Evolution of burnout and psychological distress in healthcare workers during the COVID-19 pandemic: a 1-year observational study.

BACKGROUND: Long-term psychological impacts of the COVID-19 pandemic on healthcare workers remain unknown. We aimed to determine the one-year progression of burnout and mental health since pandemic onset, and verify if protective factors against psychological distress at the beginning of the COVID-19 pandemic (Cyr et al. in Front Psychiatry; 2021) remained associated when assessed several months later. METHODS: We used validated questionnaires (Maslach Burnout Inventory, Hospital Anxiety and Depression and posttraumatic stress disorder [PTSD] Checklist for DSM-5 scales) to assess burnout and psychological distress in 410 healthcare workers from Quebec, Canada, at three and 12 months after pandemic onset. We then performed multivariable regression analyses to identify protective factors of burnout and mental health at 12 months. As the equivalent regression analyses at three months post-pandemic onset had already been conducted in the previous paper, we could compare the protective factors at both time points. RESULTS: Prevalence of burnout and anxiety were similar at three and 12 months (52% vs. 51%, p = 0.66; 23% vs. 23%, p = 0.91), while PTSD (23% vs. 11%, p < 0.0001) and depression (11% vs. 6%, p = 0.001) decreased significantly over time. Higher resilience was associated with a lower probability of all outcomes at both time points. Perceived organizational support remained significantly associated with a reduced risk of burnout at 12 months. Social support emerged as a protective factor against burnout at 12 months and persisted over time for studied PTSD, anxiety, and depression. CONCLUSIONS: Healthcare workers' occupational and mental health stabilized or improved between three and 12 months after the pandemic onset. The predominant protective factors against burnout remained resilience and perceived organizational support. For PTSD, anxiety and depression, resilience and social support were important factors over time.

Trajectory of patients consulting the emergency department for high blood pressure values.

OBJECTIVES: Emergency department (ED) visits for high blood pressure are increasing in frequency. We aimed to map those patients' trajectory, from referral sources to the type of care received at the ED to anticipated actions for future high blood pressure concerns, and to better understand their reasons for consulting the ED for high blood pressure values. METHODS: Between 2018 and 2020, patients who presented to the Montreal Heart Institute's ED for elevated blood pressure were recruited in a prospective observational study including a post hoc structured telephone interview and medical chart review. Five possible referral sources were predetermined. We provided proportions and 95% confidence intervals. RESULTS: A total of 100 patients were recruited (female: 59%, mean age: 69 ± 12). A majority (93%, 95% CI 88-98%) possessed a home blood pressure device, among which 46% (95% CI 36-56%) remembered receiving advice for its use. The main referral sources for high blood pressure to the ED were self-reference (53%, 95% CI 43-63%), advice of a lay person (19%, 95% CI 11-27%) or a nurse (13%, 95% CI 6-20%). Mainly, patients reported being concerned by concomitant symptoms or experiencing acute medical consequences (44%, 95% CI 34-54%), having followed the recommendation of a third party (33%, 95% CI 24-42%), or having concerns about their medication (6%, 95% CI 1-11%). Two weeks following their ED visits, consulting ED remained the main choice for future concerns about high blood pressure for 27% of participants. When specifically asked if they would return to the ED for elevated blood pressure, 73% (95% CI 64-83%) said yes. CONCLUSIONS: Most patients who consulted the ED for elevated blood pressure values were self-referred. More can be done to promote blood pressure education, effective use of personal blood pressure devices, and recommendations for patients and health professionals when confronted with high blood pressure results.

RéSUMé: OBJECTIFS: Les visites aux services d'urgence pour hypertension artérielle (TA) sont de plus en plus fréquentes. Nous avons cherché à cartographier le parcours de ces patients, depuis les sources d'orientation jusqu'au type de soins reçus aux urgences, en passant par les mesures prévues en cas de problèmes futurs de tension artérielle élevée, et à mieux comprendre les raisons pour lesquelles ils consultent les urgences pour des valeurs de tension artérielle élevées. MéTHODES: Entre 2018 et 2020, les patients qui se sont présentés aux urgences de l'Institut de cardiologie de Montréal pour une TA élevée ont été recrutés dans le cadre d'une étude observationnelle prospective comprenant une entrevue téléphonique structurée post-hoc et un examen des dossiers médicaux. Cinq sources de référence possibles ont été prédéterminées. Nous avons fourni des proportions et des intervalles de confiance à 95 %. RéSULTATS: Au total, 100 patients ont été recrutés (femmes : 59 %, âge moyen : 69 ± 12). Une majorité (93%, IC à 95% 88-98%) possédait un tensiomètre à domicile, parmi lesquels 46% (IC à 95% 36-56%) se souvenaient avoir reçu des conseils pour son utilisation. Les principales sources d'orientation vers les urgences en cas de tension artérielle élevée étaient l'auto-référence (53 %, IC 95 % 43-63 %), le conseil d'un tiers non-professionnel de la santé (19 %, IC à 95 % 11-27 %) ou d'une infirmière (13 %, IC à 95 % 6-20 %). Principalement, les patients ont déclaré être préoccupés par des symptômes concomitants ou des conséquences médicales aiguës (44 %, IC à 95 %, 34-54 %), avoir suivi la recommandation d'un tiers (33 %, IC à 95 %, 24-42 %) ou avoir des préoccupations au sujet de leurs médicaments (6 %, IC à 95 %, 1-11 %). Deux semaines après leur visite au service d'urgence, la consultation du service d'urgence est restée le principal choix en cas de préoccupations futures concernant l'hypertension artérielle pour 27 % des participants. À la question spécifique de savoir s'ils retourneraient aux urgences pour une TA élevée, 73% (IC à 95% 64-83%) ont répondu oui. CONCLUSIONS: La plupart des patients qui ont consulté les urgences pour des valeurs élevées de la tension artérielle se sont adressés d'eux-mêmes. Il y a place à l'amélioration pour promouvoir l'éducation sur la TA, l'utilisation efficace des appareils de pression artérielle personnels et les recommandations aux patients et aux professionnels de la santé lorsqu'ils sont confrontés à des résultats élevés en matière de TA.

Impact of rubidium imaging availability on management of patients with acute chest pain.

OBJECTIVE: Evaluate the impact of 82-Rubidium positron emission tomography (PET) myocardial perfusion imaging (MPI) availability on patient management presenting at the emergency department (ED) with chest pain (CP). METHODS: This is a single-center retrospective study of clinical databases. Patients presenting with CP with a non-definitive suspicion of acute coronary syndrome (ACS) at the ED between April 2016 and February 2020 were divided into 2 groups based on PET availability. The proportion of invasive coronary angiography (ICA) without significant coronary artery disease (CAD), length of stay (LoS), and additional downstream testing were evaluated. RESULTS: There were 21,242 ED visits for CP without definitive ACS: 5,492 when PET is not available and 15,750 when PET is available. When PET is available, proportion of patients undergoing a MPI study was greater (20.7% vs 17.6%, P<0.0001), proportion of ICA without significant CAD was similar (18.5% vs 21.4%, P=0.24), and median ED LoS was shorter (16.6 vs 18.1 hours, P=0.03). Patients undergoing SPECT MPI had significantly more downstream testing (8.9% vs 6.4%, P=0.003) and a higher rate of coronary angiogram without significant CAD (21.2% vs 14.2%, P=0.09) compared to those who underwent PET MPI. CONCLUSION: Availability of PET MPI was associated with an increased number of MPI referral from the ED, similar rates of ICA without significant CAD, decreased LoS, and fewer downstream testing.

OBJETIVO: Evaluar el impacto de la tomografía por emisión de positrones (PET) con 82-Rubidio y la disponibilidad de imágenes de perfusión miocárdica (MPI) en el manejo de los pacientes que se presentan en el servicio de urgencias (ED) con dolor torácico (CP). MéTODOS: Este es un estudio retrospectivo de bases de datos clínicas de un solo centro. Pacientes que presentaron CP con sospecha no definitiva de síndrome coronario agudo (ACS) en el ED entre abril de 2016 y febrero de 2020, se dividieron en 2 grupos según la disponibilidad de PET. Se evaluó la proporción de angiografía coronaria invasiva (ICA) sin enfermedad arterial coronaria (CAD) significativa, la duración de la estancia (LoS) y las pruebas posteriores adicionales. RESULTADOS: Hubo 21,242 visitas al ED por CP sin ACS definitivo: 5,492 cuando no se dispone de PET y 15.750 cuando se dispone de PET. Cuando se dispone de PET, la proporción de pacientes sometidos a estudio de MPI fue mayor (20.7% vs 17.6%, p=0.03). Los pacientes que se sometieron a SPECT MPI tuvieron significativamente más pruebas posteriores (8.9 % frente a 6.4 %, p = 0.003) y una tasa más alta de angiografía coronaria sin CAD significativa (21.2 % frente a 14.2 %, p = 0.09) en comparación con los que se sometieron a PET MPI. CONCLUSIóN: La disponibilidad de PET MPI se asoció con un mayor número de referencias de MPI desde el ED, tasas similares de ICA sin CAD significativa, disminución de LoS y menos pruebas posteriores.

Hair cortisol change at COVID-19 pandemic onset predicts burnout among health personnel.

BACKGROUND: The COVID-19 pandemic has put chronic pressure on worldwide healthcare systems. While the literature regarding the prevalence of psychological distress and associated risk factors among healthcare workers facing COVID-19 has exploded, biological variables have been mostly overlooked. METHODS: 467 healthcare workers from Quebec, Canada, answered an electronic survey covering various risk factors and mental health outcomes three months after the onset of the COVID-19 pandemic. Of them, 372 (80%) provided a hair sample, providing a history of cortisol secretion for the three months preceding and following the pandemic's start. We used multivariable regression models and a receiver operating characteristic curve to study hair cortisol as a predictor of burnout and psychological health, together with individual, occupational, social, and organizational factors. RESULTS: As expected, hair cortisol levels increased after the start of the pandemic, with a median relative change of 29% (IQR = 3-59%, p < 0.0001). There was a significant association between burnout status and change in cortisol, with participants in the second quarter of change having lower odds of burnout. No association was found between cortisol change and post-traumatic stress disorder, anxiety, and depression symptoms. Adding cortisol to individual-occupational-socio-organizational factors noticeably enhanced our burnout logistic regression model's predictability. CONCLUSION: Change in hair cortisol levels predicted burnout at three months in health personnel at the onset of the COVID-19 pandemic. This non-invasive biological marker of the stress response could be used in further clinical or research initiatives to screen high-risk individuals to prevent and control burnout in health personnel facing an important stressor.

The feasibility of home self-assessment of vital signs and symptoms: A new key to telehealth for individuals?

OBJECTIVE: During the COVID-19 pandemic, social distancing and self-isolation called for innovative, readily implementable, and effective short-term health solutions. The objective of this study was to assess the feasibility of self-assessment of vital signs and symptoms with electronic transmission of results, by self-isolating individuals with positive SARS-CoV-2 polymerase chain reaction (PCR) test. The secondary objective was to describe the association between the presence of abnormal vital signs and severe symptoms as well as their evolution over time. METHOD: Participants with positive SARS-CoV-2 PCR test were asked to perform twice daily standardized vital signs measurements and self-assessment of symptoms for 14 consecutive days. All data were transmitted electronically through a mobile application and a web-based platform. Participants were provided with decision support tools based on the severity of their condition and a weekly nurse practitioner telephone follow-up. Abnormal values for vital signs and severe symptoms were determined. Per participant and per days, proportions of abnormal vital signs and severe symptoms were calculated. RESULTS: Data from 46 participants (mean age 54.1 ± 6.9 years, 54% male) were available for analysis. On average, participants performed the standardized self-assessment for 12.3 ± 3.4 days (89% performed at least 7 measurement days and 61% completed all 14 days). The highest proportions abnormal values for vital signs were for oximetry (20.1%) and respiratory rate (12.1%). The highest proportions of severe symptoms were for fatigue (16.9%) and myalgia. (10.2%). The combined proportion of abnormal vital signs and severe symptoms was maximal on day 1 with 20.3% of total measurements, with a linear decrease to 3.5% on day 14. CONCLUSION: Remote initiation of home measurements of vital signs and symptoms, self-management of these measures, accompanied by a decision support tool and supported by preplanned nurse follow-up are feasible. This could allow to opening up new insight for the care of sick individuals.

Adverse Events Associated With Electrical Cardioversion in Patients With Acute Atrial Fibrillation and Atrial Flutter.

BACKGROUND: We sought to evaluate safety of electrical cardioversion (ECV) for patients with acute atrial fibrillation (AF) or atrial flutter (AFL) in the emergency department (ED). METHODS: This was an analysis of data from 4 multicentre AF/AFL studies conducted from 2008 to 2019 at 23 large EDs. We included adult patients who received attempts at ECV and who had presented acutely after symptom onset. Staff manually reviewed study and clinical records to abstract data. RESULTS: We evaluated 1736 ECV cases with a mean age of 60.1 years and 67.1% male. The overall success of ECV was 90.2% (95% confidence interval 88.7%-91.6%), with 4.9% of patients admitted. ED physicians performed the ECV in 95.2% and provided sedation in 96.5%; 13.9% (12.3%-15.7%) of cases experienced important adverse events that required treatment, and 0.4% were classified as life threatening. Another 5.6% had adverse events that did not require treatment. Logistic regression found that the RAFF-3 study cohort (odds ratio [OR] 2.0), age ≥ 85 years (OR 2.1), coronary artery disease (OR 1.5), midazolam (OR 1.9), and fentanyl (OR 1.5) were associated with important adverse events. CONCLUSIONS: This large evaluation of the safety of ECV for acute AF/AFL in the ED found that while serious adverse events were rare, there were a concerning number of events following sedation that required intervention. Physicians should be aware that older age, coronary artery disease, and fentanyl are associated with higher risks of important adverse events. This study provides more information for shared decision making discussions with patients when choosing between drug-shock and shock-only cardioversion strategies.

Front-line emergency department nurses' and physicians' assessments of processes of elder-friendly care for quality improvement.

INTRODUCTION: Geriatric emergency department (ED) care has gained increasing importance and interest due to increasing visits in seniors. AIM: Among ED front-line nurses and physicians, to assess and compare ratings of elder-friendly care process indicators, variability in ratings, and concurrent validity of ratings. METHODS: Four Quebec EDs' full-time registered nurses and physicians rated their geriatric care using 9 subscales. Nurse and physician subscale scores were compared. Inter-rater variability within disciplines and variability between nurses and physicians were measured. Associations between the subscale scores and perceived overall quality of care were tested. RESULTS: 38 nurses and 36 physicians completed the survey (83% of 89 eligible). Scores differed by discipline for 3 of 9 subscales computed; nurses had higher mean scores on Protocols, Family-Centered Discharge, and Staff Education. Very high variation for Staff Education was found within disciplines. Variations for Family-Centered Discharge differed significantly between nurses and physicians. Almost all subscale scores were significantly positively associated with perceived overall quality of care. CONCLUSIONS: ED nurses and physicians rate geriatric care components similarly except for protocols, discharge processes, and continuing education. The subscales have concurrent validity. Results suggest a need for improvement in continuing educational strategies with a particular attention to discharge processes.

Factors Associated With Burnout, Post-traumatic Stress and Anxio-Depressive Symptoms in Healthcare Workers 3 Months Into the COVID-19 Pandemic: An Observational Study.

Objective: This study examined how best to identify modifiable protective and risk factors for burnout in healthcare workers in the face of the COVID-19 pandemic. Individual, occupational, organizational and social factors were investigated. The study also assessed the impact of these factors on post-traumatic stress disorder (PTSD), anxiety, and depression. Methods: Healthcare workers in the Quebec (Canada) healthcare system were recruited between May 21 to June 5, 2020. Participants answered an electronic survey 3 months after the COVID-19 epidemic outbreak began in Canada. Using the Maslach Burnout Inventory, PTSD Checklist for DSM-5, and Hospital Anxiety and Depression Scale, we studied the prevalence of burnout, PTSD, anxiety and depression in this cohort. Multivariable logistic or linear regression models including resilience, social and organizational support, workload and access to mental health help, simulation techniques and protective personal equipment (PPE) as well as perception of PPE security were conducted for each outcome. Results: In mid-June 2020, 467 participants completed the survey. We found that half (51.8%) of the respondents experienced burnout characterized by emotional exhaustion and/or depersonalization at least once a week. In total, 158 healthcare workers (35.6%) displayed severe symptoms of at least one of the mental health disorders (24.3% PTSD, 23.3% anxiety, 10.6% depression). Resilience (OR = 0.69, 95% CI: [0.55-0.87]; p = 0.002) and perceived organizational support (OR = 0.75, 95% CI: [0.61-0.93]; p = 0.009) were significantly associated with burnout and other outcomes. Social support satisfaction, perception of PPE security, work type and environment, mental health antecedents and reassignment were associated with PTSD and/or anxiety and/or depression, but not burnout. Conclusion: Future studies should address primarily resilience and perceived organizational support to promote mental health and prevent burnout, PTSD, anxiety and depression.

RAFF-3 Trial: A Stepped-Wedge Cluster Randomised Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department.

BACKGROUND: We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the Canadian Association of Emergency Physicians (CAEP) Acute AF/AFL Best Practices Checklist. METHODS: We conducted a stepped-wedge cluster randomised trial at 11 large community and academic hospital EDs in 5 Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was introduction of the CAEP Checklist with the use of a knowledge translation-implementation approach that included behaviour change techniques and organisation/system-level strategies. The primary outcome was length of stay in ED, and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed-effects regression adjusting for covariates. RESULTS: Patient visits in the control (n = 314) and intervention (n = 404) periods were similar with mean age 62.9 years, 54% male, 71% onset < 12 hours, and 86% AF, 14% AFL. We observed a reduction in length of stay of 20.9% (95% confidence interval [CI] 5.5%-33.8%; P = 0.01), an increase in use of rhythm control (adjusted odds ratio [OR] 4.5, 95% CI 1.8-11.6; P = 0.002), and a decrease in use of rate-control medications (OR 0.5, 95% CI 0.2-0.9; P = 0.02). There was no change in adverse events and no strokes or deaths by 30 days. CONCLUSIONS: The RAFF-3 trial led to optimised care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities.

A randomized, controlled comparison of electrical versus pharmacological cardioversion for emergency department patients with acute atrial flutter.

BACKGROUND: Acute atrial flutter has one-tenth the prevalence of acute atrial fibrillation in the emergency department (ED) but shares many management strategies. Our aim was to compare conversion from acute atrial flutter to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (Drug-Shock), and electrical cardioversion alone (Shock-Only). METHODS: We conducted a randomized, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with IV procainamide followed by electrical cardioversion if necessary, and placebo infusion followed by electrical cardioversion. We enrolled stable patients with a primary diagnosis of acute acute atrial flutter at 11 academic EDs. The primary outcome was conversion to normal sinus rhythm. FINDINGS: From July 2013 to October 2018, we enrolled 76 patients, and none were lost to follow-up. Comparing the Drug-Shock to the Shock-Only group, conversion to sinus rhythm occurred in 33 (100%) versus 40 (93%) (absolute difference 7.0%; 95% CI - 0.6 to 14.6; P = 0.25). Median time to conversion from start of infusion in the Drug-Shock group was 24 min (IQR 21-82) but only 9 (27%) cases were converted with IV procainamide. Patients in both groups had similar outcomes at 14 days; there were no strokes or deaths. INTERPRETATION: This trial found that the Drug-Shock strategy is potentially superior but that either approach to immediate rhythm control in the ED for patients with acute acute atrial flutter is highly effective, rapid, and safe in restoring sinus rhythm and allowing patients to go home and return to normal activities. Unlike the case of atrial fibrillation, we found that IV procainamide alone was infrequently effective.

RéSUMé: CONTEXTE: Le flutter auriculaire aigu a un dixième de la prévalence de la fibrillation auriculaire aiguë aux services d'urgence (SU) mais partage de nombreuses stratégies de gestion. Notre objectif était de comparer la conversion du flutter auriculaire aigu en rythme sinusal entre la cardioversion pharmacologique suivie de la cardioversion électrique (Drug-Shock) et la cardioversion électrique seule (Shock-Only). MéTHODES: Nous avons effectué une comparaison randomisée, en aveugle et contrôlée par placebo d'une tentative de cardioversion pharmacologique avec le procaïnamide IV suivie d'une cardioversion électrique si nécessaire, et une perfusion de placebo suivie d'une cardioversion électrique. Nous avons inscrit des patients stables avec un diagnostic primaire de flutter auriculaire aigu aigu dans 11 services d'urgence universitaires. Le résultat principal était la conversion à un rythme sinusal normal. RéSULTATS: De juillet 2013 à octobre 2018, nous avons inscrit 76 patients qui ont tous poursuivi le suivi médical jusqu'au terme prévu. En comparant le groupe Drug-Shock au groupe Shock-Only, la conversion au rythme sinusal s'est produite dans 33 (100%) contre 40 (93%) (différence absolue 7,0%; IC à 95% − 0.6 à 14,6; P = 0,25). Le temps médian de conversion depuis le début de la perfusion dans le groupe Drug-Shock était de 24 min (IQR 21­82) mais seulement 9 (27%) cas ont converti avec le procaïnamide IV. Les patients des deux groupes ont eu des résultats similaires à 14 jours; il n'y a pas eu d'accident vasculaire cérébral ni de décès. INTERPRéTATION: Cet essai a révélé que la stratégie Drug-Shock s'est avérée potentiellement supérieure, mais quelle que soit l'approche du contrôle immédiat du rythme cardiaque aux urgences pour les patients atteints de flutter auriculaire aigu aigu, elles sont, tous les deux, très efficaces, rapides et sûres pour rétablir le rythme sinusal et permettre aux patients de rentrer chez eux et reprendre leurs activités normales. Contrairement au cas de la fibrillation auriculaire, nous avons constaté que le procaïnamide IV seul était rarement efficace.

Experiences of an Emergency Department Visit Among Older Adults and Their Families: Qualitative Findings From a Mixed-Methods Study.

BACKGROUND: Emergency department (ED) visits are critical events for older adults, but little is known regarding their experiences, particularly about their physical needs, the involvement of accompanying family members, and the transition back to the community. OBJECTIVE: To explore experiences of an ED visit among patients aged 75 and older. METHODS: In a mixed-methods study, a cohort of patients aged 75 and older (or a family member) discharged from the ED back to the community was recruited from 4 urban EDs. A week following discharge, structured telephone interviews supplemented with open-ended questions were conducted. A subsample (76 patients, 32 family members) was purposefully selected. Verbatim transcripts of responses to the open-ended questions were thematically analyzed. RESULTS: Experiences related to physical needs included comfort, equipment supporting mobility and autonomy, help when needed, and access to drink and food. Family members required opportunities to provide patient support and greater involvement in their care. At discharge, patients/families required adequate discharge education, resolution of their health problem, information on medications, and greater certainty about planned follow-up medical and home care services. CONCLUSIONS: Our findings suggest several areas that could be targeted to improve patient and family perceptions of the care at an ED visit.

Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial.

BACKGROUND: Acute atrial fibrillation is the most common arrythmia treated in the emergency department. Our primary aim was to compare conversion to sinus rhythm between pharmacological cardioversion followed by electrical cardioversion (drug-shock), and electrical cardioversion alone (shock-only). Our secondary aim was to compare the effectiveness of two pad positions for electrical cardioversion. METHODS: We did a partial factorial trial of two protocols for patients with acute atrial fibrillation at 11 academic hospital emergency departments in Canada. We enrolled adult patients with acute atrial fibrillation. Protocol 1 was a randomised, blinded, placebo-controlled comparison of attempted pharmacological cardioversion with intravenous procainamide (15 mg/kg over 30 min) followed by electrical cardioversion if necessary (up to three shocks, each of ≥200 J), and placebo infusion followed by electrical cardioversion. For patients having electrical cardioversion, we used Protocol 2, a randomised, open-label, nested comparison of anteroposterior versus anterolateral pad positions. Patients were randomly assigned (1:1, stratified by study site) for Protocol 1 by on-site research personnel using an online electronic data capture system. Randomisation for Protocol 2 occurred 30 min after drug infusion for patients who had not converted and was stratified by site and Protocol 1 allocation. Patients and all research and emergency department staff were masked to treatment allocation for Protocol 1. The primary outcome was conversion to normal sinus rhythm for at least 30 min at any time after randomisation and up to a point immediately after three shocks. Protocol 1 was analysed by intention to treat and Protocol 2 excluded patients who did not receive electrical cardioversion. This study is registered at ClinicalTrials.gov, number NCT01891058. FINDINGS: Between July 18, 2013, and Oct 17, 2018, we enrolled 396 patients, and none were lost to follow-up. In the drug-shock group (n=204), conversion to sinus rhythm occurred in 196 (96%) patients and in the shock-only group (n=192), conversion occurred in 176 (92%) patients (absolute difference 4%; 95% CI 0-9; p=0·07). The proportion of patients discharged home was 97% (n=198) versus 95% (n=183; p=0·60). 106 (52%) patients in the drug-shock group converted after drug infusion only. No patients had serious adverse events in follow-up. The different pad positions in Protocol 2 (n=244), had similar conversions to sinus rhythm (119 [94%] of 127 in anterolateral group vs 108 [92%] of 117 in anteroposterior group; p=0·68). INTERPRETATION: Both the drug-shock and shock-only strategies were highly effective, rapid, and safe in restoring sinus rhythm for patients in the emergency department with acute atrial fibrillation, avoiding the need for return to hospital. The drug infusion worked for about half of patients and avoided the resource intensive procedural sedation required for electrical cardioversion. We also found no significant difference between the anterolateral and anteroposterior pad positions for electrical cardioversion. Immediate rhythm control for patients in the emergency department with acute atrial fibrillation leads to excellent outcomes. FUNDING: Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research.

Screening for hypertension in adults during emergency department consultation: a systematic review.

A large proportion of patients affected with hypertension go undetected. A systematic review was conducted to assess the performance of a screening strategy in adults using blood pressure measurement at the time of an emergency department consultation. A systematic literature search on Embase, CINHAL and Medline was carried out. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy. Intervention studies with adults including at least one blood pressure measurement for all participants were included. A repeat blood pressure assessment had to have been carried out to assess the validity of the elevated blood pressure value within the next few days after the emergency department initial visit. Out of 1030 articles identified, published between 1985 and 2018, 10 articles met the inclusion criteria. There were no randomized clinical trials. Mean age of participants was 51.6 years. A single study reports that blood pressure screening was measured according to hypertension guidelines referred to in the study. The average follow-up rate was 61.9% (95% confidence interval 45.5-78.3). For diagnostic confirmation, four studies used a blood pressure measurement method based on the reported guidelines. Half of the patients (50.2%) with elevated blood pressure during the emergency department visit had blood pressure corresponding to uncontrolled elevated blood pressure at follow-up measurement. The contribution of emergency department to the screening for hypertension, by recognizing the presence of elevated blood pressure and then making a referral for diagnostic confirmation, could provide an opportunity to detect a large number of people with hypertension.

The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.

OBJECTIVES: Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA. METHODS: This cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression. RESULTS: A total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001). CONCLUSION: Survival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

How Older Adults Experience an Emergency Department Visit: Development and Validation of Measures.

STUDY OBJECTIVE: This study aims to develop and validate measures of experiences of an emergency department (ED) visit suitable for use by older adults or their family members. METHODS: A cohort of patients aged 75 years and older who were discharged home was recruited at 4 EDs. At 1 week after the visit, patients or family members were interviewed by telephone to assess problems experienced at the visit. Twenty-six questions based on 6 domains of care found in the literature were developed: 16 questions were administered to all patients; 10 questions were administered to bed patients only. Scales were developed with multiple correspondence analysis. Regression analyses were used to validate the scales, using 2 validation criteria: perceived overall quality of care and willingness to return to the same ED. RESULTS: Four hundred twelve patients completed the 1-week interview, 197 ambulatory and 215 bed patients; family members responded for 75 patients. Two scales were developed, assessing personal care and communication (8 questions; α=.63) and waiting times (2 questions; α=.79). Both scales were significantly independently associated with perceived overall quality of care and willingness to return to the same ED. CONCLUSION: Two scales assessing important aspects of ED care experienced by older adults are ready for further evaluation in other settings.

Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest.

AIMS: Patients suffering from out-of-hospital cardiac arrest (OHCA) are frequently transported to the closest hospital. Percutaneous coronary intervention (PCI) is often indicated following OHCA. This study's primary objective was to determine the association between being transported to a PCI-capable hospital and survival to discharge for patients with OHCA. The additional delay to hospital arrival which could offset a potential increase in survival associated with being transported to a PCI-capable center was also evaluated. METHODS: This study used a registry of OHCA in Montreal, Canada. Adult patients transported to a hospital following a non-traumatic OHCA were included. Hospitals were dichotomized based on whether PCI was available on-site or not. The effect of hospital type on survival to discharge was assessed using a multivariable logistic regression. The added prehospital delay which could offset the increase in survival associated with being transported to a PCI-capable center was calculated using that regression. RESULTS: A total of 4922 patients were included, of whom 2389 (48%) were transported to a PCI-capable hospital and 2533 (52%) to a non-PCI-capable hospital. There was an association between being transported to a PCI-capable center and survival to discharge (adjusted odds ratio = 1.60 [95% confidence interval 1.25-2.05], p < .001). Increasing the delay from call to hospital arrival by 14.0 min would offset the potential benefit of being transported to a PCI-capable center. CONCLUSIONS: It could be advantageous to redirect patients suffering from OHCA patients to PCI-capable centers if the resulting expected delay is of less than 14 min.

Elder-Friendly Emergency Department: Development and Validation of a Quality Assessment Tool.

OBJECTIVES: To develop and validate a comprehensive quality assessment tool for emergency department (ED) geriatric care. DESIGN: Four-step study: (1) Content development of tool by a multidisciplinary panel, (2) survey of ED lead physicians and nurses, (3) development of subscales using principal component analysis and clinical judgment, (4) reliability and validity assessment. SETTING: Province of Quebec, Canada. PARTICIPANTS: Lead ED nurses and physicians at 76 Quebec EDs who participated in a 2013/14 survey (66% of 116 adult nonpsychiatric EDs in the province). MEASUREMENTS: Geriatric care items (n = 62) grouped into seven preliminary content areas (screening and assessment, clinical protocols, discharge planning, staffing, physical environment, continuing education, quality assessment), lead nurse and physician perceptions of the quality of ED geriatric care, institutional prioritization of geriatric care, and ED type. RESULTS: Thirteen subscales were developed; most were associated with ED type and quality indicators. CONCLUSION: Thirteen subscales for geriatric ED services are proposed for evaluation in various ED settings.

Changes in Emergency Department Geriatric Services in Quebec and Correlates of These Changes.

BACKGROUND/OBJECTIVES: To describe changes in geriatric emergency department (ED) services from 2006 (T1) to 2013/14 (T2), associated factors, and outcomes. DESIGN: Two-wave survey design. SETTING: Province of Quebec, Canada. PARTICIPANTS: Lead nurses and physicians at 57 EDs that participated in both the T1 and T2 surveys. INTERVENTION: Changes over time in ED geriatric services, observed naturalistically. MEASUREMENTS: Survey questionnaires assessed: ED geriatric services (11 items) and nursing and geriatric staffing resources. Key administrative data indicators for ED bed visits for T1 and T2 for ages 75 and over included: volume of ED visits; length of ED stay; admission rate; and 30-day return visits. RESULTS: There was a significant overall increase in the number ED geriatric services, from mean 2.8 (SD 2.2) at T1 to mean 6.0 (SD 2.0) at T2. EDs were clustered into 3 groups based on their T1 and T2 geriatric service scores: "early adopters" (n = 12); "late adopters" (n = 27); "non-adopters" (n = 18). Group membership was associated with three T1 variables: availability of a geriatric nurse clinician, a lower ratio of nurses to ED beds, and longer ED stays. There were significant overall increases between T1 and T2 in number of ED bed visits and ED length of stay among those aged 75 and over, decreases in hospitalization rates, but no change in ED return visits. There were no differential changes in the key indicators among the three ED clusters. CONCLUSIONS: Overall, ED geriatric services improved in Quebec from 2006 to 2013/14. EDs with a geriatric nurse clinician, relatively fewer nursing resources, and longer ED stays improved more quickly.