Impact of the COVID-19 pandemic on Canadian emergency medical system management of out-of-hospital cardiac arrest: A retrospective cohort study.

AIM: We sought to describe the impact of the COVID-19 pandemic on the care provided by Canadian emergency medical system (EMS) clinicians to patients suffering out of hospital cardiac arrest (OHCA), and whether any observed changes persisted beyond the initial phase of the pandemic. METHODS: We analysed cases of adult, non-traumatic, OHCA from the Canadian Resuscitation Outcome Consortium (CanROC) registry who were treated between January 27th, 2018, and December 31st, 2021. We used adjusted regression models and interrupted time series analysis to examine the impact of the COVID-19 pandemic (January 27th, 2020 - December 31st, 2021)on the care provided to patients with OHCA by EMS clinicians. RESULTS: There were 12,947 cases of OHCA recorded in the CanROC registry in the pre-COVID-19 period and 17,488 during the COVID-19 period. We observed a reduction in the cumulative number of defibrillations provided by EMS (aRR 0.91, 95% CI 0.89 - 0.93, p < 0.01), a reduction in the odds of attempts at intubation (aOR 0.33, 95% CI 0.31 - 0.34, p < 0.01), higher rates of supraglottic airway use (aOR 1.23, 95% CI 1.16-1.30, p < 0.01), a reduction in vascular access (aOR for intravenous access 0.84, 95% CI 0.79 - 0.89, p < 0.01; aOR for intraosseous access 0.89, 95% CI 0.82 - 0.96, p < 0.01), a reduction in the odds of epinephrine administration (aOR 0.89, 95% CI 0.85 - 0.94, p < 0.01), and higher odds of resuscitation termination on scene (aOR 1.38, 95% CI 1.31 - 1.46, p < 0.01). Delays to initiation of chest compressions (2 min. vs. 3 min., p < 0.01), intubation (16 min. vs. 19 min., p = 0.01), and epinephrine administration (11 min. vs. 13 min., p < 0.01) were observed, whilst supraglottic airways were inserted earlier (11 min. vs. 10 min., p < 0.01). CONCLUSION: The COVID-19 pandemic was associated with substantial changes in EMS management of OHCA. EMS leaders should consider these findings to optimise current OHCA management and prepare for future pandemics.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis.

BACKGROUND: Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS: From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS: For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol.

INTRODUCTION: Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS: We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION: This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER: NCT05555576 ClinicalTrials.Gov PRS.

Clinical outcomes following out-of-hospital cardiac arrest: The minute-by-minute impact of bystander cardiopulmonary resuscitation.

AIMS: The time-dependent prognostic role of bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients has not been described with great precision, especially for neurologic outcomes. Our objective was to assess the association between bystander CPR, emergency medical service (EMS) response time, and OHCA patients' outcomes. METHODS: This cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registries. Bystander-witnessed adult OHCA treated by EMS were included. The primary outcome was survival to hospital discharge and secondary outcome was survival with a good neurologic outcome (modified Rankin scale 0-2). Multivariable logistic regression models were used to assess the associations and interactions between bystander CPR, EMS response time and clinical outcomes. RESULTS: Out of 229,637 patients, 41,012 were included (18,867 [46.0%] without bystander CPR and 22,145 [54.0%] with bystander CPR). Bystander CPR was independently associated with higher survival (adjusted odds ratio [AOR] = 1.70 [95%CI 1.61-1.80]) and survival with a good neurologic outcome (AOR = 1.87 [95%CI 1.70-2.06]), while longer EMS response times were independently associated with lower survival to hospital discharge (each additional minute of EMS response time: AOR = 0.92 [95%CI 0.91-0.93], p < 0.001) and lower survival with a good neurologic outcome (AOR = 0.88 [95%CI 0.86-0.89], p < 0.001). There was no interaction between bystander CPR and EMS response time's association with survival (p = 0.12) and neurologic outcomes (p = 0.65). CONCLUSIONS: Although bystander CPR is associated with an immediate increase in odds of survival and of good neurologic outcome for OHCA patients, it does not influence the negative association between longer EMS response time and survival and good neurologic outcome.

Association of Initial Pulseless Electrical Activity Heart Rate and Clinical Outcomes following Adult Non-Traumatic Out-of-Hospital Cardiac Arrest.

OBJECTIVE: Studies evaluating the prognostic value of the pulseless electrical activity (PEA) heart rate in out-of-hospital cardiac arrest (OHCA) patients have reported conflicting results. The objective of this study was to evaluate the association between the initial PEA heart rate and favorable clinical outcomes for OHCA patients. METHODS: The present post-hoc cohort study used the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry Version 3, which included OHCA patients in seven US and three Canadian sites from April 2011 to June 2015. The primary outcome was survival to hospital discharge and the secondary outcome was survival with a good functional outcome. For the primary analysis, the patients were separated into eight groups according to their first rhythms and PEA heart rates: (1) initial PEA heart rate of 1-20 beats per minute (bpm); (2) 21-40 bpm; (3) 41-60 bpm; (4) 61-80 bpm; (5) 81-100 bpm; (6) 101-120 bpm; (7) over 120 bpm; (8) initial shockable rhythm (reference category). Multivariable logistic regression models were used to assess the associations of interest. RESULTS: We identified 17,675 patients (PEA: 7,089 [40.1%]; initial shockable rhythm: 10,797 [59.9%]). Patients with initial PEA electrical frequencies ≤100 bpm were less likely to survive to hospital discharge than patients with initial shockable rhythms (1-20 bpm: adjusted odds ratio [AOR] = 0.15 [95%CI 0.11-0.21]; 21-40 bpm: AOR = 0.21 [0.18-0.25]; 41-60 bpm: AOR = 0.30 [0.25-0.36]; 61-80 bpm: AOR = 0.37 [0.28-0.49]; 81-100 bpm: AOR = 0.55 [0.41-0.65]). However, there were no statistical outcome differences between PEA patients with initial electrical frequencies of >100 bpm and patients with initial shockable rhythms (101-120 bpm: AOR = 0.65 [95%CI 0.42-1.01]; >120 bpm: AOR = 0.72 [95%CI 0.37-1.39]). Similar results were observed for survival with good functional outcomes (101-120 bpm: AOR = 0.60 [95%CI 0.31-1.15]; >120 bpm: AOR = 1.08 [95%CI 0.50-2.28]). CONCLUSIONS: We observed a good association between higher initial PEA electrical frequency and favorable clinical outcomes for OHCA patients. As there is no significant difference in outcomes between patients with initial PEA heart rates of more than 100 bpm and those with initial shockable rhythms, we can hypothesize that these patients could be considered in the same prognostic category.

Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation.

Background: In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm. Methods: All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met. Main outcomes and measures: The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2. Results: A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)]. Conclusion and relevance: Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.

Parameters associated with successful weaning of veno-arterial extracorporeal membrane oxygenation: a systematic review.

PURPOSE: Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can be used to restore organ perfusion in patients with cardiogenic shock until native heart recovery occurs. It may be challenging, however, to determine when patients can be weaned successfully from ECMO-surviving without requiring further mechanical support or heart transplant. We aimed to systematically review the medical literature to determine the biomarkers, hemodynamic and echocardiographic parameters associated with successful weaning of VA-ECMO in adults with cardiogenic shock and to present an evidence-based weaning algorithm incorporating key findings. METHOD: We systematically searched PubMed, Embase, ProQuest, Google Scholars, Web of Science and the Grey literature for pertinent original research reports. We excluded studies limited to extracorporeal cardiopulmonary resuscitation (ECPR) as the neurological prognosis may significantly alter the decision-making process surrounding the device removal in this patient population. Studies with a mixed population of VA-ECMO for cardiogenic shock or cardiac arrest were included. We excluded studies limited to patients in which ECMO was only used as a bridge to VAD or heart transplant, as such patients are, by definition, never "successfully weaned." We used the Risk of Bias Assessment tool for Non-Randomized Studies. The study was registered on the International prospective register of systematic reviews (PROSPERO CRD42020178641). RESULTS: We screened 14,578 records and included 47 that met our pre-specified criteria. Signs of lower initial severity of shock and myocardial injury, early recovery of systemic perfusion, left and right ventricular recovery, hemodynamic and echocardiographic stability during flow reduction trial and/or pump-controlled retrograde trial off predicted successful weaning. The most widely used parameter was the left ventricular outflow tract velocity time integral, an indicator of stroke volume. Most studies had a moderate or high risk of bias. Heterogeneity in methods, timing, and conditions of measurements precluded any meta-analysis. CONCLUSIONS: In adult patients on VA-ECMO for cardiogenic shock, multiple biomarkers, hemodynamic and echocardiographic parameters may be used to track resolution of systemic hypoperfusion and myocardial recovery in order to identify patients that can be successfully weaned.

Accuracy of a self-report prescription opioid use diary for patients discharge from the emergency department with acute pain: a multicentre prospective cohort study.

OBJECTIVES: Self-reported approaches that assess opioid usage can be subject to social desirability and recall biases that may underestimate actual pill consumption. Our objective was to determine the accuracy of patient self-reported opioid consumption using a 14-day daily paper or electronic diary. DESIGN: Prospective cohort study. SETTING: Multicentre study conducted in four Québec (Canada) emergency departments (ED): three university-affiliated centres, two of them Level I trauma centres and one urban community hospital. PARTICIPANTS: ED patients aged ≥18 years with acute pain (≤2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day daily diary (paper or electronic) assessing the quantity of opioids consumed. On diary completion, a random sample from the main cohort was selected for a follow-up visit to the hospital or a virtual video visit where they had to show and count the remaining pills. Patients were blinded to the main objective of the follow-up visit. OUTCOMES: Quantity of opioid pills consumed during the 2-week follow-up period self-reported in the 14-day diary (paper or electronic) and calculated from remaining pills counted during the follow-up visit. Intraclass correlation coefficient (ICC) and Bland-Altman plots were used to assess accuracy. RESULTS: A total of 166 participants completed the 14-day diary as well as the in-person or virtual visit; 49.4% were women and median age was 47 years (IQR=21). The self-reported consumed quantity of opioid in the 14-day diary and the one calculated from counting remaining opioid pills during the follow-up visit were very similar (ICC=0.992; 95% CI: 0.989 to 0.994). The mean difference between both measures from Bland-Altman analysis was almost zero (0.048 pills; 95% CI: -3.77 to 3.87). CONCLUSION: Self-reported prescription opioid use in a 14-day diary is an accurate assessment of the quantity of opioids consumed in ED discharged patients. TRIAL REGISTRATION NUMBER: NCT03953534.

Accuracy of the Initial Rhythm to Predict a Short No-Flow Time in Out-of-Hospital Cardiac Arrest.

OBJECTIVES: The no-flow time (NFT) can help establish prognosis in out-of-hospital cardiac arrest (OHCA) patients. It is often used as a selection criterion for extracorporeal resuscitation. In patients with an unwitnessed OHCA for whom the NFT is unknown, the initial rhythm has been proposed to identify those more likely to have had a short NFT. Our objective was to determine the predictive accuracy of an initial shockable rhythm for an NFT of 5 minutes or less (NFT ≤ 5). DESIGN: Retrospective analysis of prospectively collected data. SETTING: Prehospital OHCA in eight U.S. and three Canadian sites. PATIENTS: A total of 28,139 adult patients with a witnessed nontraumatic OHCA were included, of whom 11,228 (39.9%) experienced an emergency medical service-witnessed OHCA (NFT = 0), 695 (2.7%) had a bystander-witnessed OHCA, and an NFT less than or equal to 5, and 16,216 (57.6%) with a bystander-witnessed OHCA and an NFT greater than 5. INTERVENTIONS: Sensitivity, specificity, and likelihood ratios of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 minutes. MEASUREMENTS AND MAIN RESULTS: The sensitivity of an initial shockable rhythm to identify patients with an NFT less than or equal to 5 was poor (25% [95% CI, 25-26]), but specificity was moderate (70% [95% CI, 69-71]). The positive and likelihood ratios were inverted (negative accuracy) (positive likelihood ratio, 0.76 [95% CI, 0.74-0.79]; negative likelihood ratio, 1.12 [95% CI, 1.10-1.12]). Including only patients with a bystander-witnessed OHCA improved the sensitivity to 48% (95% CI, 45-52), the positive likelihood ratio to 1.45 (95% CI, 1.33-1.58), and the negative likelihood ratio to 0.77 (95% CI, 0.72-0.83), while slightly lowering the specificity to 67% (95% CI, 66-67). CONCLUSIONS: Our analysis demonstrated that the presence of a shockable rhythm at the time of initial assessment was poorly sensitive and only moderately specific for OHCA patients with a short NFT. The initial rhythm, therefore, should not be used as a surrogate for NFT in clinical decision-making.

Trajectory of patients consulting the emergency department for high blood pressure values.

OBJECTIVES: Emergency department (ED) visits for high blood pressure are increasing in frequency. We aimed to map those patients' trajectory, from referral sources to the type of care received at the ED to anticipated actions for future high blood pressure concerns, and to better understand their reasons for consulting the ED for high blood pressure values. METHODS: Between 2018 and 2020, patients who presented to the Montreal Heart Institute's ED for elevated blood pressure were recruited in a prospective observational study including a post hoc structured telephone interview and medical chart review. Five possible referral sources were predetermined. We provided proportions and 95% confidence intervals. RESULTS: A total of 100 patients were recruited (female: 59%, mean age: 69 ± 12). A majority (93%, 95% CI 88-98%) possessed a home blood pressure device, among which 46% (95% CI 36-56%) remembered receiving advice for its use. The main referral sources for high blood pressure to the ED were self-reference (53%, 95% CI 43-63%), advice of a lay person (19%, 95% CI 11-27%) or a nurse (13%, 95% CI 6-20%). Mainly, patients reported being concerned by concomitant symptoms or experiencing acute medical consequences (44%, 95% CI 34-54%), having followed the recommendation of a third party (33%, 95% CI 24-42%), or having concerns about their medication (6%, 95% CI 1-11%). Two weeks following their ED visits, consulting ED remained the main choice for future concerns about high blood pressure for 27% of participants. When specifically asked if they would return to the ED for elevated blood pressure, 73% (95% CI 64-83%) said yes. CONCLUSIONS: Most patients who consulted the ED for elevated blood pressure values were self-referred. More can be done to promote blood pressure education, effective use of personal blood pressure devices, and recommendations for patients and health professionals when confronted with high blood pressure results.

RéSUMé: OBJECTIFS: Les visites aux services d'urgence pour hypertension artérielle (TA) sont de plus en plus fréquentes. Nous avons cherché à cartographier le parcours de ces patients, depuis les sources d'orientation jusqu'au type de soins reçus aux urgences, en passant par les mesures prévues en cas de problèmes futurs de tension artérielle élevée, et à mieux comprendre les raisons pour lesquelles ils consultent les urgences pour des valeurs de tension artérielle élevées. MéTHODES: Entre 2018 et 2020, les patients qui se sont présentés aux urgences de l'Institut de cardiologie de Montréal pour une TA élevée ont été recrutés dans le cadre d'une étude observationnelle prospective comprenant une entrevue téléphonique structurée post-hoc et un examen des dossiers médicaux. Cinq sources de référence possibles ont été prédéterminées. Nous avons fourni des proportions et des intervalles de confiance à 95 %. RéSULTATS: Au total, 100 patients ont été recrutés (femmes : 59 %, âge moyen : 69 ± 12). Une majorité (93%, IC à 95% 88-98%) possédait un tensiomètre à domicile, parmi lesquels 46% (IC à 95% 36-56%) se souvenaient avoir reçu des conseils pour son utilisation. Les principales sources d'orientation vers les urgences en cas de tension artérielle élevée étaient l'auto-référence (53 %, IC 95 % 43-63 %), le conseil d'un tiers non-professionnel de la santé (19 %, IC à 95 % 11-27 %) ou d'une infirmière (13 %, IC à 95 % 6-20 %). Principalement, les patients ont déclaré être préoccupés par des symptômes concomitants ou des conséquences médicales aiguës (44 %, IC à 95 %, 34-54 %), avoir suivi la recommandation d'un tiers (33 %, IC à 95 %, 24-42 %) ou avoir des préoccupations au sujet de leurs médicaments (6 %, IC à 95 %, 1-11 %). Deux semaines après leur visite au service d'urgence, la consultation du service d'urgence est restée le principal choix en cas de préoccupations futures concernant l'hypertension artérielle pour 27 % des participants. À la question spécifique de savoir s'ils retourneraient aux urgences pour une TA élevée, 73% (IC à 95% 64-83%) ont répondu oui. CONCLUSIONS: La plupart des patients qui ont consulté les urgences pour des valeurs élevées de la tension artérielle se sont adressés d'eux-mêmes. Il y a place à l'amélioration pour promouvoir l'éducation sur la TA, l'utilisation efficace des appareils de pression artérielle personnels et les recommandations aux patients et aux professionnels de la santé lorsqu'ils sont confrontés à des résultats élevés en matière de TA.

Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department.

BACKGROUND: Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment. METHODS: A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February-August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates. RESULTS: A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff. CONCLUSION: The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis.

Importance: Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse. Objective: To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED. Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021. Study Selection: Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers. Data Extraction and Synthesis: Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values. Main Outcomes and Measures: The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies. Results: Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients' satisfaction. Conclusions and Relevance: This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed. Trial Registration: PROSPERO Identifier: CRD42020187251.

Association between fentanyl treatment for acute pain in the emergency department and opioid use two weeks after discharge.

BACKGROUND: Analgesia with fentanyl can be associated with hyperalgesia (higher sensitivity to pain) and can contribute to escalating opioid use. Our objective was to assess the relationship between emergency department (ED) acute pain management with fentanyl compared to other opioids, and the quantity of opioids consumed two-week after discharge. We hypothesized that the quantity of opioids consumed would be higher for patients treated with fentanyl compared to those treated with other opioids. METHODS: Patients were selected from two prospective cohorts assessing opioids consumed after ED discharge. Patients ≥18 years treated with an opioid in the ED for an acute pain condition (≤2 weeks) and discharged with an opioid prescription were included. Patients completed a 14-day paper or electronic diary of pain medication use. Quantity of 5 mg morphine equivalent tablets consumed during a 14-day follow-up by patients treated with fentanyl compared to those treated with other opioids during their ED stay were analyzed using a multiple linear regression and propensity scores. RESULTS: We included 707 patients (mean age ± SD: 50 ± 15 years, 47% women) in this study. During follow-up, patients treated with fentanyl (N = 91) during their ED stay consumed a median (IQR) of 5.8 (14) 5 mg morphine equivalent pills compared to 7.0 (14) for those treated with other opioids (p = 0.05). Results were similar using propensity score sensitivity analysis. However, after adjusting for confounding variables, ED fentanyl treatment showed a trend, but not a statistically significant association with a decreased opioid consumption during the 14-day follow-up (B = -2.4; 95%CI = -5.3 to 0.4; p = 0.09). CONCLUSIONS: Patients treated with fentanyl during ED stay did not consume more opioids after ED discharge, compared to those treated with other opioids. If fentanyl does cause more hyperalgesia compared to other opioids, it does not seem to have a significant impact on opioid consumption after ED discharge.

Electrical rhythm degeneration in adults with out-of-hospital cardiac arrest according to the no-flow and bystander low-flow time.

AIMS: For out-of-hospital cardiac arrest (OHCA) patients, the influence of the delay before the initiation of resuscitation, termed the no-flow time (NFT), and duration of bystander-only resuscitation low-flow time (BLFT) on the type of electrical rhythm observed has not been well described. The objective of this study is to determine the relationship between NFT, BLFT and the likelihood of a shockable rhythm over time. METHODS: Using a North American prospective registry (2005-2015; mostly urban settings), we selected adult (18 years and over) patients who experienced a witnessed OHCA from a suspected cardiac etiology. Patients with an emergency medical services witnessed OHCA were only included in sensitivity analyses. The association between the NFT, BLFT and the presence of a shockable rhythm was evaluated using a multivariable logistic regression adjusting for the registry version, age, sex, and public location. RESULTS: A total of 229,632 patients were logged in the registry, 50,957 of whom were included. Of these, 17,704 (34.7%) had an initial shockable rhythm. After the first minute, a significant decrease over time in the occurrence of shockable rhythm is observed but is slower when bystander cardiopulmonary resuscitation (CPR) is provided (each supplemental minute of BLFT: adjusted odds ratio = 0.95, 95 %CI = 0.94-0.95; each supplemental minute of NFT: adjusted odds ratio = 0.91, 95 %CI = 0.90-0.91]). CONCLUSIONS: In this large observational study, we were able to demonstrate that longer NFT were associated with lower odds of shockable presenting rhythms. Bystander CPR significantly mitigates the degradation of shockable rhythms over time, strengthening the need to improve bystander CPR rates around the world.

Opioid and non-opioid pain relief after an emergency department acute pain visit.

OBJECTIVES: Treatment of acute pain after emergency department (ED) discharge remains a challenge in the opioid crisis context. Our objective was to determine the proportion of patients using opioid vs non-opioid pain medication following discharge from the ED with acute pain, and the association of type of pain medication with average pain intensity before pain medication intake and report of pain relief. METHODS: This was a prospective cohort study of ED patients aged ≥ 18 years with an acute pain (≤ 2 weeks) who were discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level before each pain medication intake (0-10 numeric rating scale), type of pain medication use (opioid vs non-opioid), and if pain was relieved by the medication used that day. Multilevel analyses were used to compare the effect of type of analgesic used on pain intensity and relief. RESULTS: A total of 381 participants completed the 14-day diary; 50% were women and median age was 54 years (IQR = 43-66). Average daily pain intensity before pain medication intake was significantly higher for patients who used opioids (5.9; 95% CI 5.7-6.2) as compared to non-opioid analgesics (4.2; 95% CI 4.0-4.5) or no pain medication (2.2; 95% CI 1.9-2.5). Controlling for pain intensity, patients using opioids were more likely to report a pain relief (OR = 1.3; 95% CI 1.1-1.8) as compared to those who used non-opioid analgesics. CONCLUSION: Overall, opioids appear to be effective and used as intended by the prescribing physician.

RéSUMé: OBJECTIFS: Le traitement de la douleur aiguë après la sortie des départements d'urgence (DU) reste un défi dans le contexte de la crise des opioïdes. Notre objectif était de déterminer la proportion de patients utilisant des analgésiques opioïdes par rapport aux analgésiques non opioïdes après leur sortie des urgences avec une douleur aiguë, et l'association du type d'analgésique avec l'intensité moyenne de la douleur avant la prise d'analgésiques et le soulagement de la douleur rapporté. LES MéTHODES: Il s'agissait d'une étude de cohorte prospective de patients (DU) âgés de ≥18 ans souffrant de douleurs aiguës (≤ 2 semaines) et ayant reçu une ordonnance d'opioïdes à leur sortie de l'hôpital. Les patients ont rempli un journal de 14 jours évaluant le niveau d'intensité de la douleur quotidienne avant chaque prise de médicaments anti-douleur (échelle d'évaluation numérique de 0 à 10), le type d'utilisation des médicaments anti-douleur (opioïdes contre non opioïdes), et si la douleur était soulagée par les médicaments utilisés ce jour-là. Des analyses multiniveaux ont été utilisées pour comparer l'effet du type d'analgésique utilisé sur l'intensité et le soulagement de la douleur. RéSULTATS: Au total, 381 participants ont rempli le journal de 14 jours; 50% étaient des femmes et l'âge médian était de 54 ans (EI = 43­66). L'intensité moyenne de la douleur quotidienne avant la prise d'analgésiques était significativement plus élevée chez les patients qui prenaient des opioïdes (5.9; 95% IC: 5.7­6.2) par rapport aux analgésiques non opioïdes (4.2; 95% IC: 4.0­4.5) ou à l'absence d'analgésiques (2.2; 95% IC: 1.9­2.5). En contrôlant l'intensité de la douleur, les patients utilisant des opioïdes étaient plus susceptibles de déclarer un soulagement de la douleur (OR = 1.3; 95% CI: 1.1−1.8) par rapport à ceux qui utilisaient des analgésiques non opioïdes. CONCLUSION: Dans l'ensemble, les opioïdes semblent être efficaces et utilisés comme prévu par le médecin prescripteur.

Continuous flow insufflation of oxygen for cardiac arrest: Systematic review of human and animal model studies.

OBJECTIVE: To synthetize the evidence regarding the effect of constant flow insufflation of oxygen (CFIO) on the rate of return of spontaneous circulation (ROSC) and other clinical outcomes during cardiac arrest (CA). METHODS: A systematic review was performed using four databases (PROSPERO: CRD42020071960). Studies reporting on adult CA patients or on animal models simulating CA and assessing the effect of CFIO on ROSC or other clinical outcomes were considered. RESULTS: A total of 3540 citations were identified, of which 16 studies were included. Four studies (two randomized controlled trials (RCT), two cohort studies), reported on humans while 12 studies used animal models. No meta-analysis was performed due to clinical heterogeneity. There were no differences in the ROSC (18.9% vs 20.8%, p = 0.99; 27.1% vs 21.3%, p = 0.51) and sustained ROSC rates (16.1% vs 17.3%, p = 0.81; 12.5% vs 14.9%, p = 0.73) with CFIO compared to intermitant positive pressure ventilation (IPPV) in the two human RCTs. Survival to ICU discharge was similar between CFIO (2.3%) and IPPV (2.3%) in the largest RCT (p = 0.96). Human studies were at serious or high risk of bias. In animal models' studies, ROSC rates were presented in seven RCTs. CFIO was superior to IPPV in one trial, but was associated with similar ROSC rates using different ventilation strategies in the remaining six studies. CONCLUSIONS: No definitive association between CFIO and ROSC, sustained ROSC or survival compared to other ventilation strategies could be demonstrated. Future studies should assess CFIO effect on post-survival neurological functions and patient-important CA outcomes.