Trends in the role of security services in the delivery of emergency department care.

BACKGROUND: Security services in most settings are an essential part of emergency department (ED) care, but their role remains poorly understood. We sought to:(1) identify the frequency of security services involvement in ED care;(2) characterise the events security services are called for; and (3) identify temporal trends in use. METHODS: We used a hospital-wide security database at a tertiary care ED in downtown Toronto, Ontario. Data from January 2017 to June 2021 related to the ED, patient or visitor related safety calls were included. We categorised calls by type of event (e.g.: Code White or Restraints). Call numbers were calculated as rates to adjust for visit volumes for each period. Univariate analyses were used to assess association between security services' calls and shift time, day of week, and month of the year. RESULTS: Over the 4.5-year study period, 20,033 ED-related calls were recorded. On average, we identified 61 calls per 1000 patient visits. On univariate analysis, no increase in security calls were found based on day of week or month, but a disproportionate number of security calls were recorded overnight. CONCLUSION: This study reveals high security services involvement in the delivery of care in one urban ED. Security databases can inform improvement work and could be augmented by better coding of violent events and linkage with electronic health records when involving patients.

RéSUMé : CONTEXTE: Dans la plupart des contextes, les services de sécurité constituent un élément essentiel des soins dispensés dans les services d'urgence, mais leur rôle reste mal compris. Nous avons cherché à: (1) identifier la fréquence de l'intervention des services de sécurité dans les soins aux urgences; (2) caractériser les événements pour lesquels les services de sécurité sont requis; et (3) identifier les tendances temporelles de l'utilisation. MéTHODES: Nous avons utilisé une base de données de sécurité à l'échelle de l'hôpital dans un service d'urgence de soins tertiaires du centre-ville de Toronto, en Ontario. Les données de janvier 2017 à juin 2021 relatives aux appels de sécurité liés aux urgences, aux patients ou aux visiteurs ont été incluses. Nous avons catégorisé les appels par type d'événement (par exemple : Code blanc ou Contraintes). Les nombres d'appels ont été calculés sous forme de taux afin d'ajuster les volumes de visites pour chaque période. Des analyses univariées ont été utilisées pour évaluer l'association entre les appels des services de sécurité et l'heure du quart de travail, le jour de la semaine et le mois de l'année. RéSULTATS: Au cours des 4,5 années de l'étude, 20 033 appels liés aux urgences ont été enregistrés. En moyenne, nous avons recensé 61 appels pour 1 000 visites de patients. L'analyse univariée n'a révélé aucune augmentation des appels de sécurité en fonction du jour de la semaine ou du mois, mais un nombre disproportionné d'appels de sécurité a été enregistré pendant la nuit. CONCLUSION: Cette étude révèle une forte implication des services de sécurité dans la prestation des soins dans un service d'urgence urbain. Les bases de données sur la sécurité peuvent servir de base aux travaux d'amélioration et pourraient être complétées par un meilleur codage des événements violents et une liaison avec les dossiers médicaux électroniques lorsqu'ils concernent des patients.

Factors associated with SARS-CoV-2 positivity in 20 homeless shelters in Toronto, Canada, from April to July 2020: a repeated cross-sectional study.

BACKGROUND: It is unclear what the best strategy is for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among residents of homeless shelters and what individual factors are associated with testing positive for the virus. We sought to evaluate factors associated with testing positive for SARS-CoV-2 among residents of homeless shelters and to evaluate positivity rates in shelters where testing was conducted in response to coronavirus disease 2019 (COVID-19) outbreaks or for surveillance. METHODS: We conducted a retrospective chart audit to obtain repeated cross-sectional data from outreach testing done at homeless shelters between Apr. 1 and July 31, 2020, in Toronto, Ontario, Canada. We compared the SARS-CoV-2 positivity rate for shelters where testing was conducted because of an outbreak (at least 1 known case) with those tested for surveillance (no known cases). A patient-level analysis evaluated differences in demographic, health and behavioural characteristics of residents who did and did not test positive for SARS-CoV-2 at shelters with at least 2 positive cases. RESULTS: One thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive for SARS-CoV-2 and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive for SARS-CoV-2 were significantly less likely to have a health insurance card (54% v. 72%, p = 0.03) or to have visited another shelter in the last 14 days (0% v. 18%, p < 0.01). There was no association between SARS-CoV-2 positivity and medical history or symptoms. INTERPRETATION: Our findings support testing of asymptomatic shelter residents for SARS-CoV-2 when a positive case is identified at the same shelter. Surveillance testing when there are no known positive cases may detect outbreaks, but further research should identify efficient strategies given scarce testing resources.

Towards gender equity in emergency medicine: a position statement from the CAEP Women in Emergency Medicine committee.

As of January 2019, over half of all doctors working in Canada under the age of 40 were women. Despite equal representation in the profession of medicine, women still experience harassment, discrimination, and pay inequity when compared to their male colleagues. Gender discrimination is present at all levels of medical training and negatively impacts women who want to become emergency physicians. The right to gender equity is part of the Canadian Charter of Rights and Freedoms. The World Health Organization states that "gender inequities are socially generated and, therefore, can be changed." CAEP recognizes that gender equity is important to its members and that it intersects with inequities experienced by other minority groups. This position statement from the committee for Women in Emergency Medicine (EM) is intended to support women and those who identify as women who have chosen EM as their career. Furthermore, it is meant to inform and support policy makers as they consider the unique challenges that women face in their pursuit of excellence in EM.

An environmental scan of emergency medicine research support, training, and infrastructure across Canada.

OBJECTIVE: Our study objective was to describe the Canadian emergency medicine (EM) research community landscape prior to the initiation of a nationwide network. METHODS: A two-phase electronic survey was sent to 17 Canadian medical schools. The Phase 1 Environmental Scan was administered to department chairs/hospital EM chiefs, to identify EM physicians conducting clinical or educational research. The Phase 2 Survey was sent to the identified EM researchers to assess four themes: 1) geographic distribution, 2) training/career satisfaction, 3) time/financial compensation, and 4) research facilitators/barriers. Descriptive analyses were conducted, and results were stratified by Canadian regions. RESULTS: A total of 92 EM researchers were identified in Phase 1; 67 (73%) responded to the Phase 2 Survey. Of those, 42 (63%) reported being clinical researchers, and 19 (45%) had a graduate degree. Three provinces encompassed most of the researchers (n = 35). Of the respondents, 61% had a research degree, 66% felt adequately trained for their research career, 73% had financial support, 83% had access to office spaces, 52% had no mentor during their first years of their career, 69% felt satisfied with their research career, and 82% suggested that they will still be conducting research in 5 years. CONCLUSION: EM researchers reported being adequately trained, even though only a little over half had a graduate degree. Only two-thirds had financial support, and mentorship was lacking in one-third of the participants. Not all respondents had a form of infrastructure, but most felt optimistic about their careers. The Canadian EM research environment could be improved to ensure better research capacity.

The Cost of Use of the Emergency Department by Persons With Inflammatory Bowel Disease Living in a Canadian Health Region: A Retrospective Population-Based Study.

BACKGROUND: We aimed to determine the costs of emergency department (ED) attendance by persons with inflammatory bowel disease (IBD) not admitted to hospital from the ED. METHODS: This was a population-based administrative database study linking the University of Manitoba IBD Epidemiology Database with the Winnipeg Regional Health Authority (WRHA) ED Information Service database. We identified persons with IBD who presented to the ED and were not admitted between January 1, 2009 and March 31, 2012. We then applied costs in Canadian dollars for these visits including an average ED visit cost plus 26% for overhead (total = $508), an average estimated cost of laboratory investigations ($50), and costs for each of radiographic imaging, lower endoscopy and consultation with an internist/gastroenterologist or a surgeon. We tallied the costs of each unique ED presentation. We determined average costs for visits associated with specific consultations or investigations. RESULTS: One thousand six hundred and eighty-two persons with IBD (4,853 individual visits) attended the ED and did not get hospitalized. The average cost per ED visit by a person with IBD who did not get hospitalized was $650. This resulted in a total expenditure of $3,152,227 on these persons for their ED attendance or $969,916 per year. The visits with the highest mean costs were those associated with an abdominal computerized tomography scan ($979), those associated with surgical consultation ($1019), and those associated with an internist/gastroenterologist consultation ($942). CONCLUSION: Better strategies for management of acute issues for persons with IBD that can reduce the use of an ED are needed and can be considerably cost saving.

A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence.

PURPOSE: The study's purpose was to determine individual-level and neighbourhood-level risk and protective factors for severe intentional injury among youth. METHODS: We conducted a multilevel case-control study using registry data to determine individual-level and neighbourhood-level social determinants associated with severe violent injury/homicide among youth from Winnipeg, Manitoba. RESULTS: The study includes 13 206 youth, aged 12-24 years (1222 cases, 11 984 controls). Individual-level risk predictors of being a victim of violence were male sex (OR 5.72 (95% CI 4.77 to 6.86)) and First Nations (OR 2.76 (95% CI 2.32 to 3.29)). Education was inversely associated with victimisation for individuals under (OR 0.36 (95% CI 0.26 to 0.51)) and over (OR 0.58 (95% CI 0.49 to 0.69)) 18 years. Ever having been in protective care (OR 1.66 (95% CI 1.39 to 1.99)), receiving income assistance from the government (OR 1.26 (95% CI 1.05 to 1.51)) or ever having criminal charges (OR 4.76 (95% CI 4.08 to 5.56)) were also significant predictors of being a victim of violence. Neighbourhood-level risk factors for victimisation included low socioeconomic status (OR 1.14 (95% CI 1.04 to 1.25)) and high levels of assault (OR 1.07 (95% CI 1.04 to 1.10)). CONCLUSIONS: This study demonstrates a complex web of risk and protective factors among youth injured by violence. It underscores the ongoing, injurious effects of historical trauma experienced by many Canadian First Nations people. Strong victim-perpetrator overlap suggests that intersectoral policies are needed to address these issues. Our findings highlight the need to improve education and family supports.

Validation and adaptation of the danger assessment-5: A brief intimate partner violence risk assessment.

AIMS: The aim of this study was to assess the predictive validity of the DA-5 with the addition of a strangulation item in evaluating the risk of an intimate partner violence (IPV) victim being nearly killed by an intimate partner. BACKGROUND: The DA-5 was developed as a short form of the Danger Assessment for use in healthcare settings, including emergency and urgent care settings. Analyzing data from a sample of IPV survivors who had called the police for domestic violence, the DA-5 was tested with and without an item on strangulation, a potentially fatal and medically damaging IPV tactic used commonly by dangerous abusers. DESIGN: Researchers interviewed a heterogeneous sample of 1,081 women recruited by police between 2009-2013 at the scene of a domestic violence call; 619 (57.3%) were contacted and re-interviewed after an average of 7 months. METHODS: The predictive validity of the DA-5 was assessed for the outcome of severe or near lethal IPV re-assault using sensitivity, specificity and ROC curve analysis techniques. RESULTS: The original DA-5 was found to be accurate (AUC = .68), equally accurate with the strangulation item from the original DA substituted (AUC = .68) and slightly more accurate (but not a statistically significant difference) if multiple strangulation is assessed. CONCLUSION: We recommend that the DA-5 with the strangulation item be used for a quick assessment of homicide or near homicide risk among IPV survivors. A protocol for immediate referral and examination for further injury from strangulation should be adopted for IPV survivors at high risk.

Use of a social networking web site for recruiting Canadian youth for medical research.

PURPOSE: The use of advertising on Facebook for medical research is not widely utilized, and we sought to describe the effectiveness of this tool in medical research recruitment. METHODS: A survey study was designed to evaluate the prevalence of post-traumatic stress disorder (PTSD) in Canadian youth who were affected by violence. Participants were recruited from an advertisement on Facebook that targeted Canadian users aged 15 to 24 years and linked them to an online survey. This secondary analysis is a descriptive study of the effectiveness of the Facebook campaign. RESULTS: Over the course of the study, the advertisement was displayed 17.5 million times resulting in 3,440 clicks on the link to the survey (.020%). The overall cost worked out to $15.35 per final subject, totaling $1351.17. CONCLUSION: Facebook advertising is a cost-effective method of recruiting youth from a wide population. There are many potential uses for social networking in medical research.

A comparison of VerifyNowR with PlateletMappingR--detected aspirin resistance and correlation with urinary thromboxane.

BACKGROUND: Aspirin-resistant platelet activation in whole blood is attributable to a transcellular pathway not detected by isolated platelet aggregometry. Aspirin resistance as defined by urinary thromboxane levels is associated with increased risk for myocardial infarction or cardiac death. Whole blood point-of-care assays may also detect aspirin resistance. METHODS: We compared PlateletMapping® with VerifyNow® for detecting aspirin resistance in 200 patients undergoing invasive cardiac procedures. This included 10 patients not receiving aspirin therapy for comparison. The assay results were correlated with urinary 11-dehydro-thromboxane B2 collected 2 to 8 hours after the procedure. RESULTS: PlateletMapping detected aspirin resistance in 32% of patients. VerifyNow detected aspirin resistance in 6% of patients. A patient's compliance with aspirin therapy was confirmed by a <20% aggregation response to arachidonic acid by light transmission aggregometry. Aspirin-resistant patients as determined by PlateletMapping had significantly (P<0.001) higher urinary 11-dehydro-thromboxane B2 levels than aspirin-sensitive patients but significantly (P=0.001) lower levels than patients not receiving aspirin therapy. There was no significant difference in urinary 11-dehydro-thromboxane B2 for aspirin-resistant compared with aspirin-sensitive patients as determined by VerifyNow, but the confidence intervals were wide. There was no significant correlation of resistance as defined by PlateletMapping with aspirin dose. However, there was significant increased aspirin sensitivity with clopidogrel (0.0006) or statin (0.004) cotherapies. There also was a significant correlation of smoking with aspirin resistance. CONCLUSIONS: These results indicate that PlateletMapping could be a useful point-of-care assay to identify aspirin-resistant patients for better perioperative risk stratification and management.

Intimate partner violence: development of a brief risk assessment for the emergency department.

OBJECTIVES: Women assaulted by intimate partners are frequently patients in emergency departments (EDs). Many victims and health care providers fail to take into account the potential risks of repeat partner violence. The objective of this study was to use data from a larger study of domestic violence risk assessment methods to develop a brief assessment for acute care settings to identify victims at highest risk for suffering severe injury or potentially lethal assault by an intimate partner or former partner. METHODS: Victims of intimate partner violence (IPV) were interviewed twice between 2002 and 2004. The baseline interview included the 20 items of Campbell's Danger Assessment (DA; predictor). The follow-up interview, conducted 9 months later on average, assessed abuse inflicted since the baseline interview (outcome). Multiple logistic regression was used to identify questions on the DA most predictive of severe abuse and potentially lethal assaults. Female IPV victims were recruited from New York City family courts, Los Angeles County Sheriff's Department 9-1-1 calls, New York City and Los Angeles shelters, and New York City hospitals; 666 women responded to the DA at baseline, and 60% participated in follow-up interviews. RESULTS: Severe injuries or potentially lethal assaults were experienced by 14.9% of retained study participants between the baseline and follow-up interviews. The best brief prediction instrument has five questions. A positive answer to any three questions has a sensitivity of 83% (95% confidence interval = 70.6% to 91.4%). CONCLUSIONS: This instrument can help predict which victims may be at increased risk for severe injury or potentially lethal assault and can aid clinicians in differentiating which patients require comprehensive safety interventions.