Rural Emergency Medical Services Clinicians' Perceptions and Preferences in Receiving Clinical Feedback From Hospitals: A Qualitative Needs Assessment.

OBJECTIVE: Emergency medical services (EMS) clinicians experience dissatisfaction with the quality and quantity of clinical feedback from hospitals. Satisfaction is further diminished by the lack of a standardized systems approach. The purpose of this study was to identify rural clinicians' perceptions and preferences regarding clinical feedback received from hospitals, the delivery mechanisms, and its impact on their relationships with health care organizations. METHODS: This was a qualitative study focused on EMS clinicians involved in rural prehospital care at a single Midwestern academic medical center. Using a phenomenological framework, semi-structured interviews were conducted with medical directors, service directors, fire captains, air medical personnel, emergency medical responders, emergency medical technicians, advanced emergency medical technicians, and paramedics, all of whom were selected through purposive sampling. Interviews were recorded, transcribed, and independently coded by two trained reviewers. RESULTS: Twenty participants (11 frontline clinicians and 9 administrative staff members) with a wide range of clinical experience from 14 air and ground EMS agencies were interviewed. Emerging themes included: (1) the value or usefulness of feedback; (2) desired feedback system characteristics; (3) barriers to receiving feedback; (4) utilization and application of feedback; and (5) the feedback's impact on the relationship with health care organizations. Participants felt that clinical feedback from hospitals was especially important as a method of improving quality of care, though was rarely provided. Professional development was seen as a major benefit of receiving clinical feedback from hospitals. CONCLUSION: Our results suggest that consistent clinical feedback provided by hospitals was valued. Establishing a culture of providing organized feedback to practicing rural EMS clinicians is important for professional development and can strengthen the relationships between EMS clinicians and hospitals. These study findings can assist in the development and implementation of a standardized feedback instrument to benefit rural EMS clinicians, patients, and the health care system as a whole.

Substance use history is associated with lower opioid use for emergency department pain management.

INTRODUCTION: In the current national opioid crisis, where 10% of the US population has or has had a substance use disorder (SUD), emergency department (ED) clinicians are challenged when treating pain in the ED and when prescribing pain medications to these patients on discharge as there is concern for contributing to the cycle of addiction. The objective of this study was to examine whether acute pain is treated differently in patients with and without current or past SUD by quantifying the amount of opioid analgesia given in the ED and prescribed on discharge. METHODS: Retrospective cohort study of patients presenting to a 60,000-visit tertiary referral ED with acute fracture between January 1, 2016 and June 30, 2019. The primary exposure was indication of SUD (SUD+) versus those without SUD (SUD-). The primary outcome was receipt of opioids in the ED, and the secondary outcome was opioids prescribed at discharge. RESULTS: 117 matched pairs (n = 234) were included in the sample. Overall, 53.4% and 62.4% of patients received opioids in the ED or a prescription for opioids, respectively. Opioid receipt in the ED was lower among SUD+ patients compared to SUD- patients (48.7% and 58.1%, respectively; aOR: 0.33; 95%CI: 0.14, 0.77). Similarly, receipt of a prescription for opioids was lower among SUD+ patients compared to SUD- patients (56.4% and 68.4%, respectively; aOR: 0.50; 95%CI: 0.26, 0.95). CONCLUSIONS: Overall, ED clinicians gave opioids less frequently to SUD+ patients in the ED and on discharge from the ED compared to SUD- patients with acute pain secondary to acute fracture.

Prevalence of anthelmintic resistance on sheep and goat farms in the southeastern United States.

OBJECTIVE: To determine prevalence of anthelmintic resistance on sheep and goat farms in the southeastern United States. DESIGN: Cross-sectional study. ANIMALS: Sheep and goats from 46 farms in 8 southern states, Puerto Rico, and St Croix in the US Virgin Islands. PROCEDURES: Parasite eggs were isolated from fecal samples, and susceptibility to benzimidazole, imidathiazole, and avermectin-milbemycin anthelmintics was evaluated with a commercial larval development assay. RESULTS: Haemonchus contortus was the most common parasite on 44 of 46 farms; Trichostrongylus colubriformis was the second most commonly identified parasite. Haemonchus contortus from 45 (98%), 25 (54%), 35 (76%), and 11 (24%) farms were resistant to benzimidazole, levamisole, ivermectin, and moxidectin, respectively. Resistance to all 3 classes of anthelmintics was detected on 22 (48%) farms, and resistance to all 3 classes plus moxidectin was detected on 8 farms (17%). CONCLUSIONS AND CLINICAL RELEVANCE: Findings provided strong evidence that anthelmintic resistance is a serious problem on small ruminant farms throughout the southeastern United States. Owing to the frequent movement of animals among regions, the prevalence of resistance in other regions of the United States is likely to also be high. Consequently, testing of parasite eggs for anthelmintic resistance should be a routine part of parasite management on small ruminant farms.