28 results on '"Douglas Sinclair"'
Search Results
2. Identifying harm reduction strategies for alcohol and drug-use in inpatient care settings and emergency departments: a scoping review protocol
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Janet Curran, Annette Elliott Rose, Daniel Crowther, Leah Boulos, Mari Somerville, Douglas Sinclair, Shannon MacPhee, Lori Wozney, Morgan Joudrey, Caroline Jose, Alexander Caudarella, and Catie Johnson
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Population ,MEDLINE ,Addiction ,Context (language use) ,CINAHL ,PsycINFO ,preventive medicine ,social medicine ,Nursing ,Harm Reduction ,Medicine ,Humans ,education ,Harm reduction ,education.field_of_study ,Inpatients ,Inpatient care ,business.industry ,public health ,substance misuse ,General Medicine ,Hospitalization ,Review Literature as Topic ,Systematic review ,Pharmaceutical Preparations ,business ,Emergency Service, Hospital ,Systematic Reviews as Topic - Abstract
IntroductionPeople who use alcohol and/or drugs (PWUAD) are at high risk of medical complications, frequent hospitalisation and drug-related death following discharge from inpatient settings and emergency departments (EDs). Harm reduction strategies implemented in these settings may mitigate negative health outcomes for PWUAD. However, the scope of harm reduction strategies used globally within inpatient settings and EDs is unknown. The objective of this review is to identify and synthesise reported harm reduction strategies that have been implemented across inpatient settings and EDs for PWUAD.Methods and analysisThis review will include studies from any country and health service reporting on harm reduction strategies implemented in inpatient settings or EDs. The population of interest includes people of any race, gender and age identifying as PWUAD, or individuals who provided care to PWUAD. Studies which describe implementation strategies and barriers and enablers to implementation will be included. Studies published in English, or those available for English translation will be included. The following databases will be searched: MEDLINE All (Ovid), Embase (Elsevier Embase.com), CINAHL with Full Text (EBSCOhost), PsycINFO (EBSCOhost) and SCOPUS (Elsevier Scopus.com). A grey literature search will be conducted. There will be no date restrictions on the search. Titles, abstracts and full texts will be screened in duplicate. Data will be extracted using a standardised form. The results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews.Ethics and disseminationScoping reviews do not require ethical approval. Patient partners with lived experience and relevant knowledge users will be engaged as research team members throughout all phases of the research process. A report detailing context, methodology and findings from this review will be disseminated to knowledge users and relevant community stakeholders. This review will be submitted for publication to a relevant peer-reviewed journal.
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- 2021
3. Using a learning health system framework to examine COVID-19 pandemic planning and response at a Canadian Health Centre
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Christine Cassidy, Meaghan Sim, Mari Somerville, Daniel Crowther, Douglas Sinclair, Annette Elliott Rose, Stacy Burgess, Shauna Best, and Janet A. Curran
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Canada ,Multidisciplinary ,COVID-19 ,Humans ,Health Facilities ,Learning Health System ,Pandemics - Abstract
Background The COVID-19 pandemic has presented a unique opportunity to explore how health systems adapt under rapid and constant change and develop a better understanding of health system transformation. Learning health systems (LHS) have been proposed as an ideal structure to inform a data-driven response to a public health emergency like COVID-19. The aim of this study was to use a LHS framework to identify assets and gaps in health system pandemic planning and response during the initial stages of the COVID-19 pandemic at a single Canadian Health Centre. Methods This paper reports the data triangulation stage of a concurrent triangulation mixed methods study which aims to map study findings onto the LHS framework. We used a triangulation matrix to map quantitative (textual and administrative sources) and qualitative (semi-structured interviews) data onto the seven characteristics of a LHS and identify assets and gaps related to health-system receptors and research-system supports. Results We identified several health system assets within the LHS characteristics, including appropriate decision supports and aligned governance. Gaps were identified in the LHS characteristics of engaged patients and timely production and use of research evidence. Conclusion The LHS provided a useful framework to examine COVID-19 pandemic response measures. We highlighted opportunities to strengthen the LHS infrastructure for rapid integration of evidence and patient experience data into future practice and policy changes.
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- 2021
4. A Critical Qualitative Study of the Position of Middle Managers in Health Care Quality Improvement
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Douglas Sinclair and Katie N. Dainty
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Quality management ,Organizational culture ,Nurse Administrator ,Efficiency, Organizational ,Nurse's Role ,Unit (housing) ,03 medical and health sciences ,0302 clinical medicine ,Nursing ,Humans ,Nurse Administrators ,030212 general & internal medicine ,Qualitative Research ,General Nursing ,Quality Indicators, Health Care ,Ontario ,030503 health policy & services ,Middle management ,Organizational Culture ,Quality Improvement ,Leadership ,Work (electrical) ,0305 other medical science ,Psychology ,Health care quality ,Qualitative research - Abstract
To date, health care quality improvement (QI) has focused on the engagement of executive leadership and frontline staff as key factors for success. Little work has been done on understanding how mid-level unit/program managers perceive their role in QI and how capacity could be built at this level to increase success. We present ethnographic data on the experience of hospital middle managers to consider how the expectations and capacity of their current position might influence QI progress organizationally.
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- 2017
5. What Works and What's Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews
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Michelle Foisy, Lisa Hartling, Terry P. Klassen, Lisa M. Evered, Andrea Milne, Eddy Lang, and Douglas Sinclair
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Male ,medicine.medical_specialty ,medicine.drug_class ,Sedation ,Progressive Clinical Practice ,Conscious Sedation ,MEDLINE ,03 medical and health sciences ,0302 clinical medicine ,030225 pediatrics ,medicine ,Humans ,Hypnotics and Sedatives ,Ketamine ,030212 general & internal medicine ,Progressive Clinical Practices ,Child ,Intensive care medicine ,Adverse effect ,Propofol ,business.industry ,General Medicine ,3. Good health ,Systematic review ,Sedative ,Emergency Medicine ,Midazolam ,Female ,Hypotension ,Safety ,medicine.symptom ,Respiratory Insufficiency ,business ,Anesthetics, Intravenous ,medicine.drug - Abstract
Background Sedation is increasingly used to facilitate procedures on children in emergency departments (EDs). This overview of systematic reviews (SRs) examines the safety and efficacy of sedative agents commonly used for procedural sedation in children in the ED or similar settings. Methods We followed standard SR methods: comprehensive search; dual study selection, quality assessment, data extraction. We included SRs of children (1 month to 18 years) where the indication for sedation was procedure-related and performed in the ED. Results Fourteen SRs were included (210 primary studies). The most data were available for propofol (six reviews/50,472 sedations) followed by ketamine (7/8,238), nitrous oxide (5/8,220), and midazolam (4/4,978). Inconsistent conclusions for propofol were reported across six reviews. Half concluded that propofol was sufficiently safe; three reviews noted a higher occurrence of adverse events, particularly respiratory depression (upper estimate 1.1%; 5.4% for hypotension requiring intervention). Efficacy of propofol was considered in four reviews and found adequate in three. Five reviews found ketamine to be efficacious and seven reviews showed it to be safe. All five reviews of nitrous oxide concluded it is safe (0.1% incidence of respiratory events); most found it effective in cooperative children. Four reviews of midazolam made varying recommendations. To be effective, midazolam should be combined with another agent that increases the risk of adverse events (upper estimate 9.1% for desaturation, 0.1% for hypotension requiring intervention). Conclusions This comprehensive examination of an extensive body of literature shows consistent safety and efficacy for nitrous oxide and ketamine, with very rare significant adverse events for propofol. There was considerable heterogeneity in outcomes and reporting across studies and previous reviews. Standardized outcome sets and reporting should be encouraged to facilitate evidence-based recommendations for care.
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- 2016
6. Conducting Effective Physician Performance Feedback: A Primer for Healthcare Leaders
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Glen Bandiera, Amy H Y Cheng, Douglas Sinclair, D. Elizabeth Tullis, and Jason Manayathu
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Performance feedback ,Canada ,Medical Audit ,Physician-Patient Relations ,medicine.medical_specialty ,Quality management ,Leadership development ,business.industry ,Feedback, Psychological ,Alternative medicine ,Quality Improvement ,Patient Simulation ,Leadership ,Patient satisfaction ,Nursing ,Patient Satisfaction ,Physicians ,Health care ,Humans ,Medicine ,Clinical Competence ,Clinical competence ,business ,Patient simulation ,Quality Indicators, Health Care - Abstract
Physician performance feedback (PPF) can help physicians gain insight into their practice, to identify areas for improvement, and to implement changes to improve care. There is increasing interest in the use of PPF in Canada. However, little is known about the different types of PPF methods and whether PPF can lead to improved physician performance and patient outcomes. We provide a primer for healthcare leaders interested in doing PPF by reviewing common PPF methods. We then describe our institution's experience with physician multi-source feedback and provide strategies to conduct meaningful PPF.
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- 2016
7. Identifying older adults at risk of harm following elective surgery: a systematic review and meta-analysis
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Andrea C. Tricco, Patricia Rios, Sharon E. Straus, Camilla L. Wong, Ba' Pham, Agnes Grudniewicz, Douglas Sinclair, Catherine Talbot-Hamon, and Jennifer Watt
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medicine.medical_specialty ,Health Services for the Aged ,lcsh:Medicine ,Risk Assessment ,Postoperative complications ,03 medical and health sciences ,0302 clinical medicine ,Functional decline ,Internal medicine ,Odds Ratio ,Humans ,Medicine ,Prospective Studies ,030212 general & internal medicine ,Mortality ,Elective surgery ,Prospective cohort study ,business.industry ,Incidence ,Incidence (epidemiology) ,lcsh:R ,General Medicine ,Odds ratio ,Prognosis ,Patient Discharge ,Confidence interval ,3. Good health ,Hospitalization ,Meta-analysis ,Elective Surgical Procedures ,030220 oncology & carcinogenesis ,Systematic review ,business ,Risk assessment ,Elective Surgical Procedure ,Research Article - Abstract
Background Elective surgeries can be associated with significant harm to older adults. The present study aimed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery. Methods Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. Prospective studies reporting prognostic factors associated with postoperative complications (composite outcome of medical and surgical complications), functional decline, mortality, post-hospitalization discharge destination, and prolonged hospitalization among older adults undergoing elective surgery were included. Study characteristics and prognostic factors associated with the outcomes of interest were extracted independently by two reviewers. Random effects meta-analysis models were used to derive pooled effect estimates for prognostic factors and incidences of adverse outcomes. Results Of the 5692 titles and abstracts that were screened for inclusion, 44 studies (12,281 patients) reported on the following adverse postoperative outcomes: postoperative complications (n =28), postoperative mortality (n = 11), length of hospitalization (n = 21), functional decline (n = 6), and destination at discharge from hospital (n = 13). The pooled incidence of postoperative complications was 25.17% (95% confidence interval (CI) 18.03–33.98%, number needed to follow = 4). The geriatric syndromes of frailty (odds ratio (OR) 2.16, 95% CI 1.29–3.62) and cognitive impairment (OR 2.01, 95% CI 1.44–2.81) were associated with developing postoperative complications; however, there was no association with traditionally assessed prognostic factors such as age (OR 1.07, 95% CI 1.00–1.14) or American Society of Anesthesiologists status (OR 2.62, 95% CI 0.78–8.79). Besides frailty, other potentially modifiable prognostic factors, including depressive symptoms (OR 1.77, 95% CI 1.22–2.56) and smoking (OR 2.43, 95% CI 1.32–4.46), were also associated with developing postoperative complications. Conclusion Geriatric syndromes are important prognostic factors for postoperative complications. We identified potentially modifiable prognostic factors (e.g., frailty, depressive symptoms, and smoking) associated with developing postoperative complications that can be targeted preoperatively to optimize care. Electronic supplementary material The online version of this article (doi:10.1186/s12916-017-0986-2) contains supplementary material, which is available to authorized users.
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- 2018
8. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis
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Catherine Talbot-Hamon, Jennifer Watt, Agnes Grudniewicz, Ba' Pham, Camilla L. Wong, Andrea C. Tricco, Sharon E. Straus, Douglas Sinclair, and Patricia Rios
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medicine.medical_specialty ,Activities of daily living ,perioperative medicine ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Emergence Delirium ,Randomized controlled trial ,law ,Risk Factors ,Internal medicine ,Activities of Daily Living ,Internal Medicine ,medicine ,Humans ,030212 general & internal medicine ,Prospective Studies ,Elective surgery ,10. No inequality ,older adults ,Aged ,Randomized Controlled Trials as Topic ,Aged, 80 and over ,Review Paper ,business.industry ,Delirium ,prognostic factors ,Odds ratio ,Middle Aged ,Confidence interval ,3. Good health ,elective surgery ,Elective Surgical Procedures ,Meta-analysis ,medicine.symptom ,business ,030217 neurology & neurosurgery ,Cohort study - Abstract
Background Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. Methods Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. Results Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3–23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2–17.9), frailty (OR 4.1, 95% CI 1.4–11.7), cognitive impairment (OR 2.7, 95% CI 1.9–3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6–2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3–2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4–3.6) and smoking status (OR 1.8 95% CI 1.3–2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52–0.91). Discussion Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care. Electronic supplementary material The online version of this article (10.1007/s11606-017-4204-x) contains supplementary material, which is available to authorized users.
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- 2017
9. Emergency Medicine Training and Practice in Canada: Celebrating the PastEvolving for the Future
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Peter Toth, Brian R. Holroyd, Riyad B. Abu-Laban, Jason R. Frank, Constance LeBlanc, Pamela Eisener-Parsche, and Douglas Sinclair
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medicine.medical_specialty ,Medical education ,Canada ,Certification ,business.industry ,Professional Practice Location ,Internship and Residency ,030208 emergency & critical care medicine ,Training (civil) ,03 medical and health sciences ,0302 clinical medicine ,Education, Medical, Graduate ,Family medicine ,Physicians ,Emergency Medicine ,Workforce ,Medicine ,Humans ,030212 general & internal medicine ,Practice Patterns, Physicians' ,business - Published
- 2017
10. The future of emergency medicine in Canada: Reflections one year after the release of the Collaborative Working Group final report
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Paul Pageau, Constance LeBlanc, Peter Toth, Pamela Eisener-Parsche, Riyad B. Abu-Laban, Jason R. Frank, Douglas Sinclair, and Brian R. Holroyd
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medicine.medical_specialty ,Canada ,business.industry ,MEDLINE ,030208 emergency & critical care medicine ,03 medical and health sciences ,0302 clinical medicine ,Family medicine ,Emergency medicine ,Workforce ,Emergency Medicine ,Medicine ,Humans ,030212 general & internal medicine ,business ,Societies, Medical ,Forecasting - Published
- 2017
11. Emergency medicine definitions, CAEP, and the journey to excellence
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Douglas Sinclair
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Canada ,Medical education ,business.industry ,media_common.quotation_subject ,MEDLINE ,Certification ,Excellence ,Practice Guidelines as Topic ,Emergency Medicine ,Humans ,Medicine ,Clinical Competence ,Periodicals as Topic ,Clinical competence ,business ,Societies, Medical ,media_common - Published
- 2018
12. Presentation of evidence in continuing medical education programs: A mixed methods study *
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Tanya MacLeod, Richard Handfield-Jones, Douglas Sinclair, Michael Allen, and Michael Fleming
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Male ,Relative risk reduction ,Statistical literacy ,Risk Assessment ,Education ,Continuing medical education ,Nursing ,Surveys and Questionnaires ,Terminology as Topic ,Knowledge translation ,Humans ,Medicine ,Medical education ,Evidence-Based Medicine ,business.industry ,Professional development ,Absolute risk reduction ,Videotape Recording ,General Medicine ,Evidence-based medicine ,Focus Groups ,Data Interpretation, Statistical ,Number needed to treat ,Education, Medical, Continuing ,Female ,business - Abstract
Introduction Clinical trial data can be presented in ways that exaggerate treatment effectiveness. Physicians consider therapy more effective, and may be more likely to make inappropriate practice changes, when data are presented in relative terms such as relative risk reduction rather than in absolute terms such as absolute risk reduction and number needed to treat. Our purpose was to determine (1) how frequently continuing medical education (CME) speakers present research data in relative terms compared to absolute terms; (2) how knowledgeable CME speakers and learners are about these terms; and (3) how CME learners want these terms presented. Methods Analysis of videotapes and PowerPoint slides of 26 CME presentations, questionnaire survey of CME speakers and learners, and focus groups with learners. Results Speakers presented data more frequently in relative than absolute terms, but most frequently in general terms such as frequencies, percentages, graphs, and P-values with no data. Of 1367 PowerPoint slides, 269 presented research data, and of these, 225 (84%) presented data in general terms, 50 (19%) in relative terms and 19 (7%) in absolute terms. CME speakers understood relative and absolute terms better than learners. Approximately 25–35% of speakers and 45–65% of learners could not correctly calculate relative risk reduction, absolute risk reduction, and number needed to treat. Learners wished to have these terms presented in CME programs in a consistent and easily understood format and requested a brief review of them at the beginning of CME programs. Discussion Presentation of research data in most CME programs is inadequate to allow learners to make fully informed therapeutic decisions. Speakers and learners need professional development to improve their presentation and understanding of research data.
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- 2010
13. Interprofessional education for faculty and staff – A review of the Changing Worlds: Diversity and Health Care Project
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Blye Frank, Matthew Numer, Douglas Sinclair, and Anna MacLeod
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Canada ,Medical education ,Education, Medical ,business.industry ,media_common.quotation_subject ,Ethnic group ,Videotape Recording ,Human sexuality ,Cultural Diversity ,General Medicine ,Interprofessional education ,Social issues ,Social class ,Nursing ,Social Justice ,Cultural diversity ,Health care ,Humans ,Medicine ,Healthcare Disparities ,Program Development ,business ,Diversity (politics) ,media_common - Abstract
The medical community is giving increasing attention to issues of social class, gender, race, ethnicity, culture and other areas of difference in interprofessional education and patient care. The Changing Worlds: Diversity and Health Care Project, an interprofessional diversity education initiative, was designed with the aim of exploring social issues in the medical professions. This project brought together the Faculties of Medicine, Dentistry and Health Professions at Dalhousie University in an effort to address issues of difference related to multiplicities of races, ethnicities, cultures, languages, sexualities and religions. The findings of this paper include methods for the project implementation and future direction for education initiatives aimed at issues of social justice and equity in health care.
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- 2008
14. Data collection on patients in emergency departments in Canada
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Douglas Sinclair, Kenneth Bond, Michael J. Schull, Maria B. Ospina, Brian H. Rowe, Michael J. Bullard, and Sandra Blitz
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Canada ,medicine.medical_specialty ,Government ,education.field_of_study ,Data collection ,Medical Records Systems, Computerized ,business.industry ,Vendor ,Population ,Library science ,Overcrowding ,Triage ,Hospitals ,Health Care Surveys ,Family medicine ,Workforce ,Emergency Medicine ,Information system ,Humans ,Medicine ,business ,education - Abstract
Objective:Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.Methods:Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10 000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.Results:Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.Conclusion:The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.
- Published
- 2006
15. Emergency physicians versus laboratory technicians: are the urinalysis and microscopy results comparable? A pilot study
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Douglas Sinclair, Sarah Kerr, and Cindy Marshall
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Adult ,Male ,medicine.medical_specialty ,Adolescent ,Urinalysis ,Pilot Projects ,Urine ,Sensitivity and Specificity ,medicine ,Humans ,Laboratory technicians ,Aged ,Urine cytology ,Aged, 80 and over ,Microscopy ,medicine.diagnostic_test ,Clinical Laboratory Techniques ,business.industry ,Technician ,Emergency department ,Dipstick ,Middle Aged ,Surgery ,Leukocyte esterase ,Nova Scotia ,Emergency medicine ,Emergency Medicine ,Female ,Clinical Competence ,Reagent Kits, Diagnostic ,business - Abstract
In the literature to date, there are no studies that directly evaluate microscopic urine examination results obtained by a physician compared to those of a trained laboratory technician. Our purpose in undertaking this study was to determine whether there would be comparable results obtained by these two groups. The study took place in an Emergency Medicine Department with 45,000 visits annually. Each urine sample obtained on patients presenting to the Emergency Department was divided into two lots: one was sent to the laboratory and the other was analyzed by the emergency physician. A comparison of both dipstick and microscopic results by physician and laboratory staff was then made using sensitivity, specificity, and Kappa analysis. Statistical analysis of the data revealed close agreement between the emergency physician and laboratory technician with respect to the following components of urinalysis: red blood cell urinalysis and microscopy, leukocyte esterase, and nitrite testing. Microscopy for white cells and bacteria and testing for proteinuria were not in close agreement. Urinalysis by emergency physicians is comparable to laboratory technicians for a number of the testing components. However, in this limited pilot study, emergency physicians were not able to consistently perform urinalysis for the laboratory standard.
- Published
- 1999
16. Factors influencing rural and urban emergency clinicians' participation in an online knowledge exchange intervention
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Janet A, Curran, Andrea L, Murphy, Douglas, Sinclair, and Patrick, McGrath
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Adult ,Male ,Academic Medical Centers ,Canada ,Internet ,Attitude of Health Personnel ,Knowledge Bases ,Decision Making ,Pilot Projects ,Middle Aged ,Social Networking ,Surveys and Questionnaires ,Emergency Medicine ,Urban Health Services ,Workforce ,Humans ,Female ,Clinical Competence ,Rural Health Services ,Diffusion of Innovation ,Aged - Abstract
Rural emergency departments (EDs) generally have limited access to continuing education and are typically staffed by clinicians without pediatric emergency specialty training. Emergency care of children is complex and the majority of children receive emergency care in non-pediatric tertiary care centers. In recent decades, there has been a call to action to improve quality and safety in the emergency care of children. Of the one million ED visits by children in Ontario in 2005-2006, one in three visited more than once in a year and one in 15 returned to the ED within 72 hours of the index visit. This study explored factors influencing rural and urban ED clinicians' participation in a Web-based knowledge exchange intervention that focused on best practice knowledge about pediatric emergency care. The following questions guided the study: (i) What are the individual, context of practice or knowledge factors which impact a clinician's decision to participate in a Web-based knowledge exchange intervention?; (ii) What are clinicians' perceptions of organizational expectations regarding knowledge and information sources to be used in practice?; and (iii) What are the preferred knowledge sources of rural and urban emergency clinicians?A Web-based knowledge exchange intervention, the Pediatric Emergency Care Web Based Knowledge Exchange Project, for rural and urban ED clinicians was developed. The website contained 12 pediatric emergency practice learning modules with linked asynchronous discussion forums. The topics for the modules were determined through a needs assessment and the module content was developed by known experts in the field. A follow-up survey was sent to a convenience sample of 187 clinicians from nine rural and two urban Canadian EDs participating in the pediatric emergency Web-based knowledge exchange intervention study.The survey response rate was 56% (105/187). Participation in the knowledge exchange intervention was related to individual involvement in research activities (χ(2)=5.23, p=0.019), consultation with colleagues from other EDs (χ(2)=6.37, p=0.01) and perception of organizational expectations to use research evidence to guide practice (χ(2)=5.52, p=0.015). Most clinicians (95/105 or 92%) reported relying on colleagues from their own ED as a primary knowledge source. Urban clinicians were more likely than their rural counterparts to perceive that use of research evidence to guide practice was an expectation. Rural clinicians were more likely to rely on physicians from their own ED as a preferred knowledge source.The decision made by emergency clinicians to participate in a Web-based knowledge exchange intervention was influenced by a number of individual and contextual factors. Differences in these factors and preferences for knowledge sources require further characterization to enhance engagement of rural ED clinicians in online knowledge exchange interventions.
- Published
- 2013
17. The Canadian Triage and Acuity Scale for children: a prospective multicenter evaluation
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Martin H. Osmond, Devendra Amre, Serge Gouin, Kathy Boutis, Douglas Sinclair, Gary Joubert, Jocelyn Gravel, Ran D. Goldman, Sarah Curtis, Kelly Millar, Chantal Guimont, and Eleanor Fitzpatrick
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Male ,medicine.medical_specialty ,Canada ,Adolescent ,Poison control ,Nurses ,Occupational safety and health ,Hospitals, University ,Health care ,Injury prevention ,medicine ,Humans ,Single-Blind Method ,Prospective Studies ,Child ,Observer Variation ,Trauma Severity Indices ,business.industry ,Construct validity ,Infant ,Reproducibility of Results ,Length of Stay ,Hospitals, Pediatric ,Triage ,Confidence interval ,Hospitalization ,Inter-rater reliability ,Child, Preschool ,Emergency medicine ,Multivariate Analysis ,Emergency Medicine ,Health Resources ,Regression Analysis ,Female ,business ,Emergency Service, Hospital - Abstract
Study objective The aims of the study are to measure both the interrater agreement of nurses using the Canadian Triage and Acuity Scale in children and the validity of the scale as measured by the correlation between triage level and proxy markers of severity. Methods This was a prospective multicenter study of the reliability and construct validity of the Canadian Triage and Acuity Scale in 9 tertiary care pediatric emergency departments (EDs) across Canada during 2009 to 2010. Participants were a sample of children initially triaged as Canadian Triage and Acuity Scale level 2 (emergency) to level 5 (nonurgent). Participants were recruited immediately after their initial triage to undergo a second triage assessment by the research nurse. Both triages were performed blinded to the other. The primary outcome measures were the interrater agreement between the 2 nurses and the association between triage level and hospitalization. Secondary outcome measures were the association between triage level and health resource use and length of stay in the ED. Results A total of 1,564 patients were approached and 1,464 consented. The overall interrater agreement was good, as demonstrated by a quadratic weighted κ score of 0.74 (95% confidence interval 0.71 to 0.76). Hospitalization proportions were 30%, 8.3%, 2.3%, and 2.2% for patients triaged at levels 2, 3, 4, and 5, respectively. There was also a strong association between triage levels and use of health care resources and length of stay. Conclusion The Canadian Triage and Acuity Scale demonstrates a good interrater agreement between nurses across multiple pediatric EDs and is a valid triage tool, as demonstrated by its good association with markers of severity.
- Published
- 2011
18. How do physicians assess their family physician colleagues' performance?: creating a rubric to inform assessment and feedback
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Mary Power, Douglas Sinclair, Tanya MacLeod, and Joan Sargeant
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Male ,medicine.medical_specialty ,Referral ,Interprofessional Relations ,Interpersonal communication ,Education ,Alberta ,Surveys and Questionnaires ,Medicine ,Humans ,Competence (human resources) ,Physician-Patient Relations ,business.industry ,Medical record ,Rubric ,Reproducibility of Results ,General Medicine ,Focus Groups ,Focus group ,Nova Scotia ,Family medicine ,Female ,Clinical Competence ,business ,Family Practice ,Psychosocial ,Knowledge of Results, Psychological ,Qualitative research - Abstract
Introduction The Colleges of Physicians and Surgeons of Alberta and Nova Scotia (CPSNS) use a standardized multisource feedback program, the Physician Achievement Review (PAR/NSPAR), to provide physicians with performance assessment data via questionnaires from medical colleagues, coworkers, and patients on 5 practice domains: consultation communication, patient interaction, professional self-management, clinical competence, and psychosocial management of patients. Physicians receive a confidential report; the intent is practice improvement. However, research indicates that feedback from medical colleagues appears to be less understood than that from coworkers or patients, due to a lack of specificity and concerns regarding feedback credibility. The purpose of this study was to determine how physicians make decisions about performance ratings for family physician (FP) colleagues in the 5 practice domains. Methods This was an exploratory qualitative study using focus groups—one with 11 family physicians and one with 12 specialists—who had served as NSPAR “medical colleague'' reviewers. We analyzed focus group transcripts using content analysis. Results Family and specialist physicians provided examples of behaviors indicative of both high- and low-scoring performance for items within the 5 practice domains. From these, an assessment rubric was created to inform both external reviewers and the physicians being reviewed of performance expectations. Reviewers reported using varied sources of information to make assessments, including shared patients, medical records, referral letters, feedback from others, and self-reference. Discussion The CPSNS has used the assessment rubric to create an online resource to inform medical colleague assessment and enhance the usefulness of their NSPAR scores. Further research will be required to determine its impact.
- Published
- 2011
19. Bridging the gap: knowledge seeking and sharing in a virtual community of emergency practice
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Andrea L. Murphy, Janet Curran, Syed Sibte Raza Abidi, Douglas Sinclair, and Patrick J. McGrath
- Subjects
Online discussion ,medicine.medical_specialty ,Medical education ,Emergency Medical Services ,Health Knowledge, Attitudes, Practice ,business.industry ,Health Policy ,Public health ,Education, Distance ,Community of practice ,Virtual community of practice ,Content analysis ,Family medicine ,Health care ,Emergency medical services ,Emergency Medicine ,Medicine ,Humans ,Education, Medical, Continuing ,Rural Health Services ,business ,Virtual community - Abstract
Disparities exist between rural and urban emergency departments with respect to knowledge resources such as online journals and clinical specialists. As knowledge is a critical element in the delivery of quality care, a web-based learning project was proposed to address the knowledge needs of emergency clinicians. One objective of this project was to evaluate the effectiveness of the online environment for knowledge exchange among rural and urban emergency clinicians. Descriptive and content analysis of the online discussion board revealed 202 postings with rural participants contributing the largest number of postings (75%; 152/202). Postings were used to establish a clinical presence (87/202), seek clinical information (52/202), and share clinical information (63/202). Postintervention survey results indicate that this modality introduced participants to new clinical experts and resources. The results provide direction for design of a virtual community of practice, which may reduce current knowledge resource disparities.
- Published
- 2009
20. A workshop to improve workflow efficiency in emergency medicine
- Author
-
Raghu, Venugopal, Eddy, Lang, Ken, Doyle, Douglas, Sinclair, Bernard, Unger, and Marc, Afilalo
- Subjects
Self-Assessment ,Attitude of Health Personnel ,Communication ,Internship and Residency ,Documentation ,Efficiency, Organizational ,Medical Records ,Resource Allocation ,Professional Competence ,Surveys and Questionnaires ,Emergency Medicine ,Medical Staff, Hospital ,Feasibility Studies ,Humans ,Education, Medical, Continuing ,Curriculum ,Physician's Role ,Qualitative Research ,Program Evaluation ,Total Quality Management - Abstract
The emergency department (ED) environment requires physicians to focus on workflow efficiency (WFE) and manage ED throughput. We sought to determine whether an interactive workshop could be designed and favourably perceived by emergency physicians and residents as a means to improve their self-assessed WFE skills.The authors designed a 4-station workshop to simulate key components of ED throughput. These included resource management in 1) acute care, 2) minor care, 3) charting and 4) communication skills and patient sign-overs. Anonymous surveys were completed after each workshop using 5-point Likert scales and qualitative responses. Qualitative data encompassed participants' past WFE training experiences and perspectives on the current workshop. Data were analyzed using descriptive statistics. The workshops were administered on 2 separate occasions to different groups of physicians. The first occasion was primarily for residents and the second session was only for practising physicians.A total of 22 residents and 24 practising physicians participated. Evaluations were completed by 45 of 46 participants. Ratings of "definitely helpful" or "helpful" as noted for each station were received by 37 of 44 respondents for the sign-over and communication station, by 37 of 44 for the minor care station, by 41 of 44 for the acute care station and by 33 of 43 for the effective charting station. Among all participants, 42 of 45 reported that they felt the overall workshop experience was "helpful" or "definitely helpful."ED management "flow skills" are valued yet undertaught. A flow workshop designed to improve self-perceived WFE skills yields positive evaluations. Teaching this competency in a workshop setting is both feasible and appreciated by participants. Similar efforts should be considered for inclusion in both graduate and continuing medical education curricula.
- Published
- 2008
21. Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation
- Author
-
Carlos A. Camargo, Douglas Sinclair, Chu-Lin Tsai, Rita Kay Cydulka, Sunday Clark, and Brian H. Rowe
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,COPD ,Canada ,RC705-779 ,Exacerbation ,business.industry ,MEDLINE ,Follow up studies ,Pulmonary disease ,Emergency department ,medicine.disease ,humanities ,United States ,Diseases of the respiratory system ,Patient Admission ,Multicenter study ,Medicine ,Humans ,Original Article ,Lung Diseases, Obstructive ,Prospective cohort study ,business ,Intensive care medicine ,Emergency Service, Hospital - Abstract
INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.OBJECTIVES: To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.METHODS: A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.RESULTS: Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; PCONCLUSIONS: Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.
- Published
- 2008
22. Challenges in multisource feedback: intended and unintended outcomes
- Author
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Douglas Sinclair, Cees P. M. van der Vleuten, Karen Mann, Joan Sargeant, and Job F. M. Metsemakers
- Subjects
Male ,Psychometrics ,Feedback, Psychological ,Applied psychology ,MEDLINE ,Physicians, Family ,Pilot Projects ,General Medicine ,Education ,Alberta ,Formative assessment ,Nova Scotia ,Current practice ,Surveys and Questionnaires ,Credibility ,Humans ,In patient ,Education, Medical, Continuing ,Female ,Clinical Competence ,Clinical competence ,Psychology ,Family Practice ,Social psychology ,Qualitative research - Abstract
Context Multisource feedback (MSF) is a type of formative assessment intended to guide learning and performance change. However, in earlier research, some doctors questioned its validity and did not use it for improvement, raising questions about its consequential validity (i.e. its ability to produce intended outcomes related to learning and change). The purpose of this qualitative study was to increase understanding of the consequential validity of MSF by exploring how doctors used their feedback and the conditions influencing this use. Methods We used interviews with open-ended questions. We purposefully recruited volunteer participants from 2 groups of family doctors who participated in a pilot assessment of MSF: those who received high (n = 25) and those who received average/lower (n = 44) scores. Results Respondents included 12 in the higher- and 16 in the average/lower-scoring groups. Fifteen interpreted their feedback as positive (i.e. confirming current practice) and did not make changes. Thirteen interpreted feedback as negative in 1 or more domains (i.e. not confirming their practice and indicating need for change). Seven reported making changes. The most common changes were in patient and team communication; the least common were in clinical competence. Positive influences upon change included receiving specific feedback consistent with other sources of feedback from credible reviewers who were able to observe the subjects. These reviewers were most frequently patients. Discussion Findings suggest circumstances that may contribute to low consequential validity of MSF for doctors. Implications for practice include enhancing procedural credibility by ensuring reviewers' ability to observe respective behaviours, enhancing feedback usefulness by increasing its specificity, and considering the use of more objective measures of clinical competence.
- Published
- 2007
23. Understanding the influence of emotions and reflection upon multi-source feedback acceptance and use
- Author
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Job F. M. Metsemakers, Karen Mann, Cees P. M. van der Vleuten, Douglas Sinclair, and Joan Sargeant
- Subjects
Male ,Educational measurement ,media_common.quotation_subject ,Emotions ,Psychological intervention ,Self-concept ,General Medicine ,Education ,Feedback ,Interviews as Topic ,Distress ,Nova Scotia ,Feeling ,Negative feedback ,Intervention (counseling) ,Physicians ,Surveys and Questionnaires ,Consciousness raising ,Humans ,Education, Medical, Continuing ,Female ,Educational Measurement ,Psychology ,Social psychology ,media_common - Abstract
Receiving negative performance feedback can elicit negative emotional reactions which can interfere with feedback acceptance and use. This study investigated emotional responses of family physicians’ participating in a multi-source feedback (MSF) program, sources of these emotions, and their influence upon feedback acceptance and use. The authors interviewed 28 volunteer family physician participants in a pilot study of MSF, purposefully recruited to represent the range of scores. The study was conducted in 2003–2004 at Dalhousie University. Participants’ emotional reactions to feedback appeared to be elicited in response to an internal comparison of their feedback with self-perceptions of performance. Those agreeing with their feedback; i.e., perceiving it as generally consistent with or higher than self-perceptions responded positively, while those disagreeing with their feedback; i.e., seeing it as generally inconsistent with or lower than self-perceptions, generally responded with distress. For the latter group, these feelings were often strong and long-lasting. Some eventually accepted their feedback and used it for change following a long period of reflection. Others did not and described an equally long reflective period but one which focused on and questioned MSF procedures rather than addressed feedback use. Participants suggested providing facilitated reflection on feedback to enhance assimilation of troubling emotions and interpretation and use of feedback. Negative feedback can evoke negative feelings and interfere with its acceptance. To overcome this, helpful interventions may include raising awareness of the influence of emotions, assisting recipients to focus their feedback on performance tasks, and providing facilitated reflection on feedback.
- Published
- 2006
24. Learning in practice: experiences and perceptions of high-scoring physicians
- Author
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Suzanne Ferrier, Douglas Sinclair, Philip D Muirhead, Job F. M. Metsemakers, Joan Sargeant, Karen Mann, and Cees P. M. van der Vleuten
- Subjects
Nova scotia ,Adult ,Male ,Faculty, Medical ,genetic structures ,media_common.quotation_subject ,education ,Pilot Projects ,Faculty medical ,Education ,Interviews as Topic ,Reading (process) ,Perception ,Humans ,Learning ,media_common ,Medical education ,Communication ,General Medicine ,Informal learning ,Middle Aged ,Nova Scotia ,Education, Medical, Continuing ,Female ,Clinical Competence ,Clinical competence ,Psychology ,Family Practice - Abstract
To increase understanding of informal learning in practice (e.g., consulting with colleagues, reading journals) through exploring the experiences and perceptions of physicians perceived to be performing well. Objectives were to find out how physicians learned in practice and maintained their competence, and how they learned about the communication skills domain specifically.Of 142 family physicians participating in a formal multisource feedback (360-degree) formative assessment, 25 receiving high scores were invited to participate in interviews conducted in 2003 at Dalhousie University Faculty of Medicine. Twelve responded. Interviews were 1.5 hours each, recorded, transcribed, and analyzed by the research team using accepted qualitative procedures.While formal learning appeared important to most, informal learning, especially through patients and colleagues, appeared to be fundamental. The physicians appeared to learn intentionally from practice and work experiences, and reflection appeared integral to learning and monitoring the impact of learning. Two findings were surprising: participants' conceptions of competence and perceptions that communication skills were innate rather than learned.These physicians' ways of intentional learning from practice concur with current models of informal learning. However, informal learning is largely unrecognized by formal institutions. Additionally, the physicians did not in general share notions of professional competence held by educators and others in authority. These findings suggest the need to make implicit content and learning processes more explicit. Additional research areas include exploring whether physicians across the range of performance levels demonstrate similar processes of reflective learning.
- Published
- 2006
25. Profiles in patient safety: medication errors in the emergency department
- Author
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Michael Marcoux, Marc J. Shapiro, Pat Croskerry, Sam G. Campbell, Douglas Sinclair, Patty Wren, and Connie LeBlanc
- Subjects
Adult ,Male ,medicine.medical_specialty ,Adolescent ,MEDLINE ,Pharmacist ,Drug Prescriptions ,Clinical Protocols ,Team communication ,medicine ,Humans ,Medication Errors ,In patient ,Aged ,Patient Care Team ,business.industry ,Communication ,Infant ,Physician-Nurse Relations ,General Medicine ,Emergency department ,Medication administration ,Continuity of Patient Care ,Middle Aged ,medicine.disease ,Surgery ,Emergency Medicine ,Female ,Medical emergency ,Clinical Competence ,Clinical competence ,Drug Overdose ,business ,Emergency Service, Hospital - Abstract
Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here.
- Published
- 2004
26. Responses of rural family physicians and their colleague and coworker raters to a multi-source feedback process: a pilot study
- Author
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Douglas Sinclair, Joan Sargeant, Donald B. Langille, Suzanne Ferrier, Karen Mann, Vonda M Hayes, and Philip D Muirhead
- Subjects
Adult ,Male ,Rural Population ,medicine.medical_specialty ,Canada ,Process (engineering) ,Feedback, Psychological ,MEDLINE ,Pilot Projects ,Education ,Surveys and Questionnaires ,medicine ,Humans ,Practice Patterns, Physicians' ,Medical education ,Physician-Patient Relations ,Practice patterns ,business.industry ,Physicians, Family ,General Medicine ,Middle Aged ,Family medicine ,Female ,Clinical Competence ,business ,Rural population - Abstract
To describe responses of family physicians, their medical colleagues, and coworker raters to a multisource feedback assessment process.Data collection tools included multisource feedback self-assessment and medical colleague, coworker, and patient rating forms; and program evaluation physician and rater questionnaires.The pilot study included 142 physicians and their raters, with 113 (80%) physicians completing evaluations. Positive correlations were found between familiarity scores and medical colleague and coworker mean ratings. Peer medical colleagues were significantly more familiar with physicians than were consultants. Consultants were unable to rate items most frequently. Physicians disagreed with colleague feedback more frequently. Agreement was positively correlated with scores.Familiarity, ability to observe physicians appropriately to rate them, and physicians' responses to feedback are factors to consider when multisource feedback is used.
- Published
- 2003
27. Home care and emergency medicine: a pilot project to discharge patients safely from the emergency department
- Author
-
Douglas Sinclair and Stacy Ackroyd-Stolarz
- Subjects
Program evaluation ,Adult ,Male ,medicine.medical_specialty ,Time Factors ,Patient satisfaction ,Acute care ,Medicine ,Humans ,Prospective Studies ,Prospective cohort study ,Early discharge ,Aged ,Patient discharge ,Aged, 80 and over ,business.industry ,General Medicine ,Emergency department ,Middle Aged ,medicine.disease ,Home Care Services ,Patient Discharge ,Nova Scotia ,Patient Satisfaction ,Emergency medicine ,Emergency Medicine ,Observational study ,Female ,Medical emergency ,business ,Emergency Service, Hospital ,Program Evaluation - Abstract
Objectives: To describe in detail the implementation of an acute care home care program (quick response program; QRP) for the emergency department (ED). Methods: A prospective observational study with key process and outcome indicators, including number of referrals, time to initiate service, type of home care provided, number of return patients to the ED, and outcome for all patients, defined at the beginning of the project. Patients are identified for the QRP and services are in place within four hours of patient discharge. Results: Of 177 eligible patients, 121 were entered into the program. Sixty-eight percent were more than 65 years old, and 54% lived alone. All patients met the time target of services in place within four hours of discharge from the ED. Patient satisfaction was high as measured by an independent survey instrument. Fifty percent of the patients required no further service after the QRP, but 20% were admitted to hospital within 30 days. Conclusions: A QRP can be successfully implemented in the ED to discharge patients home, most of whom would have been admitted to hospital.
- Published
- 2000
28. Emergency department observation unit: can it be funded through reduced inpatient admission?
- Author
-
Douglas Sinclair and Robert S. Green
- Subjects
Adult ,medicine.medical_specialty ,Adolescent ,Observation ,Tertiary care ,Unit (housing) ,Patient Admission ,Cost Savings ,medicine ,Humans ,Bed Conversion ,Prospective Studies ,Emergency physician ,Aged ,Monitoring, Physiologic ,Aged, 80 and over ,business.industry ,Patient Selection ,Health services research ,Emergency department ,Length of Stay ,Middle Aged ,medicine.disease ,Financial Management, Hospital ,Triage ,United States ,Emergency medicine ,Emergency Medicine ,Workforce ,Medical emergency ,Health Services Research ,business ,Emergency Service, Hospital ,Hospital Units ,Observation unit ,Inpatient procedure - Abstract
Study objective: We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures. Methods: We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit. Results: Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents—not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents. Conclusion: Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources. [Sinclair D, Green R: Emergency department observation unit: Can it be funded through reduced inpatient admission? Ann Emerg Med December 1998;32:670-675.]
- Published
- 1998
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