A non-invasive direct nose to brain drug delivery platform vs. invasive brain delivery approach: patient-centered care impact analysis.

Current literature lacks structured methodologies for analyzing medical technologies' impact from the patient-centered care perspective. This study introduces, applies and validates 'Patient-Centered Care Impact Analysis' (PCIA) as a method for identifying patient-centered care associated demands and expectations for a particular technology and assessing its compliance with these demands. PCIA involves five stages: (1) demand identification, (2) ranking demands' impact magnitude, (3) scoring demand compliance (DC), (4) demand priority (DP) assignment based on impact magnitude and compliance, (5) generating a summative impact priority number (IPN). PCIA was performed as a comparative assessment of two central nervous system (CNS) drug-delivery platforms; SipNose, a novel noninvasive Direct-Nose-to-Brain (DNTB), vs. the standard-of-care invasive intrathecal/intracerebroventricular injection (Invasive I/I). Study participants included a ranking team (RT) without experience with the SipNose technology that based their scoring on experimental data; and a validation team (VT) experienced with the SipNose platform. All had experience with, or knowledge of, InvasiveI/I. Demand identification and impact magnitude were performed by one content and one assessment expert. Each participant assessed each technology's DC. DP scores, IPN's and IPN DNTB:InvasiveI/I ratios were generated for each technology, for each team, based on DC and summative DP scores, respectively. Both teams assigned DNTB higher DC scores, resulting in higher DNTB DP, IPN scores and DNTB:InvasiveI/I IPN ratios. Lack of difference between team assessments of DP and IPN ratio validate PCIA as an assessment tool capable of predicting patient-centered clinical care quality for a new technology. The significant differences between the platforms highlight SipNose's patient-care centered advantages as an effective CNS drug-delivery platform.

Improving STEMI management in the emergency department: Examining the role of minority groups and sociodemographic characteristics.

OBJECTIVE: To evaluate whether a fast-track intervention program will reduce time-lags of patients with STEMI considering minority groups, various socioeconomic status (SES) and clinical risk factors. METHODS: A retrospective-archive study was conducted according to clinical guidelines, comparing all STEMI patients (n = 140) admitted to the emergency department (ED) before (n = 60) and during (n = 80) implementation of the fast track intervention program. The program comprised four steps: (1) immediate bed rest, (2) marking patient chart, (3) assessing time-lags according to defined clinical guidelines, and (4) physician signing a dedicated sticker on the ECG. RESULTS: The major ethnic group compared to other minority patients with STEMI were less delayed for physician examination (r = -0.398, p < 0.01), spent less time at ED (r = -0.541, p < 0.01) and reached percutaneous coronary intervention earlier (r = -0.672, p < 0.01). Patients with higher SES spent less time for physician (r = -338, p < 0.05) and in the ED (r = -0.415, p < 0.01). Before intervention patients with diabetes mellitus (DM) spent more time at ED compared to non DM patients, however during intervention this difference was blurred (ß = -0.803, p < 0.001). Gaps regarding sociodemographic bias remained present throughout the intervention despite monthly staff evaluations considering patient cases. CONCLUSIONS: The fast track intervention was associated with less time at ED and to cardiac reperfusion. Yet, sociodemographic bias was present. Our findings highlight the need for the healthcare profession to address the role of biases in disparities in healthcare.

Round-off decision-making: Why do triage nurses assign STEMI patients with an average priority?

Patients with suspected ST elevation myocardial infarction should be classified with a high-priority triage level in the Emergency Department. Accurate triage can reduce mortality and morbidity in ST elevation myocardial infarction patients. Yet, half of these patients were given a low-priority score, especially the average classification (P3 on a P1-P5 scale). AIM: To identify and clarify significant factors in the triage process that result in P3 assignment for patients with ST Elevation Myocardial Infraction diagnosis. METHODS: A retrospective-archive study was conducted at a tertiary hospital from January 2015 to November 2017. We collected and measured patients' characteristics, Emergency Department setting variables, and hospitalization characteristics. Data files were extracted from the electronic database (n = 140). RESULTS: The results show several key factors that affect the decision to assign P3 in the triage process. Analysis of patients' sociodemographic characteristics show that being female (OR = 1.96, P = .05) or having Arab ethnicity (OR = 2.19, P = .01) is significant to P3 assignment. Number of cardiac events (P = .02) is the only noteworthy cardiologic comorbidity of all that were reviewed. A connection was observed between a patient being classified as average urgency and poor treatment outcomes, namely for the variables time to physician, total time in the Emergency Department, door-to-balloon time, and in-hospital mortality. CONCLUSION: Average classification demonstrates the extreme risk involved in the triage process. Our research provides considerable data to identify factors that affect the decision to classify patients as P3.

A study of the workforce in emergency medicine in Israel 2012: what has changed in the last decade?

OBJECTIVE: In 2003, we published a study on the Israeli workforce in emergency medicine (EM). We repeated the study in 2012 to assess changes in the workforce that have occurred in the interval decade. METHODS: This is an observational cross-sectional study of the physician workforce in EM in Israel in 2012. An online survey was sent to the ED medical directors of all general hospitals in Israel querying the numbers of physicians working in the ED, as well as the specialty and level of training of those manning the ED at various times during the day. The workforce in 2012 was compared to that of 2003. RESULTS: Twenty-four of 28 (86 %) EDs responded. Certified EM specialists have increased from 59 to 164 since 2003. Disparities continue regarding their presence in the ED. Most EM specialists are scheduled during the day whereas they are virtually absent during the night. A total of 58 EM specialists were scheduled countrywide for the weekday day shift and only one overnight. The preponderance of EM specialists working during the day and the large number of supervised and unsupervised residents working at night has not changed substantially since 2003. Eleven departments reported having an EM specialist present during the evenings whereas in 2003, only two departments reported so. CONCLUSION: Since 2003, there are more certified EM specialists and more specialist coverage in the ED into the evening hours. Most ED providers are still not emergency physicians, and there is still a preponderance of EM specialist coverage during the day and a lack thereof overnight.

[Non-traumatic unintentional injuries and risk factors for hospitalization in children presenting to a pediatric emergency department].

OBJECTIVE: Unintentional injuries are a major cause of morbidity and mortality in children. The authors present the results of a study in which data was collected regarding unintentional injuries presented to the Pediatrics Emergency Department (PED) at Ha'Emek Medical Center. The present study represents the first collection and analysis of such data gathered from the Pediatric Emergency Department in Northern Israel. METHODS: This was a prospective study in which data was collected regarding children who presented with non-traumatic unintentional injuries to the Pediatric Emergency Department (PED) between the years 2000 and 2002. The injuries presented included poisoning, aspiration and swallowing of foreign bodies, smoke inhalation and near drowning. Data collected included the type of injury, location and time of the accident, and data regarding the child and his family. The authors examined the association between variables in order to identify the risk factors for hospitalization. RESULTS: Of 412 children, 59% were males and 41% were females. Seventy-three percent of all accidents happened in the child's home or yard, and 36.5% occurred during the summer. Poisoning was the most common unintentional injury (61% of cases) and house cleaning material was the most common source of poisoning. The probability of hospitalization was higher for the following situations: aspiration of foreign bodies, injuries that occurred during the summer, children of Arab ethnicity and patients presenting to the hospital at night. IN CONCLUSION: This study presents initial data regarding these types of injuries from the Jezreel Valley. These data may help establish and target prevention programs.

[Biphasic versus monophasic shock waveforms for transthoracic cardioversion of atrial flutter in the emergency room].

UNLABELLED: Transthoracic electrical cardioversion (ECV), traditionally using monophasic waveform (MW) shock, has an important role in the treatment of symptomatic atrial flutter (AFI). Biphasic waveform (BW) shock has been demonstrated to be more successful than MW shock for termination of atrial fibrillation, but data about its use for ECV of AFI are limited. METHODS AND RESULTS: We retrospectively analyzed the records of 53 patients (pts) admitted -to the ER due to symptomatic AFl during the period August 2004 to August 2005: 31 pts received BW shock and 22 pts MW shock. The type of shock waveforms and the initial energy of CV were chosen by the doctor on duty in the ER; the lower energy for ECV was 20 joules, which was increased to 50, 100 and 200 joules if necessary. There were no significant differences between the clinical characteristics of the pts who received BW shock or MW shock. All pts underwent ECV via anterior-laterally positioned hand-held electrode paddles. Successful ECV by BW shock and MW shock was 41% and 42% of the pts, respectively, using 20 joules of energy (p=n.s.); 77% and 80% using 50 joules (p=n.s.); 93% and 90% using 100 joules (p = n.s.); 100% of successful ECV was reached when 200 joules of energy was used, regardless of waveforms type. Median energy for successful ECV was 50 joules in both types of electrical waveforms. No complications were reported. CONCLUSIONS: There were no significant differences in the success rates of conversion of atrial flutter to sinus rhythm by BW or MW shock. We recommend 50 joules for starting energy of ECV of AF1 regardless of waveforms type.

[Intravenous flecainide administration for conversion of paroxysmal atrial fibrillation in the emergency room].

INTRODUCTION: Since the removal of intravenous propafenone from the Israeli market, flecainide is the only intravenous antiarrhythmic class 1C drug available nowadays in Israel. AIM: The study aimed to report our experience of intravenous flecainide administration in the treatment of paroxysmal atrial fibrillation (PAF) in the Emergency Room (ER). METHODS: Patients with AF lasting > 1 hour and <48 hour duration were considered possible candidates for entry into the study. Exclusion criteria were clinical signs of congestive heart failure, acute coronary syndrome, electrolyte imbalances, significant hepatic and renal disease, and any previously documented conduction disturbance. Flecainide was administered as a bolus dose of 2mg/kg in 10 minutes (maximum 150 mg). The patients with a ventricular response > 130 beats/min received intravenous verapamil or metoprolol in order to reduce the ventricular rate. Efficacy was defined as conversion to sinus rhythm (SR) within 120 minutes of starting medication. RESULTS: Twenty three consecutive patients were enrolled in the study. Their mean age was 60 +/- 19 years; the mean ventricular response at admission was 128 +/- 26 beats/min. SR was achieved in 10 patients (43%) after the intravenous bolus of flecainide (10 minutes) and in 17 patients (74%) 120 minutes after the beginning of the therapy. COMPLICATIONS: Hypotension (systolic blood pressure < 90 mmHg) was reported in 1 patient and QRS enlargement was seen in 1 patient. CONCLUSION: Intravenous flecainide has effective and rapid action in the conversion of PAF and its administration is safe in the treatment of this arrhythmia in the ER.

[Biphasic shock waveform for cardioversion of atrial fibrillation in the emergency room].

UNLABELLED: Transthoracic electrical cardioversion, traditionally monophasic shock waveform, has been a mainstay of the therapy for atrial fibrillation (AF) since its introduction into clinical practice. Recent studies have demonstrated that biphasic shock is more efficient than monophasic shock waveforms for terminating both ventricular fibrillation and AF; however, data on the recommended initial shock energy in conversion of AF by biphasic shocks are limited. AIM: Our study aimed to evaluate the optimal dose of the initial shock energy for conversion of AF to sinus rhythm by transthoracic biphasic shock waveforms in the Emergency Room (ER). METHODS AND RESULTS: A total of 144 consecutive patients, who came to the ER because of AF, were our study population. All patients underwent cardioversion via anterior-laterally positioned hand-held electrode paddles. Patients received sequential shocks of 50 J (only the first 40 patients), 100 J, 150 J and 200 J if necessary. There was a significantly greater cumulative conversion success rate with 100 J (70.5%) than 50 J shock energy (55%), p < 0.05; but even greater with 150 J (89%) than 100 J shock energy, p < 0.003; no significant difference was observed between 200 J (94%) and 150 J shock energy, p < 0.58. Nine of 12 patients, whose body weight was less than 70 kg, were successfully converted to sinus rhythm (75%) by 50 J shock 1 energy. After cardioversion there were reports of: a five seconds asystole observed in 1 patient; pulmonary edema in another patient; hypotension was reported in 1 patient and mild erythema in 14 patients (9.7%). CONCLUSION: Our findings support that biphasic waveform shock energy of 150 J is advised as a first attempt, but in patients with a body weight less than 70 kg. lower energy shock may be used.

[Intravenous propafenone for conversion of atrial fibrillation in the emergency room].

Atrial fibrillation (AF) is the most common sustained symptomatic arrhythmia encountered in the emergency room (ER). Rapid, safe and effective conversions of AF to sinus rhythm (SR) are important aspects in the treatment of arrhythmia in a busy ER setting. The aim of our study was to investigate the rate of conversion, efficacy and safety of intravenous (i.v.) propafenone administration for the treatment of AF in the ER. Seventy five patients (pts), admitted in the ER with symptomatic AF were randomized to receive propafenone or placebo: 40 pts received propafenone as an i.v. bolus of 2 mg/kg in 15 minutes, followed by maintenance infusion of 0.0067 mg/kg/min until conversion to SR or for up to 90 minutes (Group 1). The matching placebo (an equal volume of saline solution) was administered to 35 pts in the same fashion (Group 2). Direct current (DC) cardioversion was attempted in pts still in AF 15 minutes after infusion administration was terminated. SR was achieved in 24 pts treated with propafenone (60%) versus 10 pts treated with placebo (29%) (p<0.02) and the median conversion time was 15 minutes versus 105 minutes respectively (p<0.001). None of the pts who were in AF for more than 48 hours were converted to SR by infusion. Five patients had mild and transient adverse event during propafenone treatment versus none with placebo (p=ns). Therefore, we conclude that i.v. administration of propafenone in the ER is an effective, rapid and safe therapeutic alternative for pts with symptomatic AF.