Evaluation of a Web-based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department.

BACKGROUND: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS. METHODS: This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar < 10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (take-away bottle of four tablets) of benzodiazepine given were recorded. RESULTS: Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (∆13.8%, 95% confidence interval [CI] = 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40 mg vs. 30 mg, ∆10 mg, 95% CI = 0-20 mg) and no change was detected in ED length of stay and benzodiazepines prescribed. CONCLUSIONS: Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.

Fetal outcomes following emergency department point-of-care ultrasound for vaginal bleeding in early pregnancy.

OBJECTIVE: To determine 20- and 40-week fetal outcomes following documentation of fetal cardiac activity (FCA) and intrauterine pregnancy (IUP) in women at less than 20 weeks' gestation presenting to the emergency department (ED) with vaginal bleeding. DESIGN: Prospective observational cohort study. SETTING: Single-centre tertiary care ED. PARTICIPANTS: Pregnant women at less than 20 weeks' gestation presenting to the ED with vaginal bleeding. INTERVENTION: All study participants underwent ED point-of-care ultrasound (POCUS) to document IUP and FCA. MAIN OUTCOME MEASURES: Prevalence of spontaneous abortion or pregnancy loss by 40 weeks' gestational age following ED POCUS documentation of FCA or IUP in women at less than 20 weeks' gestation. RESULTS: A total of 85 of 111 eligible patients were enrolled; FCA and IUP were detected in 43 (50.6%) and 54 (63.5%) participants, respectively. Participants with documented FCA on ED POCUS were less likely to experience pregnancy loss than participants without documented FCA were (5.0% vs 92.7%; Δ = 87.7%; 95% CI 71.0% to 93.7%), and participants with documented IUP were less likely to experience pregnancy loss than participants without documented IUP were (22.0% vs 93.5%; Δ = 71.5%; 95% CI 52.1% to 81.9%). Compared with radiologist-interpreted ultrasound, ED POCUS had sensitivity of 88.9% (95% CI 75.9% to 96.2%) and specificity of 100.0% (95% CI 89.6% to 100.0%) for documenting FCA, and sensitivity of 96.0% (95% CI 86.3% to 99.4%) and specificity of 93.1% (95% CI 77.2% to 99.0%) for documenting IUP. CONCLUSION: In this cohort of women presenting to the ED with bleeding in the first 20 weeks of pregnancy, detection of IUP and especially FCA using POCUS performed by providers certified by the Canadian Emergency Ultrasound Society was associated with ongoing viable pregnancy at 20 and 40 weeks' gestational age. These data might be useful for ED physicians counseling women with symptomatic early pregnancies about the chance of miscarriage after an episode of vaginal bleeding.

OBJECTIF: Déterminer les incidences sur le fœtus à 20 et à 40 semaines après la documentation d'une activité cardiaque fœtale (ACF) et d'une grossesse intrautérine (GIU) chez des femmes à moins de 20 semaines de gestation qui se sont présentées à l'urgence avec des saignements vaginaux. CONCEPTION: Étude observationnelle et prospective de cohortes. CONTEXTE: L'urgence d'un centre de soins tertiaires. PARTICIPANTES: Des femmes enceintes à moins de 20 semaines de gestation qui se sont présentées à l'urgence avec des saignements vaginaux. INTERVENTION: Toutes les participantes à l'étude ont subi une échographie au point d'intervention (EGPDI) à l'urgence pour documenter la GIU et l'ACF. PRINCIPAUX PARAMÈTRES À L'ÉTUDE: La prévalence d'avortements spontanés ou d'interruptions de grossesse à 40 semaines d'âge gestationnel après la documentation par EGPDI de l'ACF ou de la GIU chez des femmes à moins de 20 semaines de gestation. RÉSULTATS: Au total, 85 des 111 femmes admissibles ont participé à l'étude; une ACF et la GIU ont été détectées respectivement chez 43 (50,6 %) et 54 (63,5 %) participantes. Les participantes chez qui une ACF a été détectée par EGPDI à l'urgence ont été moins susceptibles de vivre une interruption de grossesse que celles sans ACF documentée (5,0 % c. 92,7 %; Δ = 87,7 %; IC à 95 % de 71,0 à 93,7 %), et les participantes dont la GIU a été documentée ont été moins susceptibles de vivre une interruption de grossesse par rapport à celles dont la GIU n'a pas été documentée (22,0 % c. 93,5 %; Δ = 71,5 %; IC à 95 % de 52,1 à 81,9 %). En comparaison des échographies interprétées par un radiologiste, l'EGPDI à l'urgence avait une sensibilité de 88,9 % (IC à 95 % de 75,9 à 96,2 %) et une spécificité de 100,0 % (IC à 95 % de 89,6 à100,0 %) pour documenter l'ACF et une sensibilité de 96,0 % (IC à 95 % de 86.3 à 99.4 %) et une spécificité de 93,1 % (IC à 95 % de 77,2 à 99,0 %) pour documenter la GIU. CONCLUSION: Dans cette cohorte de femmes qui se sont présentées à l'urgence avec des saignements vaginaux durant les 20 premières semaines de grossesse, la détection de la GIU et surtout de l'ACF à l'aide d'une EGPDI, effectuée par des professionnels certifiés par la Société canadienne d'échographie au département d'urgence, a été associée à une grossesse viable sans interruption à 20 et à 40 semaines d'âge gestationnel. Cette information pourrait être utile aux médecins à l'urgence pour conseiller les femmes en début de grossesse symptomatique au sujet des risques d'avortement spontané après un épisode de saignements vaginaux.

Acquisition of bacteria on health care workers' hands after contact with patient privacy curtains.

To determine whether pathogenic bacteria could be transferred to health care workers by touching privacy curtains, imprints of health care workers' fingertips were obtained when participants were approached, after hand hygiene with alcohol handrub, and directly after handling curtains. Participants' hands were heavily contaminated at baseline, in some cases with potentially pathogenic species. Half of the participants (n = 30) acquired bacteria on their fingertips from handling curtains, illustrating that privacy curtains may be involved in the transmission of infection to emergency department patients.

A quantitative evaluation of alcohol withdrawal tremors.

This paper evaluates the relation between Alcohol Withdrawal Syndrome tremors in the left and right hands of patients. By analyzing 122 recordings from 61 patients in emergency departments, we found a weak relationship between the left and right hand tremor frequencies (correlation coefficient of 0.63). We found a much stronger relationship between the expert physician tremor ratings (on CIWA-Ar 0-7 scale) of the two hands, with a correlation coefficient of 0.923. Next, using a smartphone to collect the tremor data and using a previously developed model for obtaining estimated tremor ratings, we also found a strong correlation (correlation coefficient of 0.852) between the estimates of each hand. Finally, we evaluated different methods of combining the data from the two hands for obtaining a single tremor rating estimate, and found that simply averaging the tremor ratings of the two hands results in the lowest tremor estimate error (an RMSE of 0.977). Looking at the frequency dependence of this error, we found that higher frequency tremors had a much lower estimation error (an RMSE of 1.102 for tremors with frequencies in the 3-6Hz range as compared to 0.625 for tremors with frequencies in the 7-10Hz range).