Non-invasive Respiratory Support or Intubation during Stabilization after Birth and Neonatal and Neurodevelopmental Outcomes in Infants Born Preterm at 23-25 Weeks of Gestation.

OBJECTIVE: To examine the association between non-invasive respiratory support (NRS) or tracheal intubation (TI) during stabilization in infants born at 23-25 weeks of gestation and severe brain injury (sBI) or death, and significant neurodevelopmental impairment (sNDI). STUDY DESIGN: A retrospective cohort study of infants born at 230/7-256/7 weeks of gestation in Canada. We compared infants successfully managed with NRS or TI during 30 minutes after birth. The primary outcomes were sBI or death before discharge, and sNDI among survivors with follow-up data at 18-24 months corrected age. The associations between exposures and outcomes were assessed using logistic regression models, and propensity score matched (PSM) analyses. RESULTS: The mean (SD) of gestational age and birth weight were 24.6 (0.6), 24.3 (0.7) weeks [p <0.01], and 757 (173), 705 (130) grams [p <0.01] in the NRS, and TI groups, respectively, and 77% of infants in the NRS group were intubated by 7 days of age. sBI or death occurred in 25% (283/1118), and 36% (722/ 2012) of infants in the NRS and TI groups, respectively (adjusted odds ratio [aOR] and 95% confidence interval [CI] 0.74 [0.60, 0.91]). Among survivors with follow-up data, sNDI occurred in 17% (96/551), and 23% (218/937) of infants in the NRS and TI groups, respectively (aOR [95% CI] 0.77 [0.60, 0.99]). In the PSM analyses (NRS vs TI), results were consistent for sBI or death (OR [95% CI] 0.72 [0.60, 0.86]), but not for sNDI (OR [95% CI] 0.78 [0.58, 1.05]). CONCLUSIONS: Infants born at 23-25 weeks who were successfully managed with NRS, compared with TI, in the first 30 minutes after birth had lower odds of sBI or death before discharge, but had no significant differences in neurodevelopmental outcomes among survivors.

The multicenter impacts of an emergency physician lead on departmental flow and provider experiences.

INTRODUCTION: Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. METHODS: Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. RESULTS: The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. CONCLUSION: In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

RéSUMé: INTRODUCTION: Le flux des services d'urgence a une incidence sur la sécurité des patients, la qualité des soins et la satisfaction des fournisseurs de services d'urgence. Il a été démontré que les interventions de débit améliorent le flux, mais peu d'études ont rapporté l'impact des rôles de leadership des médecins des urgences sur le flux des patients et les expériences des prestataires. L'objectif de l'étude était d'évaluer l'impact du rôle du médecin chef des urgences sur les paramètres de flux des urgences et les expériences des prestataires. MéTHODES: Les données quantitatives sur les paramètres du flux des patients ont été recueillies à partir des systèmes d'information des urgences de deux hôpitaux tertiaires et analysées afin de comparer la durée du séjour aux urgences, la durée du séjour dans le couloir des SMU, le temps d'évaluation initiale par le médecin, les réadmissions dans les 72 heures et les taux de sortie sans consultation trois mois avant et après la mise en œuvre du rôle de chef des urgences. Les paramètres de débit des urgences pour les patients adultes de chaque site ont été analysés indépendamment à l'aide de statistiques descriptives et inférentielles, de tests t et d'une analyse de régression multivariable. Les données qualitatives ont été recueillies par le biais d'enquêtes auprès de fournisseurs de services d'urgence (médecins, infirmières et services médicaux d'urgence) sur leur expérience de travail avec les médecins chefs des services d'urgence et analysées pour en dégager les thèmes concernant l'impact des médecins chefs des services d'urgence. RéSULTATS: Le nombre de visites aux urgences était relativement stable avant et après au Peter Lougheed Centre (Lougheed), mais a augmenté avant et après au Foothills Medical Center (Foothills). Après l'intervention, la durée médiane du séjour aux urgences de Lougheed a diminué de 18 minutes (p < 0.001) et celle des urgences de Foothills a augmenté de 8 minutes (p < 0.001). La durée du séjour en SMU a diminué de 20 minutes à Lougheed (p < 0.001), et a augmenté de 17 minutes à Foothills (p < 0.001). Les thèmes abordés dans les commentaires des fournisseurs étaient les suivants : les responsables des urgences (1) facilitaient le flux des patients, (2) avaient un impact sur la charge de travail des fournisseurs et (3) favorisaient le flux et la sécurité des patients grâce à des évaluations, des traitements et des examens précoces. CONCLUSION: Dans cette étude, le médecin chef des urgences a eu un impact variable sur les paramètres de débit des urgences dans les différents sites, mais les enseignements importants tirés des expériences des fournisseurs peuvent guider la mise en œuvre future du médecin chef des urgences.

The systemized exploitation of temporary migrant agricultural workers in Canada: Exacerbation of health vulnerabilities during the COVID-19 pandemic and recommendations for the future.

In 2018, 55,734 jobs in Canadian agriculture were filled by temporary migrant workers, accounting for nearly 20 percent of total employment in this sector. Though referred to as temporary, those migrant workers often fill long-term positions and provide crucial support to the Canadian agricultural industry, which has seen an increasing disengagement from the domestic workforce in the last fifteen years. Health vulnerabilities faced by temporary migrant workers are already well documented. In addition, there are multiple systemic factors inherent within the structure and implementation of the Temporary Foreign Worker Program that contribute to the perpetuation of health inequities within this population. The COVID-19 pandemic has both exacerbated many of these disparities and further increased the risk of labour rights violations and vulnerability to exploitation for these workers. As Canada's 2020 growing season comes to an end, thousands of temporary migrant agricultural workers are returning to their native countries. With planning for next year's growing season already commencing, this timely analysis aims to examine health vulnerabilities faced by TMAWs during the COVID-19 pandemic. Five key areas are examined: occupational injuries, substandard living conditions, psychological difficulties, lack of access to healthcare and barriers in exercising labour rights. Building on this analysis, recommendations for policy and practice aimed at improving migrant workers' health are discussed.