Evaluating the Reliability of a Remote Acuity Prediction Tool in a Canadian Academic Emergency Department.

STUDY OBJECTIVE: There is increasing interest in harnessing artificial intelligence to virtually triage patients seeking care. The objective was to examine the reliability of a virtual machine learning algorithm to remotely predict acuity scores for patients seeking emergency department (ED) care by applying the algorithm to retrospective ED data. METHODS: This was a retrospective review of adult patients conducted at an academic tertiary care ED (annual census 65,000) from January 2021 to August 2022. Data including ED visit date and time, patient age, sex, reason for visit, presenting complaint and patient-reported pain score were used by the machine learning algorithm to predict acuity scores. The algorithm was designed to up-triage high-risk complaints to promote safety for remote use. The predicted scores were then compared to nurse-led triage scores previously derived in real time using the electronic Canadian Triage and Acuity Scale (eCTAS), an electronic triage decision-support tool used in the ED. Interrater reliability was estimated using kappa statistics with 95% confidence intervals (CIs). RESULTS: In total, 21,469 unique ED patient encounters were included. Exact modal agreement was achieved for 10,396 (48.4%) patient encounters. Interrater reliability ranged from poor to fair, as estimated using unweighted kappa (0.18, 95% CI 0.17 to 0.19), linear-weighted kappa (0.25, 95% CI 0.24 to 0.26), and quadratic-weighted kappa (0.36, 95% CI 0.35 to 0.37) statistics. Using the nurse-led eCTAS score as the reference, the machine learning algorithm overtriaged 9,897 (46.1%) and undertriaged 1,176 (5.5%) cases. Some of the presenting complaints under-triaged were conditions generally requiring further probing to delineate their nature, including abnormal lab/imaging results, visual disturbance, and fever. CONCLUSION: This machine learning algorithm needs further refinement before being safely implemented for patient use.

Fear, health impacts, and life delays: residents' certification exam year experience.

BACKGROUND: Residency training is associated with risks of burnout and impaired well-being. This may be due to multiple factors, including navigating various transitions. Chief among these is the transition to independent practice which, in Canada, involves a certification exam administered by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. This qualitative study explored the experience of residents in their examination year, including residents impacted by pandemic-related examination postponment, to understand how these experiences may impact residents' well-being. METHODS: Qualitative description methodology was used for this study. Participants were residents and physicians in independent practice from McMaster University and the University of Toronto. In depth, semi-structured, one-on-one interviews were conducted by one of the investigators. Each was transcribed, reviewed, and coded by two members of the investigating team. RESULTS: Five themes were identified. Examinations were perceived to be a significant stressor, and the extent of preparation involved was viewed as a threat to one's physical and mental well-being. Participants identified a culture of fear surrounding the exam, as well as a perception that exam preparation requires significant sacrifice which can exacerbate the impacts of the exam year. Personal and professional supports were identified as important protective factors. CONCLUSION: This study has identified unique challenges in the examination year, and its impact on the well-being of residents immediately before they enter independent practice. Residents also experienced significant learning and a sense of accomplishment through their preparation for the examination. The COVID-19 pandemic had a unique impact on one cohort of residents. This should prompt medical education institutions to examine the support provided to residents, the culture surrounding certification examinations, and mitigation strategies for future examination disruptions.

RéSUMé: CONTEXTE: La formation en résidence est associée à des risques d'épuisement professionnel et de bien-être altéré. Cela peut être dû à plusieurs facteurs, y compris la navigation dans diverses transitions. La principale d'entre elles est la transition vers la pratique indépendante qui, au Canada, implique un examen de certification administré par le Collège royal des médecins et chirurgiens du Canada ou le Collège des médecins de famille du Canada. Cette étude qualitative a exploré l'expérience des résidents au cours de leur année d'examen, y compris les résidents touchés par le report d'examen lié à la pandémie, afin de comprendre comment ces expériences peuvent avoir un impact sur le bien-être des résidents. MéTHODES: Une méthodologie de description qualitative a été utilisée pour cette étude. Les participants étaient des résidents et des médecins en pratique indépendante de l'Université McMaster et de l'Université de Toronto. Des entretiens individuels approfondis et semi-structurés ont été menés par l'un des enquêteurs. Chaque entretien a été transcrit, revu et codé par deux membres de l'équipe d'enquêteurs. RéSULTATS: Cinq thèmes ont été identifiés. Les examens étaient perçus comme un facteur de stress important, et l'ampleur de la préparation était considérée comme une menace pour le bien-être physique et mental. Les participants ont identifié une culture de la peur autour de l'examen, ainsi que la perception que la préparation à l'examen exige des sacrifices importants, ce qui peut exacerber les impacts de l'année de l'examen. Les soutiens personnels et professionnels ont été identifiés comme d'importants facteurs de protection. CONCLUSION: Cette étude a permis d'identifier les défis uniques de l'année d'examen et son impact sur le bien-être des résidents juste avant qu'ils entrent en pratique indépendante. Les résidents ont également fait l'expérience d'un apprentissage important et d'un sentiment d'accomplissement tout au long de leur préparation à l'examen. La pandémie de COVID-19 a eu un impact unique sur une cohorte de résidents. Cela devrait inciter les établissements d'enseignement médical à examiner les soutiens apportés aux résidents, la culture entourant les examens de certification et les stratégies d'atténuation des perturbations futures des examens.

Recommendations for enhancing collaboration between the Canadian emergency department quality improvement and research communities.

OBJECTIVES: While quality improvement (QI) and clinical research embody two distinct scientific approaches, they have the same ultimate goal-to improve health and patient care outcomes. By leveraging their respective strengths there is a higher likelihood of achieving and sustaining health improvements. Our objective was to create recommendations to enhance the collaboration of the Canadian emergency medicine QI and clinical research communities. METHODS: An expert panel of eight ED clinicians with diverse QI and clinical research expertise drafted a list of recommendations based on their professional expertise and a scoping review of the literature. These recommendations were refined through consultation with national stakeholders and reviewed at the 2020 CAEP Virtual Academic Symposium, where feedback was received through several virtual platforms. RESULTS: The final six recommendations include that all emergency medicine providers should: (1) understand the role and application of both clinical research and QI science; that academic emergency medicine physicians should: (2) contribute to both local adoption and broad dissemination of project findings, (3) leverage QI methodologies in research projects to improve knowledge translation, and (4) ensure that project outcomes prioritize patient care; and that academic leaders should: (5) enhance the infrastructure for oversight of research and QI projects, and (6) encourage collaboration between researchers and QI experts by ensuring that academic and operational infrastructures align and support both. CONCLUSION: Six recommendations are presented to help the Canadian emergency medicine community achieve greater collaboration between researchers and QI experts with the ultimate goal of improving patient care outcomes.

RéSUMé: OBJECTIFS: Bien que l'amélioration de la qualité (AQ) et la recherche clinique représentent deux approches scientifiques distinctes, elles ont le même but ultime: améliorer la santé et les résultats des soins aux patients. En tirant profit de leurs atouts respectifs, les chances d'obtenir et de soutenir des améliorations de santé sont plus élevées. Notre objectif était de créer des recommandations pour renforcer la collaboration entre les communautés d'AQ et de recherche clinique en médecine d'urgence canadienne. MéTHODES: Un groupe d'experts de huit cliniciens des services d'urgence dotés d'une expertise diversifiée en matière d'AQ et de recherche clinique a rédigé une liste de recommandations basées sur leur expertise professionnelle et un examen de la revue de littérature. Ces recommandations ont été affinées en consultation avec les parties prenantes nationales et examinées lors du Symposium académique virtuel de ACMU 2020, où des commentaires ont été reçus via plusieurs plateformes virtuelles. RéSULTATS: Les six recommandations finales incluent que tous les prestataires des services de médecine d'urgence devraient: (1) comprendre le rôle et l'application de la recherche clinique et de la science de l'AQ; que les médecins universitaires en médecine d'urgence devraient: (2) contribuer à la fois à l'adoption locale et à la diffusion large des résultats de projets, (3) tirer parti des méthodologies d'AQ dans les projets de recherche afin d'améliorer l'application des connaissances, et (4) veiller à ce que les résultats de projet donnent la priorité aux soins aux patients; et que les dirigeants universitaires devraient: (5) améliorer l'infrastructure de surveillance des projets de recherche et d'AQ, et (6) encourager la collaboration entre les chercheurs et les experts en AQ en assurant que les infrastructures universitaires et opérationnelles les alignent et les soutiennent. CONCLUSION: Six recommandations sont présentées pour aider la communauté de la médecine d'urgence canadienne à parvenir à une plus grande collaboration entre les chercheurs et les experts en AQ dans le but ultime d'améliorer les résultats des soins aux patients.

Residents' perspective of quality improvement and patient safety education in Canadian emergency medicine residency programs.

OBJECTIVES: Quality improvement and patient safety (QIPS) competencies are increasingly important in emergency medicine (EM) and are now included in the CanMEDS framework. We conducted a survey aimed at determining the Canadian EM residents' perspectives on the level of QIPS education and support available to them. METHODS: An electronic survey was distributed to all Canadian EM residents from the Royal College and Family Medicine training streams. The survey consisted of multiple-choice, Likert, and free-text entry questions aimed at understanding familiarity with QIPS, local opportunities for QIPS projects and mentorship, and the desire for further QIPS education and involvement. RESULTS: Of 535 EM residents, 189 (35.3%) completed the survey, representing all 17 medical schools; 77.2% of respondents were from the Royal College stream; 17.5% of respondents reported that QIPS methodologies were formally taught in their residency program; 54.7% of respondents reported being "somewhat" or "very" familiar with QIPS; 47.2% and 51.5% of respondents reported either "not knowing" or "not having readily available" opportunities for QIPS projects and QIPS mentorship, respectively; 66.9% of respondents indicated a desire for increased QIPS teaching; and 70.4% were interested in becoming involved with QIPS training and initiatives. CONCLUSIONS: Many Canadian EM residents perceive a lack of QIPS educational opportunities and support in their local setting. They are interested in receiving more QIPS education, as well as project and mentorship opportunities. Supporting residents with a robust QIPS educational and mentorship framework may build a cohort of providers who can enhance the local delivery of care.

BET 1: Follow-up phone calls and compliance with discharge instructions in elderly patients discharged from the emergency department.

A short-cut review was carried out to establish whether follow-up phone calls improved compliance with follow-up and discharge instructions given to the elderly on discharge from the emergency department. 211 papers were found using the reported searches, of which 5 presented the best available evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that telephone follow-up can identify non-compliance with discharge instructions in the elderly, but there is currently no evidence to show that it actually improves it.

Evaluation of the McMaster Family Health Team: results and practical implications for quality improvement.

PURPOSE: To evaluate the McMaster Family Health Team (MFHT) as part of a Continuous Quality Improvement initiative using a set of provincial performance metrics to demonstrate which measures of assessment are actually clinically meaningful in context and where system-level changes might be implemented to improve operational practice. METHODS: Measures were selected from the Primary Care Performance Measurement Framework based on data availability for the MFHT and provincial comparators. The measures explored in this paper are those that were deemed to have actionable properties. Data were extracted from billing reports, electronic medical records and information collated for the Association of Family Health Teams of Ontario Data to Decisions database. Metrics were then examined to demonstrate the importance of interpretation in clinical context. CONCLUSIONS: Quantitative assessment of performance based on standardised measures is a suitable starting point when evaluating a practice, however it is not appropriate as a stand-alone report card of practice performance. Rather, quantitative measures must be of clinical relevance and applicable to the patient populations of interest in order to create conversation and impact change. Thus, the focus of quality improvement should not be to improve numbers relating to efficiency, patient satisfaction and continuity of care, but rather to determine what drives those numbers and how changes might be made at a system or practice level that will optimise clinician buy-in.

BET 1: Lenient or strict rate control for atrial fibrillation.

A short cut review was carried out to establish whether the degree of rate control influences mortality in patients with atrial fibrillation. 22 papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are shown in the two tables. It is concluded that there is insufficient evidence to recommend any specific rate control target to decrease mortality in rate-controlled rapid atrial fibrillation.

Breastfeeding Behaviors and the Innate Immune System of Human Milk: Working Together to Protect Infants against Inflammation, HIV-1, and Other Infections.

The majority of infants' breastfeeding from their HIV-infected mothers do not acquire HIV-1 infection despite exposure to cell-free virus and cell-associated virus in HIV-infected breast milk. Paradoxically, exclusive breastfeeding regardless of the HIV status of the mother has led to a significant decrease in mother-to-child transmission (MTCT) compared with non-exclusive breastfeeding. Although it remains unclear how these HIV-exposed infants remain uninfected despite repeated and prolonged exposure to HIV-1, the low rate of transmission is suggestive of a multitude of protective, short-lived bioactive innate immune factors in breast milk. Indeed, recent studies of soluble factors in breast milk shed new light on mechanisms of neonatal HIV-1 protection. This review highlights the role and significance of innate immune factors in HIV-1 susceptibility and infection. Prevention of MTCT of HIV-1 is likely due to multiple factors, including innate immune factors such as lactoferrin and elafin among many others. In pursuing this field, our lab was the first to show that soluble toll-like receptor 2 (sTLR2) directly inhibits HIV infection, integration, and inflammation. More recently, we demonstrated that sTLR2 directly binds to selective HIV-1 proteins, including p17, gp41, and p24, leading to significantly reduced NFκB activation, interleukin-8 production, CCR5 expression, and HIV infection in a dose-dependent manner. Thus, a clearer understanding of soluble milk-derived innate factors with known antiviral functions may provide new therapeutic insights to reduce vertical HIV-1 transmission and will have important implications for protection against HIV-1 infection at other mucosal sites. Furthermore, innate bioactive factors identified in human milk may serve not only in protecting infants against infections and inflammation but also the elderly; thus, opening the door for novel innate immune therapeutics to protect newborns, infants, adults, and the elderly.

Molecular identification of isolated fungi, microbial and heavy metal contamination of canned meat products sold in Riyadh, Saudi Arabia.

Several studies have shown that canned meat products may be contaminated with fungal elements, bacteria and even heavy metals which may occur during the transportation, storage and handling processes. We conducted this study to determine the fungal, microbial and heavy metal contents of canned meats in Saudi Arabia. Of the 13 canned meat samples studied, Aspergillus and Penicillium were found in more than 70% of the total samples. Sequences of Penicillium species isolated from meat samples generated a phylogenetic tree which shows that the studied isolates were clustered in four groups. No bacterial contamination was noted in all of the samples. Nine of the 13 samples had iron concentrations above the permissible limit. All samples had zinc and copper levels below the maximum permissible limit. Four samples had cadmium levels above the maximum permissible level. All samples had levels of lead above the maximum permissible levels. These results indicate that fungal elements and higher levels of heavy metals such as lead and cadmium can be found in canned meat products. This may pose as a real danger to consumers, since canned meat products are readily accessible and convenient in Saudi Arabia.