiate misuse is everywhere. Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opiates, which now kill more people than heroin and cocaine combined. Opiates are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opiate-related. Four out of 5 new heroin users report that their initial drug was a prescription opiate. In Ontario, three times the people died from opiate overdose than from HIV in 2011. Yet, we are expected to treat pain aggressively in the ED. Dr. Reuben Strayer, the brains behind the fantastic blog EM Updates tells his Best Case Ever, in which he realizes the importance of physician compassion in approaching the challenging drug seekers and malingerers that we manage in the ED on a regular basis. This Best Case Ever is in anticipation of an upcoming main episode in which Dr. Strayer and toxicologist Dr. David Juurlink discuss how to strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction, and how we best take care of our patients who we suspect might have a drug misuse problem.

By Anton Helman|2020-11-29T14:55:07-05:00October 13th, 2015|Categories: Best Case Ever, Clinical Practice, Emergency Medicine, Psychiatry, Special Populations, Toxicology|Tags: drug seekers, malingerer, opiates, opiod abuse, opiod addiction, pain management, physician compassion, Reuben Strayer|3 Comments

Episode 70 End of Life Care in Emergency Medicine

Most of us in North America live in cultures that almost never talk about death and dying. And medical progress has led the way to a shift in the culture of dying, in which death has been medicalized. While most people wish to die at home, every decade has seen an increase in the proportion of deaths that occur in hospital. Death is often seen as a failure to keep people alive rather than a natural dignified end to life. This is at odds with what a lot of people actually want at the end of their lives: 70% of hospitalized Canadian elderly say they prefer comfort measures as apposed to life-prolonging treatment, yet as many as ⅔ of these patients are admitted to ICUs. Quality End of Life Care in Emergency Medicine is not widely taught. Most of us are not well prepared for death in our EDs – and we should be. There’s no second chance when it comes to a bad death like there is if you screw up a central line placement, so you need the skills to do it right the first time. To recognize when comfort measures and compassion are what will be best for our patients, is just as important as knowing when to intervene and treat aggressively in a resuscitation. Emergency physicians should be able to recognize not only the symptoms and patterns that are common in the last hours to days of life, but also understand the various trajectories over months or years toward death, if they’re going to provide the high quality end of life care that patients deserve. So, with the help of Dr. Howard Ovens, a veteran emergency physician with over 25 years of experience who speaks at national conferences on End of Life Care in Emergency Medicine, Dr. Paul Miller, an emergency physician who also runs a palliative care unit at McMaster University and Dr. Shona MacLachlan who led the palliative care stream at the CAEP conference in Edmonton this past June, we'll help you learn the skills you need to assess dying patients appropriately, communicate with their families effectively, manage end of life symptoms with confidence and much more...

By Anton Helman|2022-01-05T23:22:16-05:00September 29th, 2015|Categories: Clinical Practice, EM Cases, Emergency Medicine, Episodes, Medical Specialty, Special Populations|Tags: Howard Ovens, pain management, palliative care, patient centered care, Paul Miller, Shona MacLachlan|8 Comments

WTBS 4 – Emergency Physician Speed: How Fast is Fast Enough?

Racing legend Mario Andretti famously said, “If everything seems under control, you’re just not going fast enough.” He was talking about cars, but to many beleaguered emergency physicians trying to keep up with the patient queue, emergency medicine often seems this way. This guest blog on emergency physician productivity began as a question to our national association, the Canadian Association of Emergency Physicians (CAEP): Are there any national standards with respect to emergency physician productivity, i.e., expected number of patients assessed per hour? The question was referred to the CAEP Public Affairs Committee and triggered a lively email discussion among our members....

By Dr. Howard Ovens|2020-05-31T23:26:17-04:00September 22nd, 2015|Categories: Clinical Practice, Emergency Medicine, Medical Specialty, Waiting to be Seen|Tags: David Petrie, Howard Ovens, physician productivity|4 Comments

Episode 62 Diagnostic Decision Making in Emergency Medicine

This is Part 1 of EM Cases' series on Diagnostic Decision Making with Walter Himmel, Chris Hicks and David Dushenski discussing the intersection of evidence-based medicine, cognitive bias and systems issues to effect our diagnostic decision making in Emergency Medicine. In this episode we first discuss 5 strategies to help you master evidence-based diagnostic decision making to minimize diagnostic error, avoid over-testing and improve patient care including: 1. The incorporation of patients' values and clinical expertise into evidence-based decisions 2. Critically appraising diagnostic studies 3. Understanding that diagnostic tests are not perfect 4. Using the concept of test threshold to guide work-ups 5. Understanding that the predictive value of a test depends on the prevalence of disease We then go on to review some of the factors that play into the clinician’s and patient’s risk tolerance in a given clinical encounter, how this plays into shared decision making and the need to adjust our risk tolerance in critical situations. Finally, we present some strategies to prevent over-testing while improving patient care, patient flow and ethical practice.

By Anton Helman|2021-03-30T16:50:56-04:00April 14th, 2015|Categories: Clinical Practice, EM Cases, Emergency Medicine, Episodes, Medical Specialty|Tags: choosing wisdely, Chris Hicks, cognitive bias, David Dushenski, EBM, evidence based medicine, likelihood ratio, LR, predictive value, risk tolerance, shared decision making, Walter HImmel|4 Comments

Best Case Ever 35: Taking Action in Emergency Medicine

In anticipation of our series of podcasts on Diagnostic Decision Making with Dr. Walter Himmel, Dr. Chris Hicks and Dr. David Dushenski we have Dr. Hicks presenting his Best Case Ever. Taking action in Emergency Medicine requires not only careful consideration of the best evidence, the experience of the clinician, the patient's values and the system that you work in, but also the will to act. Dr. Hicks describes a case of a patient who suffers a cardiac arrest, where the diagnosis is quite obvious to everyone in the room (and the required action is as well), yet a delay in treatment occurs nonetheless.

By Anton Helman|2017-02-03T11:50:08-05:00April 7th, 2015|Categories: Best Case Ever, Clinical Practice, Emergency Medicine, Medical Specialty, Resuscitation|Tags: Chris Hicks, cognitive bias, cognitive error, pulmonary embolism, thrombolysis|2 Comments

Episode 56 The Stiell Sessions: Clinical Decision Rules and Risk Scales

There are hundreds of clinical decision rules and risk scales published in the medical literature, some more widely adopted than others. Ian Stiell, the father of clinical decision rules, shares with us his views and experiences gained from co-creating some of the most influential CDRs and risk scales to date. He explains the criteria for developing a CDR, the steps to developing a valid CDR, how best to apply CDRs and risk scales to clinical practice, and the hot-off the-press new Ottawa COPD Risk Score and Ottawa Heart Failure Risk Score for helping you with disposition decisions. It turns out that in Canada, we discharge about two thirds of the acute decompensated heart failure patients that we see in the ED, while the US almost all patients with decompensated heart failure are admitted to hospital. Dr. Stiell's new risk scores may help physicians in Canada make safer disposition decisions while help physicians in the US avoid unnecessary admissions.

By Anton Helman|2021-03-30T16:56:59-04:00December 30th, 2014|Categories: Clinical Practice, EM Cases, Emergency Medicine, Episodes, Trauma|Tags: clinical decision instruments, clinical decision rules, clinical decision tools, congestive heart failure, COPD, Hans Rosenberg, Ian Stiell, risk scales, risk stratification, syncope, TIA|1 Comment