Obstetric Emergencies Requiring Rapid Response Team Activation: A Retrospective Cohort Study in a High-Risk Tertiary Care Centre.

OBJECTIVE: The purpose of this study was to better understand obstetric codes requiring rapid response team activation by examining their incidence, indications, team response, and patient outcomes. METHODS: This was a retrospective study in peripartum women who required activation of the following codes during hospitalization between January 2014 and May 2018: "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion). Hospital database and health records were searched to identify and review cases. Data on code characteristics, resuscitative measures, and maternal and neonatal outcomes were collected. RESULTS: A total of 147 codes were identified during the study period (C77, 110; CO, 25; CB 12), with an overall incidence of 1 per 203 deliveries (C77, 1:271 deliveries, CO, 1:1194 deliveries; CB, 1:2488 deliveries). Common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB, postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most codes (67%) occurred after hours. The median decision-to-delivery interval was 8 (interquartile range 5-15) minutes after C77. Emergency cesarean delivery was performed for 57% of obstetric emergencies, and general anesthesia was administered in 63% of cesarean deliveries. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% of cases. Debrief was documented for 4% of codes. CONCLUSION: Rapid response team activation was required more commonly in C77 than in CO or CB. Their response time and decision-to-delivery intervals were rapid. Mortality was low; however, one-third of parturients had major morbidities. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

Identification of early childhood caries in primary care settings.

Early childhood caries (ECC) is the most common chronic disease affecting young children in Canada. ECC may lead to pain and infection, compromised general health, decreased quality of life and increased risk for dental caries in primary and permanent teeth. A multidisciplinary approach to prevent and identify dental disease is recommended by dental and medical national organizations. Young children visit primary care providers at regular intervals from an early age. These encounters provide an ideal opportunity for primary care providers to educate clients about their children's oral health and its importance for general health. We designed an office-based oral health screening guide to help primary care providers identify ECC, a dental referral form to facilitate dental care access and an oral health education resource to raise parental awareness. These resources were reviewed and trialled with a small number of primary care providers.

Rapid Cycle Deliberate Practice in Medical Education - a Systematic Review.

Rapid Cycle Deliberate Practice (RCDP) is a novel simulation-based education model that is currently attracting interest, implementation, exploration and research in medical education. In RCDP, learners rapidly cycle between deliberate practice and directed feedback within the simulation scenario until mastery is achieved. The objective of this systematic review is to examine the literature and summarize the existing knowledge on RCDP in simulation-based medical education. Fifteen resources met inclusion criteria; they were diverse and heterogeneous, such that we did not perform a quantitative synthesis or meta-analysis but rather a narrative review on RCDP. All resources described RCDP in a similar manner. Common RCDP implementation strategies included: splitting simulation cases into segments, micro debriefing in the form of 'pause, debrief, rewind and try again' and providing progressively more challenging scenarios. Variable outcome measures were used by the studies including qualitative assessments, scoring tools, procedural assessment using checklists or video review, time to active skills and clinical reports. Results were limited and inconsistent. There is an absence of data on retention after RCDP teaching, on RCDP, with learners from specialties other than pediatrics, on RCDP for adult resuscitation scenarios and if RCDP teaching translates into practice change in the clinical realm. We have identified important avenues for future research on RCDP.

The cost effectiveness of transesophageal echocardiography for pediatric cardiac surgery: a systematic review.

BACKGROUND: Intraoperative transesophageal echocardiography (ITEE) for pediatric cardiac surgery has been described as clinically efficacious and cost-effective. There are a small number of publications supporting these claims. AIMS: The objectives were to assess the quality of the research, the variability of results across studies and, if possible, to make a consensus statement based on the results. METHODS: In March 2015, a systematic search of MEDLINE and MEDLINE In-Process, EMBASE, and the National Health Service Economic Evaluation Database was performed. The search was supplemented with a review of Health Technology Assessment reports through the Centre for Reviews and Dissemination database. English language articles including any quantitative economic evaluation were included. The quality of each study was assessed using the British Medical Journal economic evaluation quality checklist. Data extracted included the main outcomes from each study, study methodologies, itemized costs, sensitivity ranges, biases, and delayed reoperation prevented with ITEE. When possible, a cost-savings per ITEE was calculated to facilitate comparison across studies and used to create a synthesis of the results. RESULTS: Seven studies met the inclusion criteria; of these, five were included in the synthesis of results. The cost-savings per ITEE ranged from $194 to $4910 with a mean of $1930 (95%CI: $845 to $3015) (2015 USD). Prevented delayed reoperation rates using ITEE ranged from 2.8% to 10%. Earlier studies were of poorer quality (scores 8-17) and more recent studies were of higher quality (scores 22-25). Methodologies used were either retrospective chart reviews (57%) or prospective observational studies (43%) with a range of approaches to estimate costs. CONCLUSION: ITEE for pediatric cardiac surgery is effective and cost-saving. This is a validation of the current practice patterns. These finding may influence the expansion of the use of this technology.

Acceptability of bone antiresorptive therapy among HIV-infected adults at different stages of antiretroviral therapy.

PURPOSE: Both HIV infection and antiretroviral therapy (ART) are associated with significant decreases in bone mineral density (BMD) and increased fracture rates. To prepare for a randomized controlled trial of prophylactic bone antiresorptive therapy during ART initiation, we assessed the acceptability of this strategy, bone health knowledge, and fracture risk among HIV-infected adults. METHODS: HIV-infected adults with no history of osteoporosis were recruited from one tertiary and one primary care HIV clinic. Participants completed a questionnaire and underwent chart review. The primary outcome was the proportion of respondents expressing interest in taking prophylactic bone antiresorptive therapy in conjunction with ART. RESULTS: Of 112 respondents, 25.0% were ART naïve, 23.2% had been taking ART for ≤1 year, and 51.8% had been taking ART for >1 year. Half (51.9%) indicated interest in taking short-course prophylactic bone antiresorptive therapy; this did not differ by ART status (53.6% among ART-naïve, 51.3% among ART-treated; P=0.84, chi-square test). In exploratory multivariable analysis adjusted for ART status, a greater number of pills taken per day was positively associated with this outcome (adjusted odds ratio [OR] =1.12 per pill, 95% confidence limit [CL] =1.01, 1.25), while male sex was inversely associated (adjusted OR =0.05, 95% CL =0.01, 0.24). Among those willing to take therapy, most (80.4%) were willing to do so for "as long as needed" and preferred weekly dosing (70.9%) to daily dosing (12.7%). CONCLUSIONS: Half of this sample would be willing to take bone antiresorptive therapy together with ART, with preferences for weekly dosing and for whatever duration may be required. These data will inform the design of future trials to protect bone health in HIV.

From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice.

Previous research has highlighted the importance of addressing the social determinants of health to improve child health outcomes. However, significant barriers exist that limit the paediatrician's ability to properly address these issues. Barriers include a lack of clinical time, resources, training and education with regard to the social determinants of health; awareness of community resources; and case-management capacity. General practice recommendations to help the health care provider link patients to the community are insufficient. The objective of the current article was to present options for improving the link between the office and the community, using screening questions incorporating physician-based tools that link community resources. Simple interventions, such as routine referral to early-year centres and selected referral to public health home-visiting programs, may help to address populations with the greatest needs.

Des recherches antérieures ont fait ressortir l'importance de tenir compte des déterminants sociaux de la santé pour améliorer la santé des enfants. Cependant, des obstacles importants empêchent les pédiatres de bien se pencher sur la question, incluant le manque de temps clinique, de ressources, de formation et d'enseignement sur les déterminants de la santé, la connaissance des ressources communautaires et la capacité de gestion des cas. Les recommandations faites en pratique générale pour aider le dispensateur de soins à orienter les patients vers des ressources communautaires ne suffisent pas. Le présent article vise à présenter des moyens de faire de meilleurs liens entre le cabinet et la communauté, à l'aide de questions de dépistage intégrant des outils médicaux qui dirigent les patients vers des ressources communautaires. Des interventions simples, telles que l'orientation systématique vers des centres de la petite enfance et l'orientation sélective vers des programmes de visite à domicile par la santé publique, peuvent contribuer à servir les populations qui ont les besoins les plus criants.

Speech and language support: How physicians can identify and treat speech and language delays in the office setting.

Failure to recognize and intervene early in speech and language delays can lead to multifaceted and potentially severe consequences for early child development and later literacy skills. While routine evaluations of speech and language during well-child visits are recommended, there is no standardized (office) approach to facilitate this. Furthermore, extensive wait times for speech and language pathology consultation represent valuable lost time for the child and family. Using speech and language expertise, and paediatric collaboration, key content for an office-based tool was developed. THE TOOL AIMED TO HELP PHYSICIANS ACHIEVE THREE MAIN GOALS: early and accurate identification of speech and language delays as well as children at risk for literacy challenges; appropriate referral to speech and language services when required; and teaching and, thus, empowering parents to create rich and responsive language environments at home. Using this tool, in combination with the Canadian Paediatric Society's Read, Speak, Sing and Grow Literacy Initiative, physicians will be better positioned to offer practical strategies to caregivers to enhance children's speech and language capabilities. The tool represents a strategy to evaluate speech and language delays. It depicts age-specific linguistic/phonetic milestones and suggests interventions. The tool represents a practical interim treatment while the family is waiting for formal speech and language therapy consultation.

Le défaut de dépister et d'intervenir rapidement en cas de retards de la parole et du langage peut avoir des conséquences multiples au potentiel grave en matière de développement de la petite enfance et d'aptitudes à la littératie plus tard. Il est recommandé de procéder à l'évaluation systématique de la parole et du langage pendant les bilans de santé des enfants, mais il n'existe pas d'approche normalisée (en cabinet) pour la faciliter. De plus, les temps d'attente prolongés avant d'obtenir une consultation en orthophonie constituent une perte de temps précieux pour l'enfant et sa famille. Faisant appel à des compétences en orthophonie et à la collaboration de pédiatres, les chercheurs ont préparé le contenu essentiel d'un outil à utiliser en cabinet.L'outil visait à aider les médecins à réaliser trois grands objectifs : le dépistage rapide et précis des retards de la parole et du langage et des enfants vulnérables à des problèmes de littératie, l'aiguillage convenable vers des services d'orthophonie, au besoin, et l'enseignement aux parents, afin de les habiliter à créer des environnements de langage riches et réceptifs à la maison. À l'aide de cet outil, en collaboration avec le programme Lisez, parlez, chantez de la Société canadienne de pédiatrie et l'initiative Grow Literacy, les médecins seront mieux placés pour offrir des stratégies pratiques aux personnes qui s'occupent d'enfants afin de renforcer les capacités des enfants sur le plan de la parole et du langage.L'outil représente une stratégie pour évaluer les retards de la parole et du langage. Il dépeint les étapes linguistiques et phonétiques propres à l'âge et propose des interventions. L'outil représente un traitement provisoire pratique tandis que la famille attend une consultation officielle en orthophonie.