The financial and environmental impact of unopened medical supplies discarded in the emergency department.

BACKGROUND: Inefficient supply chain management within the US healthcare industry results in significant financial and environmental impact. Unopened medical supplies may routinely be discarded in the Emergency Department (ED), contributing as a source of unnecessary medical waste. OBJECTIVES: Quantify the financial and environmental impact of unopened medical supplies that are routinely discarded in two EDs. METHODS: The study utilized a waste audit of collection bins targeting unopened medical supplies that would have otherwise been discarded. Associated financial cost was calculated using data from the purchasing department and from an online search. End-of-life (EOL) environmental impact was calculated using the M+ Wastecare calculator. A lifecycle analysis was performed on a supplier-packaged intubation kit, which the study identified as a significant source of waste. RESULTS: High volumes of unused, unopened supplies (143.48 kg) were collected during the study period with a yearly extrapolated value of 1337 kg. Purchasing costs over 44 days at Hospital A and 37 days at Hospital B for these items amounted to $16,159.71 across both sites with a yearly extrapolated value of $150,631.73. Yearly extrapolated EOL impact yielded 5.79 tons per year of CO2eq. Components from supplier-packaged intubation kits were found to contribute to 45.2% of collected items at one site which purchased them. Lifecycle analysis of an intubation kit yields 23.6 kg of CO2eq. CONCLUSION: This study demonstrates that the disposal of unopened medical supplies contributes a significant source of financial and environmental waste in the ED setting. The results continue to support the trend of procedure kits generating significant environmental and financial waste.

Pushing for IV Push Medications: Cost-Effectiveness Model of Switching from IV Piggyback to IV Push for Frequently Used Emergency Department Medications.

In considering the potential to reduce the carbon footprint of our emergency department (ED) via decreasing plastic waste, we aimed to evaluate the effects of changing certain common emergency department medications from an intravenous (IV) piggyback administration route to IV push. Our team queried hospital pharmacy data to determine the number of doses of several frequently utilized antibiotics administered over a six-month time period, then calculated the resultant cost savings of a switch to IV push. Based upon our modeling calculations, switching certain medication administration routes to IVP can have significant impacts on cost, with an estimated cost savings of about $47,000 every six months. Maximizing the use of push administration could result in even more dramatic cost savings. In some scenarios, using IVP administration results in less than half the amount of plastic waste generated. Future research including a full life-cycle analysis is needed in order to precisely determine the impact on carbon footprint created by making this change.

The Climate Impact of Medical Residency Interview Travel in the United States and Canada: A Scoping Review.

Background The change from in-person to virtual interviews for graduate medical education (GME) provides the opportunity to compare the potential environmental effects. Objective To explore and summarize the existing literature on the potential climate impact of medical residency interview travel through a scoping review. Methods The search was conducted in October 2022 using 5 research databases. Results were screened for inclusion by 2 reviewers in a 2-tiered process. Inclusion criteria were limited to English language articles from the United States and Canada, with no limitations on the type of study, type of applicant (allopathic, osteopathic, or international medical graduate), or type of residency. A thematic analysis focusing on the objectives and main findings of identified studies was conducted and an iteratively created standardized data extraction worksheet was used such that all studies were explicitly assessed for the presence of the same themes. Results The search identified 1480 unique articles, of which 16 passed title and abstract screening and 13 were ultimately included following full-text review. There were 3 main themes identified: the carbon footprint of residency travel, stakeholders' perspectives on virtual interviews, and advocacy for virtual interviews. All 13 articles employed persuasive language on interview reform, ranging from neutral to strongly in favor of virtual interviews based wholly or in part on environmental concerns. Conclusions Two main findings were identified: (1) Though carbon footprint estimates for in-person interviews vary, in-person interviews create considerable carbon emissions and (2) those working in GME are concerned about the climate effects of GME practices and describe them as a compelling reason to permanently adopt virtual interviewing.

Modelling climate impacts on paediatric sepsis incidence and severity in Bangladesh.

Background: Sepsis is a leading cause of paediatric mortality worldwide, disproportionately affecting children in low- and middle-income countries. The impacts of climate change on the burden and outcomes of sepsis in low- and middle-income countries, particularly in paediatric populations, remain poorly understood. We aimed to assess the associations between climate variables (temperature and precipitation) and paediatric sepsis incidence and mortality in Bangladesh, one of the countries most affected by climate change. Methods: We conducted retrospective analyses of patient-level data from the International Centre for Diarrhoeal Disease Research, Bangladesh, and environmental data from the National Oceanic and Atmospheric Administration. Using random forests, we assessed associations between sepsis incidence and sepsis mortality with temperature and precipitation between 2009-22. Results: A nonlinear relationship between temperature and sepsis incidence and mortality was identified. The lowest incidence occurred at an optimum temperature of 26.6°C with a gradual increase below and a sharp rise above this temperature. Higher precipitation levels showed a general trend of increased sepsis incidence. A similar distribution for sepsis mortality was identified with an optimum temperature of 28°C. Conclusions: Findings suggest that environmental temperature and precipitation play a role in paediatric sepsis incidence and sepsis mortality in Bangladesh. As children are particularly vulnerable to climate impacts, it is important to consider climate change in health care planning and resource allocation, especially in resource-limited settings, to allow for surge capacity planning during warmer and wetter seasons. Further prospective research from more globally representative data sets will provide more robust evidence on the nature of the relationships between climate variables and paediatric sepsis worldwide.

Faculty support bundle for simulation education.

BACKGROUND: Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness. METHODS: Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience. RESULTS: Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03). DISCUSSION: The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies.

Supporting healthcare workers caring for ex-combatants: incentives among Colombian providers with FARC ex-combatants.

With the Peace Agreement between Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised healthcare to 13,000 'reincorporating' FARC ex-combatants. Shortages of healthcare workers in reincorporation camps means this promise is in danger of going unfulfilled. More information is needed to determine incentives, disincentives, and recruitment of healthcare providers to address this shortage. Semi-structured interviews were conducted with healthcare providers across FARC reincorporation camps, and a multidisciplinary team conducted analysis in NVivo12 using a team-based coding method. Twenty-four healthcare professionals from 15 camps participated, of which 75% were female. Incentives to work with FARC included improved clinical skills, professional advancement, increased comfort with FARC, and contributing to the peace process. Disincentives included poor living conditions, lack of support, biases, familial commitments, and sacrificing career opportunities. Three-fourths of the sample recommended working with FARC, and 92% reported a shortage of healthcare workers. Recruitment strategies included improved resources and specialised career development for healthcare workers, facilitating interactions between FARC and healthcare professionals outside clinical scenarios, and integrating medicine for vulnerable populations into health education. This study shows the impact that working with FARC ex-combatants can have on healthcare providers and tangible suggestions for increasing provider participation to address the healthcare worker shortage.

Utilisation of peripheral vasopressor medications and extravasation events among critically ill patients in Rwanda: A prospective cohort study.

Introduction: In high-income settings, vasopressor administration to treat haemodynamic instability through a central venous catheter (CVC) is the preferred standard. However, due to lack of availability and potential for complications, CVCs are not widely used in low- and middle-income countries. This prospective cohort study evaluated the use of peripheral vasopressors and associated incidence of extravasation events in patients with haemodynamic instability at the Centre Hospitalier Universitaire Kigali, Rwanda. Methods: Patients ≥18 years of age receiving peripheral vasopressors in the emergency centre (EC) or intensive care unit (ICU) for >1 hour were eligible for inclusion. The primary outcome was extravasation events. Patients were followed hourly until extravasation, medication discontinuation, death, or CVC placement. Extravasation incidence with 95% confidence intervals (CI) were calculated using Poisson exact tests. Results: 64 patients were analysed. The median age was 49 (Interquartile Range [IQR]:33-65) and 55% were female. Distributive shock was the most frequent aetiology (47%). Intravenous (IV) location was most commonly antecubital fossa/upper arm (31%) and forearm/hand (43%). IV gauges ≤18 were used in 58% of locations. Most patients were treated with adrenaline (66%) and noradrenaline (41%), and 11% received multiple vasopressors. The median treatment duration was 19 hours (IQR:8.5-37). Treatment discontinuation was predominantly due to mortality (41%) or resolution of instability (36%). There were two extravasation events (2.9%), both limited to soft tissue swelling. Extravasation incidence was 0.8 events per 1000 patient-hours (95% CI:0.2-2.2). Conclusion: Extravasation incidence with peripheral vasopressors was low, even with long use durations, suggesting peripheral infusions may be an acceptable approach when barriers exist to CVC placement.

Confidence and knowledge in emergency management among medical students across Colombia: A role for the WHO basic emergency care course.

INTRODUCTION: Globally, medical students have demonstrated knowledge gaps in emergency care and acute stabilization. In Colombia, new graduates provide care for vulnerable populations. The World Health Organization (WHO) Basic Emergency Care (BEC) course trains frontline providers with limited resources in the management of acute illness and injury. While this course may serve medical students as adjunct to current curriculum, its utility in this learner group has not been investigated. This study performs a baseline assessment of knowledge and confidence in emergency management taught in the BEC amongst medical students in Colombia. METHODS: A validated, cross-sectional survey assessing knowledge and confidence of emergency care congruent with BEC content was electronically administered to graduating medical students across Colombia. Knowledge was evaluated via 15 multiple choice questions and confidence via 13 questions using 100 mm visual analog scales. Mean knowledge and confidence scores were compared across demographics, geography and prior training using Chi-Squared or one-way ANOVA analyses. RESULTS: Data were gathered from 468 graduating medical students at 36 institutions. The mean knowledge score was 59.9% ± 23% (95% CI 57.8-62.0%); the mean confidence score was 59.6 mm ±16.7 mm (95% CI 58.1-61.2). Increasing knowledge and confidence scores were associated with prior completion of emergency management training courses (p<0.0001). CONCLUSION: Knowledge and confidence levels of emergency care management for graduating medical students across Colombia demonstrated room for additional, specialized training. Higher scores were seen in groups that had completed emergency care courses. Implementation of the BEC as an adjunct to current curriculum may serve a valuable addition.

Increased Temperatures Are Associated with Increased Utilization of Emergency Medical Services in Rhode Island.

BACKGROUND: Increasing temperatures negatively impact health and increases demands on healthcare systems. However, this has been poorly studied in Rhode Island (RI). Here we characterize the impact of heat on emergency medical services (EMS) utilization in RI. METHODS: The Rhode Island National Emergency Services Information System V3 dataset was merged with data from the National Center for Environmental Information of the National Oceanic and Atmospheric Administration from the summers of 2018 and 2019. The outcome of daily mean EMS runs were compared against the exposure increasing daily temperatures, measured as daily maximum, minimum and daily average °F, using Poisson regressions. Patient characteristics were included across temperature models. RESULTS: Increasing daily temperatures were associated with increasing EMS encounters. The adjusted incident rate ratio (IRR) for mean daily EMS encounters by increasing maximum daily temperature was 1.006 (95% CI 1.004-1.007, Table 3). This resulted in a projected 17.2% increase in EMS runs on days with a maximum temperature of 65°F compared to days with a maximum temperature of 95°F. The adjusted IRR for mean daily EMS encounters by the daily minimum temperature was 1.004 (1.003-1.006) and the adjusted IRR for the mean daily EMS encounters by the daily average temperature was 1.006 (1.005-1.008). CONCLUSIONS: Increasing minimum, maximum, and average daily temperatures were associated with increasing EMS utilization across Rhode Island in the summers of 2018 and 2019. Further research into these trends may help with planning and resource allocation as summer temperatures continue to rise.

A Scoping Review of Non-Communicable Diseases and Maternal and Child Health Needs of Venezuelan Migrants in South America.

BACKGROUND: Migration of Venezuelan citizens to other South American countries has increased in recent years. While the prevalence, morbidity, and mortality of infectious diseases in Venezuelan migrants across South America appears to be well described, the non-communicable disease (NCD) and maternal and child health needs in this population is less clear. A scoping review of existing peer-reviewed primary research and grey literature describing the epidemiology of NCDs and maternal and child health needs in Venezuelan migrants in major South American host countries was performed in order to highlight important gaps in knowledge. METHODS: A scoping review was performed of peer-reviewed research and grey literature for NCD and maternal and child health needs among Venezuelan migrants living in the following host South American countries with greater than 100,000 migrants: Argentina, Brazil, Chile, Colombia, Ecuador, and Peru. A total of 47 electronic databases were searched for primary research published between 2017 and 2020 in either English or Spanish. RESULTS: Out of 1,098 initial articles retrieved, 17 records met inclusion criteria, with the majority identified from the grey literature. Most studies were published in 2019 and most were either primary reports published by non-governmental organizations within the grey literature search or cross-sectional qualitative studies. Studies came from Argentina, Chile, Colombia, and Peru, with three records offering a regional perspective. Most studies provided broad data on NCDs and maternal and child health needs but lacked granular statistics. Our analysis found the rate of chronic disease among Venezuelan migrants to range from 9-14% within countries who reported this data. Significant rates of psychiatric conditions such as depression and post-traumatic stress disorder were reported. Other conditions described were ophthalmologic diseases, diabetes, chronic pain, asthma, cough, dyslipidemia, hypertension, arthritis, malnutrition, and obstetric complications, although exact statistics were limited. Obstacles to care included lack of healthcare access and affordability. CONCLUSIONS: Existing reports discuss important needs related to NCDs and maternal and child health in Venezuelan migrants in South American countries, but there are significant gaps in knowledge. Further research must describe in greater detail the prevalence, morbidity, and mortality of NCDs and maternal and child health needs in Venezuelan migrants in this region in order to assist local governments and international humanitarian organizations with providing strategic and unified responses.

Emergency medicine matters: epidemiology of medical pathology and changes in patient outcomes after implementation of a post-graduate training program at a Tertiary Teaching Hospital in Kigali, Rwanda.

BACKGROUND: Emergency care is a new but growing specialty across Africa where medical conditions have been estimated to account for 92% of all disability-adjusted life years. This study describes the epidemiology of medical emergencies and the impact of formalized emergency care training on patient outcomes for medical conditions in Rwanda. METHODS: A retrospective cohort study was performed using a database of randomly sampled patients presenting to the emergency center (EC) at the University Teaching Hospital of Kigali. All patients, > 15 years of age treated for medical emergencies pre- and post-implementation of an Emergency Medicine (EM) residency training program were eligible for inclusion. Patient characteristics and final diagnosis were described by time period (January 2013-September 2013 versus September 2015-June 2016). Univariate chi-squared analysis was performed for diagnoses, EC interventions, and all cause EC and inpatient mortality stratified by time period. RESULTS: A random sample of 1704 met inclusion with 929 patients in the pre-residency time period and 775 patients in the post-implementation period. Demographics, triage vital signs, and shock index were not different between time periods. Most frequent diagnoses included gastrointestinal, infectious disease, and neurologic pathology. Differences by time period in EC management included antibiotic use (37.2% vs. 42.2%, p = 0.04), vasopressor use (1.9% vs. 0.5%, p = 0.01), IV crystalloid fluid (IVF) use (55.5% vs. 47.6%, p = 0.001) and mean IVF administration (2057 ml vs. 2526 ml, p < 0.001). EC specific mortality fell from 10.0 to 1.4% (p < 0.0001) across time periods. CONCLUSIONS: Mortality rates fell across top medical diagnoses after implementation of an EM residency program. Changes in resuscitation care may explain, in part, this mortality decrease. This study demonstrates that committing to emergency care can potentially have large effects on reducing mortality.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda.

BACKGROUND: Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K). METHODS: Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids. CONCLUSIONS: Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

COVID-19 Pandemic Prompts a Paradigm Shift in Global Emergency Medicine: Multidirectional Education and Remote Collaboration.

To date, the practice of global emergency medicine (GEM) has involved being "on the ground" supporting in-country training of local learners, conducting research, and providing clinical care. This face-to-face interaction has been understood as critically important for developing partnerships and building trust. The COVID-19 pandemic has brought significant uncertainty worldwide, including international travel restrictions of indeterminate permanence. Following the 2020 Society for Academic Emergency Medicine meeting, the Global Emergency Medicine Academy (GEMA) sought to enhance collective understanding of best practices in GEM training with a focus on multidirectional education and remote collaboration in the setting of COVID-19. GEMA members led an initiative to outline thematic areas deemed most pertinent to the continued implementation of impactful GEM programming within the physical and technologic confines of a pandemic. Eighteen GEM practitioners were divided into four workgroups to focus on the following themes: advances in technology, valuation, climate impacts, skill translation, research/scholastic projects, and future challenges. Several opportunities were identified: broadened availability of technology such as video conferencing, Internet, and smartphones; online learning; reduced costs of cloud storage and printing; reduced carbon footprint; and strengthened local leadership. Skills and knowledge bases of GEM practitioners, including practicing in resource-poor settings and allocation of scarce resources, are translatable domestically. The COVID-19 pandemic has accelerated a paradigm shift in the practice of GEM, identifying a previously underrecognized potential to both strengthen partnerships and increase accessibility. This time of change has provided an opportunity to enhance multidirectional education and remote collaboration to improve global health equity.

Let's Get Personal: Academic Office Displays and Gender.

INTRODUCTION: Differential standards in academic medicine based on gender have been described for self-promoting behavior. BACKGROUND: Objective: To explore differences in office display of professional and personal items between male and female academic physicians as a proxy for self-promotion. METHODS: A university hospital's faculty was invited to participate in a study on office setup. Participants were blinded to the study aim. Investigators evaluated offices to assess the number of professional and personal displays. De-identified data on participant characteristics and office physical characteristics were recorded. Correlations with the number of items displayed were analyzed by univariable and multivariable Poisson regression. RESULTS: Forty-eight physicians participated: 23 (47.9%) from emergency medicine, 9 (18.8%) from surgery, and 16 (33.3%) from internal medicine. The median number of professional displays was 5.0 for women (interquartile range [IQR] = 3.0-9.0) and 6.0 for men (IQR = 2.0-12.0). Controlling for specialty and academic rank, no significant difference existed in professional display rates by women (incidence rate ratio = 1.1, 95% confidence interval = 0.8-1.4). The median number of personal displays was 14.5 items for women (IQR = 8.0-25.0) and 6.0 items for men (IQR = 3.0-15.0), with a significantly different rate (incidence rate ratio = 1.4, 95% confidence interval = 1.2-1.7) when we controlled for specialty, generation, rank, and office characteristics. CONCLUSION: Women displayed more personal items than did men, with no difference in professional display rates. Future studies should examine this difference to understand its cause, which may be linked to differences in academic promotion between men and women.

Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda.

BACKGROUND: Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. METHODS: This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. RESULTS: Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL. CONCLUSIONS: No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.

Evaluating emergency physicians' knowledge, attitudes, and experiences of FARC ex-combatants: A pilot study of Colombia's emergency medicine teaching hospitals.

OBJECTIVES: In the 2016 Peace Accord with the Fuerzas Armadas Revolucionarias de Colombia (FARC), Colombia promised to reincorporate 14,000 ex-combatants into the healthcare system. However, FARC ex-combatants have faced significant challenges in receiving healthcare, and little is known about physicians' abilities to address this population's healthcare needs. METHODS: An electronic questionnaire sent to the Colombian Emergency Medicine professional society and teaching hospitals assessed physicians' knowledge, attitudes, and experiences with the FARC ex-combatant reincorporation process. RESULTS: Among 53 participants, most were male (60.4%), and ∼25% were affected by the FARC conflict (22.6%). Overall knowledge of FARC reincorporation was low, with nearly two-thirds of participants (61.6%) scoring in the lowest category. Attitudes around ex-combatants showed low bias. Few physicians received training about reincorporation (7.5%), but 83% indicated they would like such training. Twenty-two participants (41.5%) had identified a patient as an ex-combatant in the healthcare setting. Higher knowledge scores were significantly correlated with training about reincorporation (r = 0.354, n = 53, P = 0.015), and experience identifying patients as ex-combatants (r = 0.356, n = 47, P = 0.014). CONCLUSION: Findings suggested high interest in training and low knowledge of the reincorporation process. Most physicians had low bias, frequent experiences with ex-combatants, and cared for these patients when they self-identify. The emergency department (ED) serves as an entrance into healthcare for this population and a potential setting for interventions to improve care delivery, especially those related to mental healthcare. Future studies could evaluate effects of care delivery following training on ex-combatant healthcare reintegration.

Evaluation of blood product transfusion therapies in acute injury care in low- and middle-income countries: a systematic review.

BACKGROUND: Worldwide, injuries account for approximately five million mortalities annually, with 90% occurring in low- and middle-income countries (LMICs). Although guidelines characterizing data for blood product transfusion in injury resuscitation have been established for high-income countries (HICs), no such information on use of blood products in LMICs exists. This systematic review evaluated the available literature on the use and associated outcomes of blood product transfusion therapies in LMICs for acute care of patients with injuries. METHODS: A systematic search of PubMed, EMBASE, Global Health, CINAHL and Cochrane databases through November 2018 was performed by a health sciences medical librarian. Prospective and cross-sectional reports of injured patients from LMICs involving data on blood product transfusion therapies were included. Two reviewers identified eligible records (κ=0.92); quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Report elements, patient characteristics, injury information, blood transfusion therapies provided and mortality outcomes were extracted and analyzed. RESULTS: Of 3411 records, 150 full-text reports were reviewed and 17 met inclusion criteria. Identified reports came from the World Health Organization regions of Africa, the Eastern Mediterranean, and South-East Asia. A total of 6535 patients were studied, with the majority from exclusively inpatient hospital settings (52.9%). Data on transfusion therapies demonstrated that packed red blood cells were given to 27.0% of patients, fresh frozen plasma to 13.8%, and unspecified product types to 50.1%. Among patients with blunt and penetrating injuries, 5.8% and 15.7% were treated with blood product transfusions, respectively. Four reports provided data on comparative mortality outcomes, of which two found higher mortality in blood transfusion-treated patients than in untreated patients at 17.4% and 30.4%. The overall quality of evidence was either low (52.9%) or very low (41.2%), with one report of moderate quality by GRADE criteria. CONCLUSION: There is a paucity of high-quality data to inform appropriate use of blood transfusion therapies in LMIC injury care. Studies were geographically limited and did not include sufficient data on types of therapies and specific injury patterns treated. Future research in more diverse LMIC settings with improved data collection methods is needed to inform injury care globally.

From Rhode Island to Colombia: Brown University Emergency Physicians Lead a Collaborative Consortium in a Post-Conflict Colombia.

INTRODUCTION: Colombia represents a country in transition, from decades of devastating civil war to a post-conflict era of peace building, to the recent management of the influx of thousands of Venezuelan migrants. Brown University, along with Colombian partners, are leading the way in an international, multi-institutional consortium with the goal of emergency medicine capacitation across Colombia. Program Implementations: Through these collaborative efforts, exchange programs for residents and faculty alike have been successfully established. A baseline assessment of emergency medicine education for medical students is underway. By the end of 2019, the Harvard Humanitarian Initiative (HHI) will launch an online tool in multiple languages, including Spanish, to help medical and nursing educators conduct systematic needs assessments of the way in which conflict has impacted medical and nursing schools. CONCLUSIONS: Successful avenues for collaboration and partnership are described between Brown Emergency physicians and Colombian collaborating universities. These programs help to build capacity in Colombia and also provide education and support for residents and faculty at Brown University. Current work will see these programs grow into the future.