Pilot case-control study of paediatric falls from windows.

BACKGROUND: Unintentional falls from windows are an important cause of paediatric morbidity. There have been no controlled studies to identify modifiable environmental risk factors for window falls in young children. The authors have piloted a case-control study to test procedures for case identification, subject enrolment, and environmental data collection. METHODS: Case windows were identified when a child 0-9 years old presented for care after a fall from that window. Control windows were identified (1) from the child's home and (2) from the home of an age- and gender-matched child seeking care for an injury diagnosis not related to a window fall. Study staff visited enrolled homes to collect window measurements and conduct window screen performance tests. RESULTS: The authors enrolled and collected data on 18 case windows, 18 in-home controls, and 14 matched community controls. Six potential community controls were contacted for every one enrolled. Families who completed the home visit viewed study procedures positively. Case windows were more likely than community controls to be horizontal sliders (100% vs 50%), to have deeper sills (6.28 vs 4.31 inches), to be higher above the exterior surface (183 vs 82 inches), and to have screens that failed below a threshold derived from the static pressure of a 3-year-old leaning against the mesh (60.0% vs 16.7%). Case windows varied very little from in-home controls. DISCUSSION: Case-control methodology can be used to study risk factors for paediatric falls from windows. Recruitment of community controls is challenging but essential, because in-home controls tend to be over-matched on important variables. A home visit allows direct measurement of window type, height, sill depth, and screen performance. These variables should all be investigated in subsequent, larger studies covering major housing markets.

Working with Senior Residents: How to get past "You're doing great!"

Audience: This content is intended for emergency medicine faculty. Introduction: Faculty at our institution noted that it can be easy to identify and address the knowledge gaps of junior learners. However, they often find different skills are needed when precepting senior residents, a sentiment shared by faculty at other institutions.1 To foster the skills needed for lifelong learning and deliberate practice, it is crucial that educators find methods to effectively assess the skills of senior residents and provide them with continued feedback.2 The goal of this faculty development session is to outline methods educators can use with senior residents to support their autonomy and independence while exploring their clinical reasoning, pushing them outside of their comfort zone, and promoting reflective and deliberate practice.2-9. Educational Objectives: By the end of the lecture, all faculty will be able to 1) describe how to use the Aunt Minnie method of precepting for senior residents, 2) list examples of ways in which they can probe the clinical reasoning of senior residents, 3) explain how to use reflective feedback techniques with senior residents, and 4) report use of the techniques discussed during this session when precepting senior residents in the emergency department. Educational Methods: This content is presented as a PowerPoint lecture with subsequent discussion. Research Methods: A post-session survey was distributed to allow participants to evaluate the session. This survey was sent four months after the session to gauge how often participants were using the covered techniques on their clinical shifts in the interim. Results: The majority of survey respondents reported that they initially felt that precepting senior learners was "somewhat difficult" and that they found this session "valuable" in helping them address this challenge. Faculty reported using all of the techniques discussed in this session during their clinical shifts, but were more likely to use methods to promote clinical reasoning or reflective feedback than the Aunt Minnie method of precepting. Overall, respondents reported learning new skills during this exercise and appreciated the format which allowed them to share their own experiences of working with the senior residents and brainstorm techniques that might be useful beyond those discussed by the instructors. Discussion: This faculty development session successfully introduced emergency medicine faculty to techniques that can be used to improve feedback and assessment of senior residents. The lecture format allowed for efficient transmission of material, while several group discussions and a role-play activity allowed for integration of material and sharing of experiences. Overall this exercise was a success with faculty reporting use of several of the techniques discussed. In future iterations, it may be beneficial to integrate more role-play activities to allow participants to practice more of the skills learned in a simulated environment prior to implementing on shifts with learners. Topics: Feedback, deliberate practice, clinical reasoning, precepting.

National survey of emergency department alcohol screening and intervention practices.

STUDY OBJECTIVE: We describe current alcohol screening and brief intervention practices in emergency departments (EDs) at Level I and Level II trauma centers and characterize ED directors' attitudes and perceived barriers associated with these practices among injured patients in the ED. METHODS: ED directors at Level I and Level II trauma centers were surveyed about current alcohol screening and intervention practices in the ED, as well as knowledge, attitudes, and perceived barriers to these practices. RESULTS: Nearly half (46.0%) of ED directors surveyed responded. The majority (64.5%) reported using a serum alcohol level to routinely screen for unhealthy alcohol use; only 23.6% routinely use standardized instruments. Sixty-five percent of ED directors support screening and 70% support intervention among injured ED patients. Only 15% reported having formal screening and intervention policies in their ED, and 9% reported offering brief alcohol intervention by trained personnel. The most commonly perceived barriers to implementation are provider time (83%) and financial resources (55%). Of injured patients identified as exhibiting alcohol misuse, few (12%) receive brief intervention conducted by trained personnel. CONCLUSION: Current alcohol screening and brief intervention practices are lagging behind national guidelines. Although the majority of ED directors support the idea of alcohol screening and intervention, these beliefs have not yet been translated to routine clinical care.

Carbon monoxide epidemic among immigrant populations: King County, Washington, 2006.

OBJECTIVES: We investigated an outbreak of carbon monoxide (CO) poisoning after a power outage to determine its extent, identify risk factors, and develop prevention measures. METHODS: We reviewed medical records and medical examiner reports of patients with CO poisoning or related symptoms during December 15 to 24, 2006. We grouped patients into households exposed concurrently to a single source of CO. RESULTS: Among 259 patients with CO poisoning, 204 cases were laboratory confirmed, 37 were probable, 10 were suspected, and 8 were fatal. Of 86 households studied, 58% (n = 50) were immigrant households from Africa (n = 21), Asia (n = 15), Latin America (n = 10), and the Middle East (n = 4); 34% (n = 29) were US-born households. One percent of households was European (n = 1), and the origin for 7% (n = 6) was unknown. Charcoal was the most common fuel source used among immigrant households (82%), whereas liquid fuel was predominant among US-born households (34%). CONCLUSIONS: Educational campaigns to prevent CO poisoning should consider immigrants' cultural practices and languages and specifically warn against burning charcoal indoors and incorrect ventilation of gasoline- or propane-powered electric generators.

Alcohol and risk of mortality in patients with traumatic brain injury.

BACKGROUND: Laboratory and clinical studies demonstrate inconsistent findings on the effect of alcohol on traumatic brain injury (TBI) outcome. The purpose of this study is to use a comprehensive trauma database to determine whether blood alcohol concentration (BAC) is associated with mortality in patients with TBI. DESIGN: Cohort study. SETTING: Eighteen trauma centers and 51 nontrauma centers in the United States. PATIENTS: A total of 1,529 patients aged 18 years to 84 years of age admitted to hospital with TBI between July 2001 and November 2002. EXPOSURE: BAC assessed in the index hospital emergency department. OUTCOME: Mortality in-hospital, 90 and 365 days after injury. RESULTS: After adjusting for confounding variables, there was no significant difference for in-hospital, 90-day, and 365-day mortality by BAC. CONCLUSIONS: When fully adjusted for injury severity, alcohol intoxication is not associated with significantly lower mortality after TBI. The trend toward lower mortality at higher BACs prompts questions about the complex interaction of alcohol and TBI, and warrants further investigation of the possible protective effect of alcohol.

Recruitment strategies for a fall prevention program: if we build it, will they really come?

BACKGROUND: More than one third of adults over the age of 65 suffer a fall each year, facing morbidity and mortality. Modifiable risk factors for falls have been identified, but specific recruitment strategies for prevention programs have not been evaluated. The purpose of this observational study was to evaluate recruitment strategies for a fall prevention program. METHODS: Participants were recruited during an 11-month period at a Level I trauma center. Participants were eligible if >65 years old, living independently, and had a fall. Recruitment modalities included (1) emergency medical services, (2) emergency department (ED), (3) primary care providers, and (4) media exposure leading to self-referral. Data were collected on baseline rate of fall victims seen in the ED, demographics, medical history, and source of referral. RESULTS: There were 91 individuals referred, with 61 (67%) enrolled. Enrollment rates were higher among patients referred by self or primary care providers than among those referred by emergency medical services or the ED. There were no significant differences in demographics or medical history among the eligible but not referred ED population, the referred population, and the enrolled population. Reasons for not enrolling included inappropriate referral (33%), no response (17%), other illness (13%), and patients thinking that they do not need the services (37%). CONCLUSIONS: These recruitment strategies were successful in enrolling a representative population of patients at risk for recurrent falls, but could be improved to capture more potential participants. Source of referral has a significant effect on rate of enrollment. We outline challenges and solutions to recruitment.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review.

INTRODUCTION: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. METHODS: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. RESULTS: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). CONCLUSION: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

A Systematic Review of Tools Used to Assess Team Leadership in Health Care Action Teams.

PURPOSE: To summarize the characteristics of tools used to assess leadership in health care action (HCA) teams. HCA teams are interdisciplinary teams performing complex, critical tasks under high-pressure conditions. METHOD: The authors conducted a systematic review of the PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, and Web of Science databases, key journals, and review articles published through March 2012 for English-language articles that applied leadership assessment tools to HCA teams in all specialties. Pairs of reviewers assessed identified articles for inclusion and exclusion criteria and abstracted data on study characteristics, tool characteristics, and validity evidence. RESULTS: Of the 9,913 abstracts screened, 83 studies were included. They described 61 team leadership assessment tools. Forty-nine tools (80%) provided behaviors, skills, or characteristics to define leadership. Forty-four tools (72%) assessed leadership as one component of a larger assessment, 13 tools (21%) identified leadership as the primary focus of the assessment, and 4 (7%) assessed leadership style. Fifty-three studies (64%) assessed leadership at the team level; 29 (35%) did so at the individual level. Assessments of simulated (n = 55) and live (n = 30) patient care events were performed. Validity evidence included content validity (n = 75), internal structure (n = 61), relationship to other variables (n = 44), and response process (n = 15). CONCLUSIONS: Leadership assessment tools applied to HCA teams are heterogeneous in content and application. Comparisons between tools are limited by study variability. A systematic approach to team leadership tool development, evaluation, and implementation will strengthen understanding of this important competency.

Leadership training in health care action teams: a systematic review.

PURPOSE: To identify and describe the design, implementation, and evidence of effectiveness of leadership training interventions for health care action (HCA) teams, defined as interdisciplinary teams whose members coordinate their actions in time-pressured, unstable situations. METHOD: The authors conducted a systematic search of the PubMed/MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, and Web of Science databases, key journals, and review articles published through March 2012. They identified peer-reviewed English-language articles describing leadership training interventions targeting HCA teams, at all levels of training and across all health care professions. Reviewers, working in duplicate, abstracted training characteristics and outcome data. Methodological quality was evaluated using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Of the 52 included studies, 5 (10%) focused primarily on leadership training, whereas the remainder included leadership training as part of a larger teamwork curriculum. Few studies reported using a team leadership model (2; 4%) or a theoretical framework (9; 17%) to support their curricular design. Only 15 studies (29%) specified the leadership behaviors targeted by training. Forty-five studies (87%) reported an assessment component; of those, 31 (69%) provided objective outcome measures including assessment of knowledge or skills (21; 47%), behavior change (8; 18%), and patient- or system-level metrics (8; 18%). The mean MERSQI score was 11.4 (SD 2.9). CONCLUSIONS: Leadership training targeting HCA teams has become more prevalent. Determining best practices in leadership training is confounded by variability in leadership definitions, absence of supporting frameworks, and a paucity of robust assessments.