The effects of bystander interventions for foreign body airway obstruction on survival and neurological outcomes: Findings of the MOCHI registry.

INTRODUCTION: Foreign body airway obstruction (FBAO) is a life-threatening condition. We aimed to quantify the impact of bystander FBAO interventions on survival and neurological outcomes. METHODS: We conducted a Japan-wide prospective, multi-center, observational study including all FBAO patients who presented to the Emergency Department from April 2020 to March 2023. Information on bystander FBAO interventions was collected through interviews with emergency medical services personnel. Primary outcomes included 1-month survival and favorable neurologic outcome defined as Cerebral Performance Category 1 or 2. We performed a multivariable logistic regression and a Cox proportional hazards modeling to adjust for confounders. RESULTS: We analyzed a total of 407 patients in the registry who had the median age of 82 years old (IQR 73-88). The FBAO incidents were often witnessed (86.5%, n = 352/407) and the witnesses intervened in just over half of the cases (54.5%, n = 192/352). The incidents frequently occurred at home (54.3%, n = 221/407) and nursing home (21.6%, n = 88/407). Common first interventions included suction (24.8%, n = 101/407) and back blow (20.9%, n = 85/407). The overall success rate of bystander interventions was 48.4% (n = 93/192). About half (48.2%, n = 196/407) survived to 1-month and 23.8% patients (n = 97/407) had a favorable neurological outcome. Adjusting for pre-specified confounders, bystander interventions were independently associated with survival (hazard ratio, 0.55; 95% CI, 0.39-0.77) and a favorable neurological outcome (adjusted OR, 2.18; 95% CI, 1.23-3.95). CONCLUSION: Bystander interventions were independently associated with survival and favorable neurological outcome, however, they were performed only in the half of patients.

Ambulance Traffic Crashes in Japan: Characteristics of Casualties and Efforts to Improve Ambulance Safety.

BACKGROUND: An ambulance traffic crash not only leads to injuries among emergency medical service (EMS) professionals but also injures patients or their companions during transportation. We aimed to describe the incidence of ambulance crashes, seating location, seatbelt use for casualties (ie, both fatal and nonfatal injuries), ambulance safety efforts, and to identify factors affecting the number of ambulance crashes in Japan. METHODS: We conducted a nationwide survey of all fire departments in Japan. The survey queried each fire department about the number of ambulance crashes between January 1, 2017, and December 31, 2019, the number of casualties, their locations, and seatbelt usage. Additionally, the survey collected information on fire department characteristics, including the number of ambulance dispatches, and their safety efforts including emergency vehicle operation training and seatbelt policies. We used regression methods including a zero-inflated negative binomial model to identify factors associated with the number of crashes. RESULTS: Among the 726 fire departments in Japan, 553 (76.2%) responded to the survey, reporting a total of 11,901,210 ambulance dispatches with 1,659 ambulance crashes (13.9 for every 100,000 ambulance dispatches) that resulted in a total of 130 casualties during the 3-year study period (1.1 in every 100,000 dispatches). Among the rear cabin occupants, seatbelt use was limited for both EMS professionals (n = 3/29, 10.3%) and patients/companions (n = 3/26, 11.5%). Only 46.7% of the fire departments had an internal policy regarding seatbelt use. About three-fourths of fire departments (76.3%) conducted emergency vehicle operation training internally. The output of the regression model revealed that fire departments that conduct internal emergency vehicle operation training had fewer ambulance crashes compared to those that do not (odds of being an excessive zero -2.20, 95% CI: -3.6 to -0.8). CONCLUSION: Two-thirds of fire departments experienced at least one crash during the study period. The majority of rear cabin occupants who were injured in ambulance crashes were not wearing a seatbelt. Although efforts to ascertain seatbelt compliance were limited, Japanese fire departments have attempted a variety of methods to reduce ambulance crashes including internal emergency vehicle operation training, which was associated with fewer ambulance crashes.

Food choking incidents in the hospital: Incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes.

AIM: Foreign body airway obstruction (FBAO) due to food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes. METHODS: We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents due to food in the hospital from January 2010 to June 2021 and collected data on the characteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents. RESULTS: We identified 300 patients who had a FBAO incident from food. The most common age group was 80-89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in successful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from these incidents. CONCLUSION: FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.

Incidence of adverse events for procedural sedation and analgesia for cardioversion using thiopental in elderly patients: a multicenter prospective observational study.

Aim: The incidence and characteristics of thiopental-related adverse events (AEs) in elderly patients during procedural sedation and analgesia (PSA) have not been well studied. We aimed to characterize thiopental-related AE in elderly patients during PSA and compare the incidence of AE in elderly patients with non-elderly adults. Methods: This is a secondary analysis of the Japanese Procedural Sedation and Analgesia Registry (JPSTAR). We included all adult patients who received thiopental for PSA in the emergency departments and excluded patients who received concomitant sedative(s) in addition to thiopental or patients with missing body weight data. We compared the incidence of AE between the non-elderly (18-64 years) and elderly groups (≥65 years). Results: The JPSTAR had data on 379 patients who received thiopental for PSA and included 311 patients for analysis. Most (222/311, 71.3%) were elderly. Cardioversion was the most common reason for PSA (96.1%). The AE incidence between groups overall was similar, however, hypoxia was significantly more frequent in the elderly compared with the non-elderly group (10.3% versus 2.2%; adjusted odds 5.63, 95% confidence interval 1.27-25.0). The initial and total doses of thiopental were significantly lower in the elderly group than in the non-elderly group (1.95 mg/kg versus 2.21 mg/kg and 2.33 mg/kg versus 2.93 mg/kg, respectively). Conclusions: Although elderly patients received lower doses of thiopental, hypoxic events were significantly more frequent in this group compared with the non-elderly patients. However, the AE incidence was similar.

Students of Change: Health Policy in Action.

BACKGROUND AND OBJECTIVES: Health policy is more impactful for public health than many other strategies as it can improve health outcomes for an entire population. Yet in the "see one, do one, teach one" environment of medical school, most students never get past the "see one" stage in learning about the powerful tools of health policy and advocacy. The University of New Mexico School of Medicine mandates health policy and advocacy education for all medical students during their family medicine clerkship rotation. The aim of this project is to describe a unique health policy and advocacy course within a family medicine clerkship. METHODS: We analyzed policy briefs from 265 third-year medical students from April 2016 through April 2019. Each brief is categorized by the level of change targeted for policy reform: national, state, city, or university/school. Implemented policies are described. RESULTS: Slightly less than one-third of the policies (30%) relate to education, 36% advocate for health system change by addressing cost, access, or quality issues, and 34% focus on public health issues. Fourteen policies have been initiated or successfully enacted. CONCLUSIONS: This curriculum gives each medical student a health policy tool kit with immediate opportunities to test their skills, learn from health policy and advocacy experts, and in some cases, implement health policies while still in medical school. A 1-week family medicine policy course can have impact beyond the classroom even during medical school, and other schools should consider this as a tool to increase the impact of their graduates.

CT imaging of extraglottic airway device-pictorial review.

Compared to intubation with a cuffed endotracheal tube, extraglottic airway devices (EGDs), such as laryngeal mask airways, are considered less definitive ventilation conduit devices and are therefore often exchanged via endotracheal intubation (ETI) prior to obtaining CT images. With more widespread use and growing comfort among providers, reports have now described use of EGDs for up to 24 h including cases for which clinicians obtained CT scans with an EGD in situ. The term EGD encompasses a wide variety of devices with more complex structure and CT appearance compared to ETI. All EGDs are typically placed without direct visualization and require less training and time for insertion compared to ETI. While blind insertion generally results in functional positioning, numerous studies have reported misplacements of EGDs identified by CT in the emergency department or post-mortem. A CT-based classification system has recently been suggested to categorize these misplacements in six dimensions: depth, size, rotation, device kinking, mechanical blockage of the ventilation opening(s), and injury from EGD placement. Identifying the type of EGD and its correct placement is critically important both to provide prompt feedback to clinicians and prevent inappropriate medicolegal problems. In this review, we introduce the main types of EGDs, demonstrate their appearance on CT images, and describe examples of misplacements.

Extraglottic Airway Device Misplacement: A Novel Classification System and Findings in Postmortem Computed Tomography.

STUDY OBJECTIVE: Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ. METHODS: We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications. RESULTS: We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries. CONCLUSION: We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.

Evaluating Target: Stroke guideline implementation on assessment and treatment times for patients with suspected stroke.

OBJECTIVES: Immediate ischemic stroke treatment improves outcomes and early alteplase administration is recommended for patients within window. We implemented stroke guidelines through a neuro-resuscitation initiative (NRI) and hypothesized that the intervention would decrease times to assessment and treatment. METHODS: We analyzed quality assurance data for EMS and triage patients arriving to our academic emergency department with suspected ischemic stroke to compare outcomes 12 months before to 6 months after initiative implementation at an academic certified primary stroke center in the U.S. Southwest. We examined four time-based outcomes: neurology at bedside, CT head without contrast, CT head angiogram, and alteplase administration. We summarized times with median and IQR values and compared pre and post times to event (in minutes) with Wilcoxon rank sum tests and Kaplan-Meier survival curves. RESULTS: We identified 203 EMS (83 pre, 120 post) and 66 (11 pre, 55 post) triage Stroke Alert patients. We observed decreased times for all outcomes in both the EMS and triage samples; however, only those in the EMS sample were significant. In the EMS sample, neurology at bedside median times decreased from 20 min to 2 min (p < 0.001); median minutes to CT head without contrast decreased from 16 min to 9 min (p < 0.001); median minutes to CT head angiogram decreased from 71 min to 21 min (p = 0.007); and, median minutes to alteplase decreased from 72 min to 49.5 min (p = 0.04). CONCLUSIONS: An academic ED led stroke care initiative streamlined evaluation and care with significantly shortened times to all four events.

A mini-review of procedural sedation and analgesia in the emergency department.

Procedural sedation and analgesia (PSA) is performed for a variety of indications in emergency departments (EDs). Although the practice of PSA in the ED is somewhat unique from other clinical areas, there is currently no guideline for this practice in Japan. Policy statements and guidelines for PSA have been published in Europe and North America. These guidelines suggest first evaluating patients carefully before performing PSA, and then deciding on target sedative level and choice of medications. Patient evaluation requires a combination of continuous visual observation by trained medical staff to assess the depth of sedation and respiration with noninvasive measurements of blood pressure, continuous electrocardiography monitoring, and pulse oximetry. Sedative selection should be based on its characteristics, peak time, effectiveness, and risks. It is important to administer sedatives and analgesics in small, incremental doses while keeping a close eye on the patient's reaction to avoid adverse events (AEs) until the planned sedation level is reached. Further, additional attention is needed for special populations such as pediatric and elderly patients. PSA is a key element for patient-centered care in emergency medicine. In this manuscript, we review the available evidence for PSA in the EDs, including guidelines for evaluation, monitoring, pharmacology, AEs, and special populations such as pediatric and elderly patients.

Protocol for a nationwide prospective, observational cohort study of foreign-body airway obstruction in Japan: the MOCHI registry.

INTRODUCTION: Foreign body airway obstruction (FBAO) is a major public health issue worldwide. In 2017, there were more than 5000 fatal choking cases in the USA alone, and it was the fourth leading cause of preventable injury-related death in the home and community. In Japan, FBAO is the leading cause of accidental death and with almost 9000 fatalities annually. However, research on FBAO is limited, particularly on the impact of a foreign body (FB) removal manoeuvres by bystanders. The primary objective of this study is to determine the impact of bystander FB removal manoeuvres on 1 month neurological outcome. Our secondary objectives include (1) evaluating the efficacy of a variety of FB removal manoeuvres; (2) identifying risk factors for unsuccessful removal and (3) evaluating the impact of time intervals from incidents of FBAO to FB removal on neurological outcome. METHODS AND ANALYSIS: We will conduct a nationwide multi-centre prospective cohort study of patients with FBAO who present to approximately 100 emergency departments in both urban and rural areas in Japan. Research personnel at each participating site will collect variables including patient demographics, type of FB and prehospital variables, such as bystander FB removal manoeuvres, medical interventions by prehospital personnel, advanced airway management and diagnostic findings. Our primary outcome is 1 month favourable neurological outcome defined as cerebral performance category 1 or 2. Our secondary outcomes include success of FB removal manoeuvres and complications from the manoeuvres. We hypothesise that bystander FB removal manoeuvres improve patient survival with a favourable neurological outcome. ETHICS AND DISSEMINATION: This study received research ethics approval from Nippon Medical School Hospital (B-2019-019). Research ethics approval will be obtained from all participating sites before entering patients into the registry. The study was registered at the University Hospital Medical Information Network (UMIN) Clinical Trials Registry. TRIAL REGISTRATION NUMBER: UMIN 000039907.

Conceptualising social accountability as an attribute of medical education.

BACKGROUND: Health professionals need to be both person- and community oriented to improve population health. For educators to create socially accountable physicians, they must move learners from understanding social accountability as an expectation to embracing and incorporating it as an aspect of professional identity that informs medical practice. AIM: The aim of this article was to assess the degree to which medical students, preceptors and community mentors understand the concept of social accountability. SETTING: The setting is the KwaZulu-Natal Province in Durban, South Africa. METHODS: Using an observational design, we surveyed 332 participants, including the first- and sixth-year medical students, physician preceptors and community mentors. RESULTS: Whilst most respondents understood social accountability as requiring an action or set of actions, it was defined by some as simply the awareness one must have about the needs of their patients, community or society at large. Some respondents defined social accountability as multi-dimensional, but these definitions were the exception, not the rule. Finally, most respondents did not identify to whom the accountable party should answer. CONCLUSION: Whilst the development of professional identity is seen as a process of 'becoming', the ability to define and understand what it means to be socially accountable is not a linear process. Assessment of this progress may start with comprehending how social accountability is understood by students when they begin their education and when they are graduating, as well as in knowing how their educators, both clinical and community, define it.

Conceptualising social accountability as an attribute of medical education

Background: Health professionals need to be both person- and community oriented to improve population health. For educators to create socially accountable physicians, they must move learners from understanding social accountability as an expectation to embracing and incorporating it as an aspect of professional identity that informs medical practice. Aim: The aim of this article was to assess the degree to which medical students, preceptors and community mentors understand the concept of social accountability. Setting: The setting is the KwaZulu-Natal Province in Durban, South Africa. Methods: Using an observational design, we surveyed 332 participants, including the first- and sixth-year medical students, physician preceptors and community mentors. Results: Whilst most respondents understood social accountability as requiring an action or set of actions, it was defined by some as simply the awareness one must have about the needs of their patients, community or society at large. Some respondents defined social accountability as multi-dimensional, but these definitions were the exception, not the rule. Finally, most respondents did not identify to whom the accountable party should answer. Conclusion: Whilst the development of professional identity is seen as a process of 'becoming', the ability to define and understand what it means to be socially accountable is not a linear process. Assessment of this progress may start with comprehending how social accountability is understood by students when they begin their education and when they are graduating, as well as in knowing how their educators, both clinical and community, define it

Contribution of the Nelson R. Mandela School of Medicine to a socially accountable health workforce.

BACKGROUND: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. 'Fit-for-purpose' can be assessed by monitoring graduate practice attributes. AIM: The aim of this article was to identify whether graduates of 'fit-for-purpose' programmes are socially accountable. SETTING: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. METHODS: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors' characteristics and reasons for leaving or staying at district hospitals. RESULTS: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors. CONCLUSION: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs.

Contribution of the Nelson R. Mandela School of Medicine to a socially accoun table health workforce

Background: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. 'Fit-for-purpose' can be assessed by monitoring graduate practice attributes. Aim: The aim of this article was to identify whether graduates of 'fit-for-purpose' programmes are socially accountable. Setting: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. Methods: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors' characteristics and reasons for leaving or staying at district hospitals. Results: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors.Conclusion: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs

Deterring Future Incidents of Intimate Partner Violence: Does Type of Formal Intervention Matter?

Few studies examine the comparative effectiveness of different formal interventions for domestic violence. Using arrest and civil protection order data, we compare three intervention scenarios (arrest, civil protection order, and both). Results suggest that intervention type has no substantive influence on the odds of reoffending. However, subsequent domestic violence is significantly associated with offender age, sex, and prior offense history as well as victim age and sex. We discuss our findings and their policy implications, noting that responding agencies should be sensitive to the characteristics that increase the odds of reoffending among those they come into contact with.

Addressing Interpersonal Violence as a Health Policy Question Using Interprofessional Community Educators.

INTRODUCTION: The health effects of intimate partner violence (IPV) not only include physical injury, but can also manifest as posttraumatic stress disorder, anxiety, and others. US medical students report receiving inadequate training about IPV. This case-based tutorial for third-year medical students examines: (1) a clinical encounter with a patient experiencing several complex challenges including IPV and homelessness; (2) the implications of existing policy on the delivery of health care services; and (3) the impact of policies on patient choices. METHODS: This case is completed during a family medicine clerkship. The 2-hour case review moves between small- and large-group sessions led by community interprofessional experts at a local family advocacy center. Optimal group size is three to four students and one or two experts per group. The large-group session should be led by a dynamic moderator who is familiar with the Socratic method of teaching to elicit a variety of responses to ad hoc challenge questions. Materials provided include student resources, student case, facilitator guide, moderator guide, and sample brochure of IPV documentation policies. RESULTS: To date, over 200 students have participated in this session. During the most recent iteration the average response to the question, "As a result of the FAC experience, I feel more empowered to care for persons experiencing IPV," was 4.1 out of 5 (5 = strongly agree). DISCUSSION: Public health, health policy, and clinical topics can be effectively taught by an interprofessional team of community experts and lead to improved student understanding of the importance of health policy to both individual and population health outcomes.