Impact of the 2016 Canadian Lipid Guidelines on Daily Practice at a Community Hospital.

OBJECTIVES: The aim of this study was to determine the impact of the 2016 Canadian cardiovascular society guidelines for the management of dyslipidemia. More specifically, we assessed the use of 1) alternate lipid targets when triglyceride (TG) levels are high; and 2) nonfasting lipid testing. METHODS: Lipid profiles and pharmacy data were obtained from patients with a history of myocardial infarction and from patients ≥40 years of age with a diagnosis of diabetes. RESULTS: As TG increased to >1.5 mmol/L, percent within target for non-high-density lipoprotein cholesterol and apolipoprotein B 18 months after guideline release remained low in both patients with atherosclerotic cardiovascular disease (40%) and patients with diabetes in primary prevention (30%). Approximately 50% of patients were fasting when presenting for lipid testing. Use of high-intensity statin was suboptimal in both groups. CONCLUSIONS: The concept of alternate lipid targets may not be well understood by many physicians, leading to undertreatment of patients. Progress was made in the promotion of routine nonfasting lipid testing.

Emergency department occupancy is useful as a simple real-time measure of crowding.

INTRODUCTION: Emergency department (ED) crowding compromises patient outcomes. Existing crowding measures are complex and difficult to use in real-time. This study evaluated readily available single flow variables as crowding measures. METHODS: Over 2 weeks in a tertiary Canadian ED, we recorded the following potential crowding measures during 168 consecutive two-hour study intervals: total ED patients (census), patients in beds, patients in waiting rooms, patients in treatment areas awaiting MD assessment; number of inpatients boarding, and ED occupancy. We also calculated four complex crowding scores-NEDOCS, EDWIN, ICMED, and a local modification of NEDOCS. We performed ROC analyses to assess the predictive validity of these measures against a reference standard of physician perception of crowding. RESULTS: We gathered data for 144 (63.9%) of 168 study intervals. ED census correlated strongly with crowding (AUC = 0.82, 95% CI 0.76-0.89), as did ED occupancy (AUC = 0.75, 95% CI 0.66-0.83). Their performance was similar to NEDOCS (AUC = 0.80) and to the local modification of NEDOCS (AUC = 0.83). CONCLUSION: ED occupancy as a single measure has similar predictive accuracy to complex crowding scores and is easily generalizable to diverse emergency departments. Real-time tracking of this simple indicator could be used to prompt investigation and implementation of crowding interventions.

RéSUMé: INTRODUCTION: L'encombrement des services d'urgence (SU) compromet les résultats pour les patients. Les mesures d'encombrement existantes sont complexes et difficiles à utiliser en temps réel. Cette étude a évalué des variables de débit unique facilement disponibles comme mesures d'encombrement. LES MéTHODES: Pendant deux semaines dans un service d'urgence tertiaire canadien, nous avons enregistré les mesures d'encombrement potentiel suivantes au cours de 168 intervalles d'étude consécutifs de deux heures : nombre total de patients dans le service d'urgence (recensement), patients dans les lits, patients dans les salles d'attente, patients dans les zones de traitement en attente d'une évaluation médicale ; nombre de patients hospitalisés en internat et occupation du service d'urgence. Nous avons également calculé quatre scores de surpeuplement complexes : NEDOCS, EDWIN, ICMED et une modification locale de NEDOCS. Nous avons effectué des analyses ROC pour évaluer la validité prédictive de ces mesures par rapport à une norme de référence de perception du surpeuplement par les médecins. RéSULTATS: Nous avons recueilli des données pour 144 (63,9 %) des 168 intervalles d'étude. Le recensement des urgences est fortement corrélé avec le surpeuplement (ASC = 0.82, IC 95 % = 0.76­0.89), tout comme l'occupation des urgences (ASC = 0.75, IC 95 % = 0.66­0.83). Leur performance était similaire à celle des NEDOCS (ASC = 0.80) et à la modification locale des NEDOCS (ASC = 0.83). CONCLUSION: L'occupation des urgences en tant que mesure unique a une précision prédictive similaire aux scores complexes de surpeuplement et est facilement généralisable à divers services d'urgence. Le suivi en temps réel de ce simple indicateur pourrait être utilisé pour accélérer l'enquête et la mise en œuvre des interventions en cas de surpeuplement.

Medical and Undergraduate Student Perceptions on Scribing in an Emergency Department.

Background  A shift towards electronic medical records (EMR) has increased physician burnout and decreased physician satisfaction and productivity. One solution to alleviate EMR stressors is the implementation of medical scribes. Scribes have been shown to increase physician productivity and satisfaction. The study objective was to elucidate medical and undergraduate student scribing experience to determine if that experience can incentivize scribes to work in the emergency department. Methods  Ten students scribed and shadowed at a tertiary ED between July 4, 2019, and August 10, 2019. Medical students participated in two scribing and two non-scribing (shadowing) sessions, each lasting four hours. Undergraduate students only had a scribing condition. To facilitate scribing, a laptop with a wireless keyboard was provided, as well as a stand-up laptop tray.  An exit survey and semi-structured interviews were conducted after the scribing experience. The majority of insights were extracted from interviews. Transcripts were coded into thematic coding trees and analyzed using thematic analysis.  Results  All undergraduate students preferred volunteering in the ED over other volunteer experiences. All undergraduates cited direct access to the medical field, resume building, and perceived value added to the health care team as motivators to continue scribing. Most students credited demystification of the medical profession as a motivator. Most medical students felt scribing should be integrated into their curriculum. Based on survey results, five undergraduate students would volunteer 40 hours/week. Conclusion Our study showed that a volunteer model of scribing is feasible. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Although a volunteer model may not provide the desired benefit in terms of ED efficiency, it may be an integral part of training the next wave of physicians.

Prevalence of Urologic Disease Among Patients Investigated for Hematuria With CT Urography.

PURPOSE: The current study evaluated the prevalence of urologic disease among patients with hematuria referred for computerized tomography (CT) urography to determine which patients require investigation with CT urography. METHODS: We retrospectively reviewed radiology reports of 1046 CT urograms performed for the indication of microscopic (43.7%) or gross hematuria (56.3%). Urological findings were categorized as negative, benign, or suspicious (pathologically confirmed) for malignancy. RESULTS: Of 1046 CT urograms performed, 53.5% were negative, 36.4% were benign, and 10% were suspicious for malignancy. The most common benign finding was urolithiasis (22.3%). Overall, urinary tract malignancies were present in 3.6% of patients, and the rate was significantly higher (P < .001) for gross (5.8%) than microscopic hematuria (0.9%). CT urography identified 0.6% patients with upper urinary tract malignancies; the malignancy rate was significantly higher (P = .038) for gross (1%) than microscopic hematuria (0%), and no significant sex (P = 1.00; male = 0.6%, female = 0.6%) or age (P = .600; < 50 years = 0%, ≥ 50 years = 0.7%) differences were observed. Logistic regression revealed that being male was associated with gross hematuria (odds ratio [OR] = 2.92), and that both age and gross hematuria (ORs = 1.06 and 5.13, respectively) were associated with malignancy. CONCLUSIONS: CT urography found no upper urinary tract malignancies in 99.4% of patients presenting with hematuria, including all patients with microscopic hematuria and those with gross hematuria <50 years old. Investigating these subgroups with CT urography may be unnecessary and result in increased patient morbidity and health-care costs.

Predictors of farther mobilization on day of surgery and shorter length of stay after total joint arthroplasty.

BACKGROUND: Mobilization on the day of total joint arthroplasty (TJA) is associated with shorter length of stay. The question of whether incrementally farther mobilization on the day of surgery (POD0) contributes to shorter length of stay has not been widely studied. The purpose of this study was to determine if farther mobilization on POD0 led to shorter length of stay and to identify the predictors of farther mobilization and length of stay. METHODS: A retrospective chart review was undertaken using data for patients who had a primary TJA and mobilized on POD0. Patients were categorized into the following 4 mobilization groups: sat on the bedside (Sat), stood by the bed or walked in place (Stood), walked in the room (Room) and walked in the hall (Hall). The primary outcome was length of stay. Predictors of farther mobilization on POD0 and length of stay were identified using regression analyses. RESULTS: The sample comprised 283 patients. The Hall group had significantly shorter length of stay than all other groups. There were sex differences across the mobilization groups. Simultaneous regression analysis showed that farther mobilization was predicted by younger age, male sex, lower body mass index, spinal anesthesia and fewer symptoms limiting mobilization. Hierarchical regression showed that shorter length of stay was predicted by male sex, lower body mass index, lower American Society of Anaesthesiologists physical status classification score, less pain/stiffness and farther mobilization on POD0. CONCLUSION: Understanding the modifiable and nonmodifiable predictors of mobilization after TJA and length of stay can help identify patients more likely to mobilize farther on the day of surgery, which would contribute to better resource allocation and discharge planning. Focusing on symptom management could increase opportunities for farther mobilization on POD0 and thereby decrease length of stay.

CONTEXTE: La mobilisation le jour même d'une arthroplastie totale (AT) est associée à une durée d'hospitalisation réduite. Or, le lien entre l'ampleur de la mobilisation le jour de la chirurgie (jour postopératoire 0 [JPO0]) et la réduction de la durée d'hospitalisation n'a pas été largement étudié. La présente étude visait à déterminer si une mobilisation plus importante au JPO0 réduit la durée d'hospitalisation, de même qu'à repérer les facteurs prédictifs de mobilisation importante et de durée d'hospitalisation. MÉTHODES: Une analyse rétrospective a été menée à l'aide des dossiers de patients ayant subi une AT primaire et ayant été mobilisés au JPO0. Les patients ont été classés en 4 groupes en fonction de l'ampleur de leur mobilisation : assis au bord du lit (assis), debout à côté du lit ou marche sur place (debout), marche dans la chambre (chambre) et marche dans le couloir (couloir). Le principal résultat à l'étude était la durée d'hospitalisation. Les facteurs prédictifs de mobilisation importante au JPO0 et de durée d'hospitalisation ont été dégagés au moyen d'analyses de régression. RÉSULTATS: L'échantillon comprenait 283 patients. Le groupe couloir présentait une durée d'hospitalisation significativement plus courte que les autres. Des différences entre les sexes ont été observées dans tous les groupes. Selon une analyse de régression simultanée, les facteurs prédictifs de mobilisation importante étaient un jeune âge, le sexe masculin, un faible indice de masse corporelle, une anesthésie rachidienne et un nombre limité de symptômes nuisant à la mobilisation. Une analyse de régression hiérarchique a quant à elle montré que les facteurs prédictifs de durée hospitalisation réduite étaient le sexe masculin, un faible indice de masse corporelle, un faible score à la classification de l'état de santé physique de l'American Society of Anesthesiologists, une douleur ou des raideurs moindres, et une mobilisation importante au JPO0. CONCLUSION: La mise en évidence des facteurs prédictifs modifiables et non modifiables de mobilisation et de durée d'hospitalisation après une AT peut faciliter le repérage des patients susceptibles d'être davantage mobilisés, ce qui contribuerait à une meilleure allocation des ressources et faciliterait la planification des congés. Accorder une attention particulière au soulagement des symptômes pourrait accroître les occasions de mobilisation importante au JPO0 et, par conséquent, réduire la durée d'hospitalisation.

The Fountain of Health: effective health promotion knowledge transfer in individual primary care and group community-based formats.

ABSTRACTBackground:The Fountain of Health (FoH) initiative is a knowledge transfer (KT) project on the science of brain health and resilience promotion, in alignment with positive psychiatry. OBJECTIVES: Assess the effectiveness of FoH KT delivered in individual and group-based formats. DESIGN: Pre- and post-intervention quality assurance survey of FoH KT. SETTING: Interventions occurred in Nova Scotia, Canada. PARTICIPANTS: Adults over age 50 years without pre-existing dementia were targeted. A total of 92 participants received FoH KT in individualized (n = 41) and group-based (n = 51) formats. INTERVENTION: FoH KT (e.g. sharing evidence, lifestyle coaching, and goal setting) using a range of KT supports (e.g. FoH website, paper materials) was delivered to (1) individual patients by primary care clinicians and (2) community-based groups by lay leaders. MEASUREMENTS: The main outcome measure was participant pre- and post-quality assurance self-reports. RESULTS: Improvements were found in participant awareness of FoH, knowledge of evidence-based mental health promotion initiatives, and in application of this information in daily life in both individual and group-based settings. Improvements in participant knowledge about epigenetic factors that impact health and confidence with health behavior goal setting were reported in both contexts. Changes in self-perceptions of aging scores reached significance in the group intervention. CONCLUSIONS: FoH KT produced short-term positive self-reported changes in participants in both individual and group formats. Larger control studies with long-term follow up are needed to better assess effects of both individual and group formats of FoH KT and longer term impacts on health behaviors and outcomes.

The Effects of Storage and Additives on Postmortem HbA1c Measurements.

HbA1c is used in forensic toxicology to identify undiagnosed diabetes mellitus (DM) and those with poor glycemic control prior to death. HbA1c is typically measured in whole blood collected in tubes containing ethylenediaminetetraacetic acid (EDTA). The effect of other additives, including sodium fluoride (NaF), is unclear. Furthermore, the assessment of short- and long-term stability of HbA1c has produced conflicting results. In this study, we collected paired postmortem blood samples in EDTA and NaF tubes (n = 142) to assess their comparability for HbA1c measurement. Stability was assessed by measuring HbA1c at baseline, 2, 3, and 4 weeks postcollection (stored at 4°C) and at 2, 4, 6, and 12 months postcollection (stored at -20°C). We found no significant difference in HbA1c between the two preservatives at any of the time points indicating NaF is a suitable preservative for HbA1c measurement. We also determined that DM status, postmortem interval, and decomposition had no effect on stability.

Multidimensional evaluation of a mental health court: Adherence to the risk-need-responsivity model.

The current study examined the impact of a mental health court (MHC) on mental health recovery, criminogenic needs, and recidivism in a sample of 196 community-based offenders with mental illness. Using a pre-post design, mental health recovery and criminogenic needs were assessed at the time of MHC referral and discharge. File records were reviewed to score the Level of Service/Risk-Need-Responsivity instrument (Andrews, Bonta, & Wormith, 2008) to capture criminogenic needs, and a coding guide was used to extract mental health recovery information at each time point. Only mental health recovery data were available at 12 months post-MHC involvement. Recidivism (i.e., charges) was recorded from police records over an average follow-up period of 40.67 months post-MHC discharge. Case management adherence to the Risk-Need-Responsivity (RNR) model of offender case management was also examined. Small but significant improvements were found for criminogenic needs and some indicators of mental health recovery for MHC completers relative to participants who were prematurely discharged or referred but not admitted to the program. MHC completers had a similar rate of general recidivism (28.6%) to cases not admitted to MHC and managed by the traditional criminal justice system (32.6%). However, MHC case plans only moderately adhered to the RNR model. Implications of these results suggest that the RNR model may be an effective case management approach for MHCs to assist with decision-making regarding admission, supervision intensity, and intervention targets, and that interventions in MHC contexts should attend to both criminogenic and mental health needs.

Construct validity of the Violence Risk Scale--Sexual Offender Version for measuring sexual deviance.

Previous studies have identified sexual deviance as a particularly strong predictor of sexual recidivism in sex offenders. The present study examined the construct validity (i.e., convergent and discriminant validity) of the three dynamic factor domains (Sexual Deviance, Criminality, Treatment Responsivity) of the Violence Risk Scale- Sexual Offender version (VRS-SO) as well as the Screening Scale for Pedophilic Interests (SSPI; for comparison purposes) with respect to phallometric measures of sexual deviance. VRS-SO and phallometric data were collected from 124 federally incarcerated sex offenders from a maximum security forensic psychiatric facility. The Sexual Deviance factor and SSPI were positively correlated to varying degrees with computed arousal indexes (Percent Full Erection, difference scores) for child stimuli but were not significantly correlated with nondeviant arousal, supporting the convergent and discriminant validity of these measures, respectively. Convergent validity also appeared stronger for sex offender subtypes with child victims. Criminality and Treatment Responsivity did not correlate with male stimuli, although they were positively correlated with arousal to female profiles. The VRS-SO Sexual Deviance factor and some phallometric indexes of deviant arousal (e.g., female children) were predictive of sexual recidivism whereas the SSPI was not. The pattern of findings across analyses broadly supports the construct validity of the VRS-SO in assessing sexual deviance.