Building patient safety culture by using interprofessional simulation with nursing, paramedic and emergency telecommunication students: A mixed-methods research study

AIM

The aim of this study was to investigate student attitudes toward interprofessional education and collaborative practice and their perceptions of simulation design elements after participating in an interprofessional simulation educational activity.

BACKGROUND

Patient safety continues to be an international healthcare priority. However, critical incidents to patients continue to persist due to poor communication between professionals and poor teamwork.

DESIGN

A mixed methods design.

METHOD

The study sample consisted of Bachelor of Nursing (n=81), Paramedic (n=38) and Emergency Telecommunication (n=11) students randomized into interprofessional groups. Following the interprofessional learning experience, students completed two standardized self-reporting instruments, Students Perceptions of Interprofessional Clinical Education, National League for Nursing Simulation Design Scale and open-ended questions of their perceptions on teamwork and collaboration, communication skills, transfer of care and patient safety.

RESULTS

Students in each program reported high scores for attitudes toward the importance of teamwork and collaborative practice. There were significant differences in scores between programs for the ranking factors 'Teamwork and Team-Based Practice' (BN=4.74 SD 0.72, PM=4.66 SD 0.81, ET=4.95 SD 0.15 *; p = 0.00005) and 'Roles & Responsibilities' (BN=3.78 SD 1.12, PM=3.55 SD 0.92, ET=4.67 SD 0.85*; p= 0.012). Themes included: communication and collaboration in teamwork; roles, responsibilities and leadership; patient-centred care and safety; and emotional dynamics and professional growth.

CONCLUSION

An interprofessional simulation is an effective strategy to practice teamwork and collaboration and communication skills during transfer of care. Ensuring earlier education of roles and responsibilities during transfer of care needs review as do strategies for structured handover communication tools.

Clinical effect on major trauma patients during simultaneous or overlapping presentations at an urban level I trauma center in Korea

OBJECTIVE

Overcrowding in an emergency department (ED) or intensive care unit (ICU) of the trauma center (TC) is an important issue for timely acute health care of a critically injured patient. Accumulated scientific evidence has indicated the negative influence of overcrowding to the process and clinical outcome of trauma care.

METHOD

The institutional trauma registry at an urban level I TC was retrospectively evaluated for 5 years (2018-2022). Major trauma was defined as an injury severity score (ISS) of >15. We determined simultaneous or overlapping presentations of major trauma (SOMT) in two or more patients with ISS of >15 who presented within a 4-h time window. When only two patients were included within a single time window, they were classified as SOMT-2, whereas when three or more patient clusters were identified in a single time window, they were classified as SOMT-3. The outcome measurement included process and clinical variables, such as trauma team activation (TTA) ratio, ED length of stay (LOS), time to blood product transfusion (TF), time to emergency surgery or intervention (ESI), ICU LOS, and mortality.

RESULT

A total of 2,815 patients were included, of which 39.6% (N = 1,116) classified as SOMT. The SOMT group had lower TTA ratio than the non-SOMT group (69.4% vs. 73.4%, P = 0.022). The TTA ratio exhibited a decreasing trend in non-SOMT, SOMT-2, and SOMT-3 groups (P = 0.006). The time to TF was significantly delayed in the SOMT group (129 vs. 91 min, P < 0.001).

CONCLUSION

SOMT regularly occurs and results in fewer trauma team activation and a delayed time to blood transfusion. The current intensive trauma care system should be strategically modified to improve critical trauma care and enhance disaster preparedness.

Time to Make Early Pregnancy Care a Priority in Canada

Early pregnancy is a critical period often accompanied by complications like early pregnancy loss. Early Pregnancy Assessment Clinics (EPACs) provide specialized and compassionate care to those experiencing these complications. First introduced in the United Kingdom, EPACs have been found to improve quality of care, reduce wait times, and cut costs. In Canada, EPACs are primarily limited to large urban centres at hospital sites. Access in other parts of the country, especially in rural areas, remains limited. Low-volume units managed by specialist nurses and family doctors, with support from specialists, are the best way to bring EPACs to more Canadians in need.

Peri-operative strategy in resuscitation of unstable injured surgical patients: a primer

BACKGROUND

Trauma remains a leading cause of death, both for individuals under 40 in North America, and globally, where it contributes to ~10% of deaths annually. Thoughtful, timely, balanced resuscitation, especially in the peri-operative period for unstable injured surgical patients, is vital for optimizing outcomes. The advanced trauma life support protocol plays a pivotal role in early evaluation and management, emphasizing hemorrhage control and resuscitation strategies.

OBJECTIVE

This narrative review provides a structured, evidence-based framework aimed at enhancing the educational experience of surgical trainees. It outlines key principles in peri-operative trauma resuscitation, emphasizing timely intervention, goal-directed fluid therapy, and damage control surgery (DCS) to improve patient outcomes.

METHODS

A comprehensive Scale for Quality Assessment of Narrative Review Articles -guideline compliant literature search was conducted using PubMed and Google Scholar for English-language articles published between January 2000 and February 2024. The search included relevant medical subject headings terms. Additional studies were identified from reference lists. Extracted data were reviewed and organized using thematic analysis, focusing on historical perspectives, evidence-based practices, and the concept of DCS.

RESULTS

Key findings from the 55 relevant studies selected underscore the importance of balanced fluid and blood product administration, the use of permissive hypotension in hemorrhagic shock, and the application of DCS principles. This review highlights educational strategies that foster a deeper understanding of trauma resuscitation practices, offering practical insights through case studies and technological innovations.

CONCLUSION

This review serves as an educational resource for surgical trainees, equipping them with a robust understanding of evidence-based trauma resuscitation. By integrating historical context, modern practices, and emerging technologies, the review aims to enhance both the theoretical knowledge and practical skills necessary for managing unstable trauma patients. Emphasis is placed on interdisciplinary teamwork, continuous education, and personalized resuscitation strategies to improve clinical outcomes.

Clinical Significance of Perinephric Fluid Collection in Patients with Renal Colic and Urolithiasis: A Retrospective Analysis

Background: Perinephric fluid is commonly identified in patients with renal colic and urolithiasis, especially in cases associated with hydronephrosis. However, its clinical relevance, particularly its impact on treatment decisions and prognosis, is not well established. Methods: This retrospective, single-center study included adult patients who presented to the emergency department (ED) with suspected renal colic between January 2021 and October 2023. Patients underwent ultrasound evaluations, which were analyzed for perinephric fluid, hydronephrosis, stone size, and stone location. Data on patient demographics, laboratory results, and clinical outcomes, including the need for urological interventions, were also collected and analyzed. Multivariate logistic regression was used to assess factors associated with perinephric fluid presence. Results: Of the 509 patients included, 200 (39.3%) had perinephric fluid. Hydronephrosis was significantly associated with perinephric fluid (OR: 4.14, p = 0.007), as were stones located in the proximal (OR: 3.06, p = 0.003) and distal ureter (OR: 2.31, p = 0.018). However, sonographic perinephric fluid did not significantly affect the likelihood of urological intervention, in-hospital complications, sepsis, acute kidney injury (AKI), acute kidney disease (AKD), and prolonged hospital stay. Conclusions: Perinephric fluid is a common finding in patients with renal colic and urolithiasis, particularly in cases involving hydronephrosis and ureteral stones. However, despite its prevalence, sonographic perinephric fluid was not significantly associated with the need for urological intervention, longer hospital stays, or worse clinical outcomes. Further prospective studies are required to clarify its clinical implications fully.

Development of a Rapid Detection Method for Ethylene Glycol and Glycolic Acid in Feline Samples: A Response to Increasing Antifreeze Poisoning Incidents in Korea

Recently, cases of antifreeze poisoning in companion animals, particularly cats, have surged in the Republic of Korea. Ethylene glycol (EG), the toxic primary component of antifreeze, is metabolized into glycolic acid (GA), leading to severe metabolic acidosis, acute kidney injury, and death. Traditional detection methods, although effective, are often time-consuming owing to complex sample preparation. This study involved a novel analytical method utilizing GC-MS for EG and LC-MS/MS for GA detection, which streamlined the detection process by eliminating the need for derivatization. The method was validated for accuracy and reliability, enabling the rapid and precise identification of EG and GA in biological samples. This study also included the successful application of this method in a case where initial exposure to antifreeze was not apparent, which highlighted the effectiveness of this method in diagnosing poisoning even in cases where clinical history is unclear. The development of this rapid diagnostic approach addresses the urgent need for the efficient detection of antifreeze poisoning, improving animal welfare and supporting forensic investigations.

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in a multidisciplinary approach for management of traumatic haemorrhagic shock: 10-year retrospective experience from a French level 1 trauma centre

BACKGROUND

The present study investigated an institutional multidisciplinary strategy for managing traumatic haemorrhagic shock by integrating the placement of REBOA (resuscitative endovascular balloon occlusion of the aorta) by anaesthesiologist-intensivists.

METHODS

All severe trauma patients who received percutaneous REBOA placement between January 2013 and December 2022 in our level 1 trauma centre were retrospectively analysed. The data collected included the clinical context, indications and location of REBOA, durations of aortic occlusion (AO), choice of haemostatic procedures and surgical teams, and specific complications.

RESULTS

In total, 38 trauma patients were included in the present study (mean age = 41 years [standard deviation = 21 years], 31 [82 %] were male, and median injury severity score was 62.5 [inter-quartile range (IQR) = 45-75]). REBOA was always placed by anaesthesiologist-intensivists, who comprised 68 % of the senior physicians (13/19) in our trauma team over the period. Twenty-eight AOs (74 %) were performed in zone 1 and 10 (26 %) in zone 3. Twelve patients (32 %) received REBOA upon circulatory arrest. Routes following REBOA placement comprised: computed tomography scan = 47 %, operating room = 34 %, angiography = 3 %, emergency room thoracotomy = 5 %, and prematurely died = 11 %. Duration of AO was 38 min (IQR = 32-44 min) in zone 1 and 78 min (IQR = 48-112 min) in zone 3. Mortality rate was 66 % (95 % CI 51-81 %) and higher in cases of AO in zone 1 (79 % versus 30 %, p = 0.018) or concomitant with circulatory arrest (92 % versus 54 %, p = 0.047). No ischemic limb needed an intervention and three endothelial injuries required delayed endovascular stenting.

CONCLUSIONS

Percutaneous REBOA placement by anaesthesiologist-intensivists included in the multidisciplinary management of traumatic haemorrhagic shock was associated with acceptable time of AO and local complications similar to those observed in other series.

Older hospitalised patients with a chief complaint of weakness and nonspecific presentations are not at risk of adverse health outcomes

RATIONALE AND OBJECTIVE

Older adults in the Emergency Department (ED) often present with nonspecific complaints (NSC) that might be associated with adverse health outcomes due to underestimating the seriousness of the illness by health care workers.

METHODS

We selected a random sample of patients aged 65 or older who complained of weakness and were hospitalised in internal medicine departments in 2019-2021. We divided the patients into those with and without specific reasons for hospitalisation after the ED evaluation. Outcome variables included changes in medical care based on CT head scans and blood tests, and whether a delay in diagnosis led to a longer stay, in-hospital mortality, or readmission within 30 days.

RESULTS

Patients were aged 82 ± 8 years and 43.6% (233/536)were female. 46.8% (260/556) of the patients had a specific reason for hospitalisation after the ED evaluation including four patients presenting with confusion, without neurological findings but with acute ischaemia found on the brain CT. Patients without a specific presentation had fewer blood tests done due to a significantly shorter hospital stay (median (1st-3rd quartiles: 3 (2-4) vs. 4 (3-6) days, p < 0.001), a lower mortality rate, 0.3% (n = 1) compared to 4.2% (n = 11), p = 0.002), and fewer readmissions 13.5%(n = 40) compared to 20.4% (n = 53). The deaths and readmissions in both groups were not due to a delay in diagnosis.

CONCLUSIONS

Elderly patients with a chief complaint of weakness with and without a specific reason for hospitalisation were not at an increased risk for inappropriate treatment or a missed diagnosis.

Clinical prediction models for the management of blunt chest trauma in the emergency department: a systematic review

BACKGROUND

The aim of this systematic review was to investigate how clinical prediction models compare in terms of their methodological development, validation, and predictive capabilities, for patients with blunt chest trauma presenting to the Emergency Department.

METHODS

A systematic review was conducted across databases from 1st Jan 2000 until 1st April 2024. Studies were categorised into three types of multivariable prediction research and data extracted regarding methodological issues and the predictive capabilities of each model. Risk of bias and applicability were assessed.

RESULTS

41 studies were included that discussed 22 different models. The most commonly observed study design was a single-centre, retrospective, chart review. The most widely externally validated clinical prediction models with moderate to good discrimination were the Thoracic Trauma Severity Score and the STUMBL Score.

DISCUSSION

This review demonstrates that the predictive ability of some of the existing clinical prediction models is acceptable, but high risk of bias and lack of subsequent external validation limits the extensive application of the models. The Thoracic Trauma Severity Score and STUMBL Score demonstrate better predictive accuracy in both development and external validation studies than the other models, but require recalibration and / or update and evaluation of their clinical and cost effectiveness.

REVIEW REGISTRATION

PROSPERO database ( https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=351638 ).

'Where is the diversity in this facility?' Experiences of emergency care among visible minority individuals in Kingston, Ontario

INTRODUCTION

Visible minorities, a growing segment of Canada's population, have voiced concerns about experiencing racism while receiving care in the emergency department (ED). Understanding the ED care experiences of visible minorities is crucial to improving care and reducing health disparities.

METHODS

From June to August 2021, we collected data from participants in Kingston, Ontario using a sensemaking approach. Individuals who had accessed emergency care or accompanied someone else to the ED in the prior 24 months were eligible to participate. After sharing a brief narrative about their care experience, participants interpreted the experience by plotting their perspectives on a variety of pre-determined questions. Here, we conducted a thematic analysis of narratives involving patients who identified as visible minorities and complemented it with quantitative analysis of the participants' interpretative responses. This mixed-methods approach highlighted the distinct experiences of visible minority participants in relation to a comparison group.

RESULTS

Of the 1973 unique participants, 117 identified as a visible minority and 949 participants did not identify with an equity-deserving group (comparison group). Visible minority participants were more likely to report that too little attention was paid to their identity and more likely to express a desire for a balance between receiving the best medical care and being treated with kindness and respect. Visible minorities' ED experiences were also more likely to be impacted by how emergency staff behaved. Qualitative analysis revealed negative experiences of feeling uninformed and disempowered, facing judgement and discrimination, and experiencing language barriers. Positive experiences of receiving compassionate care from staff also emerged.

CONCLUSION

Visible minority perceptions of ED care were often negative and mainly focused on staff treatment. Cultural competency and language translation services are key areas for improvement to make ED care more accessible and equitable.

Decision Support Tool to Improve Decision-Making for HIV Pre-Exposure Prophylaxis (PrEP): Development Process and Alpha Testing

BACKGROUND

African, Caribbean, and Black (Black) communities in Canada are disproportionately affected by the HIV epidemic. Pre-exposure prophylaxis (PrEP) is a highly effective option for the prevention of HIV. However, the use of PrEP for HIV prevention among eligible Black clients in Canada remains far below the thresholds necessary to achieve the goal of zero new HIV infections. In a recent study in Toronto, PrEP-eligible Black clients were found to have decisional conflict and unmet decisional needs, which affected the quality of their decision-making process regarding the initiation and adherence to PrEP. There is evidence that decision support tools (DSTs) can improve the quality of a decision, the quality of the decision-making process, the implementation or continuation of the chosen option, and the appropriate use of health services. Despite these benefits, there is currently no DST for PrEP-eligible Black clients being asked to consider PrEP for HIV prevention.

OBJECTIVE

Our study aimed to develop a DST to improve PrEP decision-making for Black clients and to evaluate the tool's acceptability and usability.

METHODS

We developed and evaluated the PrEP DST for Black patients using the 7-step process outlined in the Ottawa Decision Support Group Guideline for the development and evaluation of DST. To facilitate the implementation of the Ottawa Decision Support Group guideline, we assembled a multidisciplinary team of primary health care providers, researchers, community members with lived experiences, and digital content designers to serve as the steering committee. First, we assessed patients' and primary health care providers' views on decisional support needs, after which we determined the content, design, and distribution plan for the DST. Subsequently, we conducted evidence synthesis, reviews, and appraisal before developing the PrEP DST prototype. The final tool was reviewed by steering committee members for completeness before acceptability and usability testing with potential Black clients and PrEP providers.

RESULTS

The web-based DST yielded 27 pages divided into 6 distinct sections. The six sections include (1) an introduction of the DST, (2) clarify your decision, (3) knowledge, (4) a value clarification exercise, (5) support system, and (6) next steps. Both Black clients and PrEP providers reported ease of task performance, general satisfaction, and usefulness of the tool to support decision-making for Black clients. Feedback on usability centered on the need to add a user guide to increase usability. All feedback was incorporated into the final tool.

CONCLUSIONS

A PrEP DST for Black clients developed using a systematic process and a multidisciplinary steering committee was acceptable and usable by both Black clients and PrEP providers. Further study (eg, randomized controlled trials) may be needed to evaluate the efficacy of the PrEP DST.

The efficacy of socially assistive robots in improving children's pain and negative affectivity during needle-based invasive treatment: A systematic review and meta-analysis

BACKGROUND

The ability of socially assistive robots (SARs) to treat dementia and Alzheimer's disease has been verified. Currently, to increase the range of their application, there is an increasing amount of interest in using SARs to relieve pain and negative emotions among children in routine medical settings. However, there is little consensus regarding the use of these robots.

OBJECTIVE

This study aimed to evaluate the effect of SARs on pain and negative affectivity among children undergoing invasive needle-based procedures.

DESIGN

This study was a systematic review and meta-analysis of randomized controlled trials that was conducted in accordance with the Cochrane Handbook guidelines.

METHODS

The PubMed, CINAHL, Web of Science, Cochrane Library, Embase, CNKI, and WanFang databases were searched from inception to January 2024 to identify relevant randomized controlled trials (RCTs). We used the Cochrane Risk of Bias tool 2.0 (RoB2.0) to assess the risk of bias among the included studies, and we used RevMan 5.4 software to conduct the meta-analysis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to assess the quality of the evidence.

RESULTS

Ten RCTs involving 815 pediatric subjects were selected for this review and reported outcomes related to pain and emotions during IV placement, port needle insertion, flu vaccination, blood sampling, and dental treatment. Children undergoing needle-related procedures with SARs reported less anxiety (SMD= -0.36; 95% CI= -0.64, -0.09) and fewer distressed avoidance behaviors (SMD= -0.67; 95% CI= -1.04, -0.30) than did those receiving typical care. There were nonsignificant differences between these groups in terms of in pain (SMD = -0.02; 95% CI = - 0.81, 0.78) and fear (SMD = 0.38; 95% CI= -0.06, 0.82). The results of exploratory subgroup analyses revealed no statistically significant differences based on the intervention type of robots or anesthetic use.

CONCLUSIONS

The use of SARs is a promising intervention method for alleviating anxiety and distress among children undergoing needle-related procedures. However, additional high-quality randomized controlled trials are needed to further validate these conclusions.

TRIAL REGISTRATION

The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42023413279).

The impact of recreational cannabis legalization on cannabis-related acute care events among adults with schizophrenia

PURPOSE

Patients with schizophrenia have a higher risk of cannabis use disorder and may be uniquely affected by the legalization of recreational cannabis. This study examined whether cannabis legalization led to changes in acute care utilization among patients with schizophrenia.

METHOD

Using linked health administrative data, we included adult patients with schizophrenia in Ontario from October 2015 to May 2021 (n = 121,061). We examined the differences in cannabis, psychosis, and mental health-related emergency department (ED) visits over three periods: pre-legalization, legalization of flowers and herbs (phase 1), and legalization of edibles, extracts, and topicals (phase 2) using interrupted time-series methods.

RESULTS

Our study found that phase 1 was associated with decreases in cannabis-related, mental health-related, and cannabis + psychosis-related ED visits among the patients with schizophrenia. Notably, an immediate 25.8% (95% CI 13.8-37.6%) decrease in cannabis-related ED visits was observed in men, and an immediate 18.5% decrease in mental health-related ED visits (95% CI 6.0-31.2%) in women. These decreases were also shown in the comparative ITS models, demonstrating that the changes observed were distinct from trends in the general population. However, phase 2 was not associated with any significant changes.

CONCLUSIONS

Despite higher baseline rates of acute care utilization among patients with schizophrenia, cannabis legalization was associated with significant reductions, particularly during phase 1. Our findings suggest that regulatory measures accompanying legalization could enhance the quality and safety of cannabis products, potentially leading to fewer adverse health outcomes in vulnerable patient populations. Further research is needed to optimize healthcare responses for this vulnerable population.

Effectiveness of rapid access chest pain clinics: a systematic review of patient outcomes and resource utilisation

BACKGROUND

Rapid Access Chest Pain Clinics (RACPC) are widely used for the outpatient assessment of chest pain, but there appears to be limited high-quality evidence justifying this model of care. This study aimed to review the literature to determine the effectiveness of RACPCs.

METHODS

A systematic review of studies evaluating the effectiveness of RACPCs was conducted to assess the quality of the evidence supporting this model. Outcomes related to effectiveness included major adverse cardiovascular events, emergency department reattendance, cost-effectiveness and patient satisfaction. Study quality was assessed using the RoB 2 tool, Newcastle-Ottawa quality assessment tool or the Consolidated Criteria for Reporting Qualitative Studies checklist, as appropriate.

RESULTS

Thirty-two studies were eligible for inclusion, including one randomised trial. Five analytical cohort studies were included, with three comparing outcomes against non-RACPC controls. Three qualitative studies were included. Most reports were descriptive. Findings were consistent with RACPCs being associated with favourable clinical outcomes, reduced emergency department reattendance, cost-effectiveness and high patient satisfaction. However, there was significant heterogeneity in care models, and overall literature quality was low, with a high risk of publication bias.

CONCLUSION

While the literature suggests RACPCs are safe and efficient, the quality of the available evidence is limited. Further high-quality data from adequately controlled clinical trials or large scare registries are needed to inform healthcare resource allocation decisions.

PROSPERO REGISTRATION NUMBER

CRD42023417110.

Implementing Evidence-Based Pain Management Interventions Into an Emergency Department: Outcomes Guided by Use of the Ottawa Model of Research Use

AIM

To implement strategies to improve the care of patients with acute pain in the emergency department (ED).

DESIGN

Pre-post implementation study using a Type 2 hybrid effectiveness-implementation design.

METHODS

Implementation strategies were introduced and monitored through the Ottawa Model of Research Uses' assessment, monitoring and evaluation cycles, supported by focused and sustained facilitation.

RESULTS

Improvements in time-to-analgesia within 30 min (21%-27%), administration of nurse-initiated analgesia (NIA) (17%-27%) and measurement of pain (65%-75%) were achieved post-implementation. NIA was the strongest predictor of receiving analgesia within 30 min. Adoption of pain interventions into practice was not immediate yet responded to sustained facilitation of implementation strategies.

CONCLUSION

Collaboration with local clinicians to introduce simple interventions that did not disrupt workflow or substantially add to workload were effective in improving analgesia administration rates, and the proportion of patients receiving analgesia within 30 min. The assessment, monitoring and evaluation cycles enabled agile and responsive facilitation of implementation activities within the dynamic ED environment. Improvements took time to embed into practice, trending upward over the course of the implementation period, supporting the sustained facilitation approach throughout the study.

IMPLICATIONS

Sustained adoption of evidence-based pain interventions into the care of people presenting to the ED with acute pain can be achieved through sustained facilitation of implementation. NIA should be at the centre of acute pain management in the ED.

IMPACT

This study addressed the lingering gap between evidence and practice for patients with acute pain in the ED. Implementation of locally relevant/informed implementation strategies supported by focused and sustained facilitation improved the care of patients with acute pain in the ED. This research will have an impact on people presenting to EDs with acute pain, and on clinicians treating people with acute pain in the ED. Relevant equator guidelines were followed and the StaRI reporting method used.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution in this study.

Psychological Sequelae of Dog Bites in Children: A Review

BACKGROUND/OBJECTIVES

Although rare in the Western world, dog bites may be lethal or lead to physically severe outcomes. However, little attention is given to their psychological consequences. We aimed to review their psychological consequences in children 1-14 years of age, focusing on the prevalence and nature of psychological disorders, evaluating the impact on future mental health of children and their families, and assessing the effectiveness of preventive interventions and measures.

METHODS

On 23 May 2024, we investigated the PubMed, CINAHL, and PsycINFO/PsycARTICLES databases using ("dog bite" OR animal-induced OR animal-caused) AND (psychol* OR mental OR psychiatr* OR anxiety OR anxious OR depress* OR obsess* OR trauma* OR psychosis OR psychotic OR schizophren* OR schizoaffect*) filtered for ages 0-18 years. This resulted in 311 records, of which 50 were eligible. These included original research, case reports, patient surveys, and reviews/meta-analyses.

RESULTS

Findings indicate that younger children are particularly vulnerable, often suffering head/neck bites, leading to severe injuries and psychological distress, with post-traumatic stress disorder (PTSD) being a common outcome. Symptoms such as nightmares, flashbacks, anxiety, and social withdrawal were frequently reported. Positive parental support and timely psychological interventions were found to mitigate these effects.

CONCLUSIONS

Interdisciplinary approaches integrating education, cognitive restructuring, and behaviour modification are needed to effectively prevent and address the psychological impacts of dog bites. Summarising, dog bites in children result in substantial psychological sequelae, necessitating robust prevention and intervention strategies to improve their quality of life and reduce the risk of chronic mental conditions.

Flood risk assessment under the shared socioeconomic pathways: a case of electricity bulk supply points in Greater Accra, Ghana

This study evaluates flood susceptibility and risk on Bulk Supply Points in the Greater Accra region (GAR) using a Frequency Ratio model based on 15 flood conditioning factors. The model explores the influence of natural, meteorological and anthropogenic factors on flooding occurrences under the Shared Socioeconomic Pathway (SSP) scenarios and assesses flood risks at Bulk Supply Points (BSPs). Flood susceptibility mapping was conducted for both current and future periods under various SSP scenarios. Results reveal that elevation, slope, soil type, distance from urban areas, and SPI are the most influential factors contributing to flooding susceptibility in the region. The current flood map, about 37% of the total area of GAR categorized under the moderate flood-susceptible zone category followed by about 30% categorized under the low flood-vulnerable zone. However, about 16% was categorized under the very high flood-vulnerable zone. The study projects increasing flood susceptibility under the SSP scenarios with intensification under SSP2 and SSP3 scenarios. For instance, the areas categorized as high and very high flood susceptibility zones are projected to expand to approximately 32% and 26% each by 2055 under SSP3. The study also assesses flood risks at Bulk Supply Points (BSPs), highlighting the escalating susceptibility of power assets to flooding under different scenarios. For instance, in the very high scenario, flooding is estimated to reach 640 h in 2045 and exceed 800 h in 2055-more than double the 2020 baseline. The analysis shows the bulk supply points face increasing flood susceptibility, with risks escalating most sharply under the severe climate change SSP3 and SSP5 scenarios. Over 75% of BSPs are expected to fall in the low- to medium-risk categories across SSPs while more than 50% of BSPs are within medium- to high-risk categories in all scenarios except SSP1, reflecting the impact of climate change. SSP3 and SSP5 stand out with over 60% of BSPs facing high or very high flooding risks by 2055. It indicates moderate resilience with proper adaptation but highlights potential disruptions in critical infrastructure, such as BSPs, during persistent flooding. The findings of the study are expected to inform Ghana's contributions towards addressing Sustainable Development Goals (SDGs) 7, 11 and 13 in Ghana.

Prediction of emergency department presentations for acute coronary syndrome using a machine learning approach

The relationship between weather and acute coronary syndrome (ACS) incidence has been the subject of considerable research, with varying conclusions. Harnessing machine learning techniques, our study explores the relationship between meteorological factors and ACS presentations in the emergency department (ED), offering insights into seasonal variations and inter-day fluctuations to optimize patient care and resource allocation. A retrospective cohort analysis was conducted, encompassing ACS presentations to Dutch EDs from 2010 to 2017. Temporal patterns were analyzed using heat-maps and time series plots. Multivariable linear regression (MLR) and Random Forest (RF) regression models were employed to forecast daily ACS presentations with prediction horizons of one, three, seven, and thirty days. Model performance was assessed using the coefficient of determination (R²), Mean Absolute Error (MAE), and Mean Absolute Percentage Error (MAPE). The study included 214,953 ACS presentations, predominantly unstable angina (UA) (94,272; 44%), non-ST-elevated myocardial infarction (NSTEMI) (78,963; 37%), and ST-elevated myocardial infarction (STEMI) (41,718; 19%). A decline in daily ACS admissions over time was observed, with notable inter-day (estimated median difference: 41 (95%CI = 37-43, p = < 0.001) and seasonal variations (estimated median difference: 9 (95%CI 6-12, p = < 0.001). Both MLR and RF models demonstrated similar predictive capabilities, with MLR slightly outperforming RF. The models showed moderate explanatory power for ACS incidence (adjusted R² = 0.66; MAE (MAPE): 7.8 (11%)), with varying performance across subdiagnoses. Prediction of UA incidence resulted in the best-explained variability (adjusted R² = 0.80; MAE (MAPE): 5.3 (19.1%)), followed by NSTEMI and STEMI diagnoses. All models maintained consistent performance over extended prediction horizons. Our findings indicate that ACS presentation exhibits distinctive seasonal changes and inter-day differences, with marked reductions in incidence during the summer months and a distinct peak prevalence on Mondays. The predictive performance of our model was moderate. Nonetheless, we obtained good explanatory power for UA presentations. Our model emerges as a potentially valuable supplementary tool to enhance ED resource allocation or future predictive models predicting ACS incidence in the ED.

Outpatient Management Protocol for Uncomplicated Diverticulitis: A 3-Year Monocentric Experience in a Tertiary Hospital

Background/Objectives: The management of acute uncomplicated diverticulitis (AUD) has shifted towards outpatient care in the last decade, challenging the traditional inpatient approach. We aimed to analyze the safety and feasibility of a structured outpatient treatment pathway for AUD in a tertiary hospital. Methods: We conducted a retrospective observational cohort analysis of patients who underwent outpatient management for AUD at the Geneva University Hospitals from 2019 to 2021. Patient demographics, selection criteria, treatment protocols, and outcomes were analyzed. Results: Two-hundred and twenty patients were included in the outpatient cohort. Four patients (1.8%) required hospitalization due to the failure of outpatient management, whereas the majority of patients (116 patients, 98.2%) experienced a successful resolution of their symptoms without hospitalization. In a univariate analysis, factors associated with treatment failure included elevated white blood cell counts at admission (14 G/l vs. 10.6 G/l, p = 0.049) and the first follow-up appointment, (10.7 G/l vs. 7.4 G/l, p = 0.011) and the presence of free air on their CT scan (25% vs. 2,3%, p = 0.033). In a multivariate analysis, the presence of free air was the only identified risk factor for unsuccessful outpatient management (p = 0.05). We observed high rates of follow-up compliance (99.1%). Conclusion: Under the condition of a warranted outpatient follow-up appointment and with adequate selection criteria, outpatient management appears to be an effective approach for most patients with AUD, emphasizing the importance of tailored therapeutic interventions and vigilant clinical assessments for optimal outcomes.

An umbrella review of systematic reviews and meta-analyses for assessment and treatment of acute shoulder dislocation

OBJECTIVE

This study aims to provide a comprehensive review of the current evidence on accurate and rapid diagnostic methods, effective and safe shoulder dislocation reduction techniques, pharmacological treatment, and post-reduction care for acute anterior shoulder dislocation in the emergency department (ED).

METHODS

We conducted a systematic review of the literature up to December 31, 2022, with an additional search conducted up to August 31, 2024. Databases searched included Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, DARE, PROSPERO, OpenGrey, and Google Scholar. We reviewed systematic reviews and meta-analyses on assessment and intervention for acute anterior shoulder dislocation. Data extraction and quality assessment were performed independently by two reviewers. The quality of evidence was evaluated using the Cochrane Risk of Bias tool and the GRADE approach, while the methodology was assessed using AMSTAR 2.

RESULTS

From an initial 1345 records, 30 studies met the inclusion criteria. These included 4 articles on point-of-care ultrasound (POCUS), 5 on analgesia and anesthesia, 3 on closed reduction techniques, 10 on surgical Bankart repair, 9 comparing external and internal rotation immobilization, and 1 on nerve injuries, including duplicates. POCUS demonstrated high diagnostic accuracy comparable to radiography for shoulder dislocations and associated fractures. Analgesia and anesthesia studies showed that intra-articular anesthesia (IAA) is as effective as intravenous sedation (IVS) with fewer adverse events and shorter ED stays. Three meta-analyses on closed reduction techniques revealed no significant differences in success rates among various methods, but the FARES method was noted for superior pain management. Ten reviews on surgical Bankart repair consistently showed reduced redislocation rates, especially in younger patients, compared to non-surgical treatments including internal and external rotation immobilization. Four recent reviews reported external rotation immobilization was more effective than internal rotation in preventing redislocations. Nerve injuries were common, with the axillary nerve most frequently affected.

CONCLUSIONS

Emergency physicians managing anterior shoulder dislocation should employ POCUS for diagnosis, prioritize intra-articular anesthesia, master various reduction techniques including the FARES method, refer patients to an orthopedic surgeon for follow-up and potential surgery to prevent redislocation, and be vigilant about nerve damage.

The effectiveness of parenteral agents to mitigate relapses after severe acute migraine headache presentations: A systematic review and network analysis

OBJECTIVES

To compare the effectiveness of parenteral agents to reduce relapse in patients with acute migraine and identify factors that predict relapse.

BACKGROUND

Following discharge from emergency settings, many patients with acute migraine will experience a relapse in pain; severe relapses may result in re-visits to emergency settings.

METHODS

A comprehensive literature search, updated to 2023, was conducted to identify randomized controlled trials assessing the effectiveness of parenteral agents on relapse outcomes in patients with acute migraine discharged from emergency settings. Two independent reviewers completed study selection, quality assessment, and data extraction. A traditional meta-analysis compared parenteral corticosteroids to placebo; a frequentist network analysis assessed direct and indirect comparisons. Results are reported as risk ratios (RRs) and 95% confidence intervals (CIs). The review protocol was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42018099493).

RESULTS

From 8949 citations, a total of 53 unique studies were included involving 6167 patients. Most studies had a high or unclear risk of bias. Corticosteroids significantly reduced relapses compared to placebo (RR 0.67, 95% CI 0.52-0.88; I2 = 0%). Patients receiving lidocaine (RR 0.10, 95% CI 0.01-0.82), sedatives/hypnotics (RR 0.33, 95% CI 0.14-0.75), ergot agents (RR 0.44, 95% CI 0.25-0.75), neuroleptics (RR 0.47, 95% CI 0.31-0.71), opioids (RR 0.58; 95% CI 0.35-0.94), or corticosteroids (RR 0.64, 95% CI 0.47-0.86) were significantly less likely to relapse. Lidocaine (RR 0.09, 95% CI 0.01-0.71), combination therapy (RR 0.12, 95% CI 0.02-0.74), or adding corticosteroids (RR 0.61, 95% CI 0.44-0.84) were more likely to reduce severe relapses. Longer duration of headache and residual pain at discharge were significantly associated with higher relapses.

DISCUSSION

Corticosteroids remain the recommended first-line option to reduce relapse outcomes. Some parenteral agents typically provided for pain relief including ergot agents, neuroleptics, or combination therapy may effectively reduce relapse; however, opioids are not recommended due to safety concerns. Additional research is needed for some lesser studied, albeit promising, agents including lidocaine and propofol. Effective pain control in emergency settings prior to discharge and duration of headache may play a role in the success of such treatments and further investigations could provide further insight regarding how and why some parenteral agents are effective in mitigating relapse events.

Pediatric wrist fractures: variations in management across countries. An evidence-based summary of evidence

INTRODUCTION

Fractures of the distal radius are common in pediatric population, with considerable variation in the management of pediatric wrist fractures across different countries. It is crucial to consider the different approaches to conservative management and surgical intervention. The decision on the appropriate treatment method often depends on the type and severity of the fracture, as well as the available healthcare resources and expertise in each country. This article tries to identify these variations, so the various healthcare systems can work toward implementing best practices in the management of pediatric wrist fractures on a global scale.

SOURCE OF DATA

Published peer-reviewed articles identified in electronic databases, including PubMed Scopus and Google Scholar.

AREAS OF AGREEMENT

The management of pediatric wrist fractures can differ significantly among countries given the high variability in healthcare resources and cultural practices.

AREAS OF CONTROVERSY

The management of pediatric wrist fractures can be challenging in certain countries, especially in developing regions with limited resources.

GROWING POINTS

Challenges such as long therapeutic delays, lack of appropriate anesthesia, and the absence of fluoroscopy can complicate the treatment process. Randomized controlled clinical trials (RCTs) are vital in providing high-quality evidence to guide clinical decision-making, especially in the field of pediatric wrist fractures.

AREAS TIMELY FOR DEVELOPING RESEARCH

Efforts to support and prioritize the conduct and dissemination of RCTs in pediatric wrist fracture management can ultimately lead to more consistent, effective, and evidence-based care for children with wrist fractures worldwide.

Is the acute compartment syndrome diagnosed in snake bites true?: A review

Envenomation caused by venomous snakes can induce clinical symptoms and signs resembling those of traumatic acute compartment syndrome (ACS), but it is uncertain whether its treatment guidelines are applicable or beneficial for ACS that is associated to snakebites. Nonetheless, recommendations for the diagnosis and treatment of trauma-induced ACS, particularly following fractures of the tibial diaphysis, are extrapolated to the diagnosis and treatment of snakebites despite evidence that the ensuing injuries are frequently not true ACS. Most biologists agree that the venom of snakes, especially those of the Crotalinae family (vipers) evolved to immobilize, kill, and initiate the digestion of their prey. The human local effects of viper envenoming are the result of digestion like those described in biological processes as acute pancreatitis, including secondary inflammatory and induction of reparative effects. The first-line treatment should focus on mitigation of venom-induced tissue digestion rather than surgery solution for "ACS-like" symptoms and signs. This type of analysis leads to questioning that treatment of ACS associated with snakebite cannot be extrapolated from recommendations formulated for trauma-induced ACS. The cornerstone of snake envenoming treatment is antivenom, and some clinical and experimental experiences start to show that surgical procedures frequently employed for trauma-induced ACS, such as debridement and fasciotomy, may be exaggerated and even deleterious in most viper bite envenoming.

Leveraging a clinical emergency department dataset to estimate two-dose COVID-19 vaccine effectiveness and duration of protection in Canada

BACKGROUND

During the COVID-19 pandemic, clinical care shifted toward virtual and Emergency Department care. We explored the feasibility of mRNA vaccine effectiveness (VE) estimation against SARS-CoV-2-related Emergency Department visits and hospitalizations using prospectively collected Emergency Department data.

METHODS

We estimated two-dose VE using a test-negative design and data from 10 participating sites of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). We included Emergency Department patients presenting with COVID-19 symptoms and nucleic acid amplification testing for SARS-CoV-2 between July 19 and December 31, 2021. We excluded patients with unclear vaccination and one or more than 2 vaccine doses by their Emergency Department visit.

RESULTS

Among 3,405 eligible patients, adjusted two-dose mRNA VE against SARS-CoV-2-related Emergency Department visits was 93.3 % (95 % CI 87.9-96.3 %) between 7-55 days, sustained over 80 % through 139 days post-vaccination. In stratified analyses, VE was similar among patients with select immune-compromising conditions, chronic kidney disease, lung disease, unstable housing, and reported illicit substance use.

CONCLUSIONS

Two-dose mRNA VE against SARS-CoV-2-related Emergency Department visit was high and sustained, including among vulnerable subgroups. Compared to administrative datasets, active Emergency Department enrolment enables standardization for testing access and indication and supports separate VE assessment among special population subgroups. Compared to other active enrolment settings, Emergency Departments more consistently function during crises when alternate healthcare sectors become variably closed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT0470294.

Evaluating the Application of an EMS Clinical Judgment Theoretical Framework

OBJECTIVES

Clinical judgment (CJ) encompasses clinical reasoning (process of evaluating a problem) and clinical decision-making (choice made). A theoretical model to better define emergency medical services (EMS) CJ has been developed but its use has not been evaluated in EMS training and assessments. Our objective was to evaluate the performance of this EMS CJ model to assess clinical reasoning and decision-making in a simulated environment.

METHODS

In this evaluation, EMS clinician teams (2-3 members) were directed to care for a simulated older adult patient in their home following a fall. Simulations were video recorded, clinician team actions coded, and evaluated for whether proper CJ reasoning and decisions were made. We evaluated CJ in two ways: 1) EMS medical directors' (MD) determination of whether the CJ questions were addressed (MD score) and 2) objective rubric evaluation of CJ questions using the EMS CJ model focused on recognition of appropriate cues, performance of actions, and revaluation after action (rubric score). The CJ questions addressed in this simulation included: 1) Is the patient stable/unstable?, 2) Are interventions necessary before movement?, 3) How should the patient be transferred from the floor?, and 4) Does the cause of the fall require hospital evaluation? Descriptive statistics were calculated, and concordance between the two assessments was evaluated (mean, 95% CI). Percent concordance was calculated with a validity threshold set at 70%.

RESULTS

Four EMS MDs reviewed 20 videos addressing 80 clinical judgment decisions. Overall concordance between MD score and rubric score for CJ decisions was above the threshold at 88.1% (85.0, 91.2). Concordance between MD score and rubric score for each CJ decision was 92.0% (87.3, 96.7) for question 1, 79.9% (71.5, 88.3) for question 2, 95.0% (90.4, 99.6) for question 3, and 85.4% (79.5, 91.2) for question 4.

CONCLUSION

An objective evaluation of CJ decisions using a rubric derived from an EMS CJ theoretical framework demonstrated high concordance to subjective evaluations of CJ made by EMS MDs. This approach may allow for reproducible and objective CJ evaluations that could be used for competency assessment in EMS.

Strategies for equity, diversity and inclusion in geriatric healthcare professional curricula: A scoping review protocol

INTRODUCTION

The pursuit of Equity, Diversity and Inclusion (EDI) in healthcare education has garnered significant attention in recent years, reflecting a broader societal imperative for equitable healthcare delivery. However, existing curricula within geriatric healthcare education may not adequately address these diverse needs within their educational frameworks, inadvertently resulting in disparities in care delivery and outcomes. Within the realm of geriatric healthcare, addressing EDI is particularly crucial due to the diverse needs of older adult populations and the imperative for healthcare professionals to deliver culturally humble care. This review provides a comprehensive overview of strategies and curricular strategies, actions and/or initiatives to promote EDI within geriatric healthcare professional education.

METHODS

This paper presents a protocol for a forthcoming scoping review. The methodology for this scoping review adheres to the framework outlined in the Joanna Briggs Institute (JBI) Manual, encompassing four main stages: (1) formulation of a search strategy, (2) screening and selection of evidence, (3) data extraction, and (4) analysis. We will conduct a comprehensive search of peer-reviewed and empirical literature. Additionally, we will explore the reference lists of included studies to identify any relevant sources. The synthesis of findings will be conducted through a narrative approach. Reporting of the methods and results will adhere to the guidelines provided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

DISCUSSION

Healthcare professionals must possess the knowledge, skills, and attitudes necessary to deliver culturally humble care that respects and responds to diverse older adults' unique needs and preferences. The review aims to fill a crucial gap in the literature by providing a comprehensive overview of strategies and curricular interventions designed to promote EDI within geriatric healthcare professional education. By mapping these strategies, actions and/or initiatives, the review seeks to identify trends, challenges, and opportunities for advancing EDI within geriatric care. The forthcoming review serves as a call to action for educators, healthcare institutions, and decision makers to prioritize EDI within geriatric healthcare education. The review identifies effective strategies and interventions for promoting EDI, providing actionable insights to inform the development of inclusive curricula, training programs, and institutional policies, which can contribute to cultivating a healthcare workforce better equipped to address the complex and evolving needs of aging populations equitably and compassionately.

Need for a More Objective, Inclusive, and Equitable Selection Process for Gastroenterology Fellowships

Diseases related to the digestive system account for a significant proportion of the diseases burden in the United States and result in 36.8 million ambulatory visits, 3.8 million hospital admissions, and 22.2 million gastrointestinal endoscopies. To meet the challenge that this quantum of gastroenterological disorders poses, we are obligated to select and train competent gastroenterologists. Admission into a Gastroenterology (GI) fellowship program is highly selective. In 2023, only 62.7% of candidates who applied were successful in matching into a fellowship program, making it even more competitive than a cardiology fellowship (match rate of 68.4%). Therefore, it is imperative that we ensure that the selection process is fair and transparent. Additionally, we need to be socially more responsible by emphasizing diversity and inclusivity to produce gastroenterologists who reflect the changing society we live in. An analysis of current practices indicates that the process of selection is not standardized and is more subjective than objective. This review is an attempt to identify deficiencies that can be rectified by the introduction of a standardized system that includes structured interviews, Standard Letters of Recommendation (SLOR), and objective scoring protocols-all of which would make the process of selection more equitable, diverse, and inclusive. Newer methods like Casper exam, Psychometric testing, and Preference Signaling can also be explored to this end.

Predicting implementation of response to intervention in math using elastic net logistic regression

Introduction

The primary objective of this study was to identify variables that significantly influence the implementation of math Response to Intervention (RTI) at the school level, utilizing the ECLS-K: 2011 dataset.

Methods

Due to missing values in the original dataset, a Random Forest algorithm was employed for data imputation, generating a total of 10 imputed datasets. Elastic net logistic regression, combined with nested cross-validation, was applied to each imputed dataset, potentially resulting in 10 models with different variables. Variables for the models derived from the imputed datasets were selected using four methods, leading to four candidate models for final selection. These models were assessed based on their performance of prediction accuracy, culminating in the selection of the final model that outperformed the others.

Results and discussion

Method50 and Methodcoef emerged as the most effective, achieving a balanced accuracy of 0.852. The ultimate model selected relevant variables that effectively predicted RTI. The predictive accuracy of the final model was also demonstrated by the receiver operating characteristic (ROC) plot and the corresponding area under the curve (AUC) value, indicating its ability to accurately forecast math RTI implementation in schools for the following year.

Influence of Age on Outcome Following Rib Fractures - A Case-Control Analysis

Background

Thoracic injuries are a very common entity throughout all age groups. With rising numbers of geriatric patients, characteristics of this patient group need to be better defined. The aim of this study was to investigate the impact of age on the outcome of thoracic trauma. In this project we provide a stratification of differentiated age groups regarding outcome parameter on rib fractures.

Methods

The study employed a retrospective design using data from patients who sustained thoracic trauma and received treatment at a level I trauma center over a 5-year period. Patients with the same pattern of injury and gender but different age (above and below 70 years) were matched.

Results

The mean age of the study population was 57 ± 19 years, 69% were male, 54% of patients had preexisting comorbidities. Hemothorax was present in 109 (16%), pneumothorax in 204 (31%) and lung contusions in 136 patients (21%). The overall complication rate was 36%, with a mortality rate of 10%. The matched pair analysis of 70 pairs revealed a higher prevalence of comorbidities in the older age group. They had significantly fewer pulmonary contusions and pneumothoraces than the younger patients and a shorter length of stay. However, the older age group had a significantly higher mortality rate.

Conclusions

Geriatric patients with rib fractures exhibit different patterns of intrathoracic injuries compared to their younger counterparts. Although numeric age may not be the most accurate predictor of adverse outcome, we found that higher age was associated with a clear trend towards an increased mortality rate. Our findings build a basis for further research to evaluate the outcome of age for instance with the tool of a rib fracture scoring system within stratified age groups in order to identify patients at major risk.

PGY-2 emergency medicine residents are more efficient when paired with an early clinical medical student

Objectives

There is a concern that provide increased extraneous cognitive load when paired with residents on shift. However, this may be offset by the decrease in extraneous load they may provide to the residents they are paired with by offloading basic patient care tasks. We hypothesized that these forces may not be balanced.

Methods

We conducted a retrospective observational analysis of PGY-2 emergency medicine residents and junior medical students at a single academic emergency department (ED) in the Midwest. A series of efficiency metrics (relative value unit [RVUs], patients per hour [PPH], time to note completion, and resident assignment to disposition [RATD]) as well as one quality metric (number of return ED visits; "bouncebacks") were compared for resident shifts in which a student was paired with the resident as well those in which no student was paired utilizing a regression model.

Results

A total of 1844 records met the inclusion criteria (214 shifts with a paired medical student and 1630 without). After covariates were adjusted for, medical student shift status was a statistically significant predictor of increases in PPH (p < 0.0001) and RVUs (p = 0.0161) but was not significantly associated with RATD (p = 0.6941), log-time to note completion (p = 0.1604), or bounceback status (p = 0.9840). Shifts where residents were paired with medical students were predicted to see an additional 1.131 (95% confidence interval [CI] 0.660-1.602) PPH and produce an additional 1.923 RVUs (95% CI 1.130-3.273) per shift relative to shifts without medical students.

Conclusions

When junior medical students were paired with a PGY-2 resident on ED shifts, there was a significant increase in the PPH and RVUs generated when compared with shifts in which no medical student was paired with them.

Impact of COVID-19 on emergency medical services utilization and severity in the U.S. Upper Midwest

The COVID-19 pandemic has claimed over one million lives in the United States and has drastically changed how patients interact with the healthcare system. Emergency medical services (EMS) are essential for emergency response, disaster preparedness, and responding to everyday emergencies. We therefore examined differences in EMS utilization and call severity in 2020 compared to trends from 2015-2019 in a large, multi-state advanced life support EMS agency serving the U.S. Upper Midwest. Specifically, we analyzed all emergency calls made to Mayo Clinic Ambulance, the sole advanced life support EMS provider serving a large area in Minnesota and Wisconsin, and compared the number of emergency calls made in 2020 to the number of calls expected based on trends from 2015-2019. We similarly compared caller demographics, call severity, and proportions of calls made for overdose/intoxication, behavioral health, and motor vehicle accidents. Subgroup analyses were performed for rural vs. urban areas. We identified 262,232 emergent EMS calls during 2015-2019 and 53,909 calls in 2020, corresponding to a decrease of 28.7% in call volume during 2020. Caller demographics shifted slightly towards older patients (mean age 59.7 [SD, 23.0] vs. 59.1 [SD, 23.7] years; p<0.001) and to rural areas (20.4% vs. 20.0%; p = 0.007). Call severity increased, with 95.3% of calls requiring transport (vs. 93.8%; p<0.001) and 1.9% resulting in death (vs. 1.6%; p<0.001). The proportion of calls for overdose/intoxication increased from 4.8% to 5.5% (p<0.001), while the proportion of calls for motor vehicle collisions decreased from 3.9% to 3.0% (p<0.001). All changes were more pronounced in urban areas. These findings underscore the extent to which the COVID-19 pandemic impacted healthcare utilization, particularly in urban areas, and suggest that patients may have delayed calling EMS with potential implications on disease severity and risk of death.

Best Practices in the Nursing Care of Patients With Injuries From Violence: An Integrative Review

BACKGROUND

The number of patients who have experienced violence is increasing worldwide. These patients have specific psychosocial and forensic needs and can present unique challenges to the health care workers caring for them.

OBJECTIVE

To identify best practices for the care of patients with injuries from violence in the emergency department or inpatient setting.

METHODS

The framework for integrative reviews by Whittemore and Knafl was used to conduct a literature search in MEDLINE, CINAHL, and ProQuest Nursing and Allied Health databases. Fourteen qualitative, quantitative, and mixed-methods studies from peer-reviewed journals were included in the review.

RESULTS

Themes included identifying patients as survivors of intimate partner violence or child abuse, the need to collect forensic evidence, the need for emotional support of patients and their loved ones, support for health care workers caring for patients with injuries from violence, prevention of further violence, and the challenges of caring for patients with injuries from violence with concurrent substance use disorders. Best practices for these aspects of care are summarized on the basis of literature analysis.

CONCLUSION

Screening procedures are needed to identify survivors of intimate partner violence and child abuse. Forensic evidence preservation policies should be in place. For survivors of sexual assault, a sexual assault nurse examiner should be available. Hospital systems should provide psychosocial resources for patients' and health care workers' mental health, implement violence reduction programs, and provide bias training. More research is needed to determine efficacy of care models and best practice.

Effects of the bladder stimulation technique on urine sample collection in newborns: A randomized controlled study

AIM

The aim of this study is to investigate the effectiveness of the bladder stimulation technique (BST) to collect urine samples from newborns and its effects on physiological parameters and comfort of the newborn.

DESIGN

This was a randomized controlled trial conducted in a NICU. A total of 64 newborns were divided into 2 groups: 32 newborns in the experimental group and 32 newborns in the control group.

METHODS

Newborns in the experimental group (EG) were subjected to the BST, and in the control group (CG), urine collection was via sterile urine bags, which is routine practice. Procedural success was defined as the collection of urine samples within 3 min of beginning the stimulation technique in the experimental group and of placing the sterile urine bag in the control group.

RESULTS

The success rate of the procedure in 3 min was 62.5% in the EG and 28% in the CG (P = 0.006, absolute difference: 35%, 95% confidence interval 27% to 42%, NNT: 3). According to the comparison of the overall mean COMFORTneo scale and pain and distress subscale scores at the 1- and 3-min marks, there was a significant difference between the EG and CG (p < 0.05). The mean scores in the EG were higher than those in the CG. The mean oxygen-saturation was significantly lower in the EG than in the CG (p < 0.05), and the increase in heart rate was significantly higher in the EG (p = 0.018).

CONCLUSIONS

BST is a more successful method within 3 min for collecting urine samples from newborns compared to sterile urine bags. However, the newborns' comfort levels minimally decreased at 3 min, and they had moderate pain and distress, while the BST was being implemented. This increase in physiologic parameters was statistically significant but not clinically significant.

Risk factors and risk stratification approaches for delirium screening: A Geriatric Emergency Department Guidelines 2.0 systematic review

OBJECTIVE

As part of the Geriatric Emergency Department (ED) Guidelines 2.0 project, we conducted a systematic review to find risk factors or risk stratification approaches that can be used to identify subsets of older adults who may benefit from targeted ED delirium screening.

METHODS

An electronic search strategy was developed with a medical librarian, conducted in April 2021 and November 2022. Full-text studies of patients ≥65 years assessed for prevalent delirium in the ED were included. Risk of bias was assessed using the McMaster University Clarity Group tool. Outcomes measures pertained to the risk stratification method used. Due to heterogeneity of patient populations, risk stratification methods, and outcomes, a meta-analysis was not conducted.

RESULTS

Our search yielded 1878 unique citations, of which 13 were included. Six studies developed a novel delirium risk score with or without evaluation of specific risk factors, six studies evaluated specific risk factors only, and one study evaluated an existing nondelirium risk score for association with delirium. The most common risk factor was history of dementia, with odds ratios ranging from 3.3 (95% confidence interval [CI] 1.2-8.9) to 18.33 (95% CI 8.08-43.64). Other risk factors that were consistently associated with increased risk of delirium included older age, use of certain medications (such as antipsychotics, antidepressants, and opioids, among others), and functional impairments. Of the studies that developed novel risk scores, the reported area under the curve ranged from 0.77 to 0.90. Only two studies reported potential impact of the risk stratification tool on screening burden.

CONCLUSIONS

There is significant heterogeneity, but results suggest that factors such as dementia, age over 75, and functional impairments should be used to identify older adults who are at highest risk for ED delirium. No studies evaluated implementation of a risk stratification method for delirium screening or evaluated patient-oriented outcomes.

The Dunning‒Kruger effect in resident predicted and actual performance on the American Board of Emergency Medicine in-training examination

Objectives

The Dunning-Kruger effect (DKE) is a cognitive bias wherein individuals who are unskilled overestimate their abilities, while those who are skilled tend to underestimate their capabilities. The purpose of this investigation is to determine if the DKE exists among American Board of Emergency Medicine (ABEM) in-training examination (ITE) participants.

Methods

This is a prospective, cross-sectional survey of residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine (EM) residency programs. All residents who took the 2022 ABEM ITE were eligible for inclusion. Residents from international programs, residents in combined training programs, and those who did not complete the voluntary post-ITE survey were excluded. Half of the residents taking the ITE were asked to predict their self-assessment of performance (percent correct), and the other half were asked to predict their performance relative to peers at the same level of training (quintile estimate). Pearson's correlation (r) was used for parametric interval data comparisons and a Spearman's coefficient (ρ) was determined for quintile-to-quintile comparisons.

Results

A total of 7568 of 8918 (84.9%) residents completed their assigned survey question. A total of 3694 residents completed self-assessment (mean predicted percentage correct 67.4% and actual 74.6%), with a strong positive correlation (Pearson's r 0.58, p < 0.001). There was also a strong positive correlation (Spearman's ρ 0.53, p < 0.001) for the 3874 residents who predicted their performance compared to peers. Of these, 8.5% of residents in the first (lowest) quintile and 15.7% of residents in the fifth (highest) quintile correctly predicted their performance compared to peers.

Conclusions

EM residents demonstrated accurate self-assessment of their performance on the ABEM ITE; however, the DKE was present when comparing their self-assessments to their peers. Lower-performing residents tended to overestimate their performance, with the most significant DKE observed among the lowest-performing residents. The highest-performing residents tended to underestimate their relative performance.

FACTORS INFLUENCING LATE PROGNOSIS IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION TREATED WITH DIRECT PERCUTANEOUS CORONARY INTERVENTION

ABSTRACT

Objective: To investigate factors influencing the late prognosis of patients with acute ST-segment elevation myocardial infarction treated by direct percutaneous coronary intervention. Methods: We retrospectively analyzed 349 ST-segment elevation myocardial infarction patients treated with direct percutaneous coronary intervention. Patients were categorized based on catheter laboratory activation time (CLAT) (≤15 or >15 min), time of arrival (working hours or out-of-hours), and mode of arrival (emergency medical services transportation or self-presentation). The primary endpoint was the 2-year major adverse cardiovascular events (MACEs), defined as all-cause death, nonfatal myocardial infarction, and target vessel revascularization. Results: Patients with CLAT ≤15 min showed significant differences in oxygen saturation, FMC-to-device time, symptom-to-device time, symptom-to-FMC time, presentation mode, presentation duration, and MACEs (all P < 0.005). Self-presentation (odds ratio = 0.593, 95% confidence interval = 0.413-0.759) and out-of-hours presentation (odds ratio = 0.612, 95% confidence interval = 0.433-0.813) were risk factors for CLAT >15 min. The working-hours group showed significant differences in FMC-to-device time, activation-to-arrival time at the catheter laboratory, and the number of cases with activation time ≤15 min (all P < 0.005). The emergency medical services and self-presentation groups differed significantly in age, blood pressure, FMC-to-device time, and electrocardiography-to-CLAT (all P < 0.005). Conclusion: Reducing CLAT to 15 min significantly lowers the 2-year MACE rate. Self-presentation and out-of-hours presentation are risk factors for delayed catheter laboratory activation.

Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study

BACKGROUND

In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting.

OBJECTIVES

We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI.

METHODS

This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes.

RESULTS

Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff).

CONCLUSIONS

The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04430400.

Simulation tools in ultrasound-guided regional anesthesia: developing a simple, inexpensive erector spinae plane (ESP) block teaching model

The erector spinae plane (ESP) block is an increasingly utilized regional block in the emergency department, representing one effective alternative or adjunct to opioid analgesia in patients presenting with rib fractures. While there is growing interest, its widespread adoption faces hurdles, such as a lack of appropriate training resources. Gelatin-based phantoms to simulate human anatomy have been widely used to facilitate ultrasound-guided procedures, although no such model for the ESP block has yet been defined in the literature. To address this gap, we sought to design and assemble an inexpensive, simple to build, reusable phantom to simulate the sonographic anatomy of the posterior thoracic wall and serve as a task trainer for an ultrasound-guided ESP block. This novel phantom model reproduces an ultrasonographic fascial plane using a gelatin medium and 3D-printed thoracic spine with ribs allowing for needle guidance and hydrodissection.

Take-home naloxone in multicentre emergency settings: the TIME feasibility cluster RCT

Background

Opioids kill more people than any other drug. Naloxone is an opioid antagonist which can be distributed in take-home 'kits' for peer administration (take-home naloxone).

Aim

To determine the feasibility of carrying out a definitive randomised controlled trial of take-home naloxone in emergency settings.

Design

We used Welsh routine data (2015-21) to test the feasibility of developing a discriminant function to identify people at high risk of fatal opioid overdose. We carried out a cluster randomised controlled trial and qualitative study to examine experiences of service users and providers. We assessed feasibility of intervention and trial methods against predetermined progression criteria related to: site sign-up, staff trained, identification of eligible patients, proportion given kits, identification of people who died of opioid poisoning, data linkage and retrieval of outcomes.

Setting

This study was carried out in the emergency environment; sites comprised an emergency department and associated ambulance service catchment area.

Participants

At intervention sites, we invited emergency department clinicians and paramedics to participate. We recruited adult patients who arrived at the emergency department or were attended to by ambulance paramedics for a problem related to opioid use with capacity to consent to receiving the take-home naloxone and related training.

Interventions

Usual care comprised basic life support plus naloxone by paramedics or emergency department staff. The take-home naloxone intervention was offered in addition to usual care, with guidance for recipients on basic life support, the importance of calling the emergency services, duration of effect, safety and legality of naloxone administration.

Discriminant function

With low numbers of opioid-related deaths (1105/3,227,396) and a high proportion having no contact with health services in the year before death, the predictive link between death and opioid-related healthcare events was weak. Logistic regression models indicated we would need to monitor one-third of the population to capture 75% of the decedents from opioid overdose in 1-year follow-up.

Randomised controlled trial

Four sites participated in the trial and 299 of 687 (44%) eligible clinical staff were trained. Sixty take-home naloxone kits were supplied to patients during 1-year recruitment. Eligible patients were not offered take-home naloxone kits 164 times: 'forgot' (n = 136); 'too busy' (n = 15); suspected intentional overdose (n = 3).

Qualitative interviews

Service users had high levels of knowledge about take-home naloxone. They were supportive of the intervention but noted concerns about opioid withdrawal and resistance to attending hospital for an overdose. Service providers were positive about the intervention but reported barriers including difficulty with consenting and training high-risk opioid users.

Health economics

We were able to calculate costs to train staff at three sites (£40 per AS and £17 in Site 1 ED). No adverse events were reported. Progression criteria were not met - fewer than 50% of eligible staff were trained, fewer than 50% of eligible patients received the intervention and outcomes were not retrieved within reasonable timescales.

Future work

The take-home naloxone intervention needs to be developed and evaluated in emergency care settings, with appropriate methods.

Limitations

The Take-home naloxone Intervention Multicentre Emergency setting study was interrupted by coronavirus disease.

Conclusions

This study did not meet progression criteria for intervention or trial methods feasibility, so outcomes were not followed up and a fully powered trial is not planned.

Trial registration

This trial is registered as ISRCTN13232859.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/91/04) and is published in full in Health Technology Assessment; Vol. 28, No. 74. See the NIHR Funding and Awards website for further award information.

Optimizing outcomes: A retrospective analysis of discharge safety for elderly mTBI patients on anticoagulation therapy

BACKGROUND

Mild traumatic brain injuries (mTBIs) pose a significant risk, particularly in the elderly population on anticoagulation therapy. The safety of discharging these patients from the emergency department (ED) with a negative initial computed tomography (CT) scan has been debated due to the risk of delayed intracranial hemorrhage (d-ICH).

OBJECTIVE

To compare outcomes, including d-ICH, between elderly patients on anticoagulation therapy presenting with mTBI who were admitted versus discharged from the ED after an initial negative head CT scan.

METHODS

We conducted a retrospective observational study at the Chaim Sheba Medical Center, assessing outcomes of 1598 elderly patients on anticoagulation therapy who presented with mTBI and an initial negative head CT scan. Patients were either admitted for 24-h observation (Group A, n = 829) or discharged immediately from the ED (Group B, n = 769). The primary outcome was incidence of d-ICH within 14 days.

RESULTS

Among the 1598 patients included in the study, 46 admitted patients and 1 discharged patient returned within 14 days for repeat CT, identifying one asymptomatic hemorrhage in the discharged patient. Mortality at 30 days was significantly higher in admitted patients compared to discharged patients (4.8% vs. 1.8%, p = 0.001), though cause of death was unrelated to head injury in both groups.

CONCLUSION

In elderly patients on anticoagulation with mTBI and a negative initial CT, admission was associated with a higher risk of d-ICH compared to discharge. These findings have implications for clinical decision-making in this high-risk population.

Nursing student's experiences of Role-Play Scenario-Based Disaster Triage (START) training: A qualitative research

BACKGROUND

Disasters can overwhelm healthcare systems, making effective triage a crucial skill for nurses. Role-Play Scenario-Based Disaster Triage Training offers a promising approach to prepare nursing students for these situations. Understanding students' experiences with this training method can inform its development and effectiveness in fostering disaster preparedness. However, little is known about this training experience of nursing students. In particular, by examining the challenges faced by students, the emotional distress they experience and their achievements, it will provide guidance for the development of education programs in a more comprehensive and student-oriented manner.

AIM

The aim of this study is to elucidate the experiences of nursing students regarding Role-Play Scenario-Based Disaster Triage Training.

DESIGN AND METHODS

A qualitative approach was employed to comprehend participating students' experiences. Face-to-face and online semi-structured interviews were conducted with 17 students using an interview guide, and the interactions were recorded for subsequent analysis. Thematic analysis was employed to develop themes.

RESULTS

The study results emphasize the challenges experienced by students during triage training, their gains and the support they need to cope with the challenges they experience. Data were organized around four main themes: "Challenges of the triage process" with subthemes such as "Thinking of the actual earthquake moment" and "Ethical dilemmas"; "Emotional turmoil" with subthemes including "Anxiety" and "Fear and Helplessness"; "Achievements" with subthemes such as "Increase in knowledge and skills" and "The importance of the nurse"; and "Suggestions" with subthemes including "Continuous education" and "Mandatory course".

CONCLUSIONS

The findings of the study provide new insights into the experiences of nursing students during the disaster triage process. The results may contribute to the improvement of future training programs by identifying the challenges and needs faced by nursing students after disaster triage education.

Hypersensitivity vs. uncommonly severe local envenoming by the red-back spider, Latrodectus hasselti Thorell, 1870 (Araneae: Theridiidae)

The genus Latrodectus (Araneae: Theridiidae) consists of 35 widow spider species with global distribution. Envenoming by medically important species, latrodectism, commonly features bite site erythema and diaphoresis, variably severe pain that may be persistent, myalgia/cramping and/or myoclonus, autonomic symptoms, abdominal distress; severe envenoming can be prolonged and include serious effects such as oliguria, hypertension and, rarely, myocarditis/myocardial injury. Red-back spiders (Latrodectus hasselti) are the most common cause of envenoming in Australia and can cause the spectrum of effects noted for other medically important widow spiders. A 34-yr-old woman with a history of previous L. hasselti envenoming and treatment with antivenom was envenomed in her left ankle by a verified L. hasselti (hiding in her boot) while attending an appointment with her primary care physician. She reported some of the common effects of latrodectism including severe, prolonged pain, bite site diaphoresis, and malaise; however, she also developed marked edema that involved the entire left foot. She also exhibited mild hypertension and autonomic/non-specific effects limited to nausea, headache, and anxiety. She was effectively treated with red-back spider antivenom (a total of 4 ampoules) and supportive care; full resolution of the edema required almost 5 days. The uncommon clinical evolution of L. hasselti local envenoming observed in this patient may have been caused by a mixed picture of venom-induced effects and Type I hypersensitivity, but alternatively could be a rare, solely venom-induced manifestation. While provision of patient-centred care for anyone envenomed by Latrodectus spp. requires careful history collection and assessment of comorbidities, differentiation of atopic and direct venom effects may be challenging in some envenomed patients with established complex allergy history.

Educator's blueprint: Key considerations for using social media in survey-based medical education research

In this paper, we present a set of recommendations for using social media as a tool for participant recruitment in survey-based medical education research. Drawing from a limited but growing body of literature, we discuss the opportunities and challenges inherent to social media recruitment. This article builds on the authors' previous educator's blueprints about survey design and administration. We highlight the advantages of social media, including its wide reach, cost-effectiveness, and capability to access diverse and geographically dispersed populations, which can significantly enhance the representativeness of research samples. However, we also caution against potential pitfalls, such as ethical concerns, sampling bias, and the fluid nature of social media platforms. Our recommendations are informed by both empirical evidence and best practices, aiming to provide researchers with practical advice for effectively leveraging social media in survey-based medical education research. We emphasize the importance of selecting suitable platforms and engaging with targeted demographics thoughtfully. By sharing our insights, we hope to assist fellow medical education researchers in navigating the complexities of social media recruitment, thereby enriching the quality and impact of survey-based research in this field.

Predictors of early mortality following surgical or nonsurgical treatment of subaxial cervical spine fractures: a retrospective nationwide registry study

BACKGROUND

Traumatic subaxial cervical spine fractures are a significant public health concern due to their association with spinal cord injuries (SCI). Despite being mostly caused by low-energy trauma, these fractures significantly contribute to morbidity and mortality. Currently, research regarding early mortality based on the choice of treatment following these fractures is limited. Identifying predictors of early mortality may aid in postoperative patient monitoring and improve outcomes.

PURPOSE

This study aimed to identify predictors of 30-days, 90-days, and 1-year mortality in adults treated for subaxial fractures.

STUDY DESIGN

A retrospective review of the nationwide Swedish Fracture Register (SFR).

PATIENT SAMPLE

All adult patients in the SFR who underwent treatment for a subaxial cervical fracture (n = 1,963).

OUTCOME MEASURES

Analyzed variables included age, sex, injury mechanism, neurological function, fracture characteristics, and treatment type. The primary endpoints were 30-days, 90-days, and 1-year mortality.

METHODS

About 1,963 patients in the SFR, treated for subaxial cervical fractures between 2013 and 2021, were analyzed. Surgical procedures included anterior, posterior, or anteroposterior approaches. Nonsurgical treatment included collar treatment or medical examinations without intervention. Stepwise regression and Cox regression analysis were used to determine predictors. Model performance was tested using the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 620 patients underwent surgery and 1,343 received nonsurgical treatment. Surgical cases had primarily translation fractures, with 323 (52%) displaying no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 22/620 (3.5%), 35/620 (5.6%), and 53/620 (8.5%), respectively. Age and SCI were predictors of mortality. Nonsurgically treated patients mostly had compression fracture, with 1,214 (90%) experiencing no neurological deficits. Mortality rates at 30 days, 90 days, and 1 year were 41/1,343 (3.1%), 71/1,343 (5.3%), and 118/1,343 (8.7%). Age, male sex, SCI and fractures occurring at the C3 or C6 levels were predictors of mortality. An intact neurological function was a positive predictor of survival among nonsurgically treated patients (AUC >0.78).

CONCLUSIONS

Age and SCI emerged as significant predictors of early mortality in both surgically and nonsurgically treated patients. An intact neurological function served as a protective factor against early mortality in nonsurgically treated patients. Fractures at C3 or C6 vertebrae may impact mortality.

Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review

Buprenorphine initiation in the Emergency Department (ED) has been hailed as an evidence-based strategy to mitigate the opioid overdose crisis, but its implementation has been limited. This scoping review synthesizes barriers and facilitators to buprenorphine initiation in the ED, and uses the Consolidated Framework for Implementation Research and a critical lens to analyze the literature. Results demonstrate an immense effort across the U.S. and Canada to implement ED-initiated buprenorphine. Facilitators include multidisciplinary addiction teams and co-located, low-barrier, harm reduction-informed services to support transitions. Barriers include a failure to address structural stigma, client complexity, and an increasingly toxic drug supply. The literature also misses the opportunity to include the perspectives of service users, health administrators, and learners. Increased coordination of implementation efforts, and a shift to equitable and inclusive opioid agonist therapy initiation pathways are needed across the U.S. and Canada.

Changes in prenatal cannabis-related diagnosed disorders after the Cannabis Act and the COVID-19 pandemic in Quebec, Canada

BACKGROUND AND AIMS

Public health concerns regarding pregnant women's health after the enactment of the Cannabis Act in Canada (CAC) (a law that allowed non-medical cannabis use), and the potential impact of the COVID-19 pandemic, call for a contemporary assessment of these two events. Our study measured associations between the CAC, the COVID-19 pandemic and the monthly prevalence rates of cannabis-, all drug- and alcohol-related diagnosed disorders among pregnant women in the province of Quebec.

DESIGN, SETTING AND PARTICIPANTS

This was a quasi-experimental design applying an interrupted time-series methodology in the province of Quebec, Canada. The participants were pregnant women aged 15-49 years, between January 2010 and July 2022.

MEASUREMENTS

Administrative health data from the Québec Integrated Chronic Disease Surveillance System were used to classify pregnant women according to cannabis-, all drug (excluding cannabis)- and alcohol-related disorders. The CAC (October 2018) and the COVID-19 pandemic (April 2020) were evaluated as (1) slope changes and (2) level changes. Cannabis-, all drug (excluding cannabis)- and alcohol-related disorders were measured by total monthly age-standardized monthly prevalence rate of each disorder for pregnant women aged 15-49 years.

FINDINGS

Before the CAC, the prevalence rate of cannabis-related diagnosed disorders significantly increased each month by 0.5% [95% confidence interval (CI) = 0.3-0.6] in the pregnant population. After the CAC, there were significant increases of 24% (95% CI = 1-53) of cannabis-related diagnosed disorders. No significant changes were observed for all drug (excluding cannabis)- and alcohol-related diagnosed disorders associated with the CAC. A non-significant decrease of 20% (95% CI = -38 to 3) was observed during the COVID-19 pandemic in alcohol-related disorders.

CONCLUSIONS

The monthly incidence rates of diagnosed cannabis-related disorders in pregnant women in Quebec increased significantly following the enactment of the Cannabis Act in Canada. Diagnoses of all drug (excluding cannabis)- and alcohol-related disorders remained relatively stable.