Simon Berthelot

Push hard, push fast: quasi-experimental study on the capacity of elementary schoolchildren to perform cardiopulmonary resuscitation

BackgroundThe optimal age to begin CPR training is a matter of debate. This study aims to determine if elementary schoolchildren have the capacity to administer CPR efficiently.MethodsThis quasi-experimental study took place in a Quebec City school. Eighty-two children 10 to 12 years old received a 6-hour CPR course based on the American Heart Association (AHA) Guidelines. A comparison group of 20 adults who had taken the same CPR course was recruited. After training, participants’ performance was evaluated using a Skillreporter manikin. The primary outcome was depth of compressions. The secondary outcomes were compression rate, insufflation volume and adherence to the CPR sequence. Children’s performance was primarily evaluated based on the 2005 AHA standards and secondarily compared to the adults’ performance.ResultsSchoolchildren did not reach the lower thresholds for depth (28.1 +/− 5.9 vs 38 mm; one-sided p = 1.0). The volume of the recorded insufflations was sufficient (558.6 +/222.8 vs 500 ml; one-sided p = 0.02), but there were a significant number of unsuccessful insufflation attempts not captured by the Skillreporter. The children reached the minimal threshold for rate (113.9 +/−18.3 vs 90/min; one-sided p < 0.001). They did not perform as well as the adults regarding compression depth (p < 0.001), but were comparable for insufflation volume (p = 0.83) and CPR sequence.ConclusionsIn this study, schoolchildren aged 10–12 years old did not achieve the standards for compression depth, but achieved adequate compression rate and CPR sequence. When attempts were successful at generating airflow in the Skillreporter, insufflation volume was also adequate.

Derivation and Validation of a Quality Indicator to Benchmark In-Hospital Complications Among Injury Admissions.

IMPORTANCE The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge. OBJECTIVES To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity. DESIGN, SETTING, AND PARTICIPANTS Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015. MAIN OUTCOMES AND MEASURES The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting. RESULTS The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82). CONCLUSIONS AND RELEVANCE We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.

A Survey of Rounding Practices in Canadian Adult Intensive Care Units

Objective To describe rounding practices in Canadian adult Intensive Care Units (ICU) and identify opportunities for improvement. Design Mixed methods design. Cross sectional survey of Canadian Adult ICUs (n = 180) with purposefully sampled follow-up interviews (n = 7). Measurements and Main Results Medical directors representing 111 ICUs (62%) participated in the survey. Rounding practices varied across ICUs with the majority reporting the use of interprofessional rounds (81%) that employed an open (94%) and collaborative (86%) approach, occurred at the patient’s bedside (82%), and started at a standard time (79%) and standard location (56%). Most participants reported that patients (83%) and family members (67%) were welcome to attend rounds. Approximately half of ICUs (48%) used tools to facilitate rounds. Interruptions during rounds were reported to be common (i.e., ≥1 interruption for ≥50% of patients) in 46% of ICUs. Four themes were identified from qualitative analysis of participant responses to open-ended survey questions and interviews: multidisciplinarity, patient and family involvement, factors influencing productivity, and teaching and learning. Conclusions There is considerable variation in current rounding practices in Canadian medical/surgical ICUs. Opportunities exist to improve ICU rounds including ensuring the engagement of essential participants, clearly defining participant roles, establishing a standardized approach to the rounding process, minimizing interruptions, modifying the role of teaching, utilizing a structured rounding tool, and developing a metric for measuring rounding quality.

What are emergency-sensitive conditions? A survey of Canadian emergency physicians and nurses.

OBJECTIVE In a previous study, we assembled a multidisciplinary Canadian panel and identified 37 International Classification of Diseases-10-Canada Diagnosis Groups (DGs) for which emergency department (ED) management may potentially reduce mortality (emergency-sensitive conditions). Before using these 37 DGs to calculate a hospital standardized mortality ratio (HSMR) specific to emergency care, we aimed to test their face validity with ED care providers. METHODS We conducted a self-administered web survey among Canadian emergency physicians and nurses between November 22 and December 31, 2012. All members (N=2,507) of the Canadian Association of Emergency Physicians and the National Emergency Nurses Association were surveyed. They were asked to agree or disagree (binary response) with the panel classification for each of the 37 DG emergency-sensitive conditions identified and provide free text responses to identify missing entities. RESULTS A total of 719 ED providers (719 of 2,507, 29%) completed the survey, of whom 470 were physicians (470 of 1,407, 33%) and 232 were nurses (232 of 1,100, 21%). Information on professional status was not provided for 17 respondents. Of 37 DGs, 32 (e.g., A41 sepsis) were rated by more than 80% of respondents to be emergency-sensitive conditions. The remaining five DGs (e.g., E11 type 2 diabetes mellitus) were rated by 68.5 to 79.7% of the respondents to be emergency-sensitive conditions. Respondents suggested an additional 31 emergency-sensitive diagnoses. CONCLUSION We identified 37 emergency-sensitive DGs that had high face validity with emergency physicians and nurses, which will enable the calculation of an ED-HSMR.

Development of a Hospital Standardized Mortality Ratio for Emergency Department Care

STUDY OBJECTIVE Experts have recommended including measures of mortality in emergency department (ED) performance evaluation frameworks. This study aims to develop a hospital standardized mortality ratio (HSMR) for patients admitted to the hospital with conditions for which ED care may reduce mortality (emergency-sensitive conditions). METHODS Data were extracted from Canadian hospital discharge databases from April 1, 2009, to March 31, 2012. The ED HSMR is the ratio of the observed deaths among patients with emergency-sensitive conditions in a hospital during a year to the expected deaths for the same patients during the reference year (2009-2010). The expected deaths were estimated with predictive models fitted for different hospital peer groups (teaching hospitals and large, medium, and small community hospitals). RESULTS The data set included 1,770,809 admissions (9.2% deaths). The ED HSMR was calculated for 47% (294/629) of all Canadian hospitals. The majority of exclusions (98%) were for small community hospitals with fewer than 20 expected deaths. Predictive models had good calibration and discrimination, with areas under the curve ranging from 0.80 to 0.81. In comparisons of 2010-2011 and 2011-2012, the classification of hospitals by ED HSMR quartile was stable, with the majority remaining within the same quartile (43.5%) or moving up or down a single quartile (40.2%). Peer-group-level comparisons between ED HSMR measured at different points after admission (2, 7, and 30 days, and hospital discharge) did not demonstrate any significant differences. CONCLUSION The ED HSMR appears to be a reliable measure with high discrimination, calibration, and forecasting properties that can be used to guide assessment of ED performance.

Using the Bergman-Paris Question to screen seniors in the emergency department

OBJECTIVES In the fast pace of the Emergency Department (ED), clinicians are in need of tailored screening tools to detect seniors who are at risk of adverse outcomes. We aimed to explore the usefulness of the Bergman-Paris Question (BPQ) to expose potential undetected geriatric syndromes in community-living seniors presenting to the ED. METHODS This is a planned sub-study of the INDEED multicentre prospective cohort study, including independent or semi-independent seniors (≥65 years old) admitted to hospital after an ED stay ≥8 hours and who were not delirious. Patients were assessed using validated screening tests for 3 geriatric syndromes: cognitive and functional impairment, and frailty. The BPQ was asked upon availability of a relative at enrolment. BPQs sensitivity and specificity analyses were used to ascertain outcomes. RESULTS A response to the BPQ was available for 171 patients (47% of the main studys cohort). Of this number, 75.4% were positive (suggesting impairment), and 24.6% were negative. To detect one of the three geriatric syndromes, the BPQ had a sensitivity of 85.4% (95% CI [76.3, 92.0]) and a specificity of 35.4% (95% CI [25.1, 46.7]). Similar results were obtained for each separate outcome. Odds ratio demonstrated a higher risk of presence of geriatric syndromes. CONCLUSION The Bergman-Paris Question could be an ED screening tool for possible geriatric syndrome. A positive BPQ should prompt the need of further investigations and a negative BPQ possibly warrants no further action. More research is needed to validate the usefulness of the BPQ for day-to-day geriatric screening by ED professionals or geriatricians.

Performance of the French version of the 4AT for screening the elderly for delirium in the emergency department

OBJECTIVES Delirium is very frequent in older patients presenting to the emergency department (ED), but is often undetected. The purpose of this study was to evaluate the performance of the French version of the 4 A’s Test (4AT-F) for the detection of delirium and cognitive impairment in older patients. METHODS The study was conducted in four Canadian ED. Participants (n= 320) were independent or semi-independent patients (able to perform ≥5 activities of daily living) aged 65 and older and had an 8-hour exposure to the ED environment. The Telephone Interview for Cognitive Status (TICS-m), the Confusion Assessment Method (CAM) as well as the 4AT-F were administered to patients at the initial interview. The CAM and 4AT-F were then administered twice a day during the patients’ ED or hospital stay. The 4AT-F’s sensitivity and specificity were compared to those of the CAM (for delirium), and to that of the TICS (for cognitive impairment). RESULTS Our results suggest that the 4AT-F has a sensitivity of 84% (95% CI: [76, 93]) and a specificity of 74% (95% CI: [70, 78]) for delirium, as well as a sensitivity of 49% (95% CI: [34, 64]) and a specificity of 87% (95% CI: [82, 92]) for cognitive impairment. CONCLUSION The 4AT-F is a fast and reliable screening tool for delirium and cognitive impairment in ED. Due to its quick administration time, it allows a systematic screening of patients at risk of delirium, without significantly increasing the workload of the ED staff.

Incidence of delirium in the Canadian emergency department and its consequences on hospital length of stay: a prospective observational multicentre cohort study

Objective We aim to determine the incidence of delirium and describe its impacts on hospital length of stay (LOS) among non-delirious community-dwelling older adults with an 8-hour exposure to the emergency department (ED) environment. Design This is a prospective observational multicentre cohort study (March–July 2015). Patients were assessed two times per day during their entire ED stay and up to 24 hours on hospital ward. Setting The study took place in four Canadian EDs. Participants 338 included patients: (1) aged ≥65 years; (2) who had an ED stay ≥8 hours; (3) were admitted to hospital ward and (4) were independent/semi-independent. Main outcome(s) and measure(s) The primary outcomes of this study were incident delirium in the ED or within 24 hours of ward admission and ED and hospital LOS. Functional and cognitive status were assessed using validated Older Americans Resources and Services and the modified Telephone Interview for Cognitive Status tools. The Confusion Assessment Method was used to detect incident delirium. Univariate and multivariate analyses were conducted to evaluate outcomes. Results Mean age was 76.8 (±8.1), 17.7% were aged >85 years old and 48.8% were men. The mean incidence of delirium was 12.1% (n=41). Median IQR ED LOS was 32.4 (24.5–47.9) hours and hospital LOS was 146.6 (75.2–267.8) hours. Adjusted mean hospital LOS was increased by 105.4 hours (4.4 days) (95% CI 25.1 to 162.0, P<0.001) for patients who developed an episode of delirium compared with non-delirious patient. Conclusions An incident delirium was observed in one of eight independent/semi-independent older adults after an 8-hour ED exposure. An episode of delirium increases hospital LOS by 4 days and therefore has important implications for patients and could contribute to ED overcrowding through a deleterious feedback loop.

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; &agr;=.63) and waiting times (2 questions; &agr;=.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.