Quantifying unused opioids following emergency and ambulatory care: A systematic review and meta-analysis.

Objective: To quantify unused opioids among adult and pediatric patients discharged from the emergency department (ED) or ambulatory care settings with a prescription for acute pain. Methods: We searched MEDLINE, Embase, CINHAL, PsycINFO, the Cochrane Library, and the gray literature from inception to April 29, 2021. We included observational studies in which any patient with an acutely painful condition received a prescription for an opioid on discharge from an outpatient care setting, and unused opioids were quantified. Two reviewers screened records for eligibility, extracted data, and conducted the quality assessment. Where possible, we pooled data and otherwise described the results of studies narratively. Total unused prescriptions were synthesized using a weighted average. Random effects models were used, and heterogeneity was measured by the I2 statistic. Our primary outcome was the quantity of unused opioid medication available after receiving a prescription for acute pain. Secondary outcomes were the proportion of patients with unused opioids following a prescription, the proportion of patients using no opioids, morphine equivalents of unused opioids, and factors associated with leftover opioids. Results: In this systematic review and meta-analysis of 9 studies in emergency and ambulatory care settings, 59.6% of prescribed opioids remained unused; pediatric patients had 69.3% of their prescriptions remaining, compared to 54.6% among adult patients. The highest proportion of unused opioids was found following dental extractions (82.6%). Conclusions and Relevance: More than 50% of opioids remain unused following prescriptions for acute pain. Responsible prescribing must be accompanied by education on safer use, storage, and disposal.

Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis.

OBJECTIVES: To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes. METHODS: We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool. RESULTS: From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions. CONCLUSIONS: Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation. PROSPERO REGISTRATION NUMBER: CRD42020148053.

Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review.

OBJECTIVES: To conduct a scoping review to identify and summarise the existing literature on interventions involving primary healthcare professionals to manage emergency department (ED) overcrowding. DESIGN: A scoping review. DATA SOURCES: A comprehensive database search of Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) databases was conducted (inception until January 2020) using peer-reviewed search strategies, complemented by a search of grey literature sources. ELIGIBILITY CRITERIA: Interventions and strategies involving primary healthcare professionals (PHCPs: general practitioners (GPs), nurse practitioners (NPs) or nurses with expanded role) to manage ED overcrowding. METHODS: We engaged and collaborated, with 13 patient partners during the design and conduct stages of this review. We conducted this review using the JBI guidelines. Two reviewers independently selected studies and extracted data. We conducted descriptive analysis of the included studies (frequencies and percentages). RESULTS: From 23 947 records identified, we included 268 studies published between 1981 and 2020. The majority (58%) of studies were conducted in North America and were predominantly cohort studies (42%). The reported interventions were either 'within ED' (48%) interventions (eg, PHCP-led ED triage or fast track) or 'outside ED' interventions (52%) (eg, after-hours GP clinic and GP cooperatives). PHCPs involved in the interventions were: GP (32%), NP (26%), nurses with expanded role (16%) and combinations of the PHCPs (42%). The 'within ED' and 'outside ED' interventions reported outcomes on patient flow and ED utilisation, respectively. CONCLUSIONS: We identified many interventions involving PHCPs that predominantly reported a positive impact on ED utilisation/patient flow metrics. Future research needs to focus on conducting well-designed randomized controlled trials (RCTs) and systematic reviews to evaluate the effectiveness of specific interventions involving PHCPs to critically appraise and summarise evidence on this topic.

Interventions to Improve Emergency Department-Related Transitions in Care for Adult Patients With Atrial Fibrillation and Flutter.

BACKGROUND: Patients presenting to emergency departments (EDs) with acute atrial fibrillation or flutter undergo numerous transitions in care (TiC), including changes in their provider, level of care, and location. During transitions, gaps in communications and care may lead to poor outcomes. OBJECTIVE: We sought to examine the effectiveness of ED-based interventions to improve length of stay, return to normal sinus rhythm, and hospitalization, among other critical patient TiC outcomes. METHODS: Comprehensive searches of electronic databases and the gray literature were conducted. Two independent reviewers completed study selection, quality, and data extraction. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model, where appropriate. RESULTS: From 823 citations, 11 studies were included. Interventions consisted of within-ED clinical pathways (n = 6) and specialized observation units (n = 2) and post-ED structured patient education and referrals (n = 3). Three of five studies assessing hospital length of stay reported a significant decrease associated with TiC interventions. Patients undergoing within-ED interventions were also more likely to receive electrical cardioversion. Two of 3 clinical pathways reporting hospitalization proportions showed significant decreases associated with TiC interventions (RR = 0.63 [95% CI 0.42-0.92] and RR = 0.20 [95% CI 0.12-0.32]), as did 1 observation unit (RR = 0.54 [95% CI 0.36-0.80]). No significant differences in mortality, complications, or relapse were found between groupings among the studies. CONCLUSIONS: There is low to moderate quality evidence suggesting that within-ED TiC interventions may reduce hospital length of stay and decrease hospitalizations. Additional high-quality comparative effectiveness studies, however, are warranted.

Remote just-in-time telementored trauma ultrasound: a double-factorial randomized controlled trial examining fluid detection and remote knobology control through an ultrasound graphic user interface display.

BACKGROUND: Remote-telementored ultrasound involves novice examiners being remotely guided by experts using informatic-technologies. However, requiring a novice to perform ultrasound is a cognitively demanding task exacerbated by unfamiliarity with ultrasound-machine controls. We incorporated a randomized evaluation of using remote control of the ultrasound functionality (knobology) within a study in which the images generated by distant naive examiners were viewed on an ultrasound graphic user interface (GUI) display viewed on laptop computers by mentors in different cities. METHODS: Fire-fighters in Edmonton (101) were remotely mentored from Calgary (n = 65), Nanaimo (n = 19), and Memphis (n = 17) to examine an ultrasound phantom randomized to contain free fluid or not. Remote mentors (2 surgeons, 1 internist, and 1 ED physician) were randomly assigned to use GUI knobology control during mentoring (GUIK+/GUIK-). RESULTS: Remote-telementored ultrasound was feasible in all cases. Overall accuracy for fluid detection was 97% (confidence interval = 91 to 99%) with 3 false negatives (FNs). Positive/negative likelihood ratios were infinity/0.0625. One FN occurred with the GUIK+ and 2 without (GUIK-). There were no statistical test performance differences in either group (GUIK+ and GUIK-). CONCLUSIONS: Ultrasound-naive 1st responders can be remotely mentored with high accuracy, although providing basic remote control of the knobology did not affect outcomes.

Serious impact of handlebar injuries.

BACKGROUND: Injuries from bicycles is a leading cause of trauma in children. We sought to investigate the epidemiology of bicycle handlebar injuries. METHODS: A retrospective analysis of bicycle trauma treated at our institution was preformed. RESULTS: A total of 462 children younger than 17 years had bicycle trauma. Abdominal handlebar injuries, representing 9% of bicycle injuries, contributed to 19% of all internal organ injuries, and 45.4% of solid, 87.5% of hollow, 66.6% of vascular or lymphatic, and 100% of pancreatic injuries. Handlebar injuries were 10 times more likely to cause severe injury, yet more than half of the children were misdiagnosed at their initial presentation. Delayed diagnosis and longer hospital stays were observed in handlebar injuries to the abdomen. CONCLUSION: Physicians should be aware of the serious impact of bicycle handlebar injury to the abdomen. The mechanism alone should raise the suspicion of internal organ injury, and timely imaging and surgical consultation.

Retrospective review of diagnosis and treatment in children presenting to the pediatric department with acute scrotum.

OBJECTIVE: Testicular torsion is a common acute condition in boys requiring prompt accurate management. The objective of this article was to evaluate ultrasound accuracy, findings, and clinical predictors in testicular torsion in boys presenting to the Stollery pediatric emergency department with acute scrotal pain. METHODS: Retrospective review of surgical and emergency department ultrasound records for boys from 1 month to 17 years old presenting with acute scrotal pain from 2008 to 2011 was performed. Clinical symptoms, ultrasound and surgical findings, and diagnoses were recorded. Surgical results and follow-up were used as the reference standard. RESULTS: Of 342 patients who presented to the emergency department with acute scrotum, 35 had testicular torsion. Of 266 ultrasound examinations performed, 29 boys had torsion confirmed by surgery. The false-positive rate for ultrasound was 2.6%, and there were no false-negative findings. Mean times from presentation at the emergency department to ultrasound and surgery were 209.4 and 309.4 minutes, respectively. Of the torsed testicles, 69% were salvageable. Sensitivity, specificity, and diagnostic accuracy of ultrasound for testicular torsion were 100%, 97.9%, and 98.1%, respectively. Sonographic heterogeneity was seen in 80% of nonviable testes at surgery and 58% of patients with viable testes (p = 0.41). Sudden-onset scrotal pain (88%), abnormal position (86%), and absent cremasteric reflex (91%) were most prevalent in torsion patients. CONCLUSION: Color Doppler ultrasound is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. Despite heterogeneity on preoperative ultrasound, many testes were considered to be salvageable at surgery. The salvage rate of torsed testes was high.

Management of severe acute asthma in the emergency department.

PURPOSE OF REVIEW: Asthma is one of the most common chronic diseases in most developed countries and control may be elusive. Deterioration in asthma control is common when patients are exposed to airway irritants, viruses, and/or when adherence to chronic anti-inflammatory medications is suboptimal. Acute asthma exacerbations are common, important reasons for presentations to emergency departments, and severe cases may result in hospitalization. Important knowledge gaps exist in what is known and what care is delivered at the bedside. RECENT FINDINGS: The literature in asthma is rapidly expanding and recent advances in the care are important to summarize. Systematic reviews, especially high-quality syntheses performed using Cochrane methods, provide the best evidence for busy clinicians to remain current. Management of asthma is based on early recognition of severe disease with aggressive therapy using multimodal interventions that focus on both bronchoconstriction and inflammatory mechanisms. SUMMARY: Treatment of severe acute asthma can effectively and safely reduce hospitalizations, airway interventions, and even death. Using the approach outlined herein will enable clinicians to assist patients to rapidly regain asthma control, return to normal activities, and improve their quality of life in the follow-up period.

Autoresuscitation after pediatric cardiac arrest: is hyperventilation a cause?

There are a number of reports of delayed return of spontaneous circulation after pulseless arrest (the Lazarus phenomenon) in adults. There are no published reports of this phenomenon in children. We report 2 pediatric cases of the Lazarus phenomenon, likely caused by unintentional hyperventilation during resuscitation.