Screening for harmful substance use in emergency departments: a systematic review.

BACKGROUND: Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use. METHODS: We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results. RESULTS: Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain. CONCLUSIONS: Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.

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 Incidence and Associated Risk Factors of Contrast-Induced Nephropathy after Contrast-Enhanced Computed Tomography in the Emergency Setting: A Systematic Review.

Iodinated contrast media (ICM) during contrast-enhanced computed tomography (CECT) in the emergency department (ED) is essential to diagnose acute conditions, despite risks of contrast-induced nephropathy (CIN) development and its associated complications. This systematic review aims to evaluate the incidence of CIN and CIN-induced complications, and to explore the relevance of classical risk factors for CIN among ED patients receiving ICM. PubMed, Cochrane, and Web of Science were used on 30 August 2021 to search for peer-reviewed English articles reporting on CIN incidence among ED patients aged ≥18 years who underwent an intravenous CECT. The inclusion criteria included studies that were in English, peer-reviewed, and involved ED patients aged ≥18 years who underwent single intravenous CECT. Studies on intra-arterial procedures and preventive strategies, meta-analyses, clinical guidelines, review articles, and case reports were excluded. The JBI critical appraisal checklist was applied to assess the risk of bias. In total, 18 studies were included wherein 15 were retrospective studies while three were prospective studies. We found a relatively higher CIN incidence in the ED, with variations owing to the CIN definitions. Several classical risk factors including acute hypotension remain linked to CIN onset in ED settings unlike factors such as age and diabetes. While risk of adverse renal events due to CIN is low, there is higher risk of CIN-induced mortality in the ED. Therefore, with the higher incidence of CIN and CIN-induced mortality rates in the ED, ICM administration during CECT in the ED should still be clinically justified after assessing both benefits and risks.

Education about sexual and gender minorities within Canadian emergency medicine residency programs.

OBJECTIVES: The CAEP 2021 2SLGBTQIA +i panel sought whether a gap exists within Canadian emergency medicine training pertaining to sexual and gender minority communities. This panel aimed to generate practical recommendations on improving emergency medicine education about sexual and gender minorities, thereby improving access to equitable healthcare. METHODS: From August 2020 to June 2021, a panel of emergency medicine practitioners, residents, students, and community representatives met monthly via videoconference. A literature review was undertaken, and three mixed methods surveys were distributed to the CAEP member list, CAEP Resident Section, College of Family Physicians of Canada (CFPC)iii Emergency Medicine Members Interest Group, and to emergency medicine residency program directors and their residents. Informed by the review and surveys, recommendations were drafted and refined by panel members before presentation at the 2021 CAEP Academic Symposium. A plenary was presented to symposium attendees composed of national emergency medicine community members, which reported the survey results and literature review. All attendees were divided into small groups to develop an action plan for each recommendation. CONCLUSIONS: The panel outlines eight recommendations for closing the curricular gap. It identifies three perceived or real barriers to the inclusion of sexual and gender minority content in emergency medicine residency curricula. It acknowledges three enabling recommendations that are beyond the scope of individual emergency medicine programs or emergency departments (EDs), that if enacted would enable the implementation of the recommendations. Each recommendation is accompanied by two action items as a guide to implementation. Each of the three barriers is accompanied by two action items that offer specific solutions to overcome these obstacles. Each enabling recommendation suggests an action that would shift emergency medicine towards sociocultural competence nationally. These recommendations set the primary steps towards closing the educational gap.

RéSUMé: OBJECTIFS: Le panel ACMU 2021 2SLGBTQIA+ i a cherché à savoir s'il existe une lacune dans la formation en médecine d'urgence au Canada en ce qui concerne les communautés de minorités sexuelles et de genre. Ce panel visait à générer des recommandations pratiques sur l'amélioration de l'éducation en médecine d'urgence sur les minorités sexuelles et de genre, améliorant ainsi l'accès à des soins de santé équitables. MéTHODES: D'août 2020 à juin 2021, un groupe de praticiens en médecine d'urgence, de résidents, d'étudiants et de représentants communautaires se sont réunis chaque mois par vidéoconférence. Une revue de la littérature a été entreprise et trois enquêtes à méthodes mixtes ont été distribuées à la liste des membres de l'ACMU, à la Section des résidents de l'ACMU, au Groupe d'intérêt des membres en médecine d'urgence du Collège des médecins de famille du Canada (CMFC) iii, ainsi qu'aux directeurs des programmes de résidence en médecine d'urgence et à leurs résidents. À la lumière de l'examen et des sondages, les recommandations ont été rédigées et peaufinées par les membres du comité avant d'être présentées au Symposium universitaire de l'ACMU de 2021. Une séance plénière a été présentée aux participants du symposium, composés de membres de la communauté nationale de la médecine d'urgence, qui ont fait état des résultats du sondage et de la revue de la littérature. Tous les participants ont été répartis en petits groupes afin d'élaborer un plan d'action pour chaque recommandation. CONCLUSIONS: Le groupe d'experts formule huit recommandations pour combler le fossé entre les programmes d'enseignement. Il identifie trois obstacles perçus ou réels à l'inclusion du contenu sur les minorités sexuelles et de genre dans les programmes de résidence en médecine d'urgence. Il reconnaît trois recommandations habilitantes qui dépassent la portée des programmes de médecine d'urgence individuels ou des services d'urgence (SU) et qui, si elles étaient adoptées, permettraient la mise en œuvre des recommandations. Chaque recommandation est accompagnée de deux mesures de suivi comme guide de mise en œuvre. Chacun des trois obstacles est accompagné de deux éléments d'action qui offrent des solutions spécifiques pour surmonter ces obstacles. Chaque recommandation habilitante suggère une action qui ferait évoluer la médecine d'urgence vers une compétence socioculturelle au niveau national. Ces recommandations établissent les principales étapes pour combler l'écart en matière d'éducation.

Prevention of alcohol withdrawal seizure recurrence and treatment of other alcohol withdrawal symptoms in the emergency department: a rapid review.

BACKGROUND: Patients who experience harms from alcohol and other substance use often seek care in the emergency department (ED). ED visits related to alcohol withdrawal have increased across the world during the COVID-19 pandemic. ED clinicians are responsible for risk-stratifying patients under time and resource constraints and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care. Published guidelines for alcohol withdrawal are largely limited to the primary care and outpatient settings, and do not provide specific guidance for ED use. The purpose of this review was to synthesize published evidence on the treatment of alcohol withdrawal syndrome in the ED. METHODS: We conducted a rapid review by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (1980 to 2020). We searched for grey literature on Google and hand-searched the conference abstracts of relevant addiction medicine and emergency medicine professional associations (2015 to 2020). We included interventional and observational studies that reported outcomes of clinical interventions aimed at treating alcohol withdrawal syndrome in adults in the ED. RESULTS: We identified 13 studies that met inclusion criteria for our review (7 randomized controlled trials and 6 observational studies). Most studies were at high/serious risk of bias. We divided studies based on intervention and summarized evidence narratively. Benzodiazepines decrease alcohol withdrawal seizure recurrence and treat other alcohol withdrawal symptoms, but no clear evidence supports the use of one benzodiazepine over another. It is unclear if symptom-triggered benzodiazepine protocols are effective for use in the ED. More evidence is needed to determine if phenobarbital, with or without benzodiazepines, can be used safely and effectively to treat alcohol withdrawal in the ED. Phenytoin does not have evidence of effectiveness at preventing withdrawal seizures in the ED. CONCLUSIONS: Few studies have evaluated the safety and efficacy of pharmacotherapies for alcohol withdrawal specifically in the ED setting. Benzodiazepines are the most evidence-based treatment for alcohol withdrawal in the ED. Pharmacotherapies that have demonstrated benefit for treatment of alcohol withdrawal in other inpatient and outpatient settings should be evaluated in the ED setting before routine use.

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.

Unidentified patients in the emergency department: a historical cohort study.

OBJECTIVES: To characterize unidentified patients presenting to a single, urban emergency department (ED) in Canada. We report their demographics, ED course, post-ED discharge outcomes, and mode of identification. METHODS: We performed a retrospective chart review using descriptive analyses to assess unidentified patients admitted to Royal University Hospital and St. Paul's Hospital EDs between May 1, 2018, and April 30, 2019, in Saskatoon, Saskatchewan, Canada. We assessed demographic data, clinical presentation, mode of identification, discharge information, and major clinical outcomes. RESULTS: Unidentified patients were disproportionately male (64.9%), and mostly presented as Canadian Triage and Acuity Scale (CTAS) 1 (41.6%) and CTAS 2 (44.2%). Most patients arrived via emergency medical services (80.7%). The most common presenting complaints were substance misuse (33.3%) and trauma (24.6%). The average ED length of stay was 8.7 h (SD 18.6). Many patients received an inpatient consult (58.8%), and 22.3% received support services (e.g., social work). The 30-day mortality of all patients was 13.2%. Of those patients who survived to ED discharge, common dispositions included: home (36.0%), police services (3.5%), or emergency shelters (3.5%). Four (3.5%) patients returned to the hospital unidentified within the study period, and 6.7% of patients discharged from the ED returned within 48 hours. CONCLUSION: Unidentified patients are a high-needs demographic that present mostly with substance misuse or trauma. Repeat ED attendance, sometimes as unidentified patients again, calls for initiatives that facilitate prompt identification, better discharge planning, and linkage to social supports.

RéSUMé: OBJECTIFS: Caractériser les patients non identifiés se présentant à un seul service d'urgence urbain au Canada. Nous rapportons leurs données démographiques, leur parcours aux urgences, leurs résultats après leur sortie de l'urgence et leur mode d'identification. MéTHODES: Nous avons effectué un examen rétrospectif des dossiers à l'aide d'analyses descriptives pour évaluer les patients non identifiés admis à Royal University l'hôpital et St. Paul's Hospital aux urgences de l'hôpital entre le 1er mai 2018 et le 30 avril 2019, Saskatoon, Saskatchewan, au Canada. Nous avons évalué les données démographiques, la présentation clinique, le mode d'identification, les informations de sortie et les principaux résultats cliniques. RéSULTATS: Les patients non identifiés étaient en grande partie des hommes (64.9 %) et se présentaient principalement sous la forme d'une échelle canadienne de triage et de gravité (ÉTG) 1 (41.6 %) et ÉTG 2 (44.2 %). La plupart des patients sont arrivés via les services médicaux d'urgence (80.7 %). Les plaintes les plus courantes étaient l'abus de substances (33.3 %) et le traumatisme (24.6 %). La durée moyenne du séjour à l'urgence était de 8,7 heures (écart-type : 18.6). De nombreux patients ont reçu une consultation interne (58.8 %) et 22.3 % ont reçu des services de soutien (p. ex., travail social). La mortalité sur 30 jours de tous les patients était de 13.2 %. Parmi les patients qui ont survécu à la sortie du service d'urgence, les dispositions courantes comprenaient : domicile (36.0 %), services de police (3.5 %) ou refuges d'urgence (3.5 %). Quatre (3.5 %) patients sont retournés à l'hôpital sans être identifiés pendant la période d'étude, et 6.7 % des patients sortis des urgences sont revenus dans les 48 heures. CONCLUSION: Les patients non identifiés constituent un groupe démographique à besoins élevés qui se présente principalement avec un abus de substances ou de traumatisme. La fréquentation répétée des urgences, parfois en tant que patients non identifiés à nouveau, nécessite des initiatives qui facilitent une identification rapide, une meilleure planification de la sortie et la mise en relation avec des soutiens sociaux.

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures.

OBJECTIVES: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. DESIGN: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. SETTING: Fourteen level-1 trauma centers across the United States. PATIENTS: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. INTERVENTION: Delay definitive fixation and flap coverage in tibial type III fractures. MAIN OUTCOME MEASUREMENTS: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. RESULTS: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). CONCLUSION: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving clinical documentation: introduction of electronic health records in paediatrics.

Medical records are crucial facet of a patient's journey. These provide the clinician with a permanent record of the patient's illness and ongoing medical care, thus enabling informed clinical decisions. In many hospitals, patient medical records are written on paper. However, written notes are liable to misinterpretation due to illegibility and misplacement. This can affect the patient's medical care and has medico-legal implications. Electronic patient records (EPR) have been gradually introduced to replace patient's paper notes with the aim of providing a more reliable record-keeping system. It is perceived that EPR improve the quality and efficiency of patient care. The paediatric department at Queen's Hospital Burton uses a mix of paper notes and computerised medical records. Clinicians primarily use paper notes for admission clerking, ward rounds, ward reviews and outpatient clinic consultations. Laboratory tests, imaging results and prescription requests are executed via the EPR system. Documentation by nurses is also carried out electronically. We aimed to improve and standardise clinical documentation of paediatric admissions and ward round notes by developing electronic proforma for initial paediatric clerking, ward rounds and patient reviews. This quality improvement project improved clinical documentation on the paediatric wards and enhanced patient record-keeping, boosted clinical information-sharing and streamlined patient journey. It fulfilled various generic multidisciplinary record keeping audit tool standards endorsed by the Royal College of Physicians by 100%. We undertook a staff survey to investigate the opinion before and after implementing the electronic health record. Doctors, nurses and healthcare support workers overwhelmingly supported the quality, usefulness, completeness of specified fields and practicality of the electronic records.

Survival prediction algorithms for COVID-19 patients admitted to a UK district general hospital.

OBJECTIVE: To collect and review data from consecutive patients admitted to Queen's Hospital, Burton on Trent for treatment of Covid-19 infection, with the aim of developing a predictive algorithm that can help identify those patients likely to survive. DESIGN: Consecutive patient data were collected from all admissions to hospital for treatment of Covid-19. Data were manually extracted from the electronic patient record for statistical analysis. RESULTS: Data, including outcome data (discharged alive/died), were extracted for 487 consecutive patients, admitted for treatment. Overall, patients who died were older, had very significantly lower Oxygen saturation (SpO2) on admission, required a higher inspired Oxygen concentration (IpO2) and higher CRP as evidenced by a Bonferroni-corrected (P < 0.0056). Evaluated individually, platelets and lymphocyte count were not statistically significant but when used in a logistic regression to develop a predictive score, platelet count did add predictive value. The 5-parameter prediction algorithm we developed was: [Formula: see text] CONCLUSION: Age, IpO2 on admission, CRP, platelets and number of lungs consolidated were effective marker combinations that helped identify patients who would be likely to survive. The AUC under the ROC Plot was 0.8129 (95% confidence interval 0.0.773 - 0.853; P < .001).

CAEP Position Statement: Emergency department management of people with opioid use disorder.

Deaths due to opioid overdose have reached unprecedented levels in Canada; over 12,800 opioid-related deaths occurred between January 2016 and March 2019, and overdose death rates increased by approximately 50% from 2016 to 2018.1 In 2016, Health Canada declared the opioid epidemic a national public health crisis,2 and life expectancy increases have halted in Canada for the first time in decades.3 Children are not exempt from this crisis, and the Chief Public Health Officer of Canada has recently prioritized the prevention of problematic substance use among Canadian youth.4.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning.

BACKGROUND: Quality Improvement (QI) training for health professionals is essential to strengthen health systems. However, QI training during medical school is constrained by students' lack of contextual understanding of the health system and an already saturated medical curriculum. The Program for Improvement in Medical Education (PRIME), an extracurricular offered at the Michael G. DeGroote School of Medicineat McMaster University (Hamilton, Canada), addresses these obstacles by having first-year medical students engage in QI by identifying opportunities for improvement within their own education. METHODS: A sequential explanatory mixed-methods approach, which combines insights derived from quantitative instruments and qualitative interview methods, was used to examine the impact of PRIME on first-year medical students and the use of QI in the context of education. RESULTS: The study reveals that participation in PRIME increases both knowledge of, and comfort with, fundamental QI concepts, even when applied to clinical scenarios. Participants felt that education provided a meaningful context to learn QI at this stage of their training, and were motivated to participate in future QI projects to drive real-world improvements in the health system. CONCLUSIONS: Early exposure to QI principles that uses medical education as the context may be an effective intervention to foster QI competencies at an early stage and ultimately promote engagement in clinical QI. Moreover, PRIME also provides a mechanism to drive improvements in medical education. Future research is warranted to better understand the impact of education as a context for later engagement in clinical QI applications as well as the potential for QI methods to be translated directly into education.