Needs and expectations for artificial intelligence in emergency medicine according to Canadian physicians.

BACKGROUND: Artificial Intelligence (AI) is recognized by emergency physicians (EPs) as an important technology that will affect clinical practice. Several AI-tools have already been developed to aid care delivery in emergency medicine (EM). However, many EM tools appear to have been developed without a cross-disciplinary needs assessment, making it difficult to understand their broader importance to general-practice. Clinician surveys about AI tools have been conducted within other medical specialties to help guide future design. This study aims to understand the needs of Canadian EPs for the apt use of AI-based tools. METHODS: A national cross-sectional, two-stage, mixed-method electronic survey of Canadian EPs was conducted from January-May 2022. The survey includes demographic and physician practice-pattern data, clinicians' current use and perceptions of AI, and individual rankings of which EM work-activities most benefit from AI. RESULTS: The primary outcome is a ranked list of high-priority AI-tools for EM that physicians want translated into general use within the next 10 years. When ranking specific AI examples, 'automated charting/report generation', 'clinical prediction rules' and 'monitoring vitals with early-warning detection' were the top items. When ranking by physician work-activities, 'AI-tools for documentation', 'AI-tools for computer use' and 'AI-tools for triaging patients' were the top items. For secondary outcomes, EPs indicated AI was 'likely' (43.1%) or 'extremely likely' (43.7%) to be able to complete the task of 'documentation' and indicated either 'a-great-deal' (32.8%) or 'quite-a-bit' (39.7%) of potential for AI in EM. Further, EPs were either 'strongly' (48.5%) or 'somewhat' (39.8%) interested in AI for EM. CONCLUSIONS: Physician input on the design of AI is essential to ensure the uptake of this technology. Translation of AI-tools to facilitate documentation is considered a high-priority, and respondents had high confidence that AI could facilitate this task. This study will guide future directions regarding the use of AI for EM and help direct efforts to address prevailing technology-translation barriers such as access to high-quality application-specific data and developing reporting guidelines for specific AI-applications. With a prioritized list of high-need AI applications, decision-makers can develop focused strategies to address these larger obstacles.

Water supply emergency preparedness and response in health care facilities: A systematic review on international evidence.

Introduction: Enabling health care facilities to deal with impairments or outages of water supply and sewage systems is essential and particularly important in the face of growing risk levels due to climate change and natural hazards. Yet, comprehensive assessments of the existing preparedness and response measures, both in theory and practice, are lacking. The objective of this review is to assess water supply and wastewater management in health care facilities in emergency settings and low-resource contexts. It thereby is a first step toward knowledge transfer across different world regions and/or contexts. Method: A systematic review was performed to identify published articles on the subject using online MEDLINE and Web of Science. The initial searches yielded a total of 1,845 records. Two independent reviewers screened identified records using selection criteria. A total of 39 relevant studies were identified. Descriptive analyses were used to summarize evidence of included studies. Results: Overall, water supply was far more discussed than wastewater management. Studies on emergency preparedness identified back-up water storage tank, additional pipelines, and underground wells as key sources to supply health care facilities with water during an emergency. In emergency response, bottled of water, followed by in-situ back-up water storage tanks previously installed as part of disaster preparedness measures, and tanker trucks to complete were most used. Questions on how to improve existing technologies, their uptake, but also the supplementation by alternative measures remain unanswered. Only few guidelines and tools on emergency preparedness were identified, while multiple studies formulated theoretical recommendations to guide preparedness. Recovery planning was rarely discussed, despite many studies mentioning the importance of the reconstruction and restoration phases. Literature focus on recovery is mostly on technical aspects, while organizational ones are largely absent. Despite their key role for preparedness and response, citizens and patients' perspectives are hugely underrepresented. This fits into the bigger picture as communication, awareness raising and actor cooperation in general is addressed comparatively little. Discussion: Combining organizational and technical aspects, and intersecting theory and practice will be necessary to address existing gaps. Improving both, preparedness and response, is key to maintaining public health and providing primary care.

Managing innovation: a qualitative study on the implementation of telehealth services in rural emergency departments.

BACKGROUND: Telehealth studies have highlighted the positive benefits of having the service in rural areas. However, there is evidence of limited adoption and utilization. Our objective was to evaluate this gap by exploring U.S. healthcare systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability. METHODS: We conducted semi-structured interviews with 18 key informants from six U.S. healthcare systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers. RESULTS: We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability. CONCLUSIONS: The implementation of healthcare innovation can be influenced by multiple factors. Our study contributes to the field by highlighting key factors and domains that play roles in specific stages of telehealth operation in rural hospitals. By appreciating and responding to these domains, healthcare systems may achieve more predictable and favorable implementation outcomes. Moreover, we recommend strategies to motivate the diffusion of promising innovations such as telehealth.

A pessoa em situação crítica no contexto de um serviço de urgência básico: construção de um procedimento de enfermagem no âmbito da ventilação não invasiva / The Critically ill person in the context of a basic emergency service: construction of a nursing procedure in the scope of non-invasive ventilation

Este relatório surge no âmbito da Unidade Curricular - Estágio de Natureza Profissional, do Curso de Mestrado em Enfermagem Médico-Cirúrgica, e procura descrever de forma critica e reflexiva todo o processo de aquisição e desenvolvimento de competências especializadas em enfermagem médico-cirúrgica, na área da pessoa em situação crítica. Para o desenvolvimento de competências procurou-se reunir o máximo de experiências e basear a praxis clínica em evidência científica, abarcando as dimensões da prestação de cuidados à pessoa e família em situação crítica, da formação, da gestão e da investigação. Nesse sentido, o estágio desenrolou-se num serviço de urgência básico, no qual emergiu a problemática de investigação, com a necessidade de construir um procedimento de enfermagem no âmbito da pessoa em situação crítica com ventilação não invasiva. A pertinência do estudo de investigação decorreu do impacto das doenças respiratórias na saúde, sociedade e economia, e a ventilação não invasiva surge como um tratamento seguro e eficaz no doente com insuficiência respiratória aguda ou crónica agudizada, e o seu sucesso depende de uma equipa de enfermagem treinada e qualificada na preparação, adaptação e vigilância do doente durante a técnica. Por outro lado, a construção de um procedimento de enfermagem, visa ser um instrumento de apoio a uma prática de cuidados mais diferenciada e sustentada. Tendo em conta o objetivo de investigação, optou-se por um estudo com recurso à técnica de Delphi. Para tal, aplicou-se um questionário a um grupo de enfermeiros peritos para avaliação da pertinência das intervenções sugeridas com vista à obtenção de consenso. Os resultados evidenciaram um consenso global muito favorável entre os peritos. Desta forma, o estudo permitiu a construção de um procedimento com as intervenções de enfermagem validadas e consensuais, para uma abordagem uniforme, segura e de excelência. Na sequência deste estudo, sugere-se a validação e implementação do procedimento na prática clínica real para aferir lacunas e poder ser alargado em âmbito nacional. Da experiência de estágio, salienta-se o papel preponderante do enfermeiro especialista em médico-cirúrgica num ambiente tão singular como um Serviço de Urgência Básico, na promoção da aprendizagem na equipa multidisciplinar e na diferenciação e melhoria contínua dos cuidados de enfermagem. De um ponto de vista individual, destaca-se o papel da formação profissional em enfermagem no aprofundamento de competências, num continuum de aprendizagem ao longo da vida, na reflexão sobre as práticas, na interação com o contexto envolvente, no saber agir em ambientes altamente imprevisíveis e mutáveis e na valorização da profissão.

This report falls within the scope of the Curricular Unit - Professional Internship, in the Master's degree of Medical-Surgical Nursing, and aims to describe, in a critical and reflective point of view, the process of acquisition and development of specialized skills of medical-surgical nursing, in what concerns the critically ill patient. To develop such skills, the trainee sought to gather as many practical experiences as possible and to base them in the best clinical practice and in the most accurate scientifically validated data. Also, the trainee had to persuade all the dimensions of care delivery to the person in a critical ill situation and to its family. To do so, it was necessary to reunite as many data as possible, to develop all the dimensions of care giving as well as training, management, and research. To accomplish the above mentioned, the internship took place at the peripherical emergency department. Since respiratory illnesses have a huge impact in the healthcare system, society and economy, a design of nursing procedures for the critically ill patient with non-invasive ventilated support was proposed. As a matter of fact, it is known that the success of non-invasive ventilated support depends largely on a trained and qualified nursing team, which is responsible for the preparation, initiation, and surveillance of the technique. Those procedures concur for the uniformization of nursing care, thus easing the decision-making processes, and promoting safety and quality regarding nursing care of the critically ill patient with non-invasive ventilated support. Taking into consideration the objective of the study, an approach according to Delphi methodology was chosen. To accomplish this, a questionnaire was applied to a group of expert nurses, who evaluated the relevance of the suggested interventions for the nursing procedure. The results showed a global favorable consensus among the group of experts. The study allowed the development of a procedure with validated and consensual nursing care, to achieve uniform, secure, and excellency in those results. After analyzing the results of this study, It was possible to suggest the validation and implementation of the procedure in real clinical practice, to assess gaps and to make it extended to country level. From the experience obtained in this internship, we could highlight the importance of the specialist in medical-surgical nursing as part of the team in an unique environment such as the peripherical emergency department. This role was determinant in matters of professional training of the nursing team, to improve and guarantee the safety of the process and to make the difference in the established processes. From a more personal point of view, this internship allowed the increase of personal skills, the urge to the continuum life learning process, the reflection on nursing practices, the interaction with the surrounding contexts, and the capacity to act in a highly unpredictable and mutable environments. It contributed as well to the valorization of the nursing profession.

User and community coping responses to service delivery gaps in emergency obstetric care provision in a rural community in Ghana.

The study sought to explore user and community responses to service delivery gaps in emergency obstetric care provision in rural Ghana. A qualitative design was employed to draw evidence from observations, interviews and focus group discussion among healthcare providers, clients and community members. Data processing and analysis followed a thematic approach. Findings reveal community interference in obstetric care delivery processes, reliance on unskilled providers, recourse to local oxytocin use, non-compliance to prescribed treatment and mistrust in healthcare providers as user and community coping mechanisms to perceived poor quality obstetric care. These behaviours have serious consequences on the life chances of pregnant and parturient women. The need to adapt to a more responsive and affordable maternal healthcare delivery system is essential for uptake of services in rural areas. Also, standardised guidelines to regulate health worker behaviour is critical to instil trust in the healthcare system.

Local and State Policy Action Taken in the United States to Address the Emergence of E-Cigarettes and Vaping: A Scoping Review of Literature.

INTRODUCTION: In response to rising rates of youth vaping and e-cigarette use, states and localities in the United States have adopted various tobacco control policies and have extended their utility to these emerging products. However, the extent to which these policies have been evaluated for their impact on youth use is unknown. METHOD: Two databases (PubMed, Google Scholar) were searched for English language peer-reviewed articles pertaining to electronic cigarette policy evaluation between 2009 and 2020. Primary articles of interest were journal articles that evaluated an e-cigarette policy. Secondary articles of interest were journal articles that identified any e-cigarette policy action without a formal evaluation component, those that evaluated tobacco policy, or those that described e-cigarette behaviors and trends. Tertiary articles included gray literature that provided context for e-cigarette trends and additional policy identification. RESULTS: The final sample consisted of 12 relevant articles with an e-cigarette policy evaluation component and 62 relevant articles without such component, and 19 gray literature sources. Findings were synthesized based on policy type: product classification, age restrictions, smoke-free policies, flavor bans, sales restrictions, taxation, packaging, and advertising. CONCLUSION: Policies that address access and use of e-cigarettes are common on the federal, state, and local level, are mostly reactionary, and mimic tobacco control efforts. Few policies have been formally evaluated for their effectiveness in reducing or preventing youth vaping. Strengthening the evidence base should be a priority for researchers going forward, given the potential of these policies to intervene on social and environmental conditions that affect youth initiation and uptake.

Intrauterine balloon tamponade for postpartum hemorrhage / Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto

Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.

Resumo Introdução: A hemorragia pós-parto trata-se de uma emergência obstétrica com elevada prevalência e morbimortalidade significativa, sobretudo em contextos de baixa acessibilidade a serviços especializados de saúde. Objetivo: Avaliar a efetividade do tamponamento por balão intrauterino no controle da hemorragia pós-parto, redução da necessidade de intervenções cirúrgicas de emergência e redução da mortalidade materna. Métodos: Revisão sistemática de ensaios clínicos randomizados, orientada pelo Cochrane Handbook for Systematic Reviews of Interventions e relatada através do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram considerados como critérios de elegibilidade ensaios clínicos randomizados que avaliaram o uso de diferentes tipos de balão para tamponamento intrauterino enquanto estratégia para a redução ou cessação da hemorragia pós-parto quando comparados a outras intervenções (farmacológicas ou cirúrgicas). Resultados: Quatro estudos avaliaram 498 pacientes para os desfechos preconizados. Em 80% dos casos relatados observou-se a cessação da hemorragia em um intervalo médio de 15 minutos, após a inserção dos dispositivos. O tempo de permanência dos dispositivos foi de 24 horas. Não foram relatados eventos adversos graves. Devido à heterogeneidade clínica entre os estudos, não foi possível realizar síntese quantitativa. Conclusão: Os achados obtidos não fornecem evidências suficientes para sustentar a utilização rotineira dos dispositivos de tamponamento uterino enquanto prática protocolar no controle da hemorragia pós-parto refratária. A utilização destes dispositivos, no entanto, parece ser promissora diante da falha das intervenções de primeira linha, podendo desempenhar um importante papel em termos de redução de morbimortalidade materna e preservação uterina.

[Historical conditions for emergence of the National Policy for Comprehensive LGBT Health in the social space of health in the State of Bahia, Brazil]. / Condições históricas para a emergência da Política Nacional de Saúde Integral LGBT no espaço social da saúde no Estado da Bahia, Brasil.

This is a health policy analysis with a qualitative approach, consisting of 15 interviews (six administrators and nine LGBT activists). The study aimed to understand the historical conditions for the emergence of the National Policy for Comprehensive LGBT Health (PNSI-LGBT) in the social space of health in the State of Bahia, Brazil. The study was based on Pierre Bourdieu's social theory and the study of the trajectories of the main actors involved in the policy's formalization. The results evidenced two moments: (1) shaping of the social space of LGBT health, including prior initiatives; (2) space of possibilities and the official discourse for fomenting the implementation of the PNSI-LGBT in Bahia. The LGBT social movement played a crucially important role in drafting the first proposals for a specific health policy. The state's relationship with the social movements occurred through professional issues and the actors concentrated almost exclusively on bureaucratic capital. It was quite common for actors to circulate between the activist subspace and the bureaucratic subspace. The activists interviewed here that reached the bureaucratic field mostly engaged in the health space for personal reasons and reported that it was a position in which they could act more effectively. The documental findings and collaboration by interlocutors reveal a process of continuous implementation of measures that expand the range of healthcare for the LGBT population. However, the Bahia State Health Department has still not clearly taken the responsibility for a state LGBT policy, and there is thus a hesitant and fragment incorporation of the PNSI-LGBT.

Trata-se de uma análise de política em saúde com abordagem qualitativa, composta por 15 entrevistas (seis gestores e nove ativistas LGBT). Buscou-se compreender as condições históricas para a emergência da Política Nacional de Saúde Integral LGBT (PNSI-LGBT) no espaço social da saúde no Estado da Bahia, Brasil. A teoria social de Pierre Bourdieu e o estudo das trajetórias dos principais agentes envolvidos com a formalização da política fundamentaram a pesquisa. Os resultados evidenciaram dois momentos: (1) conformação do espaço social da saúde LGBT: iniciativas precursoras; (2) espaço de possíveis e discurso oficial para fomento à implementação da PNSI-LGBT na Bahia. É inequívoca a importância do movimento social LGBT na elaboração das primeiras proposições de uma política específica de saúde. A relação do estado com os movimentos sociais se deu por questões profissionais, e os agentes concentravam principalmente e quase exclusivamente capital burocrático. Destaca-se que foi bastante frequente o trânsito de agentes do subespaço militante para o subespaço burocrático. Os militantes entrevistados que chegaram ao campo burocrático, em sua maioria, engajaram-se no espaço da saúde por motivo pessoal e referiram que essa era uma posição em que poderiam atuar de forma mais concreta. Os achados documentais e as colaborações dos interlocutores revelam um processo de contínuas implementações de ações que ampliam o leque de cuidados em saúde voltados à população LGBT. Todavia evidencia-se que a Secretaria de Saúde do Estado da Bahia não assume claramente a responsabilidade sobre uma política estadual LGBT e, nesse sentido, há uma incorporação claudicante e fragmentada da PNSI-LGBT.

Se trata de un análisis de políticas en salud con abordaje cualitativo, compuesto por quince entrevistas (a seis gestores y nueve activistas LGBT). Se buscó comprender las condiciones históricas para la emergencia de la Política Nacional de Salud Integral LGBT (PNSI-LGBT) en el espacio social de la salud en el Estado de Bahía, Brasil. La teoría social de Pierre Bourdieu y el estudio de las trayectorias de los principales agentes implicados con la formalización de la política fundamentaron la investigación. Los resultados evidenciaron dos momentos: (1) conformación del espacio social de la salud LGBT: iniciativas precursoras; (2) espacio de posibilidades y discurso oficial para el fomento a la implementación de la PNSI-LGBT en Bahía. Es inequívoca la importancia del movimiento social LGBT en la elaboración de las primeras propuestas de una política específica de salud. La relación del estado con los movimientos sociales, se dio por cuestiones profesionales, y los agentes concentraban principalmente, y casi exclusivamente, el capital burocrático. Se destaca que fue bastante frecuente el tránsito de agentes del subespacio militante hacia el subespacio burocrático. Los militantes entrevistados que llegaron al campo burocrático, en su mayoría, se implicaron en el espacio de salud por motivos personales e informaron que esa era una posición en la que podrían actuar de forma más concreta. Los resultados documentales y las colaboraciones de los interlocutores revelan un proceso de continuas implementaciones de acciones, que amplían el abanico de cuidados en salud dirigidos a la población LGBT. Todavía, se evidencia que la Departamento de Salud del Estado de Bahia no asume claramente la responsabilidad sobre una política estatal LGBT y, en este sentido, hay una incorporación claudicante y fragmentada de la PNSI-LGBT.

Catalyzing the Translation of Patient-Centered Research Into United States Trauma Care Systems: A Case Example.

BACKGROUND: The expedient translation of research findings into sustainable intervention procedures is a longstanding health care system priority. The Patient-Centered Outcomes Research Institute (PCORI) has facilitated the development of "research done differently," with a central tenet that key stakeholders can be productively engaged throughout the research process. Literature review revealed few examples of whether, as originally posited, PCORI's innovative stakeholder-driven approach could catalyze the expedient translation of research results into practice. OBJECTIVES: This narrative review traces the historical development of an American College of Surgeons Committee on Trauma (ACS/COT) policy guidance, facilitated by evidence supplied by the PCORI-funded studies evaluating the delivery of patient-centered care transitions. Key elements catalyzing the guidance are reviewed, including the sustained engagement of ACS/COT policy stakeholders who have the capacity to invoke system-level implementation strategies, such as regulatory mandates linked to verification site visits. Other key elements, including the encouragement of patient stakeholder voice in policy decisions and the incorporation of end-of-study policy summits in pragmatic comparative effectiveness trial design, are discussed. CONCLUSIONS: Informed by comparative effectiveness trials, ACS/COT policy has expedited introduction of the patient-centered care construct into US trauma care systems. A comparative health care systems conceptual framework for transitional care which incorporates Research Lifecycle, pragmatic clinical trial and implementation science models is articulated. When combined with Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE), employed as a targeted implementation strategy, this approach may accelerate the sustainable delivery of high-quality patient-centered care transitions for US trauma care systems.

Implementation strategies in emergency management of children: A scoping review.

BACKGROUND: Implementation strategies are vital for the uptake of evidence to improve health, healthcare delivery, and decision-making. Medical or mental emergencies may be life-threatening, especially in children, due to their unique physiological needs when presenting in the emergency departments (EDs). Thus, practice change in EDs attending to children requires evidence-informed considerations regarding the best approaches to implementing research evidence. We aimed to identify and map the characteristics of implementation strategies used in the emergency management of children. METHODS: We conducted a scoping review using Arksey and O'Malley's framework. We searched four databases [Medline (Ovid), Embase (Ovid), Cochrane Central (Wiley) and CINAHL (Ebsco)] from inception to May 2019, for implementation studies in children (≤21 years) in emergency settings. Two pairs of reviewers independently selected studies for inclusion and extracted the data. We performed a descriptive analysis of the included studies. RESULTS: We included 87 studies from a total of 9,607 retrieved citations. Most of the studies were before and after study design (n = 68, 61%) conducted in North America (n = 63, 70%); less than one-tenth of the included studies (n = 7, 8%) were randomized controlled trials (RCTs). About one-third of the included studies used a single strategy to improve the uptake of research evidence. Dissemination strategies were more commonly utilized (n = 77, 89%) compared to other implementation strategies; process (n = 47, 54%), integration (n = 49, 56%), and capacity building and scale-up strategies (n = 13, 15%). Studies that adopted capacity building and scale-up as part of the strategies were most effective (100%) compared to dissemination (90%), process (88%) and integration (85%). CONCLUSIONS: Studies on implementation strategies in emergency management of children have mostly been non-randomized studies. This review suggests that 'dissemination' is the most common strategy used, and 'capacity building and scale-up' are the most effective strategies. Higher-quality evidence from randomized-controlled trials is needed to accurately assess the effectiveness of implementation strategies in emergency management of children.

Attaining 95-95-95 through Implementation Science: 15 Years of Insights and Best Practices from the Walter Reed Army Institute of Research's Implementation of the U.S. President's Emergency Plan for AIDS Relief.

The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR's implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR's contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.

Condições históricas para a emergência da Política Nacional de Saúde Integral LGBT no espaço social da saúde no Estado da Bahia, Brasil / Historical conditions for emergence of the National Policy for Comprehensive LGBT Health in the social space of health in the State of Bahia, Brazil / Condiciones históricas para la emergencia de la Política Nacional de Salud Integral LGBT en el espacio social de la salud en el Estado de Bahía, Brasil

Trata-se de uma análise de política em saúde com abordagem qualitativa, composta por 15 entrevistas (seis gestores e nove ativistas LGBT). Buscou-se compreender as condições históricas para a emergência da Política Nacional de Saúde Integral LGBT (PNSI-LGBT) no espaço social da saúde no Estado da Bahia, Brasil. A teoria social de Pierre Bourdieu e o estudo das trajetórias dos principais agentes envolvidos com a formalização da política fundamentaram a pesquisa. Os resultados evidenciaram dois momentos: (1) conformação do espaço social da saúde LGBT: iniciativas precursoras; (2) espaço de possíveis e discurso oficial para fomento à implementação da PNSI-LGBT na Bahia. É inequívoca a importância do movimento social LGBT na elaboração das primeiras proposições de uma política específica de saúde. A relação do estado com os movimentos sociais se deu por questões profissionais, e os agentes concentravam principalmente e quase exclusivamente capital burocrático. Destaca-se que foi bastante frequente o trânsito de agentes do subespaço militante para o subespaço burocrático. Os militantes entrevistados que chegaram ao campo burocrático, em sua maioria, engajaram-se no espaço da saúde por motivo pessoal e referiram que essa era uma posição em que poderiam atuar de forma mais concreta. Os achados documentais e as colaborações dos interlocutores revelam um processo de contínuas implementações de ações que ampliam o leque de cuidados em saúde voltados à população LGBT. Todavia evidencia-se que a Secretaria de Saúde do Estado da Bahia não assume claramente a responsabilidade sobre uma política estadual LGBT e, nesse sentido, há uma incorporação claudicante e fragmentada da PNSI-LGBT.

This is a health policy analysis with a qualitative approach, consisting of 15 interviews (six administrators and nine LGBT activists). The study aimed to understand the historical conditions for the emergence of the National Policy for Comprehensive LGBT Health (PNSI-LGBT) in the social space of health in the State of Bahia, Brazil. The study was based on Pierre Bourdieu's social theory and the study of the trajectories of the main actors involved in the policy's formalization. The results evidenced two moments: (1) shaping of the social space of LGBT health, including prior initiatives; (2) space of possibilities and the official discourse for fomenting the implementation of the PNSI-LGBT in Bahia. The LGBT social movement played a crucially important role in drafting the first proposals for a specific health policy. The state's relationship with the social movements occurred through professional issues and the actors concentrated almost exclusively on bureaucratic capital. It was quite common for actors to circulate between the activist subspace and the bureaucratic subspace. The activists interviewed here that reached the bureaucratic field mostly engaged in the health space for personal reasons and reported that it was a position in which they could act more effectively. The documental findings and collaboration by interlocutors reveal a process of continuous implementation of measures that expand the range of healthcare for the LGBT population. However, the Bahia State Health Department has still not clearly taken the responsibility for a state LGBT policy, and there is thus a hesitant and fragment incorporation of the PNSI-LGBT.

Se trata de un análisis de políticas en salud con abordaje cualitativo, compuesto por quince entrevistas (a seis gestores y nueve activistas LGBT). Se buscó comprender las condiciones históricas para la emergencia de la Política Nacional de Salud Integral LGBT (PNSI-LGBT) en el espacio social de la salud en el Estado de Bahía, Brasil. La teoría social de Pierre Bourdieu y el estudio de las trayectorias de los principales agentes implicados con la formalización de la política fundamentaron la investigación. Los resultados evidenciaron dos momentos: (1) conformación del espacio social de la salud LGBT: iniciativas precursoras; (2) espacio de posibilidades y discurso oficial para el fomento a la implementación de la PNSI-LGBT en Bahía. Es inequívoca la importancia del movimiento social LGBT en la elaboración de las primeras propuestas de una política específica de salud. La relación del estado con los movimientos sociales, se dio por cuestiones profesionales, y los agentes concentraban principalmente, y casi exclusivamente, el capital burocrático. Se destaca que fue bastante frecuente el tránsito de agentes del subespacio militante hacia el subespacio burocrático. Los militantes entrevistados que llegaron al campo burocrático, en su mayoría, se implicaron en el espacio de salud por motivos personales e informaron que esa era una posición en la que podrían actuar de forma más concreta. Los resultados documentales y las colaboraciones de los interlocutores revelan un proceso de continuas implementaciones de acciones, que amplían el abanico de cuidados en salud dirigidos a la población LGBT. Todavía, se evidencia que la Departamento de Salud del Estado de Bahia no asume claramente la responsabilidad sobre una política estatal LGBT y, en este sentido, hay una incorporación claudicante y fragmentada de la PNSI-LGBT.

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes.

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

Management of Canadian Pediatric Patients With Glomerular Diseases During the COVID-19 Pandemic: Recommendations From the Canadian Association of Pediatric Nephrologists COVID-19 Rapid Response Team.

PURPOSE: The goal of these recommendations is to provide guidance on the optimal care of children with glomerular diseases during the COVID-19 pandemic. Patients with glomerular diseases are known to be more susceptible to infection. Risk factors include decreased vaccine uptake, urinary loss of immunoglobulins, and treatment with immunosuppressive medications. The Canadian Society of Nephrology (CSN) recently published guidelines on the care of adult glomerulonephritis patients. This guideline aims to expand and adapt those recommendations for programs caring for children with glomerular diseases. SOURCES OF INFORMATION: We used the CSN COVID-19 Rapid Response Team adult glomerulonephritis recommendations, published in the Canadian Journal of Kidney Health and Disease, as the foundation for our guidelines. We reviewed documents published by nephrology and non-nephrology societies and health care agencies focused on kidney disease and immunocompromised populations. Finally, we conducted a formal literature review of publications relevant to pediatric and adult glomerular disease, chronic kidney disease, hypertension, and immunosuppression in the context of the COVID-19 pandemic. METHODS: The leadership of the Canadian Association of Pediatric Nephrologists (CAPN), which is affiliated with the CSN, identified a team of clinicians and researchers with expertise in pediatric glomerular diseases. The aim was to adapt Canadian adult glomerulonephritis guidelines to make them applicable to children and discuss pediatric-specific considerations. The updated guidelines were peer-reviewed by senior clinicians with expertise in the care of childhood glomerular diseases. KEY FINDINGS: We identified a number of key areas of glomerular disease care likely to be affected by the COVID-19 pandemic, including (1) clinic visit scheduling, (2) visit types, (3) provision of multidisciplinary care, (4) blood work and imaging, (5) home monitoring, (6) immunosuppression, (7) other medications, (8) immunizations, (9) management of children with suspected COVID-19, (10) renal biopsy, (11) patient education and support, and (12) school and child care. LIMITATIONS: There are minimal data regarding the characteristics and outcomes of COVID-19 in adult or pediatric glomerular disease patients, as well as the efficacy of strategies to prevent infection transmission within these populations. Therefore, the majority of these recommendations are based on expert opinion and consensus guidance. To expedite the publication of these guidelines, an internal peer-review process was conducted, which may not have been as rigorous as formal journal peer-review. IMPLICATIONS: These guidelines are intended to promote optimal care delivery for children with existing or newly diagnosed glomerular diseases during the COVID-19 pandemic. The implications of modified care delivery, altered immunosuppression strategies, and limited access to existing resources remain uncertain.

Emerging mental health challenges, strategies, and opportunities in the context of the COVID-19 pandemic: Perspectives from South American decision-makers

[ABSTRACT]. Objective. To identify emerging mental health problems, strategies to address them, and opportunities to reform mental health systems during the COVID-19 pandemic in South America. Methods. An online questionnaire was sent to mental health decision-makers of ministries of health in 10 South American countries in mid-April 2020. The semi-structured questionnaire had 12 questions clustered into three main sections: emerging challenges in mental health, current and potential strategies to face the pandemic, and key elements for mental health reform. We identified keywords and themes for each section through summative content analysis. Results. Increasing mental health burden and needs were reported as direct and indirect consequences of the COVID-19 pandemic. National lockdowns challenge the delivery and access to mental health treatment and care. Strategies to meet mental health needs rely heavily on timely and adequate responses by strengthened mental health governance and systems, availability of services, virtual platforms, and appropriate capacity- building for service providers. Short- and medium-term strategies focused on bolstering community-based mental health networks and telemedicine for high-risk populations. Opportunities for long-term mental health reform entail strengthening legal frameworks, redistribution of financial resources, and collaboration with local and international partners. Conclusions. Mental health and psychosocial support have been identified as a priority area by South American countries in the COVID-19 response. The pandemic has generated specific needs that require appropriate actions, including implementing virtual interventions, orienting capacity-building toward protecting users and health providers, strengthening evidence-driven decision-making, and integrating mental health and psychosocial support in high-level mechanisms guiding the response to COVID-19.

[RESUMEN]. Objetivo. Determinar los problemas de salud mental emergentes, las estrategias para abordarlos y las oportunidades para reformar los sistemas de salud durante la pandemia de COVID-19 en América del Sur. Métodos. A mediados de abril del 2020, se envió un cuestionario en línea a los encargados de tomar decisiones en materia de salud mental en los Ministerios de Salud de diez países de América del Sur. El cuestionario semiestructurado consistía en doce preguntas agrupadas en tres secciones principales: desafíos emergentes en materia de salud mental, estrategias actuales y posibles para enfrentar la pandemia, y elementos clave para la reforma de la salud mental. Establecimos palabras clave y temas para cada sección mediante el análisis del contenido sumativo. Resultados. Se informó un aumento de la carga y las necesidades en materia de salud mental como consecuencia directa e indirecta de la pandemia de COVID-19. Los confinamientos a nivel nacional representan un desafío en la prestación y el acceso al tratamiento y la atención de la salud mental. Las estrategias para satisfacer las necesidades de salud mental dependen en gran medida de las respuestas oportunas y adecuadas, que requieren el fortalecimiento de la gobernanza y de los sistemas en el ámbito de la salud mental, la disponibilidad de servicios y plataformas virtuales, y la formación de capacidad apropiada para los prestadores de servicios. Las estrategias a corto y mediano plazo se centran en reforzar las redes comunitarias de salud mental y la telemedicina para los grupos poblacionales de alto riesgo. Las oportunidades para la reforma de la salud mental a largo plazo entrañan fortalecer los marcos jurídicos, la redistribución de los recursos financieros y la colaboración con los asociados a nivel nacional e internacional. Conclusiones. En los países de América del Sur, se ha determinado que la salud mental y el apoyo psicosocial son un área prioritaria en la respuesta a la COVID-19. La pandemia ha generado necesidades específicas que requieren medidas apropiadas, como las intervenciones virtuales, la orientación de la formación de capacidad hacia la protección de los usuarios y prestadores de servicios de salud, el fortalecimiento de la toma de decisiones basadas en la evidencia, y la integración de la salud mental y el apoyo psicosocial en los mecanismos de alto nivel que guían la respuesta a la COVID-19.

[RESUMO]. Objetivo. Identificar problemas emergentes de saúde mental, as estratégias para enfrentá-los e oportunidades para reformar os sistemas de saúde mental durante a pandemia de COVID-19 na América do Sul. Métodos. Em meados de abril de 2020, enviamos um questionário online aos responsáveis pela tomada de decisões em saúde mental dos ministérios da saúde de 10 países da América do Sul. O questionário semiestruturado continha 12 perguntas agrupadas em três seções principais: desafios emergentes em saúde mental, estratégias atuais e potenciais para enfrentar a pandemia e elementos-chave para a reforma da saúde mental. Identificamos palavras-chave e temas para cada seção através da análise de conteúdo sumativa. Resultados. O aumento das necessidades e da carga sobre os serviços de saúde mental foram descritos como consequências diretas e indiretas da pandemia de COVID-19. As medidas de confinamento implementadas pelos governos nacionais dificultam o acesso e a prestação de cuidados e tratamentos de saúde mental. As estratégias para atender às necessidades de saúde mental dependem de respostas rápidas e adequadas através do fortalecimento da governança e dos sistemas de saúde mental, da disponibilidade de serviços, de plataformas virtuais e da capacitação apropriada dos prestadores de serviços. As estratégias de curto e médio prazo se concentraram no reforço das redes comunitárias de saúde mental e da telemedicina para as populações de alto risco. As oportunidades de reforma da saúde mental a longo prazo implicam o fortalecimento dos quadros jurídicos, a redistribuição de recursos financeiros e a colaboração com parceiros locais e internacionais. Conclusões. A saúde mental e o apoio psicossocial foram identificados como uma área prioritária pelos países da América do Sul na resposta à COVID-19. A pandemia criou necessidades específicas que exigem ações apropriadas, incluindo a implementação de intervenções virtuais, a capacitação orientada à proteção dos usuários e prestadores da atenção à saúde, o fortalecimento da tomada de decisões baseada em evidências e a integração da saúde mental e do apoio psicossocial em mecanismos de alto nível que orientem a resposta à COVID-19.

Methods and implementation of a pediatric asthma pharmacogenomic study in the emergency department setting.

OBJECTIVES: The emergency department (ED) is a challenging setting to conduct pharmacogenomic studies and integrate that data into fast-paced and potentially life-saving treatment decisions. Therefore, our objective is to present the methods and feasibility of a pilot pharmacogenomic study set in the ED that measured pediatric bronchodilator response (BDR) during acute asthma exacerbations. METHODS: This is an exploratory pilot study that collected buccal swabs for DNA and measured BDR during ED encounters for pediatric asthma exacerbations. We evaluated the study's feasibility with a qualitative analysis of ED provider surveys and quantitatively by the proportion of eligible patients enrolled. RESULTS: We enrolled 59 out of 90 patients (65%) that were identified and considered eligible during a 5-month period (target enrollment 60 patients over 12 months). The median patient age was 7 years (interquartile range 4-9 years), 61% (N = 36) were male, and 92% (N = 54) were African American. Quality DNA collection was successful for all 59 patients. The ED provider survey response rate was 100%. Most ED providers reported that the study did not impact their workflow (98% of physicians, 88% of nurses, and 90% of respiratory therapists). ED providers did report difficulties with spirometry in the younger age group. CONCLUSIONS: Pharmacogenomic studies can be conducted in the ED setting, and enroll a younger patient population with a high proportion of minority participants. By disseminating this study's methods and feasibility analysis, we aim to increase interest in pharmacogenomic studies set in the ED and aimed toward future ED-based pharmacogenomic decision-making.

Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake: A Quality Improvement Project.

Preexposure prophylaxis (PrEP) is highly effective in preventing HIV among both men and women, with the reduction in risk directly linked to medication adherence. Navigation services and other adherence interventions have demonstrated efficacy in medication uptake; however, their use may not be fully integrated into clinic operations or their roles clearly defined. This quality improvement (QI) project developed an evidenced-based PrEP Navigation (PN) tool to identify patient-reported barriers to uptake and to support process improvement at a large community health center in Washington, DC. Outcomes related to patient-reported barriers, patient demographics, and time to medication pickup from the pharmacy were measured before and after implementation. A total of 198 patients were included in this analysis. Mean days from initial prescription to medication pickup was reduced by 1.42 days (p = .030) following PN tool implementation. The evidenced-based PN tool is modifiable to the needs of the individual clinic and the patients they care for to support wide-scale PrEP uptake and continuous system process improvements.

Fármacos antifibrinolíticos para tratar la hemorragia posparto primaria / Antifibrinolytic drugs for treating primary postpartum hemorrhage

No disponible

Implementation of an Emergency Use Authorization Test During an Impending National Crisis.

The laboratory response to the current severe acute respiratory syndrome coronavirus 2 pandemic may be termed heroic. From the identification of the novel coronavirus to implementation of routine laboratory testing around the world to the development of potential vaccines, laboratories have played a critical role in the efforts to curtail this pandemic. In this brief report, we review our own effort at a midsized, rural, academic medical center to implement a molecular test for the virus; and we share insights and lessons learned from that process, which might be helpful in similar situations in the future.

Provider knowledge and perceptions following an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care: A mixed-methods study in Ghana.

INTRODUCTION: Little is known about the effect of integrating respectful maternity care into clinical training programs. We sought to examine the effectiveness of an integrated simulation training on emergency obstetric and neonatal care and respectful maternity care on providers' knowledge and self-efficacy, and to asess providers' perceptions of the integrated training. METHODS: The project was piloted in East Mamprusi district in Northern Ghana. Forty-three maternity providers were trained, with six participants trained as Simulation Facilitators. Data are from self-administered evaluation forms (with structured and open-ended questions) from all 43 providers and in-depth interviews with 17 providers. We conducted descriptive quantitative analysis and framework qualitative analysis. RESULTS: Provider knowledge increased from an average of 61.6% at pre-test to 74.5% at post-test. Self-efficacy also increased from an average of 5.8/10 at pretest to 9.2/10 at post-test. Process evaluation data showed that providers valued the training. Over 95% of participants agreed that the training was useful to them and that they will use the tools learned in the training in their practice. Overall, providers had positive perceptions of the training. They noted improvements in their knowledge and confidence to manage obstetric and neonatal emergencies, as well as in patient-provider communication and teamwork. Many listed respectful maternity care elements as what was most impactful to them from the training. CONCLUSIONS: Simulation and team-training on emergency obstetric and neonatal care, combined with respectful maternity care content, can enable health care providers to improve both their clinical and interpersonal knowledge and skills in a training setting that reflects their complex and stressful work environments. Our findings suggest this type of training is feasible, acceptable, and effective in limited-resource settings. Uptake of such trainings could drive efforts towards providing high quality safe, responsive, and respectful obstetric and neonatal care.