Development of the Inner City attitudinal assessment tool (ICAAT) for learners across Health care professions.

BACKGROUND: Many health professions learners report feeling uncomfortable and underprepared for professional interactions with inner city populations. These learners may hold preconceptions which affect therapeutic relationships and provision of care. Few tools exist to measure learner attitudes towards these populations. This article describes the development and validity evidence behind a new tool measuring health professions learner attitudes toward inner city populations. METHODS: Tool development consisted of four phases: 1) Item identification and generation informed by a scoping review of the literature; 2) Item refinement involving a two stage modified Delphi process with a national multidisciplinary team (n = 8), followed by evaluation of readability and response process validity with a focus group of medical and nursing students (n = 13); 3) Pilot testing with a cohort of medical and nursing students; and 4) Analysis of psychometric properties through factor analysis and reliability. RESULTS: A 36-item online version of the Inner City Attitudinal Assessment Tool (ICAAT) was completed by 214 of 1452 undergraduate students (67.7% from medicine; 32.3% from nursing; response rate 15%). The resulting tool consists of 24 items within a three-factor model - affective, behavioural, and cognitive. Reliability (internal consistency) values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the whole 24-item ICAAT was 0.90. CONCLUSIONS: The Inner City Attitudinal Assessment Tool (ICAAT) is a novel tool with evidence to support its use in assessing health care learners' attitudes towards caring for inner city populations. This tool has potential to help guide curricula in inner city health.

Emergency physician risk assessment practices prior to prescribing opioids.

BACKGROUND: Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported. METHODS: We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important. RESULTS: The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%). CONCLUSION: Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.

RéSUMé: CONTEXTE: La prescription sûre d'opioïdes reste un enjeu essentiel pour les médecins d'urgence. Avant de prescrire des opioïdes, les énoncés de politique et les lignes directrices recommandent une évaluation des risques bien réfléchie pour la probabilité d'un abus d'opiacé actuel ou éventuel. Cependant, les modalités de pratique des médecins urgentistes font l'objet d'une documentation et d'une information insuffisante. MéTHODES: Nous avons mené une enquête auprès des médecins urgentistes partout au Canada au sujet de leurs politiques locales de prescription des opioïdes, de leurs modalités de pratique d'évaluation des risques avant de prescrire des opioïdes, et des facteurs de risque cliniques qu'ils jugent les plus importants. RéSULTATS: Le taux de réponse était de 20.4% (n = 312/1532). 59.8% des répondants déclarent évaluer habituellement ou toujours le risque. Les médecins dépendent du gestalt (80.3%), des antécédents ciblés basés sur des facteurs de risque de la littérature (55.6%) ou de leur expérience (57.6%) et d'une examination des dossiers médicaux (83.1%) et des dossiers pharmaceutiques (75.6%). Il est rare de contacter les principaux prescripteurs (16.3%). Une minorité utilise régulièrement des outils d'évaluation des risques liés à la prescription des opioïdes (6.4%), dispose de politiques locales de prescription d'opiacés (27%) ou utilise les fonctions de dossier médical électronique pour aider à la stratification des risques (2.4%). CONCLUSION: De nombreux médecins urgentistes canadiens évaluent les risques en se basant sur la gestalt plutôt que sur l'identification des facteurs de risque documentés. Cela est en contradiction avec les directives exigeant une évaluation complète de routine. Des efforts supplémentaires devraient être dirigés vers l'éducation pour optimiser l'évaluation des risques; et vers des initiatives au niveau du système telles que des politiques de prescription locales claires, la fonctionnalité des systèmes électroniques et l'élaboration d'outils d'évaluation à utiliser aux urgences.

Evidence-based algorithm for heparin dosing before cardiopulmonary bypass. Part 1: Development of the algorithm.

The incidence of heparin resistance during adult cardiac surgery with cardiopulmonary bypass has been reported at 15%-20%. The consistent use of a clinical decision-making algorithm may increase the consistency of patient care and likely reduce the total required heparin dose and other problems associated with heparin dosing. After a directed survey of practicing perfusionists regarding treatment of heparin resistance and a literature search for high-level evidence regarding the diagnosis and treatment of heparin resistance, an evidence-based decision-making algorithm was constructed. The face validity of the algorithm decisive steps and logic was confirmed by a second survey of practicing perfusionists. The algorithm begins with review of the patient history to identify predictors for heparin resistance. The definition for heparin resistance contained in the algorithm is an activated clotting time < 450 seconds with > 450 IU/kg heparin loading dose. Based on the literature, the treatment for heparin resistance used in the algorithm is anti-thrombin III supplement. The algorithm seems to be valid and is supported by high-level evidence and clinician opinion. The next step is a human randomized clinical trial to test the clinical procedure guideline algorithm vs. current standard clinical practice.