Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial.

INTRODUCTION: The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness. METHODS AND ANALYSIS: A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks. ETHICS AND DISSEMINATION: Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine. TRIAL REGISTRATION NUMBER: NCT05228782.

Paramedic supportive discharge programmes to improve health system efficiency and patient outcomes: a scoping review protocol.

INTRODUCTION: Discharging older adults with frailty home from the emergency department (ED) poses unique challenges due to multiple interacting physical and social problems. Paramedic supportive discharge services help overcome these challenges by adding in-home assessment and/or interventions. Our objective is to describe existing paramedic programmes designed to support discharge from the ED or hospital to avoid unnecessary hospital admissions. A comprehensive description of paramedic supportive discharge services will be conducted by mapping the literature to describe: (1) why such programmes are needed; (2) who is being targeted, making referrals and delivering the services and (3) what assessments and interventions are offered. METHODS AND ANALYSIS: We will include studies that focus on expanded paramedic roles (community paramedicine) and extended scope postdischarge from the ED or hospital. All study designs will be included with no limit by language. We will include peer-reviewed articles and preprints and a targeted search of grey literature from January 2000 to June 2022. The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute methodology. We will use a search strategy designed by a health science librarian to search MEDLINE All (Ovid), CINAHL Full Text (EBSCO), Embase (Elsevier) and Scopus (Elsevier) for eligible studies from 2000 to present. Two independent reviewers will conduct screening and full-text review. Data extraction will be conducted by one reviewer and verified by another. We will report our findings descriptively by charting trends in the research. ETHICS AND DISSEMINATION: Research ethics review is not required as this is a scoping review comprised published studies. The results of this research will be published in a manuscript and presented at national and international geriatric and emergency medicine conferences. This research will inform future implementation studies on community paramedic supportive discharge services. REGISTRATION: This scoping review protocol was registered in Open Science Framework and can be found here: https://doi.org/10.17605/OSF.IO/X52P7.

Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol.

The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine.

Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training.

OBJECTIVES: Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium. DESIGN: Open-label feasibility study. SETTING: An academic tertiary care Canadian ED (annual visits 60 000). PARTICIPANTS: Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year. INTERVENTION: A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968). RESULTS: Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications. CONCLUSION: Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov #02892968.

Clinically important change in the visual analog scale after adequate pain control.

OBJECTIVES: To define the minimum clinically important difference (MCID) for the visual analog scale (VAS) of pain severity by measuring the change in VAS associated with adequate pain control. METHODS: The authors conducted a prospective, observational study. Adult emergency department (ED) patients with acute pain (<72 hours) were eligible. Patients rated their pain severity on a 100-mm VAS on presentation and at discharge. Patients were asked if they would accept any analgesic, then if they would accept a parenteral analgesic before treatment. At discharge, they were asked whether they had received adequate pain control. RESULTS: The authors enrolled 143 patients (mean age, 36 years; 54% female). The mean decrease in VAS was -30.0 mm (95% confidence interval [CI] = -36.4 to -23.6) for the 116 of 143 (81%) patients with adequate pain control at discharge vs. -5.7 (95% CI = -11.2 to -0.3) for the 27 with inadequate pain control (p < 0.001). At discharge, the mean VAS was 31.3 mm for those with adequate pain control vs. 55.1 for those without. Mean VAS for the 114 of 143 patients who would accept any analgesics initially was 64.7 vs. 47.1 for the 29 reporting no analgesic need. Initially, 77 patients would accept parenteral analgesics (mean VAS = 72.5 mm). CONCLUSIONS: A mean reduction in VAS of 30.0 mm represents a clinically important difference in pain severity that corresponds to patients' perception of adequate pain control. Defining MCID based on adequate analgesic control rather than minimal detectable change may be more appropriate for future analgesic trials, when effective treatments for acute pain exist.