Best practice: quality assessment outcomes of the Practice Enhancement Program among family physicians in Saskatchewan, Canada.

Increased family physician workloads have strained primary care. The objective of this study was to describe the frequency and types of quality concerns identified among Saskatchewan's family physicians, changes in these concerns over time, associated physician characteristics, and recommendations made for improvement. In this repeated cross-sectional study (1997-2020), we examined family physician assessment reports from the Saskatchewan Practice Enhancement Program, a mandatory practice review strategy, for quality concerns on three outcomes: care, medical record, and facility. We recorded demographic and practice characteristics, the presence or absence of quality concerns, and the type of recommendations made. Concern incidence was calculated both overall and across subperiods, and three outcome-specific multiple logistic regression models were developed. Recommendations made were quantified, and their nature was evaluated using thematic analysis. Among 824 assessments, 20.8% identified concerns, with a statistically significant increase in 2015-20 over earlier years (14.2% versus 43.4%, P < .001). Corresponding proportions also significantly increased within each quality outcome (6.0%-37.1%, P < .001 for care concerns; 12.7%-19.6%, P = .03 for medical record concerns; 3.9%-21.0%, P < .001 for facility concerns). We found statistically significant adjusted associations between care concerns and both urban location [odds ratio (OR): 2.2; 95% confidence interval (CI): 1.30, 3.8] and international medical training (OR: 2.4; 95% CI: 1.34, 4.2); facility concerns and solo practice (OR: 2.5 95% CI: 1.10, 5.7); and medical record concerns and male gender (OR: 1.88; 95% CI: 1.09, 3.3), solo practice (OR: 1.67; 95% CI: 1.01, 2.7), and increased age. Reflecting a statistically significant interaction found between age as a continuous covariate and time period, older physicians were more likely to have a medical record concern in later years (OR: 1.072; 95% CI: 1.026, 1.120) compared to earlier ones (OR: 1.021; 95% CI: 1.001, 1.043). Among physicians where a concern was identified, recommendations most frequently pertained to documentation (91.2%), chronic disease management (78.2%), cumulative patient profiles (62.9%), laboratory investigations (53.5%), medications (51.8%), and emergency preparedness (51.2%). A concerning and increasing proportion of family physicians have quality gaps, with identifiable factors and recurring recommendations. These findings provide direction for strategic support development.

Strength in the gap: A rapid review of principles and practices for urgent care centres.

Responding to a provincial government decision to develop two Urgent Care Centres (UCCs) in Saskatchewan, we undertook a rapid review of published literature with the objective of determining best practices for their creation and functioning. Two English-limited PubMed database searches combining "after-hours care," "ambulatory care," "emergency medicine," "urgent care," "minor emergency," "walk-in," and "Canada" over the past 10 years were the sources of articles for our review. Articles were independently reviewed by two authors and synthesized collaboratively. From 833 articles, 44 were utilized in the review. Six considerations in the following areas were subsequently outlined: expected impact, preferred location, healthcare services collaboration, available services, staffing priorities, and community partnerships. These principles were considered against the backdrop of currently successful Canadian UCCs. This review indicates that general principles for the successful development of UCCs exist; these may guide the establishment and functioning of UCCs both in Saskatchewan and elsewhere.

Is Call Karma Real? Resident After-Hours On-Call Imaging at the University of Saskatchewan: An Assessment of Call Volumes Including Inter-Resident Variability.

PURPOSE: Quantify resident caseload during call and determine if there are consistent differences in call volumes for individuals or resident subgroups. METHODS: Accession codes for after-hours computed tomography (CT) cases dictated by residents between July 1, 2012 and January 9, 2017 were reviewed. Case volumes by patient visits and body regions scanned were determined and categorized according to time period, year, and individual resident. Mean shift Relative Value Units (RVUs) were calculated by year. Descriptive statistics, linear mixed modeling, and linear regression determined mean values, differences between residents, associations between independent variables and outcomes, and changes over time. Consistent differences between residents were assessed as a measure of good or bad luck / karma on call. RESULTS: During this time there were 23,032 patients and 30,766 anatomic regions scanned during 1,652 call shifts among 32 residents. Over the whole period, there were on average 10.6 patients and 14.3 body regions scanned on weekday shifts and 22.3 patients and 29.4 body regions scanned during weekend shifts. Annually, the mean number of patients, body regions, and RVUs scanned per shift increased by an average of 0.2 (1%), 0.4 (2%), and 1.2 (5%) (all p < 0.05) respectively in regression models. There was variability in call experiences, but only 1 resident had a disproportionate number of higher volume calls and fewer lower volume shifts than expected. CONCLUSIONS: Annual increases in scan volumes were modest. Although residents' experiences varied, little of this was attributable to consistent personal differences, including luck or call karma.

Impact of Pit-Crew Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest in Saskatoon.

BACKGROUND: In the prehospital setting, pit-crew models of cardiopulmonary resuscitation (CPR) have shown improvements in survival after out-of-hospital cardiac arrest (OHCA). Certain districts in North America have adopted this model, including Saskatoon, Saskatchewan, Canada. OBJECTIVES: Our objectives were to determine whether pit-crew CPR has an impact on survival to discharge after OHCA in Saskatoon, Canada. METHODS: This was a retrospective pre- and postintervention study. All adult patients who had an OHCA between January 1, 2011 and December 31, 2017 of presumed cardiac origin, in which the resuscitation attempt included CPR by trained prehospital responders, were considered for analysis. Our primary outcome was survival to discharge. Survival to admission and return of spontaneous circulation were secondary outcomes. RESULTS: There were 860 OHCAs considered for our study. After 46 exclusions there were 442 in the non-pit-crew group (average age 63.7 years; 64.5% male) and 372 in the pit-crew group (average age 63.5 years; 67.5% male). Survival to discharge after an OHCA was 10.4% (95% confidence interval 7.7-13.6%) in the non-pit-crew group and 12.4% (95% CI 9.2-16.2%) in the pit-crew group, which did not meet statistical significance. Return of spontaneous circulation and survival to admission were 48.4% and 31.3%, respectively, in the non-pit-crew group and 46.7% and 32.3%, respectively, in the pit-crew group. CONCLUSIONS: In our study, implementation of a pit-crew CPR model was not associated with an improvement in survival to discharge after OHCA.

Randomized Clinical Trial Evaluating Complications and Complication-Related Removal of Arm-Situated Power-Injectable and Non-Power-Injectable Totally Implanted Venous Access Devices among Cancer Patients.

PURPOSE: To evaluate the hypothesis that power-injectable (PI) totally implanted venous access devices (TIVADs) situated in the arm are associated with more frequent complications and complication-related removal than non-power-injectable (NPI) arm TIVADs among adult cancer patients. MATERIALS AND METHODS: In this single-center trial, 211 adult chemotherapy patients were randomized to receive either a PI or a NPI arm TIVAD. Follow-up involved a standardized telephone interview 1 week after insertion, followed by a chest X-ray, arm X-ray, and Doppler ultrasound at 3 months and 12 months. Online complication reporting was also provided by patients and care providers for a minimum of 1 year. The primary end point was removal for port-related complications; the secondary end point was the occurrence of any port-related complication. RESULTS: Forty-two complications occurred (19.9% of patients), precipitating the removal of 6 PI ports and 7 standard ports. Time-to-removal did not differ between TIVAD types (hazard ratio 0.75, 95% confidence interval [CI] 0.25-2.24; P = .61). Complications were related to thrombosis, infection, or mechanical issues, with no statistical difference between groups for overall occurrence (23.1% vs 17.0%, odds ratio 1.47, 95% CI 0.74-2.92; P = .27); however, by type of complication, thrombosis occurred more frequently among PI TIVAD patients (15.2% vs 6.1%, odds ratio 2.79, 95% CI 1.04-7.44; P = .03). CONCLUSIONS: There was no difference in port-related complication occurrence or complication-related removal when using the arm PI port compared with the NPI port among cancer patients.

Incidence and Economic Impact of Incidental Findings on 18F-FDG PET/CT Imaging.

PURPOSE: The study sought to determine the incidence of incidental findings on whole-body positron emission tomography with computed tomography (PET/CT) imaging and the average costs of investigations to follow-up or further characterize incidental findings. METHODS: Imaging reports of 215 patients who underwent whole-body PET/CT imaging were retrospectively reviewed. Our provincial picture archiving and communication system was queried and patient charts were reviewed to identify all investigations performed to follow-up incidental findings within 1 year of the initial PET/CT study. Costs of follow-up imaging studies (professional and technical components) and other diagnostic tests and procedures were determined in Canadian dollars (CAD) and U.S. dollars (USD) using the 2015 Ontario Health Insurance Plan Schedule of Benefits and Fees and 2016 U.S. Medicare Physician Fee Schedule, respectively. RESULTS: At least 1 incidental finding was reported in 161 reports (74.9%). The mean number of incidental findings ranged from 0.64 in patients <45 years of age to 2.2 in patients 75 years of age and older. Seventy-five recommendations for additional investigations were made for 64 (30%) patients undergoing PET/CT imaging, and 14 of those were carried out specifically to follow-up incidental findings. Averaged across all 215 patients, the total cost of investigations recommended to follow-up incidental findings was CAD$105.51 (USD$127.56) per PET/CT study if all recommendations were acted on, and CAD$22.77 (USD$29.14) based on investigations actually performed. CONCLUSIONS: As the incidence of incidental findings increases with age and a larger proportion of elderly patients is expected as population demographics change, it will be increasingly important to consider incidental findings on PET/CT imaging with standardized approaches to follow-up.

Initial Experience Using a Telerobotic Ultrasound System for Adult Abdominal Sonography.

PURPOSE: The study sought to assess the feasibility of performing adult abdominal examinations using a telerobotic ultrasound system in which radiologists or sonographers can control fine movements of a transducer and all ultrasound settings from a remote location. METHODS: Eighteen patients prospectively underwent a conventional sonography examination (using EPIQ 5 [Philips] or LOGIQ E9 [GE Healthcare]) followed by a telerobotic sonography examination (using the MELODY System [AdEchoTech] and SonixTablet [BK Ultrasound]) according to a standardized abdominal imaging protocol. For telerobotic examinations, patients were scanned remotely by a sonographer 2.75 km away. Conventional examinations were read independently from telerobotic examinations. Image quality and acceptability to patients and sonographers was assessed. RESULTS: Ninety-two percent of organs visualized on conventional examinations were sufficiently visualized on telerobotic examinations. Five pathological findings were identified on both telerobotic and conventional examinations, 3 findings were identified using only conventional sonography, and 2 findings were identified using only telerobotic sonography. A paired sample t test showed no significant difference between the 2 modalities in measurements of the liver, spleen, and diameter of the proximal aorta; however, telerobotic assessments overestimated distal aorta and common bile duct diameters and underestimated kidney lengths (P values < .05). All patients responded that they would be willing to have another telerobotic examination. CONCLUSIONS: A telerobotic ultrasound system is feasible for performing abdominal ultrasound examinations at a distant location with minimal training and setup requirements and a moderate learning curve. Telerobotic sonography (robotic telesonography) may open up the possibility of remote ultrasound clinics for communities that lack skilled sonographers and radiologists, thereby improving access to care.

Satisfaction and Quality of Life Related to Chemotherapy With an Arm Port: A Pilot Study.

PURPOSE: Placement of arm ports, or totally implanted venous access devices, is a common practice in our interventional radiology suite. We implant a miniaturized port in the upper arm for the provision of long-term chemotherapy. We hypothesized that there was general satisfaction with these arm ports and they have a minimal negative impact on quality of life. In this study we aimed to assess our hypotheses. METHODS: We surveyed subjects, who having previously received an arm port for chemotherapy to treat a malignancy, attended the interventional room for its removal. The survey assessed the port's effect on lifestyle, the degree of device-related pain, the acceptance of the port, and the willingness to have another port in the future. RESULTS: Survey responses from 77 subjects were reviewed. On a scale of 1 (most negative) to 10 (most positive), respondents indicated that the port system was a very positive enhancement to their treatment (satisfaction = 9.2 ± 2.0 and positivity = 8.8 ± 2.2). The port had little impact on daily activities. The mean score for the likelihood of choosing to have another port placed if additional treatment was required was 9.1 ± 2.1. DISCUSSION: The arm port in this study did not negatively impact subject satisfaction and quality of life for this cohort. Most subjects rated the device utility highly and felt that the port was a positive enhancement to their treatment, one that they would possibly utilise again in future, if need be.

Positive-pressure ventilation during transport: a randomized crossover study of self-inflating and flow-inflating resuscitators in a simulation model.

BACKGROUND: Positive-pressure ventilation during transport of intubated patients is generally delivered via a hand-pressurized device. Of these devices, self-inflating resuscitators (SIR) and flow-inflating resuscitators (FIR) constitute the two major types used. Selection of a particular device for transport, however, remains largely an institutional practice. OBJECTIVE: To evaluate the hypothesis that transport ventilation goals of intubated pediatric patients are better achieved using an FIR compared to an SIR. METHODS: This randomized crossover simulation study compared the performance of SIR and FIR among anesthesia providers in a pediatric transport scenario. Subjects hand-ventilated a test lung while simultaneously maneuvering a stretcher bed to simulate patient transport. Hand ventilation was carried out using a Jackson-Rees circuit (FIR) and a Laerdal pediatric silicone resuscitator (SIR). The primary outcome was the proportion of total breaths delivered within the predefined target PIP/PEEP range (30+/- 3, 10+/- 3 cm H2O). Secondary outcomes included proportion of total breaths delivered with operationally defined unacceptable breath variables (PIP > 35 cm H2O or PEEP < 5 cm H2O). RESULTS: Overall, participants were four times more likely to deliver target breaths and one-third less likely to deliver unacceptable breaths using the FIR compared to the SIR. When comparing device performance, a 44% increase in the proportions of target breaths and a 40.4% decrease in unacceptable breaths using the FIR were observed (P < 0.0001 for both). CONCLUSIONS: Hand ventilation during patient transport is superior using the FIR compared to the SIR to achieve target ventilatory goals and avoid unacceptable ventilatory cycles.

Post-traumatic stress disorder in a Canadian population of medical students, residents, and physicians.

BACKGROUND: Physicians encounter stressors with potential long-term psychological consequences. However, a comprehensive picture of post-traumatic stress disorder (PTSD) prevalence and symptomatic work-related event occurrence across practice stages is lacking. OBJECTIVE: To evaluate PTSD prevalence and the occurrence of work-related symptomatic events among physicians and medical learners. METHODS: In 2017, we surveyed 3,036 physicians, residents, and students within the province of Saskatchewan, Canada. Participants completed the Life Events Checklist (LEC) for DSM 4 and the PTSD Checklist for DSM 4-Civilian version (PCL-C). They also reported work-related events that triggered PTSD-like symptoms. The prevalence of a positive PTSD screen (PCL-C ≥ 36) and the proportion identifying a symptomatic work event were determined. The t-test, Chi-square test, and multiple regression were used to evaluate associations between respondent characteristics and these outcomes. RESULTS: Among 565 respondents, 21.2% screened positively, with similarity across career stages. Thirty-nine percent reported a symptom-inducing work event, with many training-related. Although independent PTSD predictors were not identified, partnered residents and surgical residents were more likely to identify a work-related event. Internationally trained practicing physicians were less likely to identify an event. CONCLUSION: Both symptom-inducing work events and PTSD are frequent, broadly based concerns requiring better preventive strategies across career stages.

A retrospective evaluation of phenobarbital versus benzodiazepines for treatment of alcohol withdrawal in a regional Canadian emergency department.

Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.

Addressing the Long-Term Care Crisis: Identifying Opportunities for Improvement Using Rapid Reviews.

Background: Long-term care (LTC) facilities require urgent, evidence-based care renewal. During 2020 three medical student-driven research projects aiming to study care satisfaction, patient care team dynamics, and advance care directive effectiveness in a local LTC facility required a marked shift in approach due to COVID-19 regulations. Methods: All three projects were re-invented as rapid reviews from their initial designs intended to provide a baseline for quality improvement projects. English-limited PubMed searches for publications within the past 10 years were undertaken. Review articles were prioritized and supplemented by individual studies. Students reviewed the initial abstracts, reviewed them with a supervisor/mentor, assessed the articles for quality, and synthesized major themes. Results: A total of 52 publications were evaluated for the final synthesis of all three projects. Relevant information was retrieved for all three areas, suitable for local evaluation/intervention at micro, meso, and macro policy levels. Conclusions: Rapid reviews of issue-specific, long-term care literature are low resource avenues towards coordinated care improvement. They may also serve as rapid means for regular policy updates while providing next-generation care providers with improved LTC perspectives.

Cross-sectional study of pediatric pain prevalence, assessment, and treatment at a Canadian tertiary hospital.

BACKGROUND: Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized. AIMS: The study benchmarks pain prevalence, assessment, and treatment as first steps to improve pain care in a Canadian tertiary hospital. METHODS: Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment. RESULTS: Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures. CONCLUSIONS: Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.

Contexte: Les expériences douloureuses sont courantes chez les enfants hospitalisés. Les conséquences biopsychosociales négatives à long terme d'une douleur sous-traitée sont reconnues.Objectifs: L'étude compare la prévalence, l'évaluation et le traitement de la douleur comme premières étapes pour améliorer les soins de la douleur dans un hôpital tertiaire canadien.Méthodes: Des audits d'une journée ont été effectués dans les services de pédiatrie (SP), les services d'urgence pédiatrique (SU) et les services maternels (SM). Les participants (enfant ou soignant) ont rapporté des expériences de douleur à l'hôpital au cours des 24 heures précédentes; les dossiers médicaux ont été examinés pour évaluation et traitement.Résultats: Parmi les 84 participants, la prévalence de la douleur variait de 75 % à 88 % ; l'intensité moyenne de la douleur variait de 5,7 à 6,5/10. La prévalence de la douleur modérée à sévère était de 78 % pour les services de pédiatrie, 65 % pour les services d'urgence pédiatrique et 55 % pour les services maternels ; les piqûres étaient la cause la plus fréquente des pires douleurs. La documentation de l'évaluation de la douleur variait selon le contexte (SP 93 % ; SU 13 % ; SM 0 %). Les scores maximaux de douleur documentés étaient significativement inférieurs à ceux rapportés par les participants (différence moyenne 4,5 / 10, SD 3,1, P < 0,0001). Au total, 29 % (6/21) des nourrissons ayant reçu une piqûre au talon ou une injection ont reçu un allaitement ou du saccharose, et 29 % (7/24) des participants recevant d'autres procédures d'injection avaient documenté ou signalé une utilisation topique de lidocaïne. Tous les participants des services maternels ont subi une procédure impliquant une aiguille.Conclusions: La douleur est couramment ressentie par les nourrissons et les enfants dans les services de pédiatrie, les services d'urgence pédiatrique et les services maternels. La documentation relative à l'évaluation de la douleur n'est pas systématique et sous-estime la douleur rapportée par les participants. Les stratégies de prise en charge de la douleur fondées sur des données probantes sont sous-utilisées. Une approche d'amélioration de la qualité à l'échelle de l'établissement est nécessaire pour aborder les soins de la douleur. L'évaluation de la douleur et la prévention et le traitement de la douleur causée par les aiguilles devraient être prioritaires dans ces établissements de soins pédiatriques aigus et de soins aux nouveau-nés.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex.

BACKGROUND: The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis. RESULTS: Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008). CONCLUSION: Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

A Comparison Between Computer-Assisted Self-Triage by Patients and Triage Performed by Nurses in the Emergency Department.

Background and objective Emergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients' ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN). Methods This pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records. Results Among the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization. Conclusion  The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.

A Novel Anatomic Landmark to Target the Left Ventricle During Chest Compressions in Cardiac Arrest.

Background Resuscitation guidelines recommend that chest compressions be performed over the lower sternum. Current computed tomography and magnetic resonance imaging studies suggest that the current area of compression does not target the left ventricle (LV). Using transthoracic ultrasound, we sought to identify potential anatomic landmarks that would result in compressions over the LV in the majority of our study participants. Methodology We recruited 64 healthy men and women (over the age of 40) from the Simulated Patient Program at the University of Saskatchewan. Using ultrasound, we identified the LV and the associated surface anatomy in terms of intercostal space (ICS) and parasternal or mid-clavicular lines. We also collected biometric data including body mass index, chest circumference, and the corresponding inter-nipple line ICS. Results The LV was located along the left sternal border in 62 (96.9%) participants. The most frequent LV location was along the left sternal border at the sixth ICS in 26 (40.6%) participants, with 13 (20.3%) at the fifth and 10 (15.6%) participants at the seventh ICS. In two (3.1%) participants, the LV was found along the mid-clavicular zone at the fifth ICS. The area from the fifth to seventh ICS on the left sternal border, typically covered by an adult palm centered at the sixth ICS, overlaid 49 of 64 (76.6%, 95% confidence interval [CI]: 64.3-86.2%) identified LV locations. By comparison, centering the heel of the palm over the inter-nipple line at the left sternal border would cover the LV in 46 (71.9%, 95% CI: 59.2-82.4%) participants.  Conclusions A novel area of compression over the left sternal border at the inter-nipple line would result in compressions over the LV in nearly three-quarters of our study participants. Future research should investigate whether this proposed area of compression is applicable to a broader population including those with cardiac and thoracic disease.

Use of a Simple Ultrasound Device to Identify the Optimal Area of Compression for Out-of-Hospital Cardiac Arrest.

Background Despite automated defibrillation and compression-first resuscitation, out-of-hospital cardiac arrest (OHCA) survival remains low. Resuscitation guidelines recommend that chest compressions should be done over the lower half of the sternum, but evidence indicates that this is often associated with outflow obstruction. Emerging studies suggest that compression directly over the left ventricle (LV) may improve survival and outcomes, but rapid and reliable localization of the LV is a major obstacle for those first responding to OHCA. This study aimed to determine if a simplified, easy-to-use ultrasound device (bladder scanner) can reliably locate the heart when applied over the intercostal spaces of the anterior thorax in supine patients. Furthermore, we sought to describe the association between largest scan volumes and underlying cardiac anatomy with particular attention to the long axis of the LV. Methodology We recruited healthy male and female volunteers over 40 years of age. Using a bladder scanner to evaluate the left sternal border and mid-clavicular lines, we determined the maximal scan volumes at 10 intercostal spaces for each participant. Cardiac ultrasound was then used to evaluate the corresponding underlying cardiac anatomy and determine the area overlying the long-axis view of the LV. Descriptive statistics (means with standard deviations [SD], medians with interquartile ranges, and frequencies with proportions) were used to quantify demographic information, typical scan volumes across the chest, the frequencies of the best long-axis LV view location. This was then repeated for left sternal border assessments only. Kappa was determined when evaluating agreement between the largest left sternal border scan volume and the best long-axis LV view location. Results The long-axis LV was the predominant structure underlying the largest scan volume in 39/51 (76.5%) patients. When limited to left sternal border volumes only, the long axis of the LV was underlying the maximum volume intercostal space in 46/51 (90.2%; 95% confidence interval [CI]: 78.6%, 96.7%). The largest left sternal border scan volumes were located over the best long-axis LV view in 39/51 (76.5%, 95% CI: 62.5%, 87.2%) of the study participants with a Kappa statistic of 0.68 (95% CI: 0.52, 0.84; p < 0.0001).  Conclusions In this cross-sectional study of healthy volunteers, an easy-to-use ultrasound device (bladder scanner) was able to reliably localize the heart. Largest scan volumes over the left sternal border showed substantial agreement with the intercostal space overlying the long axis of the LV. Further investigations are warranted to determine if such localization is reliable in cardiac arrest patients.

Transfusion Use and Hemoglobin Levels by Blood Conservation Method After Cardiopulmonary Bypass.

BACKGROUND: Guidelines recommend modified ultrafiltration (MUF) and cell washing for blood conservation after cardiopulmonary bypass (CPB), although information on outcomes is lacking. This research compared online MUF (ultrafiltration of the patient's entire circulating volume) with off-line MUF (ultrafiltration of the residual CPB volume) and centrifugation (cell washing of the residual CPB volume). METHODS: This prospective cohort study enrolled 99 consecutive patients, grouped by method (group I, online MUF, n = 35; group II, off-line MUF, n = 30; group III, centrifugation, n = 34). Primary outcome was transfusion by 18 hours. Secondary outcomes were 18-hour hemoglobin levels, fluid balance (weight change), and biomarker levels indicating coagulation and organ function. RESULTS: By 18 hours, 22.9%, 6.7%, and 14.7% of group I, II, and III patients, respectively, had undergone transfusion (P = .19). Percentage weight gain differed by group (group I, 5.7%; group II, 1.3%; group III, 4.5%; P < .0001). Baseline to 18-hour hemoglobin change also differed by group, with the group I increase significantly exceeding that of group II (P = .002) but not differing from group III (P = .36). After adjustment for European System for Cardiac Operative Risk Evaluation II (EuroSCORE), weight gain, and transfusion, only the group II to III difference remained significant (P = .002). CONCLUSIONS: Online MUF does not appear to offer a reduction in blood transfusion over other methods. Although patients undergoing online MUF had greater improvement in baseline to 18-hour hemoglobin compared with patients undergoing off-line MUF, this benefit appeared attributable to fluid shifting. Off-line MUF was associated with the least frequent transfusions. Although online MUF does not appear to reduce blood transfusion, larger prospective randomized controlled studies are required for confirmation.