Transitions of care for older adults discharged home from the emergency department: an inductive thematic content analysis of patient comments.

OBJECTIVE: Improving care transitions for older adults can reduce emergency department (ED) visits, adverse events, and empower community autonomy. We conducted an inductive qualitative content analysis to identify themes emerging from comments to better understand ED care transitions. METHODS: The LEARNING WISDOM prospective longitudinal observational cohort includes older adults (≥ 65 years) who experienced a care transition after an ED visit from both before and during COVID-19. Their comments on this transition were collected via phone interview and transcribed. We conducted an inductive qualitative content analysis with randomly selected comments until saturation. Themes that arose from comments were coded and organized into frequencies and proportions. We followed the Standards for Reporting Qualitative Research (SRQR). RESULTS: Comments from 690 patients (339 pre-COVID, 351 during COVID) composed of 351 women (50.9%) and 339 men (49.1%) were analyzed. Patients were satisfied with acute emergency care, and the proportion of patients with positive acute care experiences increased with the COVID-19 pandemic. Negative patient comments were most often related to communication between health providers across the care continuum and the professionalism of personnel in the ED. Comments concerning home care became more neutral with the COVID-19 pandemic. CONCLUSION: Patients were satisfied overall with acute care but reported gaps in professionalism and follow-up communication between providers. Comments may have changed in tone from positive to neutral regarding home care over the COVID-19 pandemic due to service slowdowns. Addressing these concerns may improve the quality of care transitions and provide future pandemic mitigation strategies.

Understanding the integration of artificial intelligence in healthcare organisations and systems through the NASSS framework: a qualitative study in a leading Canadian academic centre.

BACKGROUND: Artificial intelligence (AI) technologies are expected to "revolutionise" healthcare. However, despite their promises, their integration within healthcare organisations and systems remains limited. The objective of this study is to explore and understand the systemic challenges and implications of their integration in a leading Canadian academic hospital. METHODS: Semi-structured interviews were conducted with 29 stakeholders concerned by the integration of a large set of AI technologies within the organisation (e.g., managers, clinicians, researchers, patients, technology providers). Data were collected and analysed using the Non-Adoption, Abandonment, Scale-up, Spread, Sustainability (NASSS) framework. RESULTS: Among enabling factors and conditions, our findings highlight: a supportive organisational culture and leadership leading to a coherent organisational innovation narrative; mutual trust and transparent communication between senior management and frontline teams; the presence of champions, translators, and boundary spanners for AI able to build bridges and trust; and the capacity to attract technical and clinical talents and expertise. Constraints and barriers include: contrasting definitions of the value of AI technologies and ways to measure such value; lack of real-life and context-based evidence; varying patients' digital and health literacy capacities; misalignments between organisational dynamics, clinical and administrative processes, infrastructures, and AI technologies; lack of funding mechanisms covering the implementation, adaptation, and expertise required; challenges arising from practice change, new expertise development, and professional identities; lack of official professional, reimbursement, and insurance guidelines; lack of pre- and post-market approval legal and governance frameworks; diversity of the business and financing models for AI technologies; and misalignments between investors' priorities and the needs and expectations of healthcare organisations and systems. CONCLUSION: Thanks to the multidimensional NASSS framework, this study provides original insights and a detailed learning base for analysing AI technologies in healthcare from a thorough socio-technical perspective. Our findings highlight the importance of considering the complexity characterising healthcare organisations and systems in current efforts to introduce AI technologies within clinical routines. This study adds to the existing literature and can inform decision-making towards a judicious, responsible, and sustainable integration of these technologies in healthcare organisations and systems.

A Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions to assess the accuracy of prehospital trauma triage protocols: a modified Delphi study.

BACKGROUND: Injury severity scales have traditionally been used to assess the performance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. METHODS: Based on a list of potential participants we obtained using data on training, experience, geographic location, affiliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. RESULTS: Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. CONCLUSION: We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools.

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity.

BACKGROUND: Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life. METHODS: A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points. RESULTS: Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up. CONCLUSIONS: Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec.

BACKGROUND: In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences. METHODS: We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation. RESULTS: Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability. INTERPRETATION: Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

A case for mandatory ultrasound training for rural general practitioners: a commentary.

CONTEXT: Point-of-care ultrasound is a rapidly evolving technology that enables rapid diagnostic imaging to be performed at a patient's bedside, reducing time to diagnosis and minimising the need for patient transfers. This has significant applications for rural emergency and general practice, and could potentially prevent unnecessary transfers of patients from rural communities to more urban centres for the purpose of diagnostic imaging, reducing costs and preventing disruption to patients' lives. Meta-analyses on point-of-care ultrasound have reported extremely high sensitivity and specificity when detecting lung pathology, and the potential applications of the technology are substantial. A significant application of the technology is in the care of rural paediatric patients, where acute lower respiratory pathology is the most common cause of preventable deaths, hospitalisations, and emergency medical retrievals from remote communities for children under five. ISSUES: Although widely available, point-of-care ultrasound technology is not widely utilised in Australian emergency departments and general practices. Issues with comprehensive training, maintenance of skills, upskilling and quality assurance programs prevent physicians from feeling confident when utilising the technology. In Canada, point-of-care ultrasound training is part of the core competency training in the Royal College of Physicians of Canada emergency medicine fellowship program. Point-of-care ultrasound is widely used in rural practice, although lack of training, funding, maintenance of skills and quality assurance were still listed as barriers to use. LESSONS LEARNED: Point-of-care ultrasound is a highly sensitive and specific technology with wide potential applications. Issues with quality control and maintenance of skills are preventing widespread use. Coupling point-of-care ultrasound with telemedicine could help increase the usability and accessibility of the technology by reducing the issues associated with maintenance of skills and quality assurance.

Artificial intelligence in health care: laying the Foundation for Responsible, sustainable, and inclusive innovation in low- and middle-income countries.

The World Health Organization and other institutions are considering Artificial Intelligence (AI) as a technology that can potentially address some health system gaps, especially the reduction of global health inequalities in low- and middle-income countries (LMICs). However, because most AI-based health applications are developed and implemented in high-income countries, their use in LMICs contexts is recent and there is a lack of robust local evaluations to guide decision-making in low-resource settings. After discussing the potential benefits as well as the risks and challenges raised by AI-based health care, we propose five building blocks to guide the development and implementation of more responsible, sustainable, and inclusive AI health care technologies in LMICs.

Identification of Swimmers in Distress Using Unmanned Aerial Vehicles: Experience at the Mont-Tremblant IRONMAN Triathlon.

Background: This preliminary report describes our experience using unmanned aerial vehicles (UAVs) to identify swimmers in distress at the 2018 Mont-Tremblant IRONMAN triathlon (Quebec, Canada). Methods: In a prospective pilot study, we sought to determine whether UAV surveillance could identify swimmers showing signs of distress quicker than conventional methods (i.e., lifeguards on the ground and on watercraft). In addition, we investigated the feasibility of using UAVs for medical surveillance at a triathlon event in terms of operations, costs, safety, legal parameters, and added value. Prior to the race, we screened participants for medical conditions that could elevate their risk of injury during the swim portion of the triathlon. Athletes deemed to be at increased risk were given a yellow swimming cap to enhance their surveillance by trained observers watching a live video feed from the UAVs. Results: On race day, a total of 3 UAVs (2 mobile, 1 tethered) were launched over Lake Tremblant and provided 3 observers with live video of the swimmers. Of the 2,473 race participants, there were 25 athletes with pre-identified medical conditions who wore a yellow cap during the swim. We did not detect any signs of distress among swimmers wearing yellow caps. Among the remaining 2,448 athletes, there were 5 swimmers who demonstrated signs of distress and required mobilization of water rescue boats; UAV surveillance identified 1 of these 5 distress events before it was seen by lifeguards on rescue boats. None of the athletes in the IRONMAN suffered an adverse event while swimming. Several technical and safety issues related to UAV surveillance arose including poor visibility, equipment loss, and flight autonomy. Conclusion: While our preliminary findings suggest that using UAVs to identify distressed swimmers during an IRONMAN race is feasible and safe, more research is necessary to determine how to optimize UAV surveillance at mass sporting events and integrate this technology within the existing emergency response teams.

Improving delivery of care in rural emergency departments: a qualitative pilot study mobilizing health professionals, decision-makers and citizens in Baie-Saint-Paul and the Magdalen Islands, Québec, Canada.

BACKGROUND: Emergency departments (EDs) in rural and remote areas face challenges in delivering accessible, high quality and efficient services. The objective of this pilot study was to test the feasibility and relevance of the selected approach and to explore challenges and solutions to improve delivery of care in selected EDs. METHODS: We conducted an exploratory multiple case study in two rural EDs in Québec, Canada. A survey filled out by the head nurse for each ED provided a descriptive statistical portrait. Semi-structured interviews were conducted with ED health professionals, decision-makers and citizens (n = 68) and analyzed inductively and thematically. RESULTS: The two EDs differed with regards to number of annual visits, inter-facility transfers and wait time. Stakeholders stressed the influence of context on ED challenges and solutions, related to: 1) governance and management (e.g. lack of representation, poor efficiency, ill-adapted standards); 2) health services organization (e.g. limited access to primary healthcare and long-term care, challenges with transfers); 3) resources (e.g. lack of infrastructure, limited access to specialists, difficult staff recruitment/retention); 4) and professional practice (e.g. isolation, large scope, maintaining competencies with low case volumes, need for continuing education, teamwork and protocols). There was a general agreement between stakeholder groups. CONCLUSIONS: Our findings show the feasibility and relevance of mobilizing stakeholders to identify context-specific challenges and solutions. It confirms the importance of undertaking a larger study to improve the delivery of care in rural EDs.

Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity.

Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI's value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step.

Rethinking the electronic health record through the quadruple aim: time to align its value with the health system.

Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The "quadruple aim" consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.

Don't take down the monkey bars: Rapid systematic review of playground-related injuries.

OBJECTIVE: To synthesize the available evidence on playground-related injuries and to determine the prevalence of these injuries in pediatric populations. DATA SOURCES: A rapid systematic review was conducted using PubMed, EMBASE, and the Cochrane Library, as well as the gray literature. STUDY SELECTION: The search was limited to studies published between 2012 and 2016 and identified a total of 858 articles, of which 22 met our inclusion criteria: original quantitative studies published in peer-reviewed journals in the past 5 years, concerning unintentional injuries in playgrounds in children aged 0 to 18 years. SYNTHESIS: Information was collected on study and injury characteristics, and the proportion of pediatric injuries related to playground activity was determined. Studies were performed in various countries and most were retrospective cohort studies. The prevalence of playground-related injury ranged from 2% to 34% (median 10%). Studies varied in the types of injuries investigated, including head injuries, genitourinary injuries, ocular and dental trauma, and various types of fractures. Most injuries were low severity. CONCLUSION: Although playgrounds are a common location where pediatric injuries occur, these injuries are relatively low in frequency and severity.

Subcutaneous Fentanyl Administration: A Novel Approach for Pain Management in a Rural and Suburban Prehospital Setting.

OBJECTIVE: To determine the feasibility, safety, and effectiveness of the subcutaneous route of fentanyl administration by Basic Life Support-Emergency Medical Technicians (BLS-EMT) in a rural and suburban region, with the support of an online pain management medical control center. METHODS: Retrospective study of patients who received subcutaneous fentanyl and were transported by BLS-EMT to the emergency department (ED) of an academic hospital between July 1, 2013 and January 1, 2014, inclusively. Fentanyl orders were obtained from emergency physicians via an online medical control (OLMC) center. Effectiveness was defined by changes in pain scores 15 minutes, 30 minutes, and 45+ minutes after initial fentanyl administration. Safety was evaluated by measuring vital signs, Ramsay sedation scores, and adverse events subsequent to fentanyl administration. Feasibility was defined as successful fentanyl administration by BLS-EMT. SPSS-20 was used for descriptive statistics, and independent t-tests and Mann-Whitney U tests were used to determine inter- and intra-group differences based on transport time. RESULTS: Two hundred and eighty-eight patients (288; 14 to 93 years old) with pain scores ≥7 were eligible for the study. Of the 284 (98.6%) who successfully received subcutaneous fentanyl, 35 had missing records or data, and 249 (86.5%) were included in analyses. Average pain score pre-fentanyl was 8.9 ± 1.1. Patients <70 years old received a higher dose of fentanyl than those ≥70 years old (1.4 ± 0.3 vs, 0.8 ± 0.2 mcg/kg, p < 0.05). Pain scores decreased significantly post-fentanyl administration and the proportion of patients achieving pain relief increased significantly (p < 0.05) over the course of transport to ED (15 minutes, 30 minutes, 45+ minutes). Only 1.6% of patients experienced adverse events, including hypotension (n = 2; 0.8%), nausea (n = 1; 0.4%), and Ramsay level >3 (n = 1; 0.4%). CONCLUSION: Prehospital subcutaneous fentanyl administration by BLS-EMT with the support of an OLMC center is a safe and feasible approach to pain relief in prehospital settings, and is not associated with major adverse events. Effectiveness, subsequent to subcutaneous fentanyl administration is characterized by a decrease in pain over the course of transport to ED. Further studies are needed to compare the effectiveness of SC administration by EMS with other routes of administration and other analgesics.

Nonfearful Panic Attacks in Patients With Noncardiac Chest Pain.

OBJECTIVE: To document the prevalence and characteristics of nonfearful panic attacks (NFPA) and their consequences on panic identification and access to mental health services in patients with noncardiac chest pain. METHOD: This cross-sectional sample included 339 patients with noncardiac chest pain and panic attacks. A structured interview was used to collect data on panic attacks, psychiatric morbidity, sociodemographic variables, and previous consultations with a psychiatrist or psychologist. Medical files were reviewed to assess the rate of NFPA identification in the emergency department. RESULTS: In our sample of patients with noncardiac chest pain, 39% of those with panic attacks reported NFPA. Psychiatric morbidity was lower in patients with NFPA than in patients with typical panic attacks (49.6% vs 71.1%), as was the mean number of panic symptoms (6 vs 7.8). The rate of panic attack identification was similar in both the groups, but patients with NFPA were less likely to have consulted a psychiatrist or psychologist during their lifetime (34% vs 46%). CONCLUSIONS: NFPA were highly prevalent in our sample of emergency department patients with noncardiac chest pain. NFPA is associated with significant psychiatric morbidity but these patients were less likely to follow through with referral to a psychiatrist or psychologist than patients with typical panic attacks were.

Portrait of rural emergency departments in Québec and utilization of the provincial emergency department management Guide: cross sectional survey.

BACKGROUND: Rural emergency departments (EDs) constitute crucial safety nets for the 20% of Canadians who live in rural areas. Pilot data suggests that the province of Québec appears to provide more comprehensive access to services than do other provinces. A difference that may be attributable to provincial policy/guidelines "the provincial ED management Guide". The aim of this study was to provide a detailed description of rural EDs in Québec and utilization of the provincial ED management Guide. METHODS: We selected EDs offering 24/7 medical coverage, with hospitalization beds, located in rural or small towns. We collected data via telephone, paper, and online surveys with rural ED/hospital staff. Data were also collected from Québec's Ministry of Health databases and from Statistics Canada. We computed descriptive statistics, ANOVA and t-tests were used to examine the relationship between ED census, services and inter-facility transfer requirements. RESULTS: A total of 23 of Québec's 26 rural EDs (88%) consented to participate in the study. The mean annual ED visits was 18 813 (Standard Deviation = 6 151). Thirty one percent of ED physicians were recent graduates with fewer than 5 years of experience. Only 6 % had residency training or certification in emergency medicine. Teams have good local access (24/7) to diagnostic equipment such as CT scanner (74%), intensive unit care (78%) and general surgical services (78%), but limited access to other consultants. Sixty one percent of participants have reported good knowledge of the provincial ED management Guide, but only 23% of them have used the guidelines. Furthermore, more than 40% of EDs were more than 300 km from levels 1 to 2 trauma centers, and only 30% had air transport access. CONCLUSIONS: Rural EDs in Québec are staffed by relatively new graduates working as solo physicians in well-resourced and moderately busy (by rural standards) EDs. The provincial ED management Guide may have contributed to this model of service attribution. However, the majority of rural ED staff report limited knowledge or use of the provincial ED management Guide and increased efforts at disseminating this Guide are warranted.

Rural Patient Access to Primary Percutaneous Coronary Intervention Centers is Improved by a Novel Integrated Telemedicine Prehospital System.

BACKGROUND: As per American Heart Association/American College of Cardiology guidelines, the delay between first medical contact and balloon inflation should not exceed 90 min for primary percutaneous coronary intervention (PCI). In North America, few prehospital systems have been developed to grant rural populations timely access to PCI. OBJECTIVES: The objective of the present study was to evaluate the ability of an ST-segment elevation myocardial infarction (STEMI) system serving suburban and rural populations to achieve the recommended 90-min interval benchmark for PCI. METHODS: A prehospital telemedicine program was implemented in a rural and suburban region of the Quebec province. Three patient groups with STEMI were created according to trajectory: 1) patients already en route to a PCI center, 2) patients initially directed to the nearest hospital who were subsequently diverted to a PCI center during transport, and 3) patients directed to the nearest hospital without transfer for PCI. Time intervals were compared across groups. RESULTS: Of the 208 patients diagnosed with STEMI, 14.9% were already on their way to a hospital with PCI capabilities, 75.0% were rerouted to a PCI center, and 10.1% were directed to the nearest local hospital. All patients but one arrived at the PCI center within the 60-min prehospital care interval, considering an additional 30 min for balloon inflation at the PCI center. CONCLUSION: This study demonstrated that a regionalized prehospital system for STEMI patients could achieve the recommended 90-min interval benchmark for PCI, while giving timely access to PCI to rural populations that would not otherwise have access to this treatment.

A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey.

BACKGROUND: Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec. METHODS: This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds. RESULTS: In total, 108 surveys were completed (participation rate = 52.4%). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95% of rural EDs; 75.9% of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4%) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60%). The most common reason (73%) for not using POCUS was limited access to POCUS training programs. Over 40% of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13% received training from the Canadian Association of Emergency Physicians, and 23% were trained in another course. Finally, 95% of respondents reported that POCUS skills are essential for rural ED practice. CONCLUSIONS: POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.

Insomnia in patients with unexplained chest pain.

OBJECTIVES: The current study was designed (1) to assess insomnia symptoms and sleep-related beliefs in a population of patients presenting in emergency department with unexplained chest pain (UCP) and (2) to examine the associations between insomnia and pain. METHODS: This is a report of secondary data from a cross-sectional study performed in the emergency department of 2 academic hospitals. Patients with UCP seen in an emergency department were assessed using sleep questionnaires and the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, fourth edition. RESULTS: Nearly every second patient with UCP (44%) seen in an emergency department suffered from clinically significant insomnia symptoms. Most patients with an anxiety or a mood disorder had insomnia, but a minority of patients with insomnia had an anxiety or a mood disorder. Insomniacs with an anxiety disorder were similar to insomniacs without comorbid anxiety for sleep-related beliefs and depressive symptoms, and both groups of insomniacs reported more depressive symptoms and faulty beliefs than both groups of good sleepers, i.e., either with or without an anxiety disorder. Results from regression analyses revealed that insomnia was associated with pain on univariate regression analysis and accounted for 1.3% of the variance in both pain intensity and interference. However, this association was rendered nonsignificant when additional variables were added to the model. CONCLUSIONS: Insomnia symptoms are an important, but often disregarded, feature present in a significant proportion of patients with UCP. As insomnia showed stronger associations with pain than anxiety or depression, it may represent an important factor contributing to the development and recurrence of UCP.

Cirque du Monde as a health intervention: perceptions of medical students and social circus experts.

OBJECTIVE: To present Cirque du Soleil's social circus program, Cirque du Monde, to explore its potential as a primary health care tool for family physicians. DATA SOURCES: A review of the literature in PubMed, the Cochrane Library, PsycINFO, LaPresse, Eureka, Google Scholar, and Érudit using the key words circus, social circus, Cirque du Monde, and Cirque du Soleil; a Montreal-based initiative, Espace Transition, modeled on Cirque du Monde; and personal communication with Cirque du Soleil's Social Circus Training Advisor. STUDY SELECTION: The first 50 articles or websites identified for each key word in each of the databases were examined on the basis of their titles and abstracts in the case of articles, and on the basis of their titles and page content in the case of websites. Articles and websites that explored an aspect of social circuses or that described an intervention that involved circuses were then retained for analysis. Because all literature on social circuses was searched, no criterion for year of publication was used. SYNTHESIS: No articles on the social circus as a health intervention were found. One study on the use of the circus as an intervention in schools was identified. It demonstrated an increase in self-esteem in the children who took part. One study on the use of the circus in a First Nations community was found; it contained nonspecific, qualitative findings. The other articles identified were merely descriptions of social circuses. One website was identified on the use of the social circus to help youth who had been treated in a hospital setting for major psychiatric disorders to re-enter the community. The team in the pediatric psychiatry department at Centre Hospitalier Universitaire Sainte-Justine, the children's hospital in Montreal, Que, was contacted; they were leading this project, called Espace Transition. The unpublished preliminary findings of its pilot project demonstrate substantial improvements in overall patient functioning. According to Cirque du Soleil, there are several projects under way around the world researching the therapeutic value of social circuses. CONCLUSION: Cirque du Monde is able to reach a marginalized population that is otherwise difficult for the health system to reach. This program has therapeutic potential because of its target population, its promotion of healthy habits, and the support that it offers through the group and its workers. Cirque du Soleil is investing heavily in this project. The lack of literature yielding robust data on the social circus is therefore an important issue.