Carolyn Snider

Predictors of Emergency Department Use by Persons with Inflammatory Bowel Diseases: A Population-based Study

Background:To describe the patterns and predictors of emergency department (ED) attendance and post-ED hospitalization by persons with inflammatory bowel disease (IBD). Methods:We linked the University of Manitoba IBD Epidemiology Database with the Emergency Department Information System of the Winnipeg Regional Health Authority to determine the rates of presentation to the ED by persons with IBD from January 01, 2009 to March 31, 2012. Incident cases were diagnosed during the study period and all others were considered prevalent cases. Multivariate logistic regression was used to determine predictors of attendance in the ED and for hospitalization within 2 days of ED attendance. Results:The study population included 300 incident and 3394 prevalent IBD cases, of whom 76% and 49%, respectively, attended the ED at least once during the study period. Incident cases with Crohns disease or with a history of opioid use were more likely to attend the ED. Those who had seen a gastroenterologist within the year before diagnosis were less likely to visit the ED. Among prevalent cases, higher comorbidity, opioid or corticosteroid use, and recent hospital admission were predictive of ED attendance and those who saw only 1 physician in the preceding year had lower ED attendance. Presenting to the ED with a primary gastrointestinal complaint was the strongest predictor of subsequent hospital admission. Conclusions:ED attendance by both incident and prevalent cases of IBD is high. Identified predictors of ED attendance and post-ED hospitalization could guide the optimization of outpatient IBD care to limit ED attendance and potentially post-ED hospitalization.

Wraparound care for youth injured by violence: study protocol for a pilot randomised control trial

Introduction Injury by violence is the fourth cause of death and the leading reason for a youth to visit an emergency department (ED) in Canada. In Winnipeg, 20% of youth who visit an ED with an injury due to violence have a second visit for a subsequent violent injury within 1 year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. Methods and analysis This protocol describes a wraparound care model delivered by a support worker with lived experience with violence, supported by social workers and links to multiple community partners. Support workers will be on call 24 h a day, 7 days a week in order to start the intervention in the ED and take advantage of the ‘teachable moment’. The protocol is of a pilot randomised control trial to assess the feasibility of a randomised control trial designed to assess efficacy. For the pilot trial, we will assess recruitment, treatment fidelity, participant adherence and safety. The intervention arm will receive wraparound care initiated at the time of their visit for injury due to violence. The control arm will receive standard care. We will use an adapted preconsent randomisation methodology. This intervention has been developed using an integrated knowledge translation approach. Discussion Interventions delivered in the ED for youth injured by violence require an approach that is appropriate for the unique situation the youth are in. Ethics The University of Manitoba Health Research Ethics Board (HS 16445 (Cohort study) and HS 16444 (WrapAround Care study) granted ethical approval. Trial registration number NCT01895738.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

Background Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV). Methods Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients. Results The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians. Conclusions PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

Improving bicycle safety in Canada

Cycling is a popular recreational and transportation option, especially in urban areas in Canada. Unfortunately, injuries resulting from cycling are common and result in many Emergency Department (ED) presentations, ranging from minor to life threatening. While it may not be possible to eliminate all cycling injuries in Canada, it should be possible to mitigate their severity and frequency, by addressing a number of important contributing factors. The most important of these factors are the built environment, the visibility of the cyclists, and the use of bicycle helmets. Addressing and improving each of these factors will help reduce injuries to cyclists. As emergency physicians, we have a responsibility to advocate for public policy changes that can prevent injury and save lives.

A multilevel analysis of risk and protective factors for Canadian youth injured or killed by interpersonal violence

Purpose The study’s purpose was to determine individual-level and neighbourhood-level risk and protective factors for severe intentional injury among youth. Methods We conducted a multilevel case–control study using registry data to determine individual-level and neighbourhood-level social determinants associated with severe violent injury/homicide among youth from Winnipeg, Manitoba. Results The study includes 13 206 youth, aged 12–24 years (1222 cases, 11 984 controls). Individual-level risk predictors of being a victim of violence were male sex (OR 5.72 (95% CI 4.77 to 6.86)) and First Nations (OR 2.76 (95% CI 2.32 to 3.29)). Education was inversely associated with victimisation for individuals under (OR 0.36 (95% CI 0.26 to 0.51)) and over (OR 0.58 (95% CI 0.49 to 0.69)) 18 years. Ever having been in protective care (OR 1.66 (95% CI 1.39 to 1.99)), receiving income assistance from the government (OR 1.26 (95% CI 1.05 to 1.51)) or ever having criminal charges (OR 4.76 (95% CI 4.08 to 5.56)) were also significant predictors of being a victim of violence. Neighbourhood-level risk factors for victimisation included low socioeconomic status (OR 1.14 (95% CI 1.04 to 1.25)) and high levels of assault (OR 1.07 (95% CI 1.04 to 1.10)). Conclusions This study demonstrates a complex web of risk and protective factors among youth injured by violence. It underscores the ongoing, injurious effects of historical trauma experienced by many Canadian First Nations people. Strong victim–perpetrator overlap suggests that intersectoral policies are needed to address these issues. Our findings highlight the need to improve education and family supports.

Validity of the days supply field in pharmacy administrative claims data for the identification of blister packaging of medications

Pharmacy claims data is often used in pharmacoepidemiology studies, but no studies to date have examined whether it was possible to identify the use of blister packs in these databases. We aimed to determine whether medications dispensed in days divisible by 7 are more likely to be blister packed than medications dispensed in other quantities.

Injury prevention in the emergency department: An ongoing challenge Reference to: Emergency Physicians as human billboards for injury prevention: A randomized controlled trial by Emily Sullivan et al.

Almost 2 million people visited Canadian emergency departments (ED) with injuries in 2013, accounting for 10% of ED visits. Only 4% of these were admitted. With injury being the number one killer of young people in Canada and a huge burden on our health care system, there is no doubt that Canadian emergency physicians must play a role in injury prevention. Yet, in the heat of a shift, all of us find it hard to fit in the counselling that may potentially help that patient avoid a future injury or even death. Finding effective injury prevention tools that will not impact our productivity, yet potentially decrease the numbers of patients coming to our ED, is difficult. In this month’s CJEM, Dr. Emily Sullivan and colleagues present a study on a novel ED-based prevention program to improve counselling on the use of bicycling helmets. The randomized control trial tested the hypothesis that if a physician wears a scrub top with the injury prevention message, “Put me out of work: wear your bike helmet,” time spent at the bedside counselling on injury prevention would increase. They also tested whether this would change bike helmet wearing behaviour. The results were negative in all outcomes. There was a minimal change in length of injury prevention counselling among those who were treated by a scrub-wearing physician versus a non-scrub-wearing physician and no change in helmet-wearing behaviour. This is likely disappointing to the authors and to others who are looking for quick opportunities to provide injury prevention counselling in the ED. The authors humbly note many limitations to their study such as the small sample size and high loss to follow-up. Would education of physicians on how to effectively counsel on bike helmet use have changed their results? Would only targeting those with cycling injuries change their results? Importantly, this study raises questions on how we can better advocate as emergency physicians in injury prevention. Our job doesn’t end at shift change. I am not alone in perseverating at home after seeing too many injuries caused by various risk-taking activities. As emergency physicians, we have a powerful voice in our community – both locally and nationally. Injury prevention can take many forms. Commonly, injury prevention practitioners acknowledge the importance of change in environment and legislation that will affect entire populations, and many physicians have been successful in initiating major changes. In the 1940s, Dr. Jay Arena saw a second child die from an aspirin (acetylsalicylic acid or ASA) overdose. He contacted the head of the pharmaceutical company that manufactured ASA, and both brainstormed ways to make the product safer – including tops that are hard for children to remove. Twenty years later, these closures became mandatory and have saved many lives. Canadian emergency physicians have lobbied for legislative change in drinking and driving, cell phone use while driving, and gun control. Yet all of the engineering and legislation cannot eliminate unsafe behaviours and resultant visits to the ED. What can we do in the ED during that teachable moment – that moment when a patient is often reflective on their risky behaviour and receptive to change?

Development of an emergency department violence intervention program for youth: an integrated knowledge translation approach

Abstract:Background: Violent interpersonal injury is a common presentation to emergency departments (EDs) and is increasingly being treated as a preventable condition. Given the complexity of the issue, it is key to ensure interventions are feasible and acceptable within the communities that are affected by violence. Our team consists of ED staff, community members who work with youth affected by violence, people who were affected by violence in their youth, and researchers.Objectives: We describe how an integrated knowledge translation (KT) process was used to develop an ED violence intervention program (EDVIP) for youth affected by violence.Methods: We used the Canadian Institutes of Health Research Guidelines for integrated KT (iKT) to develop an EDVIP. Specifically, we report the Knowledge to Action process which involves both knowledge creation and an action cycle.Results: Our team determined the research question, the research approach, assessed feasibility and determined outcomes for our study. Using the iKT approach facilitated initiation of a funded trial that is now active.Conclusions: This paper highlights the benefit of including community experts at the beginning of and throughout the research process.

339 Wraparound care for youth injured by violence: a pilot randomised control trial

Background Youth injured by violence is a major public health concern in Canada. It is the fourth leading cause of death in youth and the foremost reason youth visit an emergency department (ED). In Winnipeg, 20% of youth who visit an ED with an injury due to violence will have an ED visit for a subsequent violent injury within one year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. Methods We completed a pilot randomised control trial in November 2015 comparing wraparound care for youth age 14 – 24 who were injured by violence to standard ED care. Youth were excluded if their injury was due to child maltreatment, sexual assault or self-harm. An adapted pre-consent randomization methodology was used. The intervention was developed using a community based participatory research approach. Wraparound care was delivered by a support worker with lived experience with violence. Support workers were on call 24/7 in order to start the intervention in the ED and take advantage of the “teachable moment.” Care continued in the community for approximately one year. Results A total of 133 youth were randomised (68 intervention, 65 control) in one year. There was no difference in age, gender, or severity of injury between the two groups. Patients randomised to the intervention spent a median of 30 minutes less in the ED than those receiving standard care (p = 0.22). Youth are safely housed, have enrolled in education opportunities, and are engaged in addictions care. Results of a chart review examining repeat visits to the ED for violent injury, substance use and mental health will be completed in late 2015 and will be presented. Conclusions There were no differences between standard care and intervention groups on baseline characteristics reflecting effective randomization. The introduction of an intervention at bedside in the ED did not have a negative impact on patient length of stay.

A too-early lesson.

Last Christmas, our toddler asked Santa for a stethoscope. While initially “a black one like Mommy’s” was requested, my daughter learned that a pink and purple Dora stethoscope was possible and was impressed with Santa when it arrived. She wore it proudly, even exclaiming loudly during a toilet-training moment: “This doctor has got to Poo!” “Helping sick people,” the gist of our job as emergency physicians, according to my toddler, is simplified to putting bandages on, providing ice packs, and complete healing of all that ails by simply laying the stethoscope on various body parts. The naïve nature of my daughter’s perception is refreshing. To be honest, it is nice to have someone believe so whole-heartedly in one’s ability as a physician to heal, despite truly knowing my limitations. Recently, a young friend of my daughter’s from day care was killed in a car collision. While, as an emergency physician, I am skilled at discussing death with adults, the discussion with a toddler is new territory for me, especially my own daughter. A toddler isn’t supposed to understand the permanence of death, let alone the death of someone her own age. My daughter wonders why the doctors couldn’t fix her friend. She wonders why a bandage or ice pack didn’t help. Just when I think she may be starting to comprehend the situation, she asks when her friend is coming back to day care... and why the doctors couldn’t fix her. My daughter’s processing of this death comes in spurts peppered by totally unrelated, often happy comments. While in the bathtub, she asked if her friend fell out of the car and then started showing off her bubble blowing. At day care, she asked if her friend was coming that day but then quickly followed with giggles over my forgetting her lunch bag on the counter. A children’s grief counselor commented to me that “children have this amazing ability to balance deep sorrow and deep joy at the same time.” Witnessing my daughter experience these far-tooearly life lessons has been heartbreaking. Prior to this event, I envied her naïve perception of both eternal life and that doctors can fix everything. I admit that I enjoyed being celebrated for my work at home after long shifts of facing the reality that humans are so vulnerable to chance and that we as physicians are often quite limited in our abilities to help some. The end of my shift now brings pointed questions about the names of the people that I helped and whether I fixed them. Perhaps, I was naïve in believing that she would remain oblivious to these realities.