Emergency Medicine

In 2005, BC resuscitation researchers partnered with BC Emergency Health Services (BCEHS) to lead one of ten North American research centers under the Resuscitation Outcomes Consortium (ROC) that focused on out-of- hospital cardiac arrest and trauma. Through this collaboration, the BC Resuscitation Research Unit was created and led by Dr. Jim Christenson to identify and study consecutive out-of-hospital cardiac arrest cases in urban BC. Over the next decade, affiliated researchers performed numerous interventional clinical trials, observational analyses, and quality improvement initiatives. The BC Cardiac Arrest Registry was created in 2015 to capture data for out-of-hospital cardiac arrests responded to by BCEHS and Fire Department first responders in BC’s metropolitan regions. In 2016, the unit joined 3 other provinces to create the Canadian Resuscitation Outcomes Consortium (CanROC) national cardiac arrest registry. CanROC has grown to include most provinces as a national registry of sudden unexpected death, in partnership with the Heart and Stroke Foundation of Canada. It supports quality improvement and research, and BC continues to play a lead role. As a result of this active focus on the quality and outcomes of resuscitation, the likelihood of survival in BC from an out-of-hospital cardiac arrest significantly increased. In 2020, the unit spearheaded “CanSAVE”, a national research collaborative to transform the response to cardiac arrest beyond traditional emergency response models and improve survival through world class resuscitation research.

In 2021, the resuscitation research unit formally became the BC Resuscitation Research Collaborative (RESURECT). Under the shared leadership of Dr. Jim Christenson and Dr. Brian Grunau, BC RESURECT continues to work on strengthening BC’s contributions to resuscitation science.

Two of the most common cardiovascular emergencies are chest pain and arrhythmias (Irregular heart rhythms). Chest pain accounts for nearly one million ED visits annually in Canada, and quickly distinguishing serious heart problems, such as heart attacks, from the many patients who have non-serious diagnoses, without administering unnecessary tests or using excessive resources, can be very challenging. Research by Dr. Christenson and Dr. Frank Scheuermeyer has demonstrated that many patients who would previously have prolonged ED lengths-of-stay, or been admitted to hospital, or had extensive testing, can be quickly and safely discharged home, or have testing deferred to outpatient settings.

Atrial fibrillation and flutter are two common arrhythmias. Many patients have prolonged ED stays, or are admitted to hospital, or, in some cases, undergo treatments that worsen the illness. Dr. Scheuermeyer’s research has allowed emergency physicians to quickly identify high-risk patients while permitting the safe, rapid discharge of lower-risk patients. For both conditions, research goals are to improve the identification of high-risk patients, while decreasing patient anxiety and ED resource use.

Other areas of research in cardiovascular emergencies undertaken by the Program include:

• Using cardiac computed tomography (CT), a new technology, in diagnosing heart disease;
• Demonstrating stroke prevention as an important part of ED care;
• Identifying vulnerable patients with atrial fibrillation and flutter who may be unexpectedly critically ill and who may not benefit from traditional care; and
• Writing evidence-based guidelines for ED treatment of cardiovascular emergencies.

Stroke is a devastating illness and many patients struggle to regain their pre-stroke lives. Early recognition and treatment are some of the most important aspects of care. Dr. Christenson is the lead investigator in a multi-provincial randomized trial, funded by Brain Canada, investigating a new neuroprotective drug (Nerinetide) to reduce damage caused by stroke. The intervention is given by paramedics prior to hospital arrival, and patients are followed for neurologic outcomes over 90 days.

St. Paul’s Hospital serves a large number of patients with infections, sepsis, and septic shock. Dr. Rob Stenstrom has been leading the infections and sepsis research program at St. Paul’s for over 10 years. St. Paul’s has been an innovator in sepsis diagnosis and treatment in the ED and was awarded the Canadian College of Health Care3M Canadian Health Team Award for the development and implementation of the Providence Health Care Emergency Department Sepsis Protocol. Dr. Stenstrom has been involved with the development of the Canadian Association of Emergency Physicians (CAEP) guidelines for ED sepsis management with three iterations over the past decade and recently published a multi-center trial optimizing the utility of blood cultures.

Current studies include:

• Characterizing the role of biomarkers for identifying patients at risk for bacteremia;
• A multi-center randomized controlled trial of the use of point-of-care C-reactive protein to decrease the use of blood cultures in patients with sepsis (Link); and
• A multicenter Canadian initiative investigating improvement in sepsis care (Link)

Every ED serves patients with acute and chronic mental health concerns; at SPH many patients also struggle with social determinants of health including access to housing, food, and water. Dr. David Barbic leads research in mental health.

Current projects include:

• Rapid Agitation Control with Ketamine in the Emergency Department (RACKED) Study (Link);
• Collaborating with CHÉOS Scientists Drs. Skye Barbic and Steve Mathias in enhancing access to youth with mental health concerns via the provincial network of Foundry centers;
• Decreasing the stigma faced by patients with mental health concerns; and
• Dr. Rob Stenstrom has partnered with specialists at BC Children’s hospital to optimize recognition, care, and outcomes for pediatric patients with mental health concerns (Link)

Dr. Andrew Kestler enhances care and improves outcomes for patients with opioid use disorder. Building on SPH’s expertise in harm reduction, the CHÉOS Emergency Medicine Program, in collaboration with addictions specialists, the City of Vancouver, and provincial public health officials, implements and studies novel approaches to deliver care to vulnerable populations. The aim of the Program is not only to improve patient care but also to contribute evidence that will help patients beyond SPH. He is currently focused on:

• Examining ED physician attitudes on initiating buprenorphine/naloxone for patients with opioid use disorder;
• Characterizing the general public’s attitudes on responding to overdoses in the community; and
• Evaluating a novel program combining the low-barrier distribution of buprenorphine/naloxone

Alcohol use disorder is a severe public health problem and many patients attend EDs with alcohol-related complaints. Dr. Scheuermeyer is investigating optimal ED care, as well as the scope of this issue.

Patient safety is a complex and multifaceted problem, and patient harm remains a pervasive global healthcare issue. The ED can be a crowded and often high-hazard unit. A mismatch between demand and capacity contributes to adverse patient outcomes, including unnecessary hospital admission, injury, or death. Dr. Garth Hunte advances work to implement a proactive and productive safety strategy in urban emergency care.

Current work includes:

• Development of proactive system responses guided by operational thresholds;
• Calibration of a predictive analytics forecasting model for capacity and demand; and
• Prospective evaluation of the National Early Warning Score at triage

Previous work included an ethnographic analysis of how emergency care providers create safety for patients in everyday practice, implementation of a framework based on resilience engineering principles in the context of emergency care, and retrospective evaluation of the effect of structured clinical assessment to risk-stratify patients with a higher likelihood of admission.