Louis Hugo Francescutti

Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction.

EXECUTIVE SUMMARY Emergency departments in most developed countries have been experiencing significant overcrowding under a regime of severe resource constraints. Physicians in emergency departments increasingly find themselves toiling in workplaces that are characterized by diminished availability of, limited access to, and decreased stability of critical resources. Severe resource constraints have the potential to greatly weaken the overall job satisfaction of emergency physicians. This article examines the impact of hospital resource constraints on the job satisfaction of a large sample of emergency physicians in Canada. After controlling for workflow and patient characteristics and for various institutional and physician characteristics, institutional resource constraints are found to be major contributors to emergency physician job dissatisfaction. Resource factors that have the greatest impact on job satisfaction include availability of emergency room physicians, access to hospital technology and emergency beds, and stability of financial (investment) resources.

Health promotion and disease prevention in the emergency department: a feasibility study.

BACKGROUND Health promotion and disease prevention have been increasingly recognized as activities that may be within the scope of emergency medicine. The purpose of this feasibility study was to identify health risks and offer immediate interventions to adult patients who have drug and/or alcohol problems, incomplete immunization, are overdue for a Pap (Papanicolaou) smear, and/or are smokers. METHODS The study took place in a busy tertiary Emergency Department (ED) serving an inner-city population with a significant proportion of patients who are homeless, substance abusers, working poor, and/or recent immigrants. A convenience sample of patients completed a computer-based health-risk survey. Trained health promotion nurses offered appropriate interventions to patients following review and discussion of their self-reported data. Interventions included counseling for problem drinking, substance abuse, and smoking cessation, screening for cervical cancer, and immunization. RESULTS From October 20, 2000 to June 30, 2003, we enrolled 2366 patients. One thousand and eleven subjects (43%) reported substance abuse and 1095 (46%) were smokers. Of the 158 smokers contacted in follow-up, 19 (12%) had quit, 63 (40%) had reduced the number of cigarettes/day and 76 (48%) reported no change. Of 1248 women surveyed, 307 (25%) were overdue for a Pap smear and 54 (18%) received this intervention. Forty-four percent of subjects were overdue for at least one immunization and of those, 414 (40%) were immunized in the ED. CONCLUSION At-risk patients can be identified using a computer-based screening tool, and appropriate interventions can be given to a proportion of these patients in a busy inner city ED without increasing wait time.

Development and evaluation of evidence-informed quality indicators for adult injury care.

Objective:To develop and evaluate evidence-informed quality indicators of adult injury care. Background:Injury is a leading cause of morbidity and mortality, but there is a lack of consensus regarding how to evaluate injury care. Methods:Using a modification of the RAND/UCLA Appropriateness Methodology, a panel of 19 injury and quality of care experts serially rated and revised quality indicators identified from a systematic review of the literature and international audit of trauma center quality improvement practices. The quality indicators developed by the panel were sent to 133 verified trauma centers in the United States, Canada, Australia, and New Zealand for evaluation. Results:A total of 84 quality indicators were rated and revised by the expert panel over 4 rounds of review producing 31 quality indicators of structure (n = 5), process (n = 21), and outcome (n = 5), designed to assess the safety (n = 8), effectiveness (n = 17), efficiency (n = 6), timeliness (n = 16), equity (n = 2), and patient-centeredness (n = 1) of injury care spanning prehospital (n = 8), hospital (n = 19), and posthospital (n = 2) care and secondary injury prevention (n = 1). A total of 101 trauma centers (76% response rate) rated the indicators (1 = strong disagreement, 9 = strong agreement) as targeting important health improvements (median score 9, interquartile range [IQR] 8–9), easy to interpret (median score 8, IQR 8–9), easy to implement (median score 8, IQR 7–8), and globally good indicators (median score 8, IQR 8–9). Conclusions:Thirty-one evidence-informed quality indicators of adult injury care were developed, shown to have content validity, and can be used as performance measures to guide injury care quality improvement practices.

Heavy physician workloads: impact on physician attitudes and outcomes:

The intensity of physician workload has been increasing with the well-documented changes in the financing, organization and delivery of care. It is possible that these stressors have reached a point where they pose a serious policy issue for the entire healthcare system through their diminution of physicians ability to effectively interact with patients as they are burned out, stressed and dissatisfied. This policy question is framed in a conceptual model linking workloads with five key outcomes (patient care quality, individual performance, absenteeism, turnover and organizational performance) mediated by physician stress and satisfaction. This model showed a good fit to the data in a structural equation analysis. Ten of the 12 hypothesized pathways between variables were significant and supported the mediating role of stress and satisfaction. These results suggest that workloads, stress and satisfaction have significant and material impacts on patient care quality, individual performance, absenteeism, turnover and organizational performance. Implications of these results and directions for future research are discussed.

Impact of culture on commitment, satisfaction, and extra‐role behaviors among Canadian ER physicians

PURPOSE The purpose of this paper is to explore the impact of hospital emergency department culture on the job satisfaction, patient commitment, and extra-role performance of Canadian emergency physicians. The conceptual model related four cultural archetypes from the competing valued model to the three outcome variables. DESIGN/METHODOLOGY/APPROACH In total, 428 Canadian emergency physicians responded to a national survey. The conceptual model was tested via structural equation modeling via LISREL 8. FINDINGS Culture had a relatively weak impact on the outcomes. Human resources culture related positively to job satisfaction while bureaucratic culture related positively to patient commitment. Patient commitment, but not job satisfaction strongly and positively related to extra-role behavior. A direct relationship between entrepreneurial culture and extra-role behavior emerged from an extended analysis. PRACTICAL IMPLICATIONS Organizational culture seems to have more distal relationships with outcome variables and its influence is likely to be mediated by more proximal workplace variables. ORIGINALITY/VALUE Of value by showing that a key modern leadership challenge is to create the kind of work culture that can become a source of competitive advantage through generating particular organizational outcomes valued by stakeholders.

CAEP position statement on cellphone use while driving

Distracted driving caused by cellphone use is a significant source of needless injuries. These injuries place unnecessary financial burden, emotional stress and health care resource misuse on society. This paper states the Canadian Association of Emergency Physicians (CAEPs) position on cellphone use while driving. In recent years, numerous studies were conducted on the danger of cellphone use while driving. Research has shown that cellphone use while driving negatively impacts cognitive functions, visual fields, reaction time and overall driving performances. Some studies found that cellphone use is as dangerous as driving under the influence of alcohol. Moreover, vehicle crash rates were shown to be significantly higher when drivers used cellphones. Countermeasures have been implemented in recent years. Over 50 countries worldwide have laws limiting the use of cellphones while driving. Six Canadian provinces, Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, British Columbia and Saskatchewan, currently have legislation prohibiting cellphone use. Other provinces are considering implementing similar bans. As emergency physicians, we must advocate for injury prevention. Cell phone related road traumas are avoidable. CAEP supports all measures to ban cellphone use while driving.

Health promoting attitudes and behaviors of emergency physicians: exploring gender differences.

PURPOSE The purpose of this paper is to report on gender differences in emergency physicians with respect to their attitudes, knowledge, and practices concerning health promotion and disease prevention. DESIGN/METHODOLOGY/APPROACH A mail survey of 325 male and 97 female Canadian emergency physicians. FINDINGS Results suggest female emergency physicians report having greater knowledge of health promotion topics, spend more time with each of their patients in the emergency setting, and engage in more health promotion counseling in the emergency setting than do their male counterparts. ORIGINALITY/VALUE The paper argues that in the future, educating and socializing emergency physicians, both male and female, in the practice of health promotion will enhance the potential of the emergency department to be a more effective resource for their community.

Development and Application of a Framework for Analyzing the Impacts of Urban Transportation

To adequately analyze the impacts associated with the rising use of automobiles, an assessment framework is needed that includes environment, health, economic, and sociocultural impacts. Such a framework was developed and applied to a proposed freeway-widening project in Edmonton, Canada. The assessment framework was developed using both Multi-Criteria Analysis and the Ecosystem Approach to Human Health (Ecohealth). Community participation was vital in the application of the assessment framework to this case study. Six stakeholder groups, including community members, City Councillors, and health, environment, and transportation experts, provided needed qualitative data for the assessment framework. Quantitative data were gathered from an ecological study design that associated traffic volumes with respiratory conditions in Edmonton. Community members’ perceptions about the impacts of the freeway widening differed from those of the expert groups in a number of areas. Environmental and health degradation was more of an issue to community members than to expert groups. Though respiratory conditions were not projected to increase by a significant amount because of the freeway widening, further analysis is necessary on other biophysical and socioeconomic impacts listed in the assessment framework. The divergence in opinion between community members and experts suggests that more communication is needed between these groups in relation to transportation planning. The Ecohealth approach ensures that community concerns are addressed in transportation planning.

Alcohol, Health, and Injuries

Although alcohol has existed almost as long as human existence, its consumption and abuse can have many detrimental effects. Alcohol has been associated with a wide variety of injuries, both intentional and unintentional, and can lead to physical, verbal, and sexual violence as well as family dysfunction. The role of alcohol advertising and media plays a role in alcohol’s contribution to society, and youth may be more heavily influenced than adults. Moreover, alcohol has psychological, social, and physical consequences in addition to a direct impact on health. A number of methods may be advantageous for lifestyle medicine practitioners targeting this issue, including prevention strategies for alcohol misuse, increased legal reinforcement, screening and brief intervention, public campaigns, and media advocacy.

Time for Lifestyle Medicine to Take Injury Prevention Seriously

Over 2 decades ago, the United States National Academy of Sciences described injuries as “the most under-recognized major public health problem facing the nation.” Our progress since then has been limited. Injuries still account for nearly 1 out of every 10 deaths in the world, and the global burden of injury is projected to increase over the next decade, predominately in low- and middle-income countries. Despite this, injury prevention receives scant attention from legislators, the education system, and, most strikingly, the health care system. The lifestyle medicine community, however, is beginning to focus on injury prevention and will play an increasing role in helping control the burden of injury. Lifestyle medicine practitioners are in a tremendous position to promote injury prevention. Physical activity and positive lifestyle changes can be accompanied with an increased focus on preventing injury. Lifestyle medicine can prevent injuries by supporting legislation, advancing medical advocacy, providing community education, and linking clinical care with injury prevention.