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Introduction: Access block is a pervasive problem, even during times of minimal boarding in the ED, suggesting suboptimal use of ED stretchers can contribute. A tracking board utility was embedded into the electronic health record in Calgary, AB, allowing MDs and RNs to consider patients who could be relocated from a stretcher to a chair. Objectives of this study were to evaluate the feature's impact on total stretcher time (TST) and ED length of stay (LOS) for patients relocated to a chair. We also sought to identify facilitators and barriers to the tool's use amongst ED MDs and RNs. Methods: A retrospective cohort design was used to compare TST between those where the tool was used and not used amongst patients relocated to a chair between September 1 2017 and August 15 2018. Each use of the location tool was time-stamped in an administrative database. Median TST and ED LOS were compared between patients where the tool was used and not used using a Mann-Whitney U Test. A cross sectional convenience sample survey was used to determine facilitators and barriers to the tool's use amongst ED staff. Response proportions were used to report Likert scale questions; thematic analysis was used to code themes. Results: 194882 patients met inclusion criteria. The tool was used 4301 times, with “Ok for Chairs” selected 3914(2%) times and “Not Ok for Chairs” selected 384(0.2%) times; 54462(30%) patients were moved to a chair without the tool's use. Mean age, sex, mode of arrival and triage scores were similar between both groups. Median (IQR) TST amongst patients moved to a chair via the prompt was shorter than when the prompt was not used [142.7 (100.5) mins vs 152.3 (112.3) mins, p < 0.001], resulting in 37574 mins of saved stretcher time. LOS was similar between both groups (p = 0.22). 125 questionnaires were completed by 90 ED nurses and 35 ED MDs. 95% of staff were aware of the tool and 70% agreed/strongly agreed the tool could improve ED flow; however, 38% reported only “sometimes” using the tool. MDs reported the most common barrier was forgetting to use the tool and lack of perceived action in relocating patients. Commonly reported nursing barriers were lack of chair space and increased workload. Conclusion: Despite minimal use of the tracking board utility, triggering was associated with reduced TST amongst ED patients eventually relocated to a chair. To encourage increased use, future versions should prompt staff to select a location.
Ischemic stroke treatment is time-sensitive, and barriers to providing prehospital care encountered by Emergency Medical Services (EMS) providers have been under-studied.
This study described barriers to providing prehospital care, identified predictors of these barriers, and assessed the impact of these barriers on EMS on-scene time and administration of tissue plasminogen activator (tPA) in the emergency department (ED).
A retrospective cohort study was performed using the Get With The Guidelines-Stroke (GWTG-S; American Heart Association [AHA]; Dallas, Texas USA) registry at two hospitals to identify ischemic stroke patients arriving by EMS. Variables were abstracted from prehospital and hospital medical records and merged with registry data. Barriers to care were grouped into themes. Logistic regression was used to identify predictors of barriers to care, and bi-variate tests were used to assess differences in EMS on-scene time and the proportion of patients receiving tPA between patients with and without barriers.
Barriers to providing prehospital care were documented for 15.5% of patients: 29.6% related to access, 26.7% communication, 23.0% extrication and transportation, 20.0% refusal, and 14.1% assessment/management. Non-white and non-black race (OR: 3.69; 95% CI, 1.63-8.36) and living alone (OR: 1.53; 95% CI, 1.05-2.23) were associated with greater odds of barriers to providing care. The EMS on-scene time was ≥15 minutes for 70.4% of patients who had a barrier to care, compared with 49.0% of patients who did not (P<.001). There was no significant difference in the proportion of patients who were administered tPA between those with and without barriers to care (14.1% vs 19.2%; P=.159).
Barriers to providing prehospital care were documented for a sizable proportion of ischemic stroke patients, with the majority related to patient access and communication, and occurred more frequently among non-white and non-black patients and those living alone. Although EMS on-scene time was longer for patients with barriers to care, the proportion of patients receiving tPA in the ED did not differ.
LiT, CushmanJT, ShahMN, KellyAG, RichDQ, JonesCMC. Barriers to Providing Prehospital Care to Ischemic Stroke Patients: Predictors and Impact on Care. Prehosp Disaster Med.2018;33(5):501–507.
To explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.
Retrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.
The study included 27 transplant centers in freestanding children’s hospitals.
The primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.
Adjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.
Among a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.
Introduction: Hospital admission within 72 hours of emergency discharge is a widely accepted measure of emergency department quality of care. Patients returning for unplanned admission may reveal opportunities for improved emergency or followup care. Calgary emergency physicians, however, are rarely notified of these readmissions. Aggregate site measures provide a high level view of readmissions for managers, but dont allow for timely, individual reflection on practice and learning opportunities. These aggregations may also not correctly account for variation in planned readmissions and other workflow nuances. There was a process in place at one facility to compile and communicate readmission details to each physician, but it was manual, provided limited visit detail, and was done weeks or months following discharge. Methods: A new, realtime 72 hour readmission notification recently implemented within the Calgary Zone provides direct and automated email alerts to all emergency physicians and residents involved in the care of a patient that has been readmitted. This alert is sent within hours of a readmission occurring and contains meaningful visit detail (discharge diagnosis, readmit diagnosis, patient name, etc) to help support practice reflection. An average of 15 alerts per day are generated and have been sent since implementation in April, 2017. Although an old technology, the use of email is a central component of the solution because it allows physicians to receive notifications at home and outside the hospital network where they routinely perform administrative tasks. A secondary notification is sent to personal email accounts (Gmail, Hotmail, etc) to indicate an unplanned admission has occurred, but without visit detail or identifiable information. It also allowed implementation with no new hardware or software cost. Results: A simple thumbs up/down rating system is used to adjust the sensitivity of the alert over time. More than 66% of those providing feedback have indicated the alert is helpful for practice reflection (i.e., thumbs up). And of those that indicated it was not helpful, comments were often entered indicating satisfaction with the alert generally, or suggestions for improvement. For example, consulted admitting physicians are often responsible for discharge decisions and should be added as recipients of the alert. Conclusion: Many physicians have indicated appreciation in knowing about return patients, and that they will reflect on their care, further review the chart, or contact the admitting physician for further discussion. Most are accepting of some ‘expected’ or ‘false positive’ alerts that aren’t helpful for practice reflection. Further tuning and expansion of the alert to specialist and consult services is needed to ensure all physicians involved in a discharge decision are adequately notified.
Introduction: There is a growing interest in providing clinicians with performance reports via audit and feedback (A&F). Despite significant evidence exists to support A&F as a tool for self-reflection and identifying unperceived learning needs, there are many questions that remain such as the optimal content of the A&F reports, the method of dissemination for emergency physicians (EP) and the perceived benefit. The goal of the project was to 1. evaluate EP perceptions regarding satisfaction with A&F reports and its’ ability to stimulate physicians to identify opportunities for practice change and 2. identify areas for optimization of the A&F reports. Methods: EP practicing at any of the four adult hospital sites in Calgary were eligible. We conducted a web survey using a modified Dillman technique eliciting EP perspectives regarding satisfaction, usefulness and suggestions for improvement regarding the A&F reports. Quantitative data were analyzed descriptively and free-text were subjected to thematic analysis. Results: From 2015 onwards, EP could access their clinical performance data via an online dashboard. Despite the online reports being available, few physicians reviewed their reports stating access and perceived lack of utility as a barrier. In October 2016, we began disseminated static performance reports to all EP containing a subset of 10 clinical and operational performance metrics via encrypted e-mail. These static reports provided clinician with their performance with peer comparator data (anonymized), rationale and evidence for A&F, information on how to use the report and how to obtain continuing medical education credits for reviewing the report. Conclusion: Of 177 EP in Calgary, we received 49 completed surveys (response rate 28%). 86% of the respondents were very/satisfied with the report. 88% of EP stated they would take action based on the report including self-reflection (91%) and modifying specific aspects of their practice (63%). Respondents indicated that by receiving static reports, 77% were equally or more likely to visit the online version of the eA&F tool. The vast majority of EP felt that receiving the A&F reports on a semi-annual basis was preferred. Three improvements were made to the eA&F based on survey results: 1) addition of trend over time data, 2) new clinical metrics, and 3) optimization of report layout. We also initiated a separate, real-time 72-hour bounceback electronic notification system based on the feedback. EP value the dissemination of clinical performance indicators both in static report and dashboard format. Eliciting feedback from clinicians allows iterative optimization of eA&F. Based on these results, we plan to continue to provide physicians with A&F reports on a semi-annual basis.
Introduction: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the emergency department (ED) accounting for significant morbidity, mortality and health care resource usage. In Alberta, a provincial care pathway was recently developed to provide an evidence informed approach to managing patients with an UGIBs in the ED. Pantoprazole infusions are a commonly used treatment despite evidence that suggests they are generally not indicated prior to endoscopy in the ED. The goal of this project was to optimize management of patients with a NVUGIB, in particular reduce pre-endoscopy pantoprazole infusions. Methods: In July 2016, we implemented a multi-faceted intervention to optimize management of ED patients with NVUGIB including 1. de-emphasizing IV pantoprazole infusions in the ED, 2. clinical decision support (CDS) embedded (for endoscopy, disposition and transfusions) within the order set and 3. educating clinicians about the care pathway. We used a pre/post-order set design, analyzing 391 days pre and 189 days post-order set changes. Data was extracted from our fully integrated electronic health records system. The primary outcome was the % of patients receiving IV pantoprazole infusion ordered by an emergency physician (EP) among all patients with NVUGIB. Secondary outcomes included % transfused with hgb >70g/L and whether using the GIB order set impacted management of NVUGIB patients. Results: In the 391 days pre-order set changes, there were 2165 patients included and in the 189 days post-order set changes, there were 901 patients. For baseline characteristics, patients in the post-order set change group were significantly older (64.4 yrs vs 60.9 yrs p-value=0.0016) and had a lower hgb (115 vs 118, p-value=0.049) but otherwise for gender, measures of severity of illness (systolic blood pressure, heart rate, CTAS, % admitted) there were no significantly differences. For the primary outcome, in the pre-order set phase, 47.1% received a pantoprazole infusion ordered by an EP, compared to 31.5% in the post-order phase, for an absolute reduction of 15.6% (p-value= <0.001). For the secondary outcomes, transfusion rates were similar pre/post (22.08% vs 22.75%). Significant inter-site variability exists with respect to the reduction in pantoprazole infusion rates across the four sites (-23.3% to +6.12%). Conclusion: Our interventions resulted in a significant overall reduction in pantoprazole infusions in ED patients with NVUGIB. Reductions in pantoprazole infusions varied significantly across the different sites, future work in our department will explore and address this variability. Keys to the success of this project included engaging clinicians as well as leveraging the SCM order sets as well as the provincial care pathway. Although there were no changes in transfusion rates, it in unclear if this a function of the CDS not being effective or whether these transfusions were clinically indicated.
Owing to their extreme crowding and high and variable extinction, stars in the Galactic Bulge, within ±2° of the Galactic plane, and especially those in the Nuclear Star Cluster, have only rarely been targeted for an analyses of their detailed abundances. There is also some disagreement about the high end of the abundance scale for these stars. It is now possible to obtain high dispersion, high S/N spectra in the infrared K band (~2.0 − 2.4 µm) for these giants; we report our progress at Keck and VLT in using these spectra to infer the composition of this stellar population.
A major avenue in the study of the Galaxy is the investigation of stellar populations and Galactic chemical evolution by stellar spectroscopy. Due to the dust obscuration, stars in the centre of the Galaxy can only be observed in the near-IR wavelength region. However, existing line lists in this wavelength region are demonstratively not of good enough quality for use in stellar spectroscopy. In response to this, we have developed an empirical astrophysical line list in the K-band based on modelling against the Sun and testing against Arcturus. Of ca. 700 identified interesting lines about 570 lines have been assigned empirically determined values.
Introduction: The addition of computerized physician order entry (CPOE) to Emergency Departments in recent years has led to speculation over potential benefits and pitfalls. Recent studies have shown benefits to CPOE, though there lacks sufficient evidence on how it could change physician behaviour. Physician practices are known to be difficult to change, with getting evidence into daily practice being the main challenge of knowledge translation. Our study aims were to determine if well-designed electronic order sets for CPOE improved MD practices. Methods: The Calgary Zone Pain Management in the Emergency Department Working Group relied on a GRADE-based literature review for identifying best practices for analgesia and antiemetics, resulting in soft changes to the dedicated analgesia and antiemetic electronic order set noting working group preference, and emphasizing hydromorphone over morphine, as well as 4 mg ondansetron over 8 mg. The new electronic order set was started in the only Calgary Region order entry system on December 11th, 2014. Data was collected from July 2014 - May 2015. A Yates chi-squared analysis was completed on all orders in a category, as well as the subgroups of ED staff and residents, and orders placed using the new order set. Results: A total of 100460 orders were analyzed. The use of hydromorphone increased significantly across all 4 EDs. IV hydromorphone use increased (5.82% of all opioid orders up to 26.93%, P<0.0001) with a reciprocal decline in IV morphine (67.81% of all opioid orders down to 46.56%, P<0.0001). Similar effects were observed with ondansetron 4 mg IV orders increasing (1.37% of all ondansetron orders to 18.64%, P<0.0001) with a decrease in 8 mg dosing (15.75% of all ondansetron orders to 7.23%, P<0.0001). These results were replicated to a lesser degree in the non-ED staff and non-order set subgroups. Implementation of the new order set resulted in an increase of its use (37.64% of all opioid orders up to 49.29%, P<0.0001). Finally, a cost-savings analysis was completed showing a projected annual savings of $185,676.52 on medications alone. Conclusion: This data supports the manipulation of electronic order sets to help shape physician behaviour towards best practices. This provides another strong argument towards the benefits of CPOE, and can help maintain best practices in Emergency Medicine.
Introduction: In certain circumstances, skin and soft tissue infections are managed with intravenous (IV) antibiotics. In our center, patients initiated on outpatient IV antibiotics are followed up by a home parental therapy program the following day. A significant number of these patients require a repeat visit to the ED because of clinic hours. Probenecid is a drug that can prolong the half-life of certain antibiotics (such as cefazolin) and can therefore avoid a repeat ED visit, reducing health care costs and improve ED capacity. Our goal was to increase probenecid usage in the ED in order to optimize management of skin and soft tissue infections (SSTI) in the ED. The primary outcome was to compare the usage of probenecid in the pre and post-intervention phase. Secondary outcomes were to compare revisit rates between patients receiving cefazolin alone vs cefazolin + probenecid. Methods: Using administrative data merged with Computerized Physician Order Entry (CPOE), we extracted data 90 days pre- and 90 post-intervention (February 11, 2015 to August 11, 2015). The setting for the study is an urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The multi-faceted intervention involved modifying all relevant SSTI order sets in the CPOE system to link any cefazolin order with an order for probenecid. Physicians and nurses were provided with a 1 page summary of probenecid (indications, contra-indications, pharmacology), as well as decision support with the CPOE. Any patients who were receiving outpatient cefazolin therapy were included in the study. Results: Our analysis included 2512 patients (1148 and 1364 patients in the pre/post phases) who received cefazolin in the ED and were discharged during the 180 day period. Baseline variables (gender, age, % admitted) and ED visits were similar in both phases. In the pre-intervention phase 30.2% of patients received probenecid and in the post-intervention phase 43.0%, for a net increase of 12.8% (p=<0.0001). Patients who received probenecid had a 2.2% (11.4% vs 13.6%, p=0.014) lower re-visit rate in the following 72H. Conclusion: We have implemented a CPOE based clinical decision support intervention that demonstrated significant increase in probenecid usage by emergency physician and resulted in a decrease in ED revisits. This intervention would result in health care cost-savings.
Introduction: In light of escalating health care costs, initiatives such as Choosing Wisely have been advocating the need to “reduce unnecessary or wasteful medical tests, treatments and procedures”. We have identified coagulation studies as one of those low cost, but frequently ordered items, where we can decrease unnecessary testing and costs by leveraging our Computerized Practitioner Order Entry (CPOE). Considerable evidence exists to suggest a low yield of doing coagulation studies (herein defined as PTT AND INR’s) in suspected cardiac chest pain patients (SCCP). Methods: Using administrative data merged with CPOE we extracted data 90 days pre- and 90 post-intervention (Pre-intervention: May 20, 2015 to August 19th 2015, Post-intervention: August 20th, 2015 to November 18th 2015). The setting for the study is a large urban center (4 adult ED’s with an annual census of over 320,000 visits per year). Our CPOE system is fully integrated into the ED patient care. The intervention involved modifying the nursing CPOE to remove the pre-selected coagulation studies in SCCP and providing education around appropriate usage of coagulation studies. Patients were included in the study if the bedside nurse or physician felt 1. the chest pain may be cardiac in nature and 2. Labs were ordered. The primary outcome was to compare the number of coagulation studies ordered pre and post-intervention. Results: Our analysis included 10,776 patients that were included in an SCCP pathway as determined by the CPOE database. Total number of visits in these two phases were similar (73,551 pre and 72, 769 post). In the pre-intervention phase, 5255 coagulation studies were done (4246 ordered by nursing staff and 1009 studies ordered by ED physicians). In the post-intervention phase, 1464 coagulation studies were ordered (1211 by nursing staff and 253 additional tests were ordered by ED physicians). With our intervention, we identified a net reduction of 3791 coagulation studies in our post-intervention phase for a reduction of 72.14% reduction (p=<0.0001) At a cost of 15.00$ (CDN$ at our center), we would realize an estimated cost -savings of 56,865$ for this intervention over a 90 day period. Conclusion: We have implemented a simple, sustainable, evidence based intervention that significantly minimizes the use of unnecessary coagulation studies in patients presenting with SCCP.
The GALLEX collaboration aims at the detection of solar neutrinos in a radiochemical experiment employing 30 tons of Gallium in form of concentrated aqueous Gallium-chloride solution. The detector is primarily sensitive to the otherwise inaccessible pp-neutrinos. Details of the experiment have been repeatedly described before [1-7]. Here we report the present status of implementation in the Laboratori Nazionali del Gran Sasso (Italy). So far, 12.2 tons of Gallium are at hand. The present status of development allows to start the first full scale run at the time when 30 tons of Gallium become available. This date is expected to be January, 1990.
We investigate the correlation of star formation quenching with internal galaxy properties and environment by comparing observation and theoretical models. We first classify galaxies as the most massive “central” or “satellite” in each halo in order to investigate the environmental effect. For observed central galaxies, we are unable to determine whether star formation quenching is primarily connected with halo mass or stellar mass, because these two quantities are strongly correlated. For satellite galaxies, a nearly equal dependence on halo mass and stellar mass is seen. We find that theoretical models with AGN feedback reproduce the dependence on colours and specific star formation rates for central galaxies reasonably. However, the same models seriously fail to reproduce the star formation rates of satellite galaxies by over-quenching star formation via strong strangulation: satellite over-quenching problem.
Among US racial/ethnic minority women, we examined associations between maternal experiences of racial discrimination and child growth in the first 3 years of life. We analyzed data from Project Viva, a pre-birth cohort study. We restricted analyses to 539 mother–infant pairs; 294 were Black, 127 Hispanic, 110 Asian and 8 from additional racial/ethnic groups. During pregnancy, mothers completed the Experiences of Discrimination survey that measured lifetime experiences of racial discrimination in diverse domains. We categorized responses as 0, 1–2 or ⩾3 domains. Main outcomes were birth weight for gestational age z-score; weight for age (WFA) z-score at 6 months of age; and at 3 years of age, body mass index (BMI) z-score. In multivariable analyses, we adjusted for maternal race/ethnicity, nativity, education, age, pre-pregnancy BMI, household income and child sex and age. Among this cohort of mostly (58.2%) US-born and economically non-impoverished mothers, 33% reported 0 domains of discrimination, 33% reported discrimination in 1–2 domains and 35% reported discrimination in ⩾3 domains. Compared with children whose mothers reported no discrimination, those whose mothers reported ⩾3 domains had lower birth weight for gestational age z-score (β −0.25; 95% CI: −0.45, −0.04), lower 6 month WFA z-score (β −0.34; 95% CI: −0.65, −0.03) and lower 3-year BMI z-score (β −0.33; 95% CI: −0.66, 0.00). In conclusion, we found that among this cohort of US racial/ethnic minority women, mothers’ report of experiencing lifetime discrimination in ⩾ 3 domains was associated with lower fetal growth, weight at 6 months and 3-year BMI among their offspring.