An Emergency Medical Technician Administered Falls-Assessment Protocol to Safely Identify Elderly Adults with Non-Urgent Conditions that may Avoid Transport to Emergency Department.

Background: Approximately two-thirds of patients transported to emergency departments (ED) for a fall are discharged from the ED without urgent treatment. This pilot study tests the feasibility of implementing a pre-hospital falls-assessment protocol performed by emergency medical technicians (EMTs) to determine whether a patient who fell needs an ED assessment or could be referred safely to a community resource. Methods: The protocol was administered by trained EMTs to adults aged ≥ 65 after a fall between October 2019 and March 2020 in Sherbrooke (QC). All patients were transported to ED regardless of protocol outcome (transport recommended/not recommended). The objective was to assess if EMTs could complete the protocol and make the appropriate decision concerning the transport to ED. Secondary objectives aimed to assess the accuracy in identifying patients who do not require transport, and to measure the impact on avoidable ambulance transports. Results: A total of 125 EMTs interventions were carried out: 17 patients were in the transport not recommended group, representing 14% of transport to hospital for falls-related EMTs calls that could be possibly avoided. Of these, 110 were transported to ED. Mean duration of on-site EMTs interventions was of 31 minutes. Forty-seven patients were admitted, mostly for infections and fractures, including four in the transport not recommended group. Conclusions: This study showed that EMTs can administer a falls-assessment protocol aimed at identifying patients that need an ED evaluation. Results permitted to amend the protocol before the second phase of the project evaluating the safety of the protocol.

Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial.

BACKGROUND: While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS: We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION: On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION: This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).

The Association Between Frailty and a Nurse-Identified Need for Comprehensive Geriatric Assessment Referral from the Emergency Department.

BACKGROUND: Emergency nurses commonly conduct geriatric assessments in the emergency department (ED). However, little is known about what geriatric syndromes or clinical presentations prompt a nurse to document an identified need for comprehensive geriatric assessment (CGA). OBJECTIVES: To examine the association between geriatric syndromes, like frailty, and a nurse-identified need for a CGA following emergency care. METHODS: We conducted a secondary analysis of a multi-province Canadian cohort from the InterRAI Multinational Cohort Study. We collected data at ED registration from patients 75 years of age and older (n = 2,274) from eight ED sites across Canada between November 2009 and April 2012. Geriatric syndromes were assessed by trained emergency nurses using the interRAI ED Contact Assessment; and we retrospectively calculated the ED frailty index. We employed binary logistic regression to determine the adjusted associations between geriatric syndromes and a nurse-identified need for a CGA. RESULTS: Approximately one-quarter (28%) of older adults were identified to need a CGA following emergency care. A 0.1 unit increase in the ED frailty index increased the likelihood of a nurse identify a need for CGA (RD: 6.6; 95% CI = 5.5-7.9). Most geriatric syndromes increased the probability of a nurse documenting the need for a CGA. CONCLUSION: When assessed by emergency nurses, the identified need for CGA is strongly linked to the presence of geriatric syndromes, including frailty. We provide face validity for the continued use of emergency nurses for screening and assessing older ED patients.

Personalised risk prediction following emergency department assessment for syncope.

BACKGROUND: Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS: We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS: 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.

What do community paramedics assess? An environmental scan and content analysis of patient assessment in community paramedicine.

OBJECTIVES: Patient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs. METHODS: We performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy. RESULTS: A total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments. CONCLUSION: Although community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.

OBJECTIFS: L'évaluation des patients est un élément fondamental de la pratique de la paramédecine communautaire, mais l'absence de norme reconnue en matière d'évaluation contribue à l'incertitude qui plane sur les facteurs pris en considération dans la planification des soins et les prises de décision relatives au traitement. L'étude visait donc à présenter un résumé du contenu des instruments d'évaluation et à décrire l'état de la pratique actuelle dans les programmes de visites à domicile en paramédecine communautaire. MÉTHODE: L'étude consistait en une analyse environnementale de tous les programmes de paramédecine communautaire offerts en Ontario et en une analyse de contenu visant à décrire les pratiques actuelles d'évaluation des patients appliquées dans le cadre des programmes de visites à domicile. Les chercheurs se sont référés à la Classification internationale du fonctionnement, du handicap et de la santé (CIF) pour comparer et classer les évaluations, et chacun des éléments inscrits sur chaque formulaire d'évaluation a été classé selon la taxonomie de la CIF. RÉSULTATS: Au total, 43 services paramédicaux sur 52, en Ontario, ont participé à l'analyse environnementale, dont 24 se prêtaient à une recherche approfondie reposant sur une analyse de contenu des formulaires d'évaluation initiale. Sur les 24 services, 16 répondaient aux critères de sélection en vue d'une analyse de contenu. Le nombre d'éléments évalués variait de 13 à 252 selon les formulaires (médiane : 116,5; écart interquartile : 134,5). La plupart des questionnaires contenaient des éléments tirés de chacun des domaines inscrits dans la CIF. Au niveau des sous-domaines, seule l'évaluation des troubles de fonctionnement des systèmes cardiovasculaire, sanguin, immunitaire et respiratoire figuraient sur tous les formulaires. CONCLUSION: Les programmes de visites à domicile en paramédecine communautaire peuvent certes avoir des différences de conception et de but, mais ils permettent tous une évaluation pluridimensionnelle des nouveaux patients. Si les programmes de visites à domicile en paramédecine communautaire ont des caractéristiques communes mais des formes d'évaluation différentes, il est difficile de s'attendre à des résultats comparables en ce qui concerne les consultations, les plans de soins, les traitements et les interventions.

Identification of older adults with frailty in the Emergency Department using a frailty index: results from a multinational study.

Objective: frailty is a central concept in geriatric medicine, yet its utility in the Emergency Department (ED) is not well understood nor well utilised. Our objectives were to develop an ED frailty index (FI-ED), using the Rockwood cumulative deficits model and to evaluate its association with adverse outcomes. Method: this was a large multinational prospective cohort study using data from the interRAI Multinational Emergency Department Study. The FI-ED was developed from the Canadian cohort and validated in the multinational cohort. All patients aged ≥75 years presenting to an ED were included. The FI-ED was created using 24 variables included in the interRAI ED-Contact Assessment tool. Results: there were 2,153 participants in the Canadian cohort and 1,750 in the multinational cohort. The distribution of the FI-ED was similar to previous frailty indices. The mean FI-ED was 0.26 (Canadian cohort) and 0.32 (multinational cohort) and the 99th percentile was 0.71 and 0.81, respectively. In the Canadian cohort, a 0.1 unit increase in the FI-ED was significantly associated with admission (odds ratio (OR) = 1.43 [95% CI: 1.34-1.52]); death at 28 days (OR = 1.55 [1.38-1.73]); prolonged hospital stay (OR = 1.37 [1.22-1.54]); discharge to long-term care (OR = 1.30 [1.16-1.47]); and need for Comprehensive geriatric Assessment (OR = 1.51 [1.41-1.60]). The multinational cohort showed similar associations. Conclusion: the FI-ED conformed to characteristics previously reported. A FI, developed and validated from a brief geriatric assessment tool could be used to identify ED patients at higher risk of adverse events.

[Is haemostasis assessment mandatory in case of pregnancy loss?]. / Faut-il faire un bilan d'hémostase en cas de pertes foetales?

Pregnancy losses must be categorised into biochemical loss, early embryonic loss, late foetal loss and stillbirth cases. No haemostasis-related investigations are necessary for biochemical losses. Antiphospholipid antibodies must be checked for three early losses or one late loss. A complete blood count will reveal the rare essential thrombocytemias, a functional fibrinogen assay the exceptional dysfibrinogenemia cases. Vitamin B12 and intracellular folates levels must be checked in case of clinical or biological suspicion. Constitutive thrombophilias must not be routinely assessed because a therapeutic option is not definitively demonstrated. Screening for constitutive thrombophilias should be only indicated for clinical research purposes, only for late foetal loss and stillbirth cases.

Talking Wellness: a description of a community-academic partnered project to engage an African-American community around depression through the use of poetry, film, and photography.

The design, implementation, and preliminary evaluation of an enhanced community-engagement program that uses poetry, film, and photography at a film festival in south Los Angeles is described. This project is one of several Talking Wellness projects designed to develop social capital and enhance community engagement in projects designed to improve the community's capacity to communicate effectively about depression, to decrease the associated stigma, and to participate in the design and evaluation of research interventions. The high degree of collaboration in the development and evaluation of this community participatory research model is illustrated by describing the selection and design of the intervention and the development of the survey questionnaires used for data collection. The project is described from the perspective of community members involved in the process.