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.

How Should Risks and Benefits of Short-Acting Opioids Be Evaluated in the Care of Inpatients With OUD?

Severe opioid withdrawal, risk of patient-initiated discharge, and some inpatients' use of unregulated substances prompt clinical and ethical questions considered in this commentary on a case. Short-acting opioids can be used to manage inpatients' pain and opioid use disorder (OUD) withdrawal symptoms. Including evidence-based interventions-such as naloxone kits, substance use equipment, and supervised consumption-in some inpatients' care plans may make those patients safer and reduce their risk of death. These and other strategies align with clinicians' ethical duties to minimize harms and maximize benefits for inpatients with OUD.

Experiences of pediatric emergency physicians in providing alcohol-related care to adolescents in the emergency department.

OBJECTIVE: The emergency department (ED) is a key clinical care setting for identifying and managing patients with alcohol-related presentations. We explored the experiences of emergency physicians in providing alcohol-related care to adolescents. METHODS: Purposeful sampling was used to identify pediatric emergency physicians with at least 1 year of experience (n = 12) from pediatric EDs across Canada. Data were collected via telephone using a semistructured interview guide. Hermeneutic phenomenology was used to identify common and unique experiences among respondents, using Moustakas' immersion/crystallization procedures. RESULTS: Physicians expressed frustration with patient behaviors accompanying intoxication and described providing care as a struggle; developing an effective therapeutic alliance was challenging. Physicians believed intoxicated adolescent patients required more clinical time and resources than they could offer. Although physicians described the ED as unsuitable for ensuring continuity of care and addressing the broader social issues that accompany alcohol use, they did view the ED as a place to medically stabilize the patient and initiate a discussion on alcohol use and its harmful effects. CONCLUSIONS: Pediatric ED physicians struggled during the caring experience and were skeptical that broader, more chronic social issues that are often associated with adolescent alcohol misuse can be effectively managed in a clinical setting where they feel primarily responsible for providing medical stabilization. Physicians did believe the ED was an appropriate place to ensure medical stability of a patient and then initiate a conversation regarding alcohol use and its harmful effects.

Temporal trends in pediatric mental health visits: using longitudinal data to inform emergency department health care planning.

OBJECTIVE: Understanding the temporality of mental health presentations to the emergency department (ED) during the 24-hour cycle, day of the week, and month of the year may facilitate strategic planning of ED-based mental health services. METHODS: Data on 30,656 ED presentations for mental illness, substance use, or intentional self-harm by 20,956 patients (≤ 17 years) were examined. We studied patient demography, discharge diagnosis, and time and date of presentation. RESULTS: Most pediatric mental health ED visits (66.0%) occurred after the average work and school day (after 5 PM). Presentations related to substance use and intentional self-harm steadily increased in the evening. Emergency department visits related to substance use peaked on Friday through Sunday (4723/7475; 63.2%), whereas visits for mood disorders (4127/5093; 81.0%), neurotic/stress-related disorders (5960/7989; 74.6%), and behavioral/emotional disorders (237/304; 78%) were highest during the work/school week (Monday to Friday). Visits for intentional self-harm peaked following the weekend (Monday: 771/4676; 16.5%). Summer months had fewer visits (6862/30,656; 22.4%), whereas March to May (range: 2752-2912 visits) and October to November (range: 2701-2751 visits) showed more steady peaks in volume. Most presentations by diagnostic group decreased in volume during the winter months (December to February) to increase again in the spring (March to May). CONCLUSIONS: Peak times for pediatric mental health presentations to the ED are evenings throughout the week, suggesting that mental health services for children, adolescents, and their families should be available after work and school hours, 7 days a week.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study.

BACKGROUND: Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay. METHODS: Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use). RESULTS: Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis. CONCLUSIONS: After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study.

OBJECTIVES: The objective of this study was to examine the perspectives of Canadian emergency physicians on the care of patients with opioid use disorders in the emergency department (ED), in particular the real-world facilitators to prescribing buprenorphine/naloxone (BUP) in the ED. METHODS: We conducted semistructured qualitative interviews using a multi-site-focused ethnographic design. Purposive sampling via an existing national research network was used to recruit ED physicians. Interviews were conducted by phone using an interview guide and continued until theoretical data saturation was reached. Interviews were transcribed and analyzed using latent content analysis. Interviews took place between June 21, 2019, and February 11, 2020. RESULTS: A total of 32 physicians were included in the analysis. Participants had a median of 10 years of experience, and most (29/32) worked in urban settings. Clinical care of patients with opioid use disorder was found to be variable and physician dependent. Although some physicians reported routinely prescribing BUP, others felt that this was outside the clinical scope of emergency medicine. Access to clinical pathways, incentivized training, dedicated human resources, and follow-up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient-centered approach that enhanced patient autonomy. ED BUP prescribing became self-reinforcing over time. CONCLUSIONS: Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow-up care.

Resident Physician Wellness Curriculum: A Study of Efficacy and Satisfaction.

Background Recent literature highlights the alarming prevalence of burnout, depression, and illness during residency training; a trend that is also linked to suboptimal patient care. Dedicated wellness curricula may be one solution to this concerning issue. Purpose To determine the effect of a multi-faceted wellness curriculum during emergency medicine residency training on wellness scores and to assess resident satisfaction with the program. Methods This study was conducted via a longitudinal survey. In 2009, a faculty-derived resident wellness curriculum (F-RWC) was initiated. This program was then bolstered with a parallel resident-derived curriculum (R-RWC) one year later, in 2010. Emergency medicine residents were surveyed in 2009, 2010, and 2011 to assess wellness at baseline, after one year of the F-RWC, and after one year of combined RWCs, respectively. Surveys included two validated assessment instruments (the Brief Resident Wellness Profile (BRWP) and the SF-8TM Health Survey), a satisfaction Likert scale, and a demographics information sheet. Results The survey response rates were 89% (n=17), 100% (n=17), and 83% (n=24) from 2009, 2010, and 2011, respectively, for a total of 58 participants. From baseline in 2009, there was a significant improvement in resident wellness, with the addition of parallel RWC by 2011, as measured by the BRWP (p=0.024). The faces scale, a subset of the BRWP, showed a trend toward benefit but did not reach statistical significance (p=0.085). There was no evidence of a statistically significant change in SF-8TM scores over time. Participants consistently reported positive satisfaction scores with RWC initiatives. Conclusions Dedicated RWC, with input from both faculty and resident physicians, improved wellness during residency training with a high degree of participant satisfaction. Such programs are needed to support resident physicians during their training.

Evaluating mental health service use during and after emergency department visits in a multisite cohort of Canadian children and youth.

OBJECTIVES: The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed. METHODS: A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher's exact test to compare sites. RESULTS: The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed. CONCLUSIONS: Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.

An Inner City Emergency Medicine Rotation Does Not Improve Attitudes toward the Homeless among Junior Medical Learners.

Introduction Learners in the emergency department (ED) frequently encounter individuals who are homeless. We sought to evaluate the effect of an inner city emergency medicine rotation at the Royal Alexandra Hospital (RAH) on the attitudes of medical students and residents towards this population. Methods Data were collected both pre- and post-rotation using an electronic survey. Data collected included demographic information and as well as scores on the Health Professionals' Attitudes Towards the Homeless Inventory (HPATHI). Pre- and post-survey results were compared using Wilcoxon tests. Results Ninety-eight students completed the rotation. A total of 40 (41%) students completed both pre- and post-surveys. Demographic information was available for 66 respondents. Most participants were male (42 {64%}), single (47 {71%}), and 30 years of age or younger (59 {89%}). Most participants were of a Caucasian or East/South Asian background (61 {92%}) and grew up in an urban setting (51 {77%}). Overall, 43 (90%) participants saw at least one person who was homeless during their rotation. There was no significant difference between pre- and post-aggregate scores (z = -0.78, p = 0.44), or any of its three subscales (Personal Advocacy, Social Advocacy, and Cynicism). Conclusion First year residents and medical students are frequently exposed to patients who are homeless during an inner city ED rotation. Attitudes towards these patients did not significantly change following the rotation. Educational objectives should be set to improve attitudes of learners towards those with unstable housing throughout the ED rotation.

What are kids getting into these days? A retrospective chart review of substance use presentations to a Canadian pediatric emergency department.

OBJECTIVES: Goals for this study were to characterize the substances being used by youth who presented to an emergency department (ED), their demographic descriptors, and to describe the associated acute morbidity and mortality. METHODS: We conducted a retrospective review of all youth, ages 10-16 years, who presented to a pediatric ED with complaints related to recreational drug use (n=641) for 2 years ending on December 31, 2009. RESULTS: The median age of patients was 15 years; 56% were female. Six percent of patients were homeless, and 21% were wards of the state. The most frequent ingestions included ethanol (74%), marijuana (20%), ecstasy (19%), and medications (15%). Over one third of patients had ingested two or more substances. Ninety percent of patients were brought to the ED by the emergency medical services; 63% of these activations were by non-acquaintances. Of the 47% of youth who presented with a decreased level of consciousness, half had a Glasgow Coma Scale less than 13. The Canadian Triage and Acuity Scale score was 1 or 2 for 44% of patients. Sixty-eight percent received IV fluids, 42% received medication, and 4% were intubated. The admission rate was 9%. CONCLUSIONS: Youth who presented to the ED for substance use represented a socially vulnerable population whose use of recreational substances resulted in high medical acuity and significant morbidity. Improved clinical identification of such high-risk youth and subsequent design of interventions to address problematic substance use and social issues are urgently needed to complement the acute medical care that youth receive.

Recent self-harm and psychological measures in the emergency department.

The assessment of self-harm risk is a common, difficult, and perplexing task for many physicians, especially those working in emergency departments (ED). Attempts have been made to determine objective methods for assessing patients with suicidal ideation or self-harm though there is still a lack of knowledge about objective assessments of these patients. A study was conducted where 181 suicidal patients were enrolled in two EDs within the city of Edmonton, Canada. Initial interviews were conducted in the ED which collected basic demographics and medical history as well as psychometric measures including the Beck Hopelessness Scale, Barratt Impulsiveness Scale, Brief Symptom Inventory, Drug Abuse Screening Test 10, and CAGE questionnaire. The results of these measures were compared between those who presented to the ED with self-harm and those who presented only with ideation. Those with recent self-harm scored lower on many of the scales and subscales of distress and impulsivity measured compared to those with no recent self-harm. Possible explanations for this difference include differences in psychological traits between the two groups and possible cathartic effects of self-harm. The lower scores obtained by those that present with self-harm may complicate attempts to use psychometric tools to determine future self-harm risk.

Assessment of self-harm risk using implicit thoughts.

Assessing for the risk of self-harm in acute care is a difficult task, and more information on pertinent risk factors is needed to inform clinical practice. This study examined the relationship of 6 forms of implicit cognition about death, suicide, and self-harm with the occurrence of self-harm in the future. We then attempted to develop a model using these measures of implicit cognition along with other psychometric tests and clinical risk factors. We conducted a prospective cohort of 107 patients (age > 17 years) with a baseline assessment that included 6 implicit association tests that assessed thoughts of death, suicide, and self-harm. Psychometric questionnaires were also completed by the patients, and these included the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), Barratt impulsiveness scale (Patton, Stanford, & Barratt, 1995), brief symptom inventory (Derogatis & Melisaratos, 1983), CAGE questionnaire for alcoholism (Ewing, 1984), and the drug abuse screening test 10 (Skinner, 1982). Medical and demographic information was also obtained for patients as potential confounders or useful covariables. The outcome measure was the occurrence of self-harm within 3 months. Implicit associations with death versus life as a predictor added significantly (odds ratio = 5.1, 95% confidence interval [1.3, 20.3]) to a multivariable model. The model had 96.6% sensitivity and 53.9% specificity with a high cutoff, or 58.6% sensitivity and 96.2% specificity with a low cutoff. This scale shows promise for screening emergency department patients with mental health presentations who may be at risk for future self-harm or suicide.