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Implementation of the tool
Sir Mortimer B. Davis – Jewish General Hospital, Hôtel Dieu de Lévis, and Hôpital Charles
LeMoyne were ED research sites that had expressed a firm commitment to this project. These
sites were approached because of their interest, their informatic infrastructure and their
geographical location. However, despite the interest in participation from the major stakeholders
(emergency physicians, primary care givers and directors of EDs), the information technology
department of Charles LeMoyne and Hôtel Dieu de Lévis could not assure the manpower nor to
support the SCS application. The decision to cease collaboration with the 2 centres necessitated
a review of the study methodology.
Study design
The following elements influenced the choice in study design. First, a randomized, controlled
though unblinded study design was necessary to best appreciate the effects of the SCS
intervention. Secondly, family physicians rather than patients were chosen as the unit of
randomization to create two similar cohorts. This decision was mandated by the importance of
preventing contamination within a PCPs practice at any one time. Thirdly, to counter the effect
of any cluster phenomena, it was necessary for all physicians participating in this study to
experience the SCS. Therefore, a triple cross-over design was employed. The advantage of this
design also allowed for adjustment of any lag effect that might occur as a result of the learning
phase encountered through the cross-over between the control and intervention arms. The triple
cross-over allowed for each physician to be exposed to 2 intervention periods and 2 control
periods. Finally, to ensure balance in PCP practices, stratified randomization was used to ensure
that PCP were allocated to each cohort according to the age and size of their clientele presenting
to the ED.
Period I
Period II
Period III Period IV
2001/06/15 2001/08/25 2001/11/03 2002/01/18
to 2001/08/24 to 2001/11/02 to 2002/01/17 to 2002/03/22
Cohort #1 n=11 Intervention Control Intervention Control
Cohort #2 n=12 Control Intervention Control Intervention
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