Environmentally sustainable opportunities for health systems: metered-dose inhaler prescribing, dispensing, usage, and waste at The Ottawa Hospital.

BACKGROUND: The carbon footprint of Canada's health sector is among the worst in the world, responsible for 4·6% of Canada's total greenhouse gas emissions. A quarter of emissions from Canada's health sector are linked to pharmaceuticals, including metered dose inhalers (MDIs). MDIs use propellants, such as hydrofluorocarbons, which act as greenhouse gas emissions and contribute to the health-care sector's overall carbon footprint. The objective of this study was to describe MDI prescribing, dispensing, usage, and waste patterns at The Ottawa Hospital (Ottawa, ON, Canada). Secondary objectives included estimating the monetary and carbon cost of current practice and the potential benefits and costs of switching to the more environmentally friendly dry powder inhalers. METHODS: In this retrospective point-prevalence cohort study, we identified 100 consecutive patients from medical and surgical services at both campuses of The Ottawa Hospital from health records discharged from medical and surgical services and who were prescribed at least one MDI during their admission. Medical records were reviewed and data related to demographics, MDI prescribing, dispensing, usage, and wastage were collected using a pre-piloted electronic case report form. Financial cost was calculated using local costing estimates and carbon cost was calculated using published estimates. FINDINGS: Between Jan 1, 2023, and June 1, 2023, we collected data for 100 eligible patients, of whom 60 (60%) were female and 90 (90%) were admitted to hospital medicine wards (10% from surgical wards). The median length of stay was 7 (range 1-47) days. The most common inpatient diagnoses were respiratory tract infections in 43 (43%) of 100 patients and chronic obstructive pulmonary disease exacerbations in 28 (28%) of 100 patients. The median number of MDIs prescribed during a patients stay was two (range one to 15) and the median number dispensed was one (range one to seven). For formulary options of MDIs, of the 200 (range 30-1400) actuations dispensed per patient, 8% were used, representing 92% wastage. During the audit, 315 MDIs were dispensed in total, of which 97 were not used at all. INTERPRETATION: MDIs are significant contributors to the carbon footprint attributed to pharmaceutical use in hospitals. This study suggests that 90% of MDI doses are wasted, showing that there is substantial room for improvement. FUNDING: None.

Test characteristics of point-of-care ultrasonography in patients with acute kidney injury.

BACKGROUND: Acute kidney injury is a common disorder that is associated with significant morbidity and mortality. Point-of-care ultrasonography (PoCUS) is an imaging modality performed at the bedside and is used to assess for obstructive causes of acute kidney injury. Little is known about the test characteristics of PoCUS in patients with acute kidney injury. OBJECTIVE: Our primary objective was to describe the test characteristics of PoCUS for the detection of hydronephrosis in patients presenting with acute kidney injury at our centre. Our secondary objective was to describe the current rate of use of PoCUS for this indication. RESULTS: In total, 7873 patients were identified between June 1, 2019 and April 30, 2021, with 4611 meeting inclusion criteria. Of these, 94 patients (2%) underwent PoCUS, and 65 patients underwent both PoCUS and reference standard, for a total of 124 kidneys included in our diagnostic accuracy analysis. The prevalence of hydronephrosis in our cohort was 33% (95% CI 25-41%). PoCUS had a sensitivity of 85% (95% CI 71-94%) and specificity of 78% (95% CI 68-87%) for the detection of hydronephrosis. CONCLUSION: We describe the test characteristics of PoCUS for the detection of hydronephrosis in a cohort of patients with acute kidney injury. The low uptake of this test presents an opportunity for quality improvement work to increase its use for this indication.

Start spreading the news: a deliberate approach to POCUS program development and implementation.

While there is an expanding body of literature on Point-of-Care Ultrasound (POCUS) pedagogy, administrative elements that are necessary for the widespread adoption of POCUS in the clinical environment have received little attention. In this short communication, we seek to address this gap by sharing our institutional experience with POCUS program development and implementation. The five pillars of our program, selected to tackle local barriers to POCUS uptake, are education, workflow, patient safety, research, and sustainability. Our program logic model outlines the inputs, activities, and outputs of our program. Finally, key indicators for the monitoring of program implementation efforts are presented. Though designed for our local context, this approach may readily be adapted toward other clinical environments. We encourage others leading the integration of POCUS at their centers to adopt this approach not only to achieve sustainable change but also to ensure that quality safeguards are in place.

An overview of Internal Medicine Point-of-Care Ultrasound rotations in Canada.

BACKGROUND: Point-of-care ultrasound (POCUS) is a growing part of internal medicine training programs. Dedicated POCUS rotations are emerging as a particularly effective tool in POCUS training, allowing for longitudinal learning and emphasizing both psychomotor skills and the nuances of clinical integration. In this descriptive paper, we set out to review the state of POCUS rotations in Canadian Internal Medicine training programs. RESULTS: We identify five programs currently offering a POCUS rotation. These rotations are offered over two to thirteen blocks each year, run over one to four weeks and support one to four learners. Across all programs, these rotations are set up as a consultative service that offers POCUS consultation to general internal medicine inpatients, with some extension of scope to the hospitalist service or surgical subspecialties. The funding model for the preceptors of these rotations is predominantly fee-for-service using consultation codes, in addition to concomitant clinical work to supplement income. All but one program has access to hospital-based archiving of POCUS exams. Preceptors dedicate ten to fifty hours to the rotation each week and ensure that all trainee exams are reviewed and documented in the patient's medical records in the form of a consultation note. Two of the five programs also support a POCUS fellowship. Only two out of five programs have established learner policies. All programs rely on In-Training Evaluation Reports to provide trainee feedback on their performance during the rotation. CONCLUSIONS: We describe the different elements of the POCUS rotations currently offered in Canadian Internal Medicine training programs. We share some lessons learned around the elements necessary for a sustainable rotation that meets high educational standards. We also identify areas for future growth, which include the expansion of learner policies, as well as the evolution of trainee assessment in the era of competency-based medical education. Our results will help educators that are endeavoring setting up POCUS rotations achieve success.

The Effect of Maternal Stress during Pregnancy on IQ and ADHD Symptomatology.

OBJECTIVE: Maternal stress during pregnancy (MSDP) has been linked to a decrease in Intelligence Quotient (IQ) in the general population. The purpose of this study is to first examine the association between MSDP and IQ in children with Attention-Deficit/Hyperactivity Disorder (ADHD) and second, to confirm, in a large sample, the link between MSDP and ADHD behavioral symptomatology. METHODS: Four hundred ten children diagnosed with ADHD, ages six to 12, were consecutively recruited from the ADHD clinic and day hospital at the Douglas Institute from 1999 to 2013. IQ was assessed using the WISC III and IV. Symptom severity was evaluated using the Child Behavior Checklist (CBCL) and Connor's Global Index for Parents (CGI-P) and Teachers (CGI-T). RESULTS: No significant effect of MSDP on full scale IQ was observed, but MSDP had a significant effect on CBCL and CGI scores. Elevated MSDP was significantly associated with increased CBCL internalizing scores (ß=4.2, p<.01), CBCL externalizing scores (ß=1.9, p=.04), CGI-P restless-impulsive scores (ß=2.6, p=.01), CGI-P emotional lability scores (ß=3.1, p=.02), and CGI-T restless-impulsive (ß=2.2, p=.05) and emotional lability (ß=3.4, p=.04) scores. MSDP increased the variance explained of ADHD symptomatology even after controlling for various factors (i.e. familial income, parental education, smoking and drinking during pregnancy, gender and age). CONCLUSION: The study demonstrates that in children with ADHD, MSDP does not have an impact on IQ but rather on ADHD symptomatology, highlighting the importance of potentially offering psychological and social support to mothers who experience stress during pregnancy.

OBJECTIF: Le stress maternel durant la grossesse (SMDG) a été lié à une diminution du quotient intellectuel (QI) dans la population générale. Cette étude vise d'abord à examiner l'association entre le SMDG et le QI chez les enfants souffrant du trouble de déficit de l'attention avec hyperactivité (TDAH) et deuxièmement, à confirmer, dans un vaste échantillon, le lien entre le SMDG et la symptomatologie comportementale du TDAH. MÉTHODES: Quatre cent dix enfants de 6 à 12 ans ayant reçu un diagnostic de TDAH ont été consécutivement recrutés dans la clinique du TDAH et l'hôpital de jour de l'Institut Douglas, de 1999 à 2013. Le QI a été évalué à l'aide des échelles WISC III et IV. La gravité des symptômes a été évaluée à l'aide de la liste du comportement de l'enfant (CBCL) et de l'index global de Conner pour les parents (CGI-P) et les enseignants (CGI-T). RÉSULTATS: Aucun effet significatif du SMDG sur le QI global n'a été observé, mais le SMDG avait un effet significatif sur les scores à la CBCL et au CGI. Un SMDG élevé était significativement associé à des scores d'internalisation accrus à la CBCL (ß = 4,2; p<0,01), à des scores d'externalisation à la CBCL (ß = 1,9; p = 0,04), à des scores agité-impulsif au CGI-P (ß = 2,6; p = 0,01), à des scores de labilité émotionnelle au CGI-P (ß = 3,1; p = 0,02), et à des scores agité-impulsif (ß = 2,2; p = 0,05) et de labilité émotionnelle au CGI-T (ß = 3,4; p = 0,04). Le SMDG augmentait la variance expliquée de la symptomatologie du TDAH même après contrôle de facteurs variés (c.-à-d., revenu familial, instruction des parents, tabagisme et consommation d'alcool durant la grossesse, sexe et âge). CONCLUSION: L'étude démontre que chez les enfants souffrant du TDAH, le SMDG n'a pas d'incidence sur le QI mais plutôt sur la symptomatologie du TDAH, ce qui souligne l'importance d'offrir potentiellement un soutien psychologique et social aux mères aux prises avec le stress durant la grossesse.