Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review.

STUDY OBJECTIVE: This scoping review was conducted to collate and summarize the published research literature addressing sexual and gender minority care in the emergency department (ED). METHODS: Using PRISMA-ScR criteria, an electronic search was conducted of CINAHL, Embase, Ovid Medline, and Web of Science for all studies that were published after 1995 involving sexual and gender minorities, throughout all life stages, presenting to an ED. We excluded non-US and Canadian studies and editorials. Titles and abstracts were screened, and full-text review was performed independently with 4 reviewers. Abstraction focused on study design, demographics, and outcomes, and the resulting data were analyzed using an ad hoc iterative thematic analysis. RESULTS: We found 972 unique articles and excluded 743 after title and abstract screening. The remaining 229 articles underwent full-text review, and 160 articles were included. Themes identified were HIV in sexual and gender minorities (n=61), population health (n=46), provider training (n=29), ED avoidance or barriers (n=23), ED use (n=21), and sexual orientation/gender identity information collection (n=9). CONCLUSION: The current literature encompassing ED sexual and gender minority care cluster into 6 themes. There are considerable gaps to be addressed in optimizing culturally competent and equitable care in the ED for this population. Future research to address these gaps should include substantial patient stakeholder engagement in all aspects of the research process to ensure patient-focused outcomes congruent with sexual and gender minority values and preferences.

Public awareness and knowledge of sepsis: a cross-sectional survey of adults in Canada.

BACKGROUND: Sepsis is a life-threatening complication of the body's response to infection. The financial, medical, and psychological costs of sepsis to individuals and to the healthcare system are high. Most sepsis cases originate in the community, making public awareness of sepsis essential to early diagnosis and treatment. There has been no comprehensive examination of adult's sepsis knowledge in Canada. METHODS: We administered an online structured survey to English- or French-literate adults in Canada. The questionnaire comprised 28 questions in three domains: awareness, knowledge, and information access. Sampling was stratified by age, sex, and geography and weighted to 2016 census data. We used descriptive statistics to summarize responses; demographic differences were tested using the Rao-Scott correction for weighted chi-squared tests and associations using multiple variable regression. RESULTS: Sixty-one percent of 3200 adults sampled had heard of sepsis. Awareness differed by respondent's residential region, sex, education, and ethnic group (p < 0.001, all). The odds of having heard of sepsis were higher for females, older adults, respondents with some or completed college/university education, and respondents who self-identified as Black, White, or of mixed ethnicity (p < 0.01, all). Respondent's knowledge of sepsis definitions, symptoms, risk factors, and prevention measures was generally low (53.0%, 31.5%, 16.5%, and 36.3%, respectively). Only 25% of respondents recognized vaccination as a preventive strategy. The strongest predictors of sepsis knowledge were previous exposure to sepsis, healthcare employment, female sex, and a college/university education (p < 0.001, all). Respondents most frequently reported hearing about sepsis through television (27.7%) and preferred to learn about sepsis from healthcare providers (53.1%). CONCLUSIONS: Sepsis can quickly cause life-altering physical and psychological effects and 39% of adults sampled in Canada have not heard of it. Critically, a minority (32%) knew about signs, risk factors, and strategies to lower risk. Education initiatives should focus messaging on infection prevention, employ broad media strategies, and use primary healthcare providers to disseminate evidence-based information. Future work could explore whether efforts to raise public awareness of sepsis might be bolstered or hindered by current discourse around COVID-19, particularly those centered on vaccination.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

If we could turn back time: Imagining time-variable, competency-based medical education in the context of COVID-19.

The COVID-19 pandemic has exposed a paradox in historical models of medical education: organizations responsible for applying consistent standards for progression have needed to adapt to training environments marked by inconsistency and change. Although some institutions have maintained their traditional requirements, others have accelerated their programs to rush nearly graduated trainees to the front lines. One interpretation of the unplanned shortening of the duration of training programs during a crisis is that standards have been lowered. But it is also possible that these trainees were examined according to the same standards as usual and were judged to have already met them. This paper discusses the impacts of the COVID-19 pandemic on the current workforce, provides an analysis of how competency-based medical education (CBME) in the context of the pandemic might have mitigated wide-scale disruption, and identifies structural barriers to achieving an ideal state. The paper further calls upon universities, health centres, governments, certifying bodies, regulatory authorities, and health care professionals to work collectively on a truly time-variable model of CBME. The pandemic has made clear that time variability in medical education already exists and should be adopted widely and formally. If our systems today had used a framework of outcome competencies, sequenced progression, tailored learning, focused instruction, and programmatic assessment, we may have been even more nimble in changing our systems to care for our patients with COVID-19.

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association.

The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This focused update to the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care follows the Pediatric Task Force of the International Liaison Committee on Resuscitation evidence review. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, and updates are published when the International Liaison Committee on Resuscitation completes a literature review based on new science. This update provides the evidence review and treatment recommendation for chest compression-only CPR versus CPR using chest compressions with rescue breaths for children <18 years of age. Four large database studies were available for review, including 2 published after the "2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Two demonstrated worse 30-day outcomes with chest compression-only CPR for children 1 through 18 years of age, whereas 2 studies documented no difference between chest compression-only CPR and CPR using chest compressions with rescue breaths. When the results were analyzed for infants <1 year of age, CPR using chest compressions with rescue breaths was better than no CPR but was no different from chest compression-only CPR in 1 study, whereas another study observed no differences among chest compression-only CPR, CPR using chest compressions with rescue breaths, and no CPR. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children.

National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders.

Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.

Mechanical versus manual chest compressions for cardiac arrest.

BACKGROUND: This is the first update of the Cochrane review on mechanical chest compression devices published in 2011 (Brooks 2011). Mechanical chest compression devices have been proposed to improve the effectiveness of cardiopulmonary resuscitation (CPR). OBJECTIVES: To assess the effectiveness of mechanical chest compressions versus standard manual chest compressions with respect to neurologically intact survival in patients who suffer cardiac arrest. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Studies (CENTRAL; 2013, Issue 12), MEDLINE Ovid (1946 to 2013 January Week 1), EMBASE (1980 to 2013 January Week 2), Science Citation abstracts (1960 to 18 November 2009), Science Citation Index-Expanded (SCI-EXPANDED) (1970 to 11 January 2013) on Thomson Reuters Web of Science, biotechnology and bioengineering abstracts (1982 to 18 November 2009), conference proceedings Citation Index-Science (CPCI-S) (1990 to 11 January 2013) and clinicaltrials.gov (2 August 2013). We applied no language restrictions. Experts in the field of mechanical chest compression devices and manufacturers were contacted. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs and quasi-randomised studies comparing mechanical chest compressions versus manual chest compressions during CPR for patients with atraumatic cardiac arrest. DATA COLLECTION AND ANALYSIS: Two review authors abstracted data independently; disagreement between review authors was resolved by consensus and by a third review author if consensus could not be reached. The methodologies of selected studies were evaluated by a single author for risk of bias. The primary outcome was survival to hospital discharge with good neurological outcome. We planned to use RevMan 5 (Version 5.2. The Nordic Cochrane Centre) and the DerSimonian & Laird method (random-effects model) to provide a pooled estimate for risk ratio (RR) with 95% confidence intervals (95% CIs), if data allowed. MAIN RESULTS: Two new studies were included in this update. Six trials in total, including data from 1166 participants, were included in the review. The overall quality of included studies was poor, and significant clinical heterogeneity was observed. Only one study (N = 767) reported survival to hospital discharge with good neurological function (defined as a Cerebral Performance Category score of one or two), demonstrating reduced survival with mechanical chest compressions when compared with manual chest compressions (RR 0.41, 95% CI 0.21 to 0.79). Data from four studies demonstrated increased return of spontaneous circulation, and data from two studies demonstrated increased survival to hospital admission with mechanical chest compressions as compared with manual chest compressions, but none of the individual estimates reached statistical significance. Marked clinical heterogeneity between studies precluded any pooled estimates of effect. AUTHORS' CONCLUSIONS: Evidence from RCTs in humans is insufficient to conclude that mechanical chest compressions during cardiopulmonary resuscitation for cardiac arrest are associated with benefit or harm. Widespread use of mechanical devices for chest compressions during cardiac events is not supported by this review. More RCTs that measure and account for the CPR process in both arms are needed to clarify the potential benefit to be derived from this intervention.

Paramedic self-reported exposure to violence in the emergency medical services (EMS) workplace: a mixed-methods cross-sectional survey.

INTRODUCTION: Studies from Australia, Sweden, the United States, and elsewhere have found that paramedics experience violence in the emergency medical services (EMS) workplace. The objective of this study was to describe and explore violence experienced by paramedics in the ground ambulance setting, including types of violence experienced, by whom the violence was perpetrated, actions taken by paramedics, and effects of these episodes. METHOD: A cross-sectional study utilizing a mixed-methods paper survey was provided to a convenience sample of rural, suburban, and urban-based ground ambulance paramedics in two Canadian provinces. Paramedics were asked to describe episodes of verbal assault, intimidation, physical assault, sexual harassment, and sexual assault they were exposed to during the past 12 months. Qualitative questions inquired about the impact of these experiences. Response selections were analyzed using descriptive statistics and regression analysis, and qualitative data was analyzed using descriptive content analysis. RESULTS: A total of 1,884 paramedics were invited to participate and 1,676 responded (89.0%). Most participants (75%) reported experiencing violence in the past 12 months. The most common form of violence reported was verbal assault (67%), followed by intimidation (41%), physical assault (26%), sexual harassment (14%), and sexual assault (3%). Patients were identified as the most common perpetrators of violence. Serious sequellae were qualitatively reported. CONCLUSION: The majority of Canadian paramedics surveyed experience violence in the workplace, which can lead to serious personal and professional sequellae. Strategies should be devised and studied to reduce violent events toward paramedics and to mitigate the impact such events have on the wellbeing of paramedics.

A novel online training program for sexual and gender minority health increases allyship in cisgender, heterosexual paramedics.

Introduction: Sexual and gender minorities (SGM) make up 4% of the Canadian population. Due to existing barriers to care in the community, SGM patients may seek more help and be sicker at presentation to hospital. Paramedics occupy a unique role and can remove or decrease these barriers. There are no existing evaluations of training programs in SGM health for prehospital providers. A training program to develop better allyship in paramedics toward SGM populations was developed and assessed. Methods: A 70- to 90-min mandatory, asynchronous, online training module in SGM health in the prehospital environment was developed and delivered via the emergency medical service (EMS) system's learning management system. A before-and-after study of cisgender, heterosexual, frontline paramedics was performed to measure the impact of the training module on the care of SGM patients. The validated Ally Identity Measure (AIM) tool was used to identify success of training and includes subscales of knowledge and skills, openness and support, and oppression awareness. Demographics and satisfaction scores were collected in the posttraining survey. Matched and unmatched pairs of surveys and demographic associations were analyzed using nonparametric statistics. Results: Of 609 paramedics, 571 completed the training, and 239 surveys were completed before and 105 (n = 344) surveys after the training; 60 surveys were paired. Overall AIM scores of matched pairs (n = 60) improved by 12% (p < 0.001), with knowledge and skills accounting for most of the increase (21%, p < 0.001). Unmatched pairs (n = 344) were similar in demographics and scores. Rural paramedics also had significantly lower pretraining oppression awareness scores and had lower posttraining AIM scores compared to suburban paramedics (6% difference). Satisfaction scores rated the training as relevant and applicable (87% and 82%, respectively). Conclusions: A novel prehospital training program in the care of SGM patients resulted in a statistically significant increase in allyship in cisgender, heterosexual-identified frontline paramedics.

Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People: Recommendations for Immediate Action to Improve Care.

Introduction: We conducted this systematic review to identify emergency department (ED) relevant recommendations in current guidelines for care of transgender and gender-diverse (TGD) people internationally. Methods: Using PRISMA criteria, we did a systematic search of Ovid Medline, EMBASE, and CINAHL and a hand search of gray literature for clinical practice guidelines (CPG) or best practice statements (BPS) published until June 31, 2021. Articles were included if they were in English, included medical or paramedical care of TGD populations of any age, in any setting, region or nation, and were national or international in scope. Exclusion criteria included primary research studies, review articles, narrative reviews or otherwise non-CPG or BPS, editorials, or letters to the editor, articles of regional or individual hospital scope, non-medical articles, articles not in English, or if a more recent version of the guideline existed. Recommendations relevant to ED care were identified, recorded, and assessed for quality using the AGREE-II and AGREE-REX criteria. We performed interclass correlation coefficient for interrater reliability. Recommendations were coded for the relevant point of care while in the ED (triage, registration, rooming, investigations, etc.). Results: We screened 1,658 unique articles, and 1,555 were excluded. Of the remaining 103 articles included, seven had recommendations relevant to care in the ED, comprising a total of 10 recommendations. Four guidelines and eight recommendations were of high quality. They included recommendations for testing, prevention, referral, and provision of post-exposure prophylaxis for HIV, and culturally competent care of TGD people. Conclusions: This is the most comprehensive review to date of guidelines and best practices statements offering recommendations for care of ED TGD patients, and several are immediately actionable. There are also many opportunities to build community-led research programs to synthesize and inform a comprehensive dedicated guideline for care of TGD people in emergency settings.

Gender, Socioeconomic Status, Race, and Ethnic Disparities in Bystander Cardiopulmonary Resuscitation and Education-A Scoping Review.

BACKGROUND: Social determinants are associated with survival from out-of-hospital sudden cardiac arrest (SCA). Because prompt delivery of bystander CPR (B-CPR) doubles survival and B-CPR rates are low, we sought to assess whether gender, socioeconomic status (SES), race, and ethnicity are associated with lower rates of B-CPR and CPR training. METHODS: This scoping review was conducted as part of the continuous evidence evaluation process for the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care as part of the Resuscitation Education Science section. We searched PubMed and excluded citations that were abstracts only, letters or editorials, and pediatric studies. RESULTS: We reviewed 762 manuscripts and identified 24 as relevant; 4 explored gender disparities; 12 explored SES; 11 explored race and ethnicity; and 3 had overlapping themes, all of which examined B-CPR or CPR training. Females were less likely to receive B-CPR than males in public locations. Observed gender disparities in B-CPR may be associated with individuals fearing accusations of inappropriate touching or injuring female victims. Studies demonstrated that low-SES neighborhoods were associated with lower rates of B-CPR and CPR training. In the US, predominantly Black and Hispanic neighborhoods were associated with lower rates of B-CPR and CPR training. Language barriers were associated with lack of CPR training. CONCLUSION: Gender, SES, race, and ethnicity impact receiving B-CPR and obtaining CPR training. The impact of this is that these populations are less likely to receive B-CPR, which decreases their odds of surviving SCA. These health disparities must be addressed. Our work can inform future research, education, and public health initiatives to promote equity in B-CPR knowledge and provision. As an immediate next step, organizations that develop and deliver CPR curricula to potential bystanders should engage affected communities to determine how best to improve training and delivery of B-CPR.

International facets of the 'chain of survival' for out-of-hospital and in-hospital cardiac arrest - A scoping review.

Background: The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described. Objectives: To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes. Methods eligibility criteria and sources of evidence: A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis. Results: A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported. Conclusion: There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes.

Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics.

Between 0.25% and 3% of admissions to the NICU, PICU, and PCICU receive cardiopulmonary resuscitation (CPR). Most CPR events occur in patients <1 year old. The incidence of CPR is 10 times higher in the NICU than at birth. Therefore, optimizing the approach to CPR in hospitalized neonates and infants is important. At birth, the resuscitation of newborns is performed according to neonatal resuscitation guidelines. In older infants and children, resuscitation is performed according to pediatric resuscitation guidelines. Neonatal and pediatric guidelines differ in several important ways. There are no published recommendations to guide the transition from neonatal to pediatric guidelines. Therefore, hospitalized neonates and infants can be resuscitated using neonatal guidelines, pediatric guidelines, or a hybrid approach. This report summarizes the current neonatal and pediatric resuscitation guidelines, considers how to apply them to hospitalized neonates and infants, and identifies knowledge gaps and future priorities. The lack of strong scientific data makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines. Therefore, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice in a given location or situation, considering local circumstances, health care team preferences, and resource limitations.

Relationship between chest compression rates and outcomes from cardiac arrest.

BACKGROUND: Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions per minute. Animal and human studies have reported that blood flow is greatest with chest compression rates near 120/min, but few have reported rates used during out-of-hospital (OOH) cardiopulmonary resuscitation or the relationship between rate and outcome. The purpose of this study was to describe chest compression rates used by emergency medical services providers to resuscitate patients with OOH cardiac arrest and to determine the relationship between chest compression rate and outcome. METHODS AND RESULTS: Included were patients aged ≥ 20 years with OOH cardiac arrest treated by emergency medical services providers participating in the Resuscitation Outcomes Consortium. Data were abstracted from monitor-defibrillator recordings during cardiopulmonary resuscitation. Multiple logistic regression analysis assessed the association between chest compression rate and outcome. From December 2005 to May 2007, 3098 patients with OOH cardiac arrest were included in this study. Mean age was 67 ± 16 years, and 8.6% survived to hospital discharge. Mean compression rate was 112 ± 19/min. A curvilinear association between chest compression rate and return of spontaneous circulation was found in cubic spline models after multivariable adjustment (P=0.012). Return of spontaneous circulation rates peaked at a compression rate of ≈ 125/min and then declined. Chest compression rate was not significantly associated with survival to hospital discharge in multivariable categorical or cubic spline models. CONCLUSIONS: Chest compression rate was associated with return of spontaneous circulation but not with survival to hospital discharge in OOH cardiac arrest.

Expanding paramedic scope of practice in the community: a systematic review of the literature.

BACKGROUND: Paramedics are an important health human resource and are uniquely mobile in most communities across Canada. In the last dozen years, challenges in the delivery of health care have prompted governments from around the globe to consider expanding the role paramedics play in health systems. Utilizing paramedics for the management of urgent, low-acuity illnesses and injuries has been coined "community paramedicine," but the role, safety, and effectiveness of this concept are poorly understood. OBJECTIVE: We undertook a systematic review of the international literature to describe existing community paramedic programs. METHOD: We used the Cochrane methodology for systematic reviews. An international group of experts developed a search strategy and a health information specialist executed this search in Medline, Embase, and CINAHL starting January 1, 2000. We included all research articles in the English language that reported a research methodology. We excluded commentaries and letters to the editor. Two investigators independently screened citations in a hierarchical manner and abstracted data. RESULTS: Of 3,089 titles, 10 articles were included in the systematic review and one additional paper was author-nominated. The nature of the 11 articles was heterogeneous, and only one randomized controlled trial (RCT) was found. This trial showed community paramedicine to be beneficial to patients and health systems. The other articles drew conclusions favoring community paramedicine. CONCLUSION: Community paramedicine research to date is lacking, but programs in the United Kingdom, Australia, and Canada are perceived to be promising, and one RCT shows that paramedics can safely practice with an expanded scope and improve system performance and patient outcomes. Further research is required to fully understand how expanding paramedic roles affect patients, communities, and health systems.

Exploring a case for education about sexual and gender minorities in postgraduate emergency medicine training: forming recommendations for change.

Social medicine and health advocacy curricula are known to be uncommon in postgraduate medical education. As justice movements work to unveil the systemic barriers experienced by sexual and gender minority (SGM) populations, it is imperative that the emergency medicine (EM) community progress in its efforts to provide equitable, accessible, and competent care for these vulnerable groups. Given the paucity of literature on this subject in the context of EM in Canada, this commentary borrows evidence from other specialties across North America. Trainees across specialties and of all stages are caring for an increasing number of SGM patients. Lack of education at all levels of training is identified as a significant barrier to adequately caring for these populations, thereby precipitating significant health disparities. Cultural competency is often mistakenly attributed to a willingness to treat rather than the provision of quality care. However, positive attitudes do not necessarily correlate with trainee knowledge. Barriers to creating and implementing culturally competent curricula are plentiful, yet facilitating policies and resources are rare. While international bodies continuously publish position statements and calls to action, concrete change is seldom made. The scarcity of SGM curricula can be attributed to the universal absence of formal acknowledgment of SGM health as a required competency by accreditation boards and professional membership associations. This commentary synthesizes hand-picked literature in an attempt to inform healthcare professionals on their journey toward developing culturally competent postgraduate medical education. By thematically organizing evidence into a stepwise approach, the goal of this article is to borrow ideas across medical and surgical specialties to inform the creation of recommendations and make a case for an SGM curriculum for EM programs in Canada.