Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review.

BACKGROUND: Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies. METHODS: We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers. RESULTS: Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number. CONCLUSIONS: Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias. STUDY REGISTRATION: OSF - https://osf.io/7kea3.

Implementation of an audit and feedback module targeting low-value clinical practices in a provincial trauma quality assurance program: a cost-effectiveness study.

BACKGROUND: Audit and Feedback (A&F) interventions based on quality indicators have been shown to lead to significant improvements in compliance with evidence-based care including de-adoption of low-value practices (LVPs). Our primary aim was to evaluate the cost-effectiveness of adding a hypothetical A&F module targeting LVPs for trauma admissions to an existing quality assurance intervention targeting high-value care and risk-adjusted outcomes. A secondary aim was to assess how certain A&F characteristics might influence its cost-effectiveness. METHODS: We conducted a cost-effectiveness analysis using a probabilistic static decision analytic model in the Québec trauma care continuum. We considered the Québec Ministry of Health perspective. Our economic evaluation compared a hypothetical scenario in which the A&F module targeting LVPs is implemented in a Canadian provincial trauma quality assurance program to a status quo scenario in which the A&F module is not implemented. In scenarios analyses we assessed the impact of A&F characteristics on its cost-effectiveness. Results are presented in terms of incremental costs per LVP avoided. RESULTS: Results suggest that the implementation of A&F module (Cost = $1,480,850; Number of LVPs = 6,005) is associated with higher costs and higher effectiveness compared to status quo (Cost = $1,124,661; Number of LVPs = 8,228). The A&F module would cost $160 per LVP avoided compared to status quo. The A&F module becomes more cost-effective with the addition of facilitation visits; more frequent evaluation; and when only high-volume trauma centers are considered. CONCLUSION: A&F module targeting LVPs is associated with higher costs and higher effectiveness than status quo and has the potential to be cost-effective if the decision-makers' willingness-to-pay is at least $160 per LVP avoided. This likely represents an underestimate of true ICER due to underestimated costs or missed opportunity costs. Results suggest that virtual facilitation visits, frequent evaluation, and implementing the module in high-volume centers can improve cost-effectiveness.

Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study.

BACKGROUND: Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury. METHODS: We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination). RESULTS: Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes. CONCLUSION: We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

The current state of knowledge on care for co-occurring chronic pain and opioid use disorder: A scoping review.

BACKGROUND AND AIMS: Opioid use disorder often co-occurs with chronic pain but assessment and treatment of these co-occurring disorders is complex. This review aims to identify current treatments and delivery models for co-occurring chronic pain and opioid use disorder (OUD) documented in the scientific literature. DESIGN: Scoping review. METHODS: The review was conducted in six databases in June 2022 (no time limit): CINAHL, PsycINFO, Web of Science, Cochrane, PubMed and Embase. The PRISMA-ScR checklist was used to guide reporting. RESULTS: Forty-seven publications addressing the issue of co-occurring chronic pain and OUD management were included. Randomized controlled trials provide evidence for the effectiveness of opioid agonist treatments (OAT) such as methadone or buprenorphine/naloxone, as well as for combining OAT with Mindfulness-Oriented Recovery Enhancement or cognitive behavioural therapy. A number of other pharmacological treatments (opioid and nonopioid), nonpharmacological treatments (e.g. physiotherapy) and service delivery models (e.g. simultaneous treatment of comorbidities, interdisciplinary and interprofessional collaboration) are also underlined. In most cases, authors recommend a combination of strategies to meet patient needs. CONCLUSIONS: The scoping review reveals gaps in evidence-based knowledge to effectively care for co-occurring chronic pain and OUD, but several experts recommend the uptake of known 'best' practices such as integrated treatment of the multiple biopsychosocial dimensions of the co-occurring disorders as well as collaborative interdisciplinary work. CLINICAL RELEVANCE: Improving services is dependent on alleviating barriers such as working in silos, the costs associated with nonpharmacological treatments, and the double stigma associated with pain in people with a substance use disorder.

Selection of knowledge translation strategies to implement best practices on nonpharmacological prevention of delirium in intensive care unit / Sélection de stratégies de transfert des connaissances visant à implanter les pratiques recommandées de prévention non pharmacologiques du délirium en soins intensifs.

Background: Delirium prevention in the ICU should focus on a non-pharmacological approach. However, these recommendations are not always applied by care providers. Objective: To select knowledge translation strategies to facilitate the implementation of non-pharmacological best practices to prevent delirium in the ICU. Method: A consensus study was conducted. Barriers and facilitators to the implementation of nonpharmacological methods, and knowledge translation strategies, were identified in two nominal groups. A context assessment was also carried out. Nine professionals and one patient-partner participated. Results: The barriers and facilitators on which consensus was reached were most frequently related to environmental context and resources, intention, and knowledge. The areas of organizational context with the highest levels of agreement were interpersonal relations, culture and leadership. Consequently, knowledge translation strategies were selected to facilitate practices, as well as to modify the environment and improve knowledge. Conclusion: A structured method was used during this study to guide the selection of knowledge translation strategies. The application of these strategies could potentially improve clinical practice in intensive care.

Introduction: La prévention du délirium aux soins intensifs devrait être axée sur les méthodes non pharmacologiques. Toutefois, ce type de recommandation n'est pas toujours appliqué. Objectif: Sélectionner des stratégies de transfert des connaissances afin de faciliter l'implantation des pratiques non pharmacologiques pouvant prévenir le délirium en soins intensifs. Méthode: Une étude de consensus a été réalisée autour de deux thèmes. Deux groupes nominaux ont été constitués pour identifier les barrières et les facilitateurs à l'implantation des méthodes et les stratégies de transfert des connaissances. Une évaluation du contexte a aussi été réalisée. Neuf professionnels et une patiente-partenaire ont participé. Résultats: Les barrières et les facilitateurs ayant fait l'objet d'un consensus étaient plus fréquemment reliés au contexte environnemental et aux ressources, à l'intention et aux connaissances. Les domaines du contexte organisationnel qui ont obtenu le plus haut niveau d'accord sont les relations interpersonnelles, la culture et le leadership. Conséquemment, des stratégies de transfert des connaissances pour faciliter les pratiques, modifier l'environnement et améliorer les connaissances ont été sélectionnées. Conclusion: Une méthode structurée a été utilisée afin de guider la sélection de stratégies de transfert des connaissances. L'application de ces stratégies pourrait potentiellement améliorer la pratique clinique en soins intensifs.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review.

OBJECTIVE: To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND: Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS: We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS: We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS: We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study.

OBJECTIVE: Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN: A consensus study using the nominal group technique. SETTING: Four trauma systems in Canada. SUBJECTS: Participants included expert clinicians and decision makers, and people with lived experience. METHODS: Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS: A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION: This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey.

PURPOSE: To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS: We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS: Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS: Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

RéSUMé: OBJECTIF: Évaluer comment les cliniciens canadiens impliqués dans les soins aux patients traumatisés et prescrivant des opioïdes perçoivent l'utilisation et l'efficacité des stratégies visant à prévenir le traitement prolongé par opioïde après un traumatisme. Les obstacles et facilitateurs de la mise en œuvre de ces stratégies ont aussi été analysés. MéTHODES: Nous avons réalisé une enquête transversale via le Web. Les participants potentiels ont été identifiés par les gestionnaires et directeurs de programmes de traumatologie des départements ciblés dans trois provinces canadiennes. Nous avons conçu notre questionnaire en utilisant la méthodologie de recherche usuelle des enquêtes de santé. Le questionnaire a été administré entre avril 2021 et novembre 2021. RéSULTATS: Notre taux de réponse a été de 47 % (350/744) et 52 % (181/350) des participants ont complété l'enquête dans sa totalité. La majorité des personnes interrogées (71 %, 129/181) travaillait dans des hôpitaux universitaires. L'analgésie multimodale (93 %, 240/257), les anti-inflammatoires non stéroïdiens (77 %, 198/257) et la stimulation physique (75 %, 193/257) étaient les stratégies perçues comme étant le plus fréquemment utilisées. Plusieurs stratégies préventives étaient perçues comme étant très efficaces par plus de 80 % des répondants. Parmi celles-ci, certaines étaient signalées comme n'étant pas utilisées très souvent, mais perçues comme étant les plus efficaces, notamment les lignes directrices et protocoles évaluant les facteurs de risque d'utilisation abusive des opioïdes, le suivi de la santé physique par un professionnel, la formation des cliniciens, l'éducation des patients et les systèmes de suivi des prescriptions. La pénurie de personnels, les contraintes de temps et les pratiques de l'établissement ont été identifiées comme étant les principaux obstacles à la mise en place des stratégies préventives classées parmi les premières. CONCLUSIONS: Plusieurs stratégies de prévention du traitement par opioïdes à long terme après un traumatisme sont perçues comme efficaces par ceux qui les prescrivent à cette population de patients. Certaines de ces stratégies apparaissent comme couramment utilisées dans la pratique quotidienne et d'autres moins souvent. La recherche future devrait se concentrer sur la détermination des stratégies préventives auxquelles il faudrait accorder la plus grande priorité de mise en œuvre avant d'évaluer leur efficacité.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC.

OBJECTIVE: The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings. METHODS: The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence. RESULTS: Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version. CONCLUSIONS: A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.

Tapering Opioid Prescription Program for High-Risk Trauma Patients: A Pilot Randomized Controlled Trial.

BACKGROUND: Chronic opioid use has been documented in up to 20% of patients with traumatic injuries. Hence, we developed the Tapering Opioids Prescription Program for high-risk Trauma (TOPP-Trauma) patients. AIMS: To assess the feasibility and acceptability of TOPP-Trauma, examine the feasibility of the research methods, and describe its potential efficacy in reducing long-term opioid use. DESIGN: A two-arm pilot randomized controlled trial. METHODS: Fifty participants discharged home were assigned to TOPP-Trauma or an educational pamphlet. Feasibility was assessed based on ability to provide the program components. The acceptability was assessed with the Treatment Acceptability and Preference Questionnaire. The feasibility of the research methods was evaluated according to standard parameters. Self-reported morphine equivalent dose (MED) and MEDs supplied by pharmacies were measured at 6 and 12 weeks. RESULTS: Eighty percent or more of TOPP-Trauma components were delivered as planned, and the program was deemed highly acceptable. Approximately 10% of screened patients were eligible. Eighty-five percent of eligible patients agreed to participate with 20% attrition rates. TOPP-Trauma participants used less MED/day compared to the control group at 6 and 12 weeks (1.2. vs. 12.2 mg; 0.4. vs 4.0 mg), and pharmacies supplied less than half of cumulative MEDs to those who received the program at 12 weeks, but the differences were not statistically significant. CONCLUSIONS: Some challenges need to be addressed before testing TOPP-Trauma. These include creating strategies to decrease attrition, offering the program throughout the care continuum to higher risk patients, and evaluating the impacts of reduced opioid use.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study.

BACKGROUND: Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. METHODS: A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0-10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4-8); (b) altered LOC (GCS 9-12); and (c) conscious (GCS 13-15). RESULTS: Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters' CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. CONCLUSIONS: The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool's performance in clinical practice.

Low-value injury care in the adult orthopaedic trauma population: A systematic review.

OBJECTIVES: Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS: We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS: Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION: In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study.

BACKGROUND: Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation. METHODS: We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years). RESULTS: The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%). CONCLUSION: One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Determinants of pain assessment documentation in intensive care units.

PURPOSE: The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation. METHODS: A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed. RESULTS: All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (ß = 0.37), using only breakthrough doses (ß = 0.24), and lower opioid doses (ß = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25). CONCLUSION: Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.

RéSUMé: OBJECTIF: La sous-évaluation de la douleur constitue un obstacle majeur à une gestion efficace de la douleur, et le manque de documentation de l'évaluation de la douleur a été associé à des conséquences défavorables pour les patients. Cette étude visait à : 1) décrire les facteurs contextuels liés à l'évaluation et à la gestion de la douleur dans cinq unités de soins intensifs (USI) du Québec; 2) décrire leurs pratiques de documentation de l'évaluation de la douleur; et 3) identifier les déterminants sociodémographiques et cliniques liés à la documentation de l'évaluation de la douleur. MéTHODE: Un devis de recherche rétrospectif descriptif-corrélationnel a été utilisé. Les données sociodémographiques (c.-à-d. l'âge, le sexe), les données cliniques (c.-à-d. le diagnostic, la ventilation mécanique, le niveau de conscience, la gravité de la maladie, les opioïdes, les sédatifs) et les évaluations de la douleur ont été extraites de 345 dossiers médicaux avec admissions à l'USI de cinq hôpitaux universitaires entre 2017 et 2019. Des statistiques descriptives et une régression linéaire multiple ont été effectuées. RéSULTATS: Tous les sites ont déclaré utiliser l'échelle d'évaluation numérique de 0 à 10, mais l'implantation d'une échelle de douleur comportementale variait d'un site à un autre. Une médiane de trois évaluations de douleur étaient documentées par 24 heures, ce qui est inférieur à la recommandation minimale de huit à 12 évaluations de douleur par 24 heures. Dans l'ensemble, l'évaluation de la douleur était présente dans 70 % des dossiers, mais seulement 20 % des doses d'opioïdes étaient suivies d'une réévaluation documentée de la douleur dans l'heure suivant leur'administration. Un niveau de conscience plus élevé (ß = 0,37), l'utilisation exclusive d'entredoses d'opioïdes pour les percées de douleur (ß = 0,24) et des doses d'opioïdes plus faibles (ß = -0,21) ont constitué les déterminants significatifs dans la documentation de l'évaluation de la douleur (R2 ajusté = 0,25). CONCLUSION: La documentation de l'évaluation de la douleur est sous-optimale dans les USI, en particulier pour les patients incapables de s'exprimer ou ceux qui reçoivent des doses plus élevées d'opioïdes. Les résultats de cette étude soulignent l'importance d'implanter des outils pour optimiser l'évaluation et la documentation de la douleur.

Implementation of the best practice guidelines on geriatric trauma care: a Canadian perspective.

BACKGROUND: traumatic injuries are increasingly affecting older patients who are prone to more complications and poorer recovery compared to younger patients. Practices of trauma health care providers therefore need to be adapted to meet the needs of geriatric trauma patients. OBJECTIVE: to assess the implementation of the American College of Surgeons best practice guidelines on geriatric trauma management across level I to III Canadian trauma centres. METHODS: 69 decision-makers working in Canadian trauma centres were approached to complete a web-based practice survey. Percentages and means were calculated to describe the level of best practice guideline implementation. RESULTS: 50 decision-makers completed the survey for a response rate of 72%. Specialised geriatric trauma resources were utilised in 37% of centres. Implementation of mechanisms to evaluate common geriatric issues (e.g. frailty, malnutrition and delirium) varied from 28 to 78% and protocols for the optimisation of geriatric care (e.g. Beers criteria to adjust medication, anticoagulant reversal and early mobilisation) from 8 to 56%. Guideline recommendations were more often implemented in level I and level II trauma centres. The adjustment of trauma team activation criteria to the geriatric population and transition of care protocols were more frequently used by level III centres. CONCLUSION: despite the growing number of older patients admitted in Canadian trauma centres annually, the implementation of best practice guidelines on geriatric trauma management is still limited. Prospective multicentre studies are required to develop and evaluate interdisciplinary knowledge translation initiatives that will promote the uptake of guidelines by trauma centres.

Incidence and Risk Factors of Long-term Opioid Use in Elderly Trauma Patients.

OBJECTIVE: Evaluate the incidence and risk factors of opioid use 1 year after injury in elderly trauma patients. BACKGROUND: The current epidemic of prescription opioid misuse and overdose observed in North America generally concerns young patients. Little is known on long-term opioid use among the elderly trauma population. METHODS: In a retrospective observational multicenter cohort study conducted on registry data, all patients 65 years and older admitted (hospital stay >2 days) for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014 were included. We searched for filled opioid prescriptions in the year preceding the injury, up to 3 months and 1 year after the injury. RESULTS: In all, 39,833 patients were selected for analysis. Mean age was 79.3 years (±7.7), 69% were women, and 87% of the sample was opioid-naive. After the injury, 38% of the patients filled an opioid prescription within 3 months and 10.9% [95% confidence interval (CI) 10.6%-11.2%] filled an opioid prescription 1 year after trauma: 6.8% (95% CI 6.5%-7.1%) were opioid-naïve and 37.6% (95% CI 36.3%-38.9%) were opioid non-naive patients. Controlling for confounders, patients who filled 2 or more opioid prescriptions before the injury and those who filled an opioid prescription within 3 months after the injury were, respectively, 11.4 and 3 times more likely to use opioids 1 year after the injury compared with those who did not fill opioid prescriptions. CONCLUSIONS: These results highlight that elderly trauma patients are at risk of long-term opioid use, especially if they had preinjury or early postinjury opioid consumption.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma.

PURPOSE: Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma). METHODS: Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients. RESULTS: The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery. CONCLUSION: This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.

Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury.

BACKGROUND: The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. OBJECTIVES: The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. METHODS: A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient's LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. RESULTS: Regardless of the patient's LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. CONCLUSIONS: Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient's LOC and ability to express specific behaviours.