Intubator Performance and Contamination with the Use of Barrier Enclosure Devices: Results from a Simulated COVID-19 Resuscitation.

INTRODUCTION: Medical institutions are using barrier enclosure devices during intubation procedures and other aerosol-generating medical procedures without evidence of their effectiveness or usability, potentially compromising patient care, and provider safety. Our objective was to determine the degree of protection offered by these devices and explore other usability factors for two popular barrier systems. METHODS: A simulated trial comparing an intubation box, a frame and plastic tarp system, and unprotected intubation was performed in an academic emergency department. Ten emergency physicians were recruited to participate. Our primary outcome was the degree of contamination from secretions measured by average surface area exposed to phosphorescent material. Secondary outcomes included: laryngoscopy time and time to barrier application, unsuccessful intubation attempts, and usability ratings for each system. Descriptive statistics were reported for all variables of interest and a linear mixed model was used to analyze contamination and laryngoscopy time. Usability was captured through electronic questionnaires using a five-point Likert scale. RESULTS: Contamination was more prevalent with the box, compared to the frame and tarp, and no device, however, this did not achieve statistical significance (13.2% versus 8.1% versus 12.2%, P = 0.17). A barrier system delayed intubation when compared to using no system (no system = 24.4 s [95% CI 17.3-27.5], frame = 54.4 s [95% CI 13.8-95.0], box = 33.8 s [95% CI 21.4-46.1], P = 0.02). In assessing usability, 30% of users preferred the use of a box barrier, 40% of users preferred the frame, and 30% would not use either in future intubation. CONCLUSIONS: Compared to no barrier protection, an intubation box enclosure offers limited additional protection. A frame and tarp system reduces exposure at the expense of visibility and operator comfort. Finally, barrier systems do not appear to have a clinically significant impact on airway management.

Recommendations for enhancing collaboration between the Canadian emergency department quality improvement and research communities.

OBJECTIVES: While quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal-to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities. METHODS: An expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms. RESULTS: The final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both. CONCLUSION: Six recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes.

RéSUMé: OBJECTIFS: Bien que l'amélioration de la qualité (AQ) et la recherche clinique représentent deux approches scientifiques distinctes, elles ont le même but ultime: améliorer la santé et les résultats des soins aux patients. En tirant profit de leurs atouts respectifs, les chances d'obtenir et de soutenir des améliorations de santé sont plus élevées. Notre objectif était de créer des recommandations pour renforcer la collaboration entre les communautés d'AQ et de recherche clinique en médecine d'urgence canadienne. MéTHODES: Un groupe d'experts de huit cliniciens des services d'urgence dotés d'une expertise diversifiée en matière d'AQ et de recherche clinique a rédigé une liste de recommandations basées sur leur expertise professionnelle et un examen de la revue de littérature. Ces recommandations ont été affinées en consultation avec les parties prenantes nationales et examinées lors du Symposium académique virtuel de ACMU 2020, où des commentaires ont été reçus via plusieurs plateformes virtuelles. RéSULTATS: Les six recommandations finales incluent que tous les prestataires des services de médecine d'urgence devraient: (1) comprendre le rôle et l'application de la recherche clinique et de la science de l'AQ; que les médecins universitaires en médecine d'urgence devraient: (2) contribuer à la fois à l'adoption locale et à la diffusion large des résultats de projets, (3) tirer parti des méthodologies d'AQ dans les projets de recherche afin d'améliorer l'application des connaissances, et (4) veiller à ce que les résultats de projet donnent la priorité aux soins aux patients; et que les dirigeants universitaires devraient: (5) améliorer l'infrastructure de surveillance des projets de recherche et d'AQ, et (6) encourager la collaboration entre les chercheurs et les experts en AQ en assurant que les infrastructures universitaires et opérationnelles les alignent et les soutiennent. CONCLUSION: Six recommandations sont présentées pour aider la communauté de la médecine d'urgence canadienne à parvenir à une plus grande collaboration entre les chercheurs et les experts en AQ dans le but ultime d'améliorer les résultats des soins aux patients.

Barrier enclosure use during aerosol-generating medical procedures: A scoping review.

INTRODUCTION: Barrier enclosure devices were introduced to protect against infectious disease transmission during aerosol generating medical procedures (AGMP). Recent discussion in the medical community has led to new designs and adoption despite limited evidence. A scoping review was conducted to characterize devices being used and their performance. METHODS: We conducted a scoping review of formal databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CENTRAL, Scopus), grey literature, and hand-searched relevant journals. Forward and reverse citation searching was completed on included articles. Article/full-text screening and data extraction was performed by two independent reviewers. Studies were categorized by publication type, device category, intended medical use, and outcomes (efficacy - ability to contain particles; efficiency - time to complete AGMP; and usability - user experience). RESULTS: Searches identified 6489 studies and 123 met criteria for inclusion (k = 0.81 title/abstract, k = 0.77 full-text). Most articles were published in 2020 (98%, n = 120) as letters/commentaries (58%, n = 71). Box systems represented 42% (n = 52) of systems described, while plastic sheet systems accounted for 54% (n = 66). The majority were used for airway management (67%, n = 83). Only half of articles described outcome measures (54%, n = 67); 82% (n = 55) reporting efficacy, 39% (n = 26) on usability, and 15% (n = 10) on efficiency. Efficacy of devices in containing aerosols was limited and frequently dependent on use of suction devices. CONCLUSIONS: While use of various barrier enclosure devices has become widespread during this pandemic, objective data of efficacy, efficiency, and usability is limited. Further controlled studies are required before adoption into routine clinical practice.

Reducing unnecessary testing in the emergency department: The case for INR and aPTT.

OBJECTIVE: Routine coagulation testing is rarely indicated in the emergency department. Our goal is to determine the combined effects of uncoupling routine coagulation testing (i.e., international normalized ratio [INR]; activated partial thromboplastin time [aPTT]), disseminating an educational module, and implementing a clinical decision support system (CDSS) on coagulation testing rates in two academic emergency departments. METHODS: A prospective pre-post study of INR-aPTT uncoupling, educational module distribution, and CDSS implementation in two academic emergency departments. All patients ages 18 years and older undergoing evaluation and treatment during the period of August 1, 2015, to November 30, 2017, were included. Primary outcome was coagulation testing utilization during the emergency department encounter. Secondary outcomes included associated costs, frequency of downstream testing, and frequency of blood transfusions. RESULTS: Uncoupling INR-aPTT testing combined with educational module distribution and CDSS implementation resulted in significantly decreased coupled INR-aPTT testing, with significantly increased selective INR and aPTT testing. Overall, the aggregate rate of coagulation testing declined for both INR and aPTT testing (48 tests/100 patients/day to 26 tests/100 patients/day). There was a significant decrease in associated daily costs (median cost per day: $1048.32 v. $601.68), realizing estimated annual savings of $163,023 Canadian dollars (CAD). There was no signal of increased downstream testing or patient blood product requirements. CONCLUSION: Compared to baseline practice patterns, our multimodal initiative significantly decreased coagulation testing, with meaningful cost savings and without evidence of patient harm. Clinicians and administrators now have a growing toolkit to target the plethora of low-value tests and treatments in emergency medicine.

Altered mental status in older adults with histamine2-receptor antagonists: a population-based study.

BACKGROUND: Standard doses of histamine2-receptor antagonists (H2RAs) may induce altered mental status in older adults, especially in those with chronic kidney disease (CKD). METHODS: Population-based cohort study of older adults who started a new H2RA between 2002 and 2011 was conducted. Ninety percent received the current standard H2RA dose in routine care. There was no significant difference in 27 baseline patient characteristics. The primary outcome was hospitalization with an urgent head computed tomography (CT) scan (proxy for altered mental status), and the secondary outcome was all-cause mortality also within 30days of a new H2RA prescription. RESULTS: Standard vs. low H2RA dose was associated with a higher risk of hospitalization with an urgent head CT scan (0.98% vs. 0.74%, absolute risk difference 0.24% [95% CI 0.11% to 0.36%], relative risk 1.33 [95% CI 1.12 to 1.58]). This risk was not modified by the presence of CKD (interaction P value=0.71). Standard vs. low H2RA dose was associated with a higher risk of mortality (1.07% vs.0.74%; absolute risk difference 0.34% [95% CI 0.20% to 0.46%], relative risk 1.46 [95% CI 1.23 to 1.73]). INTERPRETATION: Compared to a lower dose, initiation of the current standard dose of H2RA in older adults is associated with a small absolute increase in the 30-day risk of altered mental status (using neuroimaging as a proxy), even in the absence of CKD. This risk may be avoided by initiating older adults on low doses of H2RAs for gastroesophogeal reflux disease, and increasing dosing as necessary for symptom control.

Higher anti-depressant dose and major adverse outcomes in moderate chronic kidney disease: a retrospective population-based study.

BACKGROUND: Many older patients have chronic kidney disease (CKD), and a lower dose of anti-depressants paroxetine, mirtazapine and venlafaxine is recommended in patients with CKD to prevent drug accumulation from reduced elimination. Using information available in large population-based healthcare administrative databases, we conducted this study to determine if ignoring the recommendation and prescribing a higher versus lower dose of anti-depressants associates with a higher risk of adverse events. METHODS: We conducted a population-based cohort study to describe the 30-day risk of delirium in older adults who initiated a higher vs. lower dose of these three anti-depressants in routine care. We defined delirium using the best proxy available in our data sources - hospitalization with an urgent head computed tomography (CT) scan. We determined if CKD status modified the association between anti-depressant dose and outcome, and examined the secondary outcome of 30 day all-cause mortality. We used multivariable logistic regression analyses to estimate adjusted odds ratios (relative risk (RR)) and 95% confidence intervals. RESULTS: We identified adults (mean age 75) in Ontario who started a new study anti-depressant at a higher dose (n=36,651; 31%) or lower dose (n=81,160; 69%). Initiating a higher vs. lower dose was not associated with an increased risk of hospitalization with head CT (1.09% vs. 1.27% (adjusted RR 0.90; 95% CI, 0.80 to 1.02), but was associated with a lower risk of all-cause mortality (0.76% vs. 0.97% RR 0.82; 95% CI, 0.71 to 0.95). Neither of these relative risks were modified by the presence of CKD (p=0.16, 0.68, respectively). CONCLUSIONS: We did not observe an increase in two adverse outcomes when study anti-depressants were initiated at a higher dose in elderly patients with moderate CKD. Contrary to our hypothesis, the 30-day risk of mortality was lower when a higher versus lower dose of anti-depressant was initiated in these patients, a finding which requires corroboration and further study.

Use of clinical decision support systems for kidney-related drug prescribing: a systematic review.

BACKGROUND: Clinical decision support systems (CDSSs) have the potential to improve kidney-related drug prescribing by supporting the appropriate initiation, modification, monitoring, or discontinuation of drug therapy. STUDY DESIGN: Systematic review. We identified studies by searching multiple bibliographic databases (eg, MEDLINE and EMBASE), conference proceedings, and reference lists of all included studies. SETTING & POPULATION: CDSSs used in hospital or outpatient settings for acute kidney injury and chronic kidney disease, including end-stage renal disease (chronic dialysis patients or transplant recipients). SELECTION CRITERIA FOR STUDIES: Studies prospectively using CDSSs to aid in kidney-related drug prescribing. INTERVENTION: Computerized or manual CDSSs. OUTCOMES: Clinician prescribing and patient-important outcomes as reported by primary study investigators. CDSS characteristics, such as whether the system was computerized, and system setting. RESULTS: We identified 32 studies. In 17 studies, CDSSs were computerized, and in 15 studies, they were manual pharmacist-based systems. Systems intervened by prompting for drug dosing adjustments in relation to the level of decreased kidney function (25 studies) or in response to serum drug concentrations or a clinical parameter (7 studies). They were used most in academic hospital settings. For computerized CDSSs, clinician prescribing outcomes (eg, frequency of appropriate dosing) were considered in 11 studies, with all 11 reporting statistically significant improvements. Similarly, manual CDSSs that incorporated clinician prescribing outcomes showed statistically significant improvements in 6 of 8 studies. Patient-important outcomes (eg, adverse drug events) were considered in 7 studies of computerized CDSSs, with statistically significant improvements in 2 studies. For manual CDSSs, 6 studies measured patient-important outcomes and 5 reported statistically significant improvements. Cost-savings also were reported, mostly for manual CDSSs. LIMITATIONS: Studies were heterogeneous in design and often limited by the evaluation method used. Benefits of CDSSs may be reported selectively in this literature. CONCLUSION: CDSSs are available for many dimensions of kidney-related drug prescribing, and results are promising. Additional high-quality evaluations will guide their optimal use.