Emerging evidence for non-pharmacologic interventions in reducing the burden of respiratory illnesses.

The global pandemic caused by SARS-CoV-2 (COVID-19) has led to significant morbidity and mortality, and unprecedented economic and health system disruption. Non-pharmacologic interventions (NPIs) such as masking and physical distancing have formed the underpinnings of COVID-19 infection control strategies. Concomitantly, numerous jurisdictions have seen a decrease in hospitalizations for non-COVID-19 respiratory illnesses (NCRIs) such as asthma, community-acquired pneumonia, influenza, and chronic obstructive pulmonary disease relative to pre-pandemic levels. These associations give rise to a number of testable hypotheses regarding the efficacy of NPIs in reducing the substantial burden of NCRIs. Here, we review emerging perspectives on the role of NPIs in NCRI prevention with the ultimate goal of informing future research and public policy development as we move into what may be the endemic phase of the COVID-19 pandemic.

Factors influencing time to computed tomography in emergency department patients with suspected subarachnoid haemorrhage.

BACKGROUND: CT has excellent sensitivity for subarachnoid haemorrhage (SAH) when performed within 6 hours of headache onset, but it is unknown to what extent patients with more severe disease are likely to undergo earlier CT, potentially inflating estimates of sensitivity. Our objective was to evaluate which patient and hospital factors were associated with earlier neuroimaging in alert, neurologically intact ED patients with suspected SAH. METHODS: We analysed data from two large sequential prospective cohorts of ED patients with acute headache undergoing CT for suspected SAH. We examined the time interval from headache onset to CT, both overall and subdivided from headache onset to hospital registration and from registration to CT. RESULTS: Among 2412 patients with headache, 194 had SAH, with 178 identified on unenhanced CT. Of these, 91 (51.1%) were identified by CT within 6 hours of headache onset and 87 after 6 hours. Patients with SAH had a shorter time from headache onset to hospital presentation (median 4.5 hours, IQR 1.7-22.7 vs 9.6 hours, IQR 2.8-46.0, p<0.001) and were imaged sooner after headache onset (6.4 hours, IQR 3.5-27.1 vs 12.6 hours, IQR 5.5-48.0, p<0.001) compared with those without SAH. The median time from in-hospital registration to CT scan was significantly shorter in those patients with SAH although this difference was less than 1 hour (1.9 hours, IQR 1.2-2.8 vs 2.5 hours, IQR 1.5-3.9, p<0.001). Arrival by ambulance (OR 3.1, 95% CI 1.94 to 4.98, p<0.001) and higher acuity at triage (OR 1.39, 95% CI 1.02 to 1.88, p=0.032) were among the factors associated with having CT imaging within 6 hours of headache onset. CONCLUSIONS: Time from headache onset to imaging is moderately associated with positive imaging for SAH. Delay to hospital presentation accounts for the largest fraction of time to imaging, especially those without SAH. These findings suggest limited opportunity to reduce lumbar puncture rates simply by accelerating in-hospital processes when imaging delays are under 2 hours, as diagnostic yield of imaging decreases beyond the 6-hour imaging window from headache onset.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study.

OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. DESIGN: A substudy of a prospective multicenter cohort study. SETTING: 12 Canadian academic emergency departments, from November 2000 to December 2009. PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). CONCLUSION: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

Characteristics of evidence-based medicine training in Royal College of Physicians and Surgeons of Canada emergency medicine residencies - a national survey of program directors.

BACKGROUND: Recent surveys suggest few emergency medicine (EM) training programs have formal evidence-based medicine (EBM) or journal club curricula. Our primary objective was to describe the methods of EBM training in Royal College of Physicians and Surgeons of Canada (RCPSC) EM residencies. Secondary objectives were to explore attitudes regarding current educational practices including e-learning, investigate barriers to journal club and EBM education, and assess the desire for national collaboration. METHODS: A 16-question survey containing binary, open-ended, and 5-pt Likert scale questions was distributed to the 14 RCPSC-EM program directors. Proportions of respondents (%), median, and IQR are reported. RESULTS: The response rate was 93% (13/14). Most programs (85%) had established EBM curricula. Curricula content was delivered most frequently via journal club, with 62% of programs having 10 or more sessions annually. Less than half of journal clubs (46%) were led consistently by EBM experts. Four programs did not use a critical appraisal tool in their sessions (31%). Additional teaching formats included didactic and small group sessions, self-directed e-learning, EBM workshops, and library tutorials. 54% of programs operated educational websites with EBM resources. Program directors attributed highest importance to two core goals in EBM training curricula: critical appraisal of medical literature, and application of literature to patient care (85% rating 5 - "most importance", respectively). Podcasts, blogs, and online journal clubs were valued for EBM teaching roles including creating exposure to literature (4, IQR 1.5) and linking literature to clinical practice experience (4, IQR 1.5) (1-no merit, 5-strong merit). Five of thirteen respondents rated lack of expert leadership and trained faculty educators as potential limitations to EBM education. The majority of respondents supported the creation of a national unified EBM educational resource (4, IQR 1) (1-no support, 5- strongly support). CONCLUSIONS: RCPSC-EM programs have established EBM teaching curricula and deliver content most frequently via journal club. A lack of EBM expert educators may limit content delivery at certain sites. Program directors supported the nationalization of EBM educational resources. A growing usage of electronic resources may represent an avenue to link national EBM educational expertise, facilitating future collaborative educational efforts.

Clinical decision rules to rule out subarachnoid hemorrhage for acute headache.

IMPORTANCE: Three clinical decision rules were previously derived to identify patients with headache requiring investigations to rule out subarachnoid hemorrhage. OBJECTIVE: To assess the accuracy, reliability, acceptability, and potential refinement (ie, to improve sensitivity or specificity) of these rules in a new cohort of patients with headache. DESIGN, SETTING, AND PATIENTS: Multicenter cohort study conducted at 10 university-affiliated Canadian tertiary care emergency departments from April 2006 to July 2010. Enrolled patients were 2131 adults with a headache peaking within 1 hour and no neurologic deficits. Physicians completed data forms after assessing eligible patients prior to investigations. MAIN OUTCOMES AND MEASURES: Subarachnoid hemorrhage, defined as (1) subarachnoid blood on computed tomography scan; (2) xanthochromia in cerebrospinal fluid; or (3) red blood cells in the final tube of cerebrospinal fluid, with positive angiography findings. RESULTS: Of the 2131 enrolled patients, 132 (6.2%) had subarachnoid hemorrhage. The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for subarachnoid hemorrhage. Adding "thunderclap headache" (ie, instantly peaking pain) and "limited neck flexion on examination" resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity. CONCLUSIONS AND RELEVANCE: Among patients presenting to the emergency department with acute nontraumatic headache that reached maximal intensity within 1 hour and who had normal neurologic examination findings, the Ottawa SAH Rule was highly sensitive for identifying subarachnoid hemorrhage. These findings apply only to patients with these specific clinical characteristics and require additional evaluation in implementation studies before the rule is applied in routine clinical care.

Teaching and evaluation of ethics and professionalism: in Canadian family medicine residency programs.

OBJECTIVE: To document the scope of the teaching and evaluation of ethics and professionalism in Canadian family medicine postgraduate training programs, and to identify barriers to the teaching and evaluation of ethics and professionalism. DESIGN: A survey was developed in collaboration with the Committee on Ethics of the College of Family Physicians of Canada. The data are reported descriptively and in aggregate. SETTING: Canadian postgraduate family medicine training programs. PARTICIPANTS: Between June and December of 2008, all 17 Canadian postgraduate family medicine training programs were invited to participate. MAIN OUTCOME MEASURES: The first part of the survey explored the structure, resources, methods, scheduled hours, and barriers to teaching ethics and professionalism. The second section focused on end-of-rotation evaluations, other evaluation strategies, and barriers related to the evaluation of ethics and professionalism. RESULTS: Eighty-eight percent of programs completed the survey. Most respondents (87%) had learning objectives specifically for ethics and professionalism, and 87% had family doctors with training or interest in the area leading their efforts. Two-thirds of responding programs had less than 10 hours of scheduled instruction per year, and the most common barriers to effective teaching were the need for faculty development, competing learning needs, and lack of resident interest. Ninety-three percent of respondents assessed ethics and professionalism on their end-of-rotation evaluations, with 86% assessing specific domains. The most common barriers to evaluation were a lack of suitable tools and a lack of faculty comfort and interest. CONCLUSION: By far most Canadian family medicine postgraduate training programs had learning objectives and designated faculty leads in ethics and professionalism, yet there was little curricular time dedicated to these areas and a perceived lack of resident interest and faculty expertise. Most programs evaluated ethics and professionalism as part of their end-of-rotation evaluations, but only a small number used novel means of evaluation, and most cited a lack of suitable assessment tools as an important barrier.

Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.

OBJECTIVE: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. DESIGN: Prospective cohort study. SETTING: 11 tertiary care emergency departments across Canada, 2000-9. PARTICIPANTS: Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. MAIN OUTCOME MEASURES: Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. RESULTS: Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). CONCLUSION: Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

Identifying bioethics learning needs: a survey of Canadian emergency medicine residents.

OBJECTIVES: Emergency medicine (EM) postgraduate training programs must prepare residents for the ethical challenges of clinical practice. Bioethics curricula have been developed for EM residents, but they are based on expert opinion rather than resident learning needs. Educational interventions based on identified learning needs are more effective at changing practice than interventions that are not. The goal of this study was to identify the bioethics learning needs of Canadian EM residents. METHODS: A survey-based needs assessment of Canadian EM residents was performed between July 2000 and June 2001. Residents were asked to identify their learning needs by rating bioethics topics and by relating their clinical experiences. Physicians and nurses who work with residents were surveyed in a similar manner and also asked to identify the residents' bioethics learning needs. RESULTS: A total of 129 EM residents (77% of eligible residents), 94 physicians, and 87 nurses responded. Residents, physicians, and nurses all identified issues in end-of-life care as the greatest bioethics learning needs of the residents. Other areas identified as learning needs included negotiating consent, capacity assessment, truth telling, and breaking bad news. A learning need identified by nurses, but not residents, was the manner in which residents interact with patients and colleagues. CONCLUSIONS: This needs assessment provides valuable information about the ethical challenges EM residents encounter and the ethical issues they believe they have not been prepared to face. This information should be used to direct and shape ethics education interventions for EM residents.

Ethics in the trenches: Part 2. Case studies of ethical challenges in emergency medicine.

Unique ethical issues arise in the practice of emergency medicine, and common ethical problems are often more difficult to address in the emergency department than in other medical settings. This article is Part 2 of the Series "Ethics in the Trenches" and it presents and analyses 2 cases--each dealing with an ethical challenge that emergency physicians are likely to encounter. The first case deals with patient refusal of care. When a patient refuses recommended care, the emergency physician must ensure the patient's decision is informed and that the patient comprehends the implications of his or her choice. The second case deals with patient involvement in criminal activities. Emergency physicians often encounter patients who have engaged in illegal activities. Although certain activities must be reported, physicians should be mindful of their responsibility to protect patient privacy and confidentiality.