The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers.

OBJECTIVE: High-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revisits with cardiology admissions for patients undergoing testing for suspected AMI. METHODS: This control pre-post design analysis included patients evaluated using hs-TnT or conventional troponin T. Data were collected from 3 ED databases for patients who had a troponin assay for suspected AMI for the periods February 12, 2011-April 22, 2011 (Ctrl); November 20, 2011-January 28, 2012 (Pre); and February 12, 2012-April 21, 2012 (Post). The primary outcome was ED LOS; secondary outcomes included the proportions of patients who received ED cardiology consultations, patients who were admitted to hospital, and discharged patients who revisited the ED within 30 days. RESULTS: Data were analyzed from 6650 (Ctrl), 6866 (Pre), and 5754 (Post) patients. Median ED LOS decreased following hs-TnT implementation (6.60 hours in Ctrl and Pre vs 6.10 hours in Post, P < .001). There was no change in cardiology consultations or admissions following hs-TnT implementation. Fewer ED revisits occurred within 30 days in Post (16.0% Ctrl, 16.5% Pre vs 14.9% Post; P < .01). These results were preserved after adjusting for age and Canadian Triage Acuity Score. CONCLUSIONS: This hs-TnT implementation strategy, using an equivalent cutoff for the conventional troponin T and hs-TnT assays, decreased ED LOS for patients with suspected AMI and did not increase cardiology resource utilization or ED revisits.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians.

OBJECTIVE: To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. METHODS: We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. RESULTS: We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. CONCLUSIONS: Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

The multicenter impacts of an emergency physician lead on departmental flow and provider experiences.

INTRODUCTION: Emergency department (ED) flow impacts patient safety, quality of care and ED provider satisfaction. Throughput interventions have been shown to improve flow, yet few studies have reported the impact of ED physician leadership roles on patient flow and provider experiences. The study objective was to evaluate the impacts of the emergency physician lead role on ED flow metrics and provider experiences. METHODS: Quantitative data about patient flow metrics were collected from ED information systems in two tertiary hospital EDs and analyzed to compare ED length of stay, EMS hallway length of stay, physician initial assessment time, 72-h readmission and left without being seen rates three months before and following emergency physician lead role implementation. ED flow metrics for adult patients at each site were analyzed independently using descriptive and inferential statistics, t tests and multivariable regression analysis. Qualitative data were collected via surveys from ED providers (physicians, nurses, and EMS) about their experiences working with the emergency physician leads and analyzed for themes about emergency physician leads impact. RESULTS: The number of ED visits was relatively stable pre-post at the Peter Lougheed Centre (Lougheed) but increased pre-post at the Foothills Medical Centre (Foothills). Post-intervention at Lougheed median ED length of stay decreased by 18 min (p < 0.001) and at Foothills ED length of stay increased by 8 min (p < 0.001). EMS length of stay at Lougheed decreased by 20 min (p < 0.001), and at Foothills length of stay increased by 17 min (p < 0.001). Themes in provider feedback were that emergency physician leads (1) facilitated patient flow, (2) impacted provider workload, and (3) supported patient flow and safety with early assessments, treatments and investigations. CONCLUSION: In this study, the emergency physician lead impacted ED flow metrics variably at different sites, but important learnings from provider experiences can guide future emergency physician lead implementation.

RéSUMé: INTRODUCTION: Le flux des services d'urgence a une incidence sur la sécurité des patients, la qualité des soins et la satisfaction des fournisseurs de services d'urgence. Il a été démontré que les interventions de débit améliorent le flux, mais peu d'études ont rapporté l'impact des rôles de leadership des médecins des urgences sur le flux des patients et les expériences des prestataires. L'objectif de l'étude était d'évaluer l'impact du rôle du médecin chef des urgences sur les paramètres de flux des urgences et les expériences des prestataires. MéTHODES: Les données quantitatives sur les paramètres du flux des patients ont été recueillies à partir des systèmes d'information des urgences de deux hôpitaux tertiaires et analysées afin de comparer la durée du séjour aux urgences, la durée du séjour dans le couloir des SMU, le temps d'évaluation initiale par le médecin, les réadmissions dans les 72 heures et les taux de sortie sans consultation trois mois avant et après la mise en œuvre du rôle de chef des urgences. Les paramètres de débit des urgences pour les patients adultes de chaque site ont été analysés indépendamment à l'aide de statistiques descriptives et inférentielles, de tests t et d'une analyse de régression multivariable. Les données qualitatives ont été recueillies par le biais d'enquêtes auprès de fournisseurs de services d'urgence (médecins, infirmières et services médicaux d'urgence) sur leur expérience de travail avec les médecins chefs des services d'urgence et analysées pour en dégager les thèmes concernant l'impact des médecins chefs des services d'urgence. RéSULTATS: Le nombre de visites aux urgences était relativement stable avant et après au Peter Lougheed Centre (Lougheed), mais a augmenté avant et après au Foothills Medical Center (Foothills). Après l'intervention, la durée médiane du séjour aux urgences de Lougheed a diminué de 18 minutes (p < 0.001) et celle des urgences de Foothills a augmenté de 8 minutes (p < 0.001). La durée du séjour en SMU a diminué de 20 minutes à Lougheed (p < 0.001), et a augmenté de 17 minutes à Foothills (p < 0.001). Les thèmes abordés dans les commentaires des fournisseurs étaient les suivants : les responsables des urgences (1) facilitaient le flux des patients, (2) avaient un impact sur la charge de travail des fournisseurs et (3) favorisaient le flux et la sécurité des patients grâce à des évaluations, des traitements et des examens précoces. CONCLUSION: Dans cette étude, le médecin chef des urgences a eu un impact variable sur les paramètres de débit des urgences dans les différents sites, mais les enseignements importants tirés des expériences des fournisseurs peuvent guider la mise en œuvre future du médecin chef des urgences.

A cross-sectional survey on buprenorphine-naloxone practice and attitudes in 22 Canadian emergency physician groups: a cross-sectional survey.

BACKGROUND: Buprenorphine-naloxone (BUP) initiation in emergency departments improves follow-up and survival among patients with opioid use disorder. We aimed to assess self-reported BUP-related practices and attitudes among emergency physicians. METHODS: We designed a cross-sectional physician survey by adapting a validated questionnaire on opioid harm reduction practices, attitudes and barriers. We recruited physician leads from 6 Canadian provinces to administer surveys to the staff physicians in their emergency department groups between December 2018 and November 2019. We included academic and community non-locum emergency department staff physicians. We excluded responses from emergency department groups with response rates less than 50% to minimize nonresponse bias. Primary (BUP prescribing practices) and secondary (willingness and attitudes) outcomes were analyzed using descriptive statistics. RESULTS: After excluding 1 group for low response (9/26 physicians), 652 of 798 (81.7%) physicians responded from 22 groups serving 34 emergency departments. Among respondents, 64.1% (95% confidence interval [CI] 60.4%-67.8%, emergency department group range 7.1%-100.0%) had prescribed BUP at least once in their career, 38.4% had prescribed it for home initiation and 24.8% prescribed it at least once a month. Overall, 68.9% (95% CI 65.3%-72.4%, emergency department group range 24.1%-97.6%) were willing to administer BUP, 64.2% felt it was a major responsibility and 37.1% felt they understood people who use drugs. Respondents most frequently rated lack of adequate training (58.2%) and lack of time (55.2%) as very important barriers to BUP initiation. INTERPRETATION: Two-thirds of the emergency physicians surveyed prescribed BUP, although only one-quarter did so regularly and one-third prescribed it for home initiation; wide variation between emergency department groups existed. Strategies to increase BUP initiation must address physicians' lack of time and training for BUP initiation and improve their understanding of people who use drugs.

Sonic activation of molecularly-targeted nanoparticles accelerates transmembrane lipid delivery to cancer cells through contact-mediated mechanisms: implications for enhanced local drug delivery.

Liquid perfluorocarbon nanoparticles serve as sensitive and specific targeted contrast and drug delivery vehicles by binding to specific cell surface markers. We hypothesized that application of acoustic energy at diagnostic power levels could promote nanoparticle-associated drug delivery by stimulating increased interaction between the nanoparticle's lipid layer and the targeted cell's plasma membrane. Ultrasound (mechanical index = 1.9) applied with a conventional ultrasound imaging system to nanoparticles targeted to alpha(v)beta3-integrins on C32 melanoma cancer cells in vitro produced no untoward effects. Within 5 min, lipid delivery from nanoparticles into cell cytoplasm was dramatically augmented. We also demonstrate the operation of a potential physical mechanism for this effect, the acoustic radiation force on the nanoparticles, which may contribute to the enhanced lipid delivery. Accordingly, we propose that local delivery of lipophilic substances (e.g., drugs) from targeted nanoparticles directly into cell cytoplasm can be augmented rapidly and safely with conventional ultrasound imaging devices through nondestructive mechanisms.

Targeted nanoparticles for quantitative imaging of sparse molecular epitopes with MRI.

Before molecular imaging with MRI can be applied clinically, certain problems, such as the potential sparseness of molecular epitopes on targeted cell surfaces, and the relative weakness of conventional targeted MR contrast agents, must be overcome. Accordingly, the conditions for diagnostic conspicuity that apply to any paramagnetic MRI contrast agent with known intrinsic relaxivity were examined in this study. A highly potent paramagnetic liquid perfluorocarbon nanoparticle contrast agent ( approximately 250 nm diameter, >90,000 Gd3+/particle) was imaged at 1.5 T and used to successfully predict a range of sparse concentrations in experimental phantoms with the use of standard MR signal models. Additionally, we cultured and targeted the smooth muscle cell (SMC) monolayers that express "tissue factor," a glycoprotein of crucial significance to hemostasis and response to vascular injury, by conjugating an anti-tissue factor antibody fragment to the nanoparticles to effect specific binding. Quantification of the signal from cell monolayers imaged at 1.5 T demonstrated, as predicted via modeling, that only picomolar concentrations of paramagnetic perfluorocarbon nanoparticles were required for the detection and quantification of tissue factor at clinical field strengths. Thus, for targeted paramagnetic agents carrying high payloads of gadolinium, it is possible to quantify molecular epitopes present in picomolar concentrations in single cells with routine MRI.