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The use of Spratt’s dog cakes is well documented in the diaries and reminiscences of many early Antarctic expedition members. Commercially produced dog food was promoted by the likes of Spratt’s as an advanced form of animal nutrition and would have been of interest to expedition planners who were already concerned with the nutritional requirements of expedition members. An approximately 100-year-old dog cake recovered from Antarctica was compared by chemical analysis and spectroscopic methods with a series of model dog cakes and a commercial dog biscuit to determine the composition and calorific content. The presence of bone fragments within the dog cake was confirmed, whereas starch in the bulk matrix of the sample was consistent with being a mixture of wheat and oat flour, while only minimal fat or oil was present. Calorific content, while insufficient compared to a modern feed for high-performance dogs, would nonetheless have been a valuable addition to the use of dried or frozen whole meat such as seal, fish, or pemmican and contributed additional energy compared to meat alone.
Introduction: Distal radial fractures (DRF) remain the most commonly encountered fracture in the Emergency Department (ED). The initial management of displaced DRFs by Emergency Physicians (EP) poses considerable resource allocation. We wished to determine the adequacy of reduction, both initially and at follow up. This data updates previously presented high level findings. Methods: We performed a mixed-methods study including patients who underwent procedural sedation and manipulation by an EP for a DRF. Radiological images performed at initial assessment, post-reduction, and clinic follow up were reviewed by a panel of orthopedic surgeons and radiologists blinded to outcomes, and assessed for evidence of displacement. Demographic data were pooled from patient records and included in statistical analysis. Results: Seventy patients were included and had follow-up completed. Initial reduction was deemed to be adequate in 37 patients (53%; 95% CI 41.32 to 64.10%). At clinic follow-up assessment, 26 reductions remained adequate; a slippage rate of 30% (95% CI of 17.37 to 45.90). Overall 7 patients (10%; 95% CI 4.65 to 19.51%) required revision of the initial reduction in the operating room. Agreement on adequacy of reduction on post-reduction radiographs between radiologists and orthopedic surgeons was 38.6% (95% CI -38.3 to -7.4, Kappa -0.229). The statistical strength of this agreement is worse than what would be expected by chance alone. There was no association found between age, sex, or of time of initial presentation and final outcomes. Conclusion: Although blinded review by specialists determined only half of initial EP DRF reductions to be radiographically adequate, only 10 percent actually required further intervention. Agreement between specialists on adequacy was poor. The majority of DRFs reduced by EPs do not require further surgical intervention.
Introduction: Determining fluid status prior to resuscitation provides a more accurate guide for appropriate fluid administration in the setting of undifferentiated hypotension. Emergency Department (ED) point of care ultrasound (PoCUS) has been proposed as a potential non-invasive, rapid, repeatable investigation to ascertain inferior vena cava (IVC) characteristics. Our goal was to determine the feasibility of using PoCUS to measure IVC size and collapsibility. Methods: This was a planned secondary analysis of data from a prospective multicentre international study investigating PoCUS in ED patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility using a standard data collection form in 6 centres. The primary outcome was the proportion of patients with a clinically useful (determinate) scan defined as a clearly visible intrahepatic IVC, measurable for size and collapse. Descriptive statistics are provided. Results: A total of 138 scans were attempted on 138 patients; 45.7% were women and the median age was 58 years old. Overall, one hundred twenty-nine scans (93.5%; 95% CI 87.9 to 96.7%) were determinate. 131 (94.9%; 89.7 to 97.7%) were determinate for IVC size, and 131 (94.9%; 89.7 to 97.7%) were determinate for collapsibility. Conclusion: In this analysis of 138 ED patients with undifferentiated hypotension, the vast majority of PoCUS scans to investigate IVC characteristics were determinate. Future work should include analysis of the value of IVC size and collapsibility in determining fluid status in this group.
Introduction: Crowding is associated with poor patient outcomes in emergency departments (ED). Measures of crowding are often complex and resource-intensive to score and use in real-time. We evaluated single easily obtained variables to establish the presence of crowding compared to more complex crowding scores. Methods: Serial observations of patient flow were recorded in a tertiary Canadian ED. Single variables were evaluated including total number of patients in the ED (census), in beds, in the waiting room, in the treatment area waiting to be assessed, and total inpatient admissions. These were compared with Crowding scores (NEDOCS, EDWIN, ICMED, three regional hospital modifications of NEDOCS) as predictors of crowding. Predictive validity was compared to the reference standard of physician perception of crowding, using receiver operator curve analysis. Results: 144 of 169 potential events were recorded over 2 weeks. Crowding was present in 63.9% of the events. ED census (total number of patients in the ED) was strongly correlated with crowding (AUC = 0.82 with 95% CI = 0.76 - 0.89) and its performance was similar to that of NEDOCS (AUC = 0.80 with 95% CI = 0.76 - 0.90) and a more complex local modification of NEDOCS, the S-SAT (AUC = 0.83, 95% CI = 0.74 - 0.89). Conclusion: The single indicator, ED census was as predictive for the presence of crowding as more complex crowding scores. A two-stage approach to crowding intervention is proposed that first identifies crowding with a real-time ED census statistic followed by investigation of precipitating and modifiable factors. Real time signalling may permit more standardized and effective approaches to manage ED flow.
Introduction: There is currently no protocol for the initiation of extra corporeal cardiopulmonary resuscitation (ECPR) in out of hospital cardiac arrest (OHCA) in Atlantic Canada. Advanced care paramedics (ACPs) perform advanced cardiac life support in the prehospital setting often completing the entire resuscitation on-scene. Implementation of ECPR will present a novel intervention that is only available at the receiving hospital, altering how ACPs manage selected patients. Our objective is to determine if an educational program can improve paramedic identification of ECPR candidates. Methods: An educational program was delivered to paramedics including a short seminar and pocket card coupled with simulations of OHCA cases. A before and after study design using a case-based survey was employed. Paramedics were scored on their ability to correctly identify OHCA patients who met the inclusion criteria for our ECPR protocol. Scores before and after the education delivery were compared using a two tailed t-test. A 6-month follow-up is planned to assess knowledge retention. Qualitative data was also collected from paramedics during simulation to help identify potential barriers to implementation of our protocol in the prehospital setting. Results: Nine advanced care paramedics participated in our educational program. Mean score pre-education was 9.7/16 (61.1%) compared to 14/16 (87.5%) after education delivery. The mean difference between groups was 4.22 (CI = 2.65-5.80, p = 0.0003). There was a significant improvement in the paramedics’ ability to correctly identify ECPR candidates after completing our educational program. Conclusion: Paramedic training through a didactic session coupled with a pocket card and simulation appears to be a feasible method of knowledge translation. 6-month retention data will help ensure knowledge retention is achieved. If successful, this pilot will be expanded to train all paramedics in our prehospital system as we seek to implement an ECPR protocol at our centre.
Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.
Introduction: Chest tube insertion, a critical procedure with a published complication rate (30%), is a required competency for emergency physicians. Microskills training has been shown to identify steps that require deliberate practice. Objectives were: 1. Develop a chest tube insertion microskills checklist to facilitate IPE, 2. Compare the microskills checklist with published best available evidence, 3. Develop an educational video based on the process map, 4. Evaluate the video in an interprofessional team prior to cadaver training as a proof of concept. Methods: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student). A final microskills list was produced and compared to the procedural steps described in consensus publications. An educational video was produced and evaluated by an interprofessional team prior to cadaver training using a survey and Likert scales as a proof of concept. Participants were 7 EM RNs and 6 ATLS trained physicians. Participants were asked to fill out a nine-question survey, using a 5-point Likert Scale (1-strongly disagree to 5 strongly agree). Results: The final process map contained 54 interdisciplinary steps, compared to ATLS that describes 14 main steps and peer reviewed articles that describe 9 main steps. The microskills checklist described, in more detail, the steps that relate to team interaction and the operational environment. Physicians rated the training video were able to apply what they learned in the video with an average of 4.67 (median of 5, mode of 5, and an IQR of 0.75). Conclusion: The development of the process maps and microkills checklists provides interprofessional teams with more information about chest tube insertion than instructions described in commonly available courses and procedural steps derived by consensus.
After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.
Introduction: Patients with chronic diseases are known to benefit from exercise. Such patients often visit the emergency department (ED). There are few studies examining prescribing exercise in the ED. We wished to study if exercise prescription in the ED is feasible and effective. Methods: In this pilot prospective block randomized trial, patients in the control group received routine care, whereas the intervention group received a combined written and verbal prescription for moderate exercise (150 minutes/week). Both groups were followed up by phone at 2 months. The primary outcome was achieving 150 min of exercise per week. Secondary outcomes included change in exercise, and differences in reported median weekly exercise. Comparisons were made by Mann-Whitney and Fishers tests (GraphPad). Results: Follow-up was completed for 22 patients (11 Control; 11 Intervention). Baseline reported median (with IQR) weekly exercise was similar between groups; Control 0(0-0)min; Intervention 0(0-45)min. There was no difference between groups for the primary outcome of 150 min/week at 2 months (Control 3/11; Intervention 4/11, RR 1.33 (95%CI 0.38-4.6;p=1.0). There was a significant increase in median exercise from baseline in both groups, but no difference between the groups (Control 75(10-225)min; Intervention 120(52.5-150)min;NS). 3 control patients actually received exercise prescription as part of routine care. A post-hoc comparison of patients receiving intervention vs. no intervention, revealed an increase in patients meeting the primary target of 150min/week (No intervention 0/8; Intervention 7/14, RR 2.0 (95%CI 1.2-3.4);p=0.023). Conclusion: Recruitment was feasible, however our study was underpowered to quantify an estimated effect size. As a significant proportion of the control group received the intervention (as part of standard care), any potential measurable effect was diluted. The improvement seen in patients receiving intervention and the increase in reported exercise in both groups (possible Hawthorne effect) suggests that exercise prescription for ED patients may be beneficial.
Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Microskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Surgical cricothyrotomy is a rarely performed safety critical task. Methods: Two doctors and three nurses developed stepwise team microskills checklists from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 30 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. Commonly available airway trainers were retrofitted with the 3-D printed larynx. The microskills checklist was used in four phases: 1. Group discussion of each microskill step; 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback - changes are recorded; 3. Total task run through without interruption - changes are recorded; 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 12/21, RNs 6/12. The commonest changes in practice were equipment preparation (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 5/5). Conclusion: Microskills checklists facilitate cricothyrotomy skill development in interprofessional teams in this provisional analysis.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.
Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.
Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
To characterize trends in outpatient antibiotic prescriptions in the United States
Retrospective ecological and temporal trend study evaluating outpatient antibiotic prescriptions from 2013 to 2015
National administrative claims data from a pharmacy benefits manager PARTICIPANTS. Prescription pharmacy beneficiaries from Express Scripts Holding Company
Annual and seasonal percent change in antibiotic prescriptions
Approximately 98 million outpatient antibiotic prescriptions were filled by 39 million insurance beneficiaries during the 3-year study period. The most commonly prescribed antibiotics were azithromycin, amoxicillin, amoxicillin/clavulanate, ciprofloxacin, and cephalexin. No significant changes in individual or overall annual antibiotic prescribing rates were found during the study period. Significant seasonal variation was observed, with antibiotics being 42% more likely to be prescribed during February than September (peak-to-trough ratio [PTTR], 1.42; 95% confidence interval [CI], 1.39–1.61). Similar seasonal trends were found for azithromycin (PTTR, 2.46; 95% CI, 2.44–3.47), amoxicillin (PTTR, 1.52; 95% CI, 1.42–1.89), and amoxicillin/clavulanate (PTTR, 1.78; 95% CI, 1.68–2.29).
This study demonstrates that annual national outpatient antibiotic prescribing practices remained unchanged during our study period. Furthermore, seasonal peaks in antibiotics generally used to treat viral upper respiratory tract infections remained unchanged during cold and influenza season. These results suggest that inappropriate prescribing of antibiotics remains widespread, despite the concurrent release of several guideline-based best practices intended to reduce inappropriate antibiotic consumption; however, further research linking national outpatient antibiotic prescriptions to associated medical conditions is needed to confirm these findings.
Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.
Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.
Introduction: The positive health outcomes of exercise have been well-studied, and exercise prescription has been shown to reduce morbidity in several chronic health conditions. However, patient attitudes around the prescription of exercise in the emergency department (ED) have not been explored. The aim of our pilot study is to explore patients’ willingness and perceptions of exercise being discussed and prescribed in the ED. Methods: This study is a survey of patients who had been previously selected for exercise prescription in a pilot study conducted at a tertiary care ED. This intervention group were given a standardized provincial written prescription to perform moderate exercise for 150 minutes per week. Participants answered a discharge questionnaire and were followed up by a telephone interview 2 months later. A structured interview of opinions around exercise prescription was conducted. Questions included a combination of non-closed style interview questions and Likert scale. Patients rated prescription detail, helpfulness and likelihood on a Likert scale from 1-5 (1 being strongly disagree and 5 being strongly agree). Median values (+/-IQRs) are presented, along with dominant themes. Results: 17 people consented to exercise prescription and follow up surveys. 2 were excluded due to hospital admission. 15 participants were enrolled and completed the discharge survey. Two-month follow up survey response rate was 80%. Patients rated the detail given in their prescription as 5 (+/-1). Helpfulness of prescription was rated as 4 (+/-2). Likelihood to continue exercising based on the prescription was rated as 4 (+/-2). 11/12 participants felt that exercise should be discussed in the Emergency Department either routinely or on a case-by-case basis.1 participant felt it should not be discussed at all. Conclusion: Our study demonstrates that most patients are open to exercise being discussed during their Emergency Department visit, and that the prescription format was well-received by study participants.
Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.