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Objectives This project seeks to improve providers’ practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention.Design We conduct a two-arm, controlled, mixed-methods, hybrid type II study.Setting This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa.Interventions We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites.Outcome measures We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model.Results 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (−1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99).Conclusions In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.

Introduction: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT). Methods: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets. Results: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215. Conclusion: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.

BackgroundNeutralizing monoclonal antibody (mAb) treatment for COVID-19 prevents hospitalization and death but is underused, especially in racial/ethnic minority and rural populations. Reasons for underuse and inequity may include community member lack of awareness or healthcare access barriers, among others. This study assessed mAbs community awareness and opportunities for improving equitable mAb access.MethodsA concurrent mixed methods study including surveys and focus groups with adults with high-risk conditions or their proxy decision-makers. Surveys and focus group guides addressed diffusion of innovation theory factors. Descriptive statistics and Fisher's exact method was used to report and compare survey findings by race and ethnicity. Rapid qualitative methods were used for focus group analysis.ResultsSurveys from 515 individuals (460 English, 54 Spanish, 1 Amharic), and 8 focus groups (6 English, 2 Spanish) with 69 participants, completed June 2021 to January 2022. Most survey respondents (75%) had heard little or nothing about mAbs, but 95% would consider getting mAb treatment. Hispanic/Latino and Non-Hispanic People of Color (POC) reported less awareness, greater concern about intravenous infusions, and less trust in mAb safety and effectiveness than White, Non-Hispanic respondents. Focus group themes included little awareness but high interest in mAb treatment and concerns about cost and access barriers such as lacking established sources of care and travel from rural communities. Focus groups revealed preferences for broad-reaching but tailored messaging strategies using multiple media and trusted community leaders.ConclusionsDespite unfamiliarity with mAb treatment, most respondents were open to receiving mAbs or recommending mAbs to others. While mAb messaging should have broad reach "to everyone everywhere," racial and geographic disparities in awareness and trust about mAbs underscore need for tailored messaging to promote equitable access. Care processes should address patient-level barriers like transportation, insurance, or primary care access. COVID-19 treatment dissemination strategies should promote health equity.

Introduction Intubation-related complications are less frequent when intubation is successful on the first attempt. The rate of first attempt success in the emergency department (ED) and intensive care unit (ICU) is typically less than 90%. The bougie, a semirigid introducer that can be placed into the trachea to facilitate a Seldinger-like technique of tracheal intubation and is typically reserved for difficult or failed intubations, might improve first attempt success. Evidence supporting its use, however, is from a single academic ED with frequent bougie use. Validation of these findings is needed before widespread implementation.Methods and analysis The BOugie or stylet in patients Undergoing Intubation Emergently trial is a prospective, multicentre, non-blinded randomised trial being conducted in six EDs and six ICUs in the USA. The trial plans to enrol 1106 critically ill adults undergoing orotracheal intubation. Eligible patients are randomised 1:1 for the use of a bougie or use of an endotracheal tube with stylet for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is severe hypoxaemia, defined as an oxygen saturation less than 80% between induction until 2 min after completion of intubation. Enrolment began on 29 April 2019 and is expected to be completed in 2021.Ethics and dissemination The trial protocol was approved with waiver of informed consent by the Central Institutional Review Board at Vanderbilt University Medical Center or the local institutional review board at an enrolling site. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences.Trial registration number ClinicalTrials.gov Registry (NCT03928925).

Background: Randomised controlled trials (RCTs) exploring the potential of vitamin D to prevent acute respiratory infections have yielded mixed results. Individual participant data (IPD) meta-analysis has the potential to identify factors that may explain this heterogeneity. Objectives: To assess the overall effect of vitamin D supplementation on the risk of acute respiratory infections (ARIs) and to identify factors modifying this effect. Data sources: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, ClinicalTrials.gov and the International Standard Randomised Controlled Trials Number (ISRCTN) registry. Study selection: Randomised, double-blind, placebo-controlled trials of supplementation with vitamin D3 or vitamin D2 of any duration having incidence of acute respiratory infection as a prespecified efficacy outcome were selected. Study appraisal: Study quality was assessed using the Cochrane Collaboration Risk of Bias tool to assess sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, completeness of outcome data, evidence of selective outcome reporting and other potential threats to validity. Results: We identified 25 eligible RCTs (a total of 11,321 participants, aged from 0 to 95 years). IPD were obtained for 10,933 out of 11,321 (96.6%) participants. Vitamin D supplementation reduced the risk of ARI among all participants [adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.81 to 0.96; heterogeneity p

Introduction: Emergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.Methods: This study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.Results: Of 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.Conclusions: Successful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations. [West J Emerg Med. 2013;14(3):287–295.]

BACKGROUND: In a previous small retrospective study, the authors reported that hepatopulmonary syndrome was less common among liver transplant candidates at high-altitude centres compared with low-altitude centres.

Background: Tracheostomy is used for patients who require prolonged mechanical ventilation. Extensive research has described the provision and optimal timing of tracheostomy, but very little describes tracheostomy utilization in low- and middle-income countries, particularly in sub-Saharan Africa., Methods: This prospective cohort study describes patients admitted to the intensive care unit (ICU) of a tertiary hospital in Malawi who received tracheostomy versus those who did not, with a primary outcome of hospital mortality. We performed subgroup analysis of patients with severe head injuries., Results: The analysis included 451 patients admitted to the study ICU between September 2016 and July 2018. Overall hospital mortality was 40% for patients who received tracheostomy and 63% for patients who did not. Logistic regression modeling revealed an odds ratio (OR) of 0.34 (95% CI 0.18-0.64) for hospital mortality among patients who received tracheostomy versus those who did not (p < 0.001). Standardized mortality ratio weighting revealed an odds ratio of 0.81 (95% CI 0.65-0.99, p < 0.001) for hospital death among patients who received tracheostomy versus those who did not. In the subgroup excluding severe head injury, both ICU (50%) and hospital mortality (75%) were higher overall, but hospital mortality was not more common for patients with tracheostomy versus without (OR 1.28, 95% CI 0.94-1.74, p = 0.104)., Conclusions: Tracheostomy is not associated with hospital mortality in a Malawi ICU cohort, but these results are affected by the presence of head injury. Research may focus on home tracheostomy care given the lack of hospital discharge options for patients in austere settings., (© 2021. Société Internationale de Chirurgie.)

Importance: Data on the efficacy of hydroxychloroquine for the treatment of coronavirus disease 2019 (COVID-19) are needed., Objective: To determine whether hydroxychloroquine is an efficacious treatment for adults hospitalized with COVID-19., Design, Setting, and Participants: This was a multicenter, blinded, placebo-controlled randomized trial conducted at 34 hospitals in the US. Adults hospitalized with respiratory symptoms from severe acute respiratory syndrome coronavirus 2 infection were enrolled between April 2 and June 19, 2020, with the last outcome assessment on July 17, 2020. The planned sample size was 510 patients, with interim analyses planned after every 102 patients were enrolled. The trial was stopped at the fourth interim analysis for futility with a sample size of 479 patients., Interventions: Patients were randomly assigned to hydroxychloroquine (400 mg twice daily for 2 doses, then 200 mg twice daily for 8 doses) (n = 242) or placebo (n = 237)., Main Outcomes and Measures: The primary outcome was clinical status 14 days after randomization as assessed with a 7-category ordinal scale ranging from 1 (death) to 7 (discharged from the hospital and able to perform normal activities). The primary outcome was analyzed with a multivariable proportional odds model, with an adjusted odds ratio (aOR) greater than 1.0 indicating more favorable outcomes with hydroxychloroquine than placebo. The trial included 12 secondary outcomes, including 28-day mortality., Results: Among 479 patients who were randomized (median age, 57 years; 44.3% female; 37.2% Hispanic/Latinx; 23.4% Black; 20.1% in the intensive care unit; 46.8% receiving supplemental oxygen without positive pressure; 11.5% receiving noninvasive ventilation or nasal high-flow oxygen; and 6.7% receiving invasive mechanical ventilation or extracorporeal membrane oxygenation), 433 (90.4%) completed the primary outcome assessment at 14 days and the remainder had clinical status imputed. The median duration of symptoms prior to randomization was 5 days (interquartile range [IQR], 3 to 7 days). Clinical status on the ordinal outcome scale at 14 days did not significantly differ between the hydroxychloroquine and placebo groups (median [IQR] score, 6 [4-7] vs 6 [4-7]; aOR, 1.02 [95% CI, 0.73 to 1.42]). None of the 12 secondary outcomes were significantly different between groups. At 28 days after randomization, 25 of 241 patients (10.4%) in the hydroxychloroquine group and 25 of 236 (10.6%) in the placebo group had died (absolute difference, -0.2% [95% CI, -5.7% to 5.3%]; aOR, 1.07 [95% CI, 0.54 to 2.09])., Conclusions and Relevance: Among adults hospitalized with respiratory illness from COVID-19, treatment with hydroxychloroquine, compared with placebo, did not significantly improve clinical status at day 14. These findings do not support the use of hydroxychloroquine for treatment of COVID-19 among hospitalized adults., Trial Registration: ClinicalTrials.gov: NCT04332991.

The quick sequential organ failure assessment (qSOFA) score has been proposed as a means to rapidly identify adult patients with suspected infection, in pre-hospital, Emergency Department (ED), or general hospital ward locations, who are in a high-risk category with increased likelihood of "poor outcomes:" a greater than 10% chance of dying or an increased likelihood of spending 3 or more days in the ICU. This score is intended to replace the use of systemic inflammatory response syndrome (SIRS) criteria as a screening tool; however, its role in ED screening and identification has yet to be fully elucidated. In this retrospective observational study, we explored the performance of triage qSOFA (tqSOFA), maximum qSOFA, and first initial serum lactate (> 3 mmol/L) at predicting in-hospital mortality and compared these results to those for the initial SIRS criteria obtained in triage. A total of 2859 sepsis cases were included and the in-hospital mortality rate was 14.4%. The sensitivity of tqSOFA ≥ 2 and maximum qSOFA ≥ 2 to predict in-hospital mortality were 33% and 69%, respectively. For comparison, the triage SIRS criteria and the initial lactate > 3 mmol/L had sensitivities of 82% and 65%, respectively. These results demonstrate that in a large ED sepsis database the earliest measurement of end organ impairment, tqSOFA, performed poorly at identifying patients at increased risk of mortality and maximum qSOFA did not significantly outperform initial serum lactate levels.

Study objectives Older adults who sustain hip fractures are susceptible to high rates of morbidity and mortality. The systemic administration of opioids is associated with side effects disproportionately affecting the elderly. The ultrasound-guided fascia iliaca compartment block procedure (FICB) is associated with a reduced patient need for oral and parenteral opioids and with improved functional outcomes. We designed a multi-disciplinary quality improvement initiative to train emergency physicians (EPs) to perform the ultrasound-guided FICB procedure for geriatric hip fracture patients. We examined the lessons derived from the EPs' resistance to implementing a practice-changing behavior. Methods This study was a prospective observational cohort study. We included all emergency department (ED) patients > 65 years with X-ray confirmation of isolated hip fractures. We also enrolled the treating EPs. Patients were enrolled from March 2016 to January 2017 in an urban, academic ED with 100,000 annual visits. The ED ultrasound faculty trained ED faculty and residents in the FICB procedure. Seventeen of 50 attending EPs completed the training: classroom lecture and online narrated video instruction. The hands-on sessions consisted of three stations: scan a human model volunteer to review the sonoanatomy, practice the needle technique using a Blue Phantom TM Regional Anesthesia Ultrasound Training Block Model (Simulaids, Inc., NY, US), and practice the needle technique using a static simulator. We created a multi-disciplinary geriatric hip fracture order set for the electronic medical record. The attending EPs, caring for eligible patients, were asked to complete a Research Electronic Data Capture (REDCap) survey, and we analyzed the data using descriptive statistics. Results We enrolled 77 geriatric hip fracture patients. Two of the 77 patients received FICB. Thirty-two EPs participated as providers for these patients while 97% of these providers completed the post-intervention survey. Providers used the geriatric hip fracture order set in 10 of 77 encounters. Most EPs did not perform the block because they were not trained or did not feel comfortable performing it. Conclusion Despite the efficacy supported by the literature and training sessions offered, the EPs in this study did not adopt the FICB procedure. Future efforts could include developing a FICB on-call team, increasing the proportion of trained EPs through initial supervised hands-on practice, and partnering financial or education incentives with getting trained., Competing Interests: The authors have declared that no competing interests exist.

Background: Sub-Saharan Africa bears a disproportionate burden of mortality from trauma. District hospitals, although not trauma centres, play a critical role in the trauma care system by serving as frontline hospitals. However, the clinical characteristics of patients receiving trauma care in African district hospitals remains under-described and is a barrier to trauma care system development. We aim to describe the burden of trauma at district hospitals by analysing trauma patients at a prototypical district hospital emergency centre., Methods: An observational study was conducted in August, 2014 at Wesfleur Hospital, a district facility in the Western Cape Province of South Africa. Data were manually collected from a paper registry for all patients visiting the emergency centre. Patients with trauma were selected for further analysis., Results: Of 3299 total cases, 565 (17.1%) presented with trauma, of which 348 (61.6%) were male. Of the trauma patients, 256 (47.6%) were ages 18-34 and 298 (52.7%) presented on the weekend. Intentional injuries (assault, stab wounds, and gunshot wounds) represented 251 (44.4%) cases of trauma. There were 314 (55.6%) cases of injuries that were unintentional, including road traffic injuries. There were 144 (60%) intentionally injured patients that arrived overnight (7pm-7am). Patients with intentional injuries were three times more likely to be transferred (to higher levels of care) or admitted than patients with unintentional injuries., Conclusion: This district hospital emergency centre, with a small complement of non-EM trained physicians and no trauma surgical services, cared for a high volume of trauma with over half presenting on weekends and overnight when personnel are limited. The high volume and rate of admission/ transfer of intentional injuries suggests the need for improving prehospital trauma triage and trauma referrals. The results suggest strengthening trauma care systems at and around this resource-limited district hospital in South Africa may help alleviate the high burden of post-trauma morbidity and mortality.

Objective: The objective was to evaluate the impact of evidence-based clinical decision support tools integrated directly into provider workflow in the electronic health record on utilization of computed tomography (CT) brain, C-spine, and pulmonary embolism (PE)., Methods: Validated, well-accepted scoring tools for head injury, C-spine injury, and PE were embedded into the electronic health record in a manner minimally disruptive to provider workflow. This was a longitudinal, before/after study in five emergency departments (EDs) in a healthcare system with a common electronic health record. Attending ED physicians practicing during the entire study period were included. The main outcome measure was proportion of CTs ordered by provider (total number of CT scans of a given type divided by total patients seen by that provider) in aggregate in the pre- and post intervention period., Results: There were 235,858 total patient visits analyzed in this study with an absolute decrease of 6,106 CT scan ordering for the three studies. Across all sites, there was greater than 6% decrease in utilization of CT brain and CT C-spine (-10%, 95% CI = -13% to -7%, p < 0.001; and -6%, 95% CI =-11% to -1%, p = 0.03, respectively). The use of CT PE also decreased but was not significant (-2%, 95% CI = -9% to +5%, p = 0.42). For all CT types, high utilizers in the pre-intervention period decreased usage over 14% in the post-intervention period with CT brain (-18%, 95% CI = -22% to -15%, p < 0.001), CT C-spine (-14%, 95% CI = -20% to -8%, p = 0.001), and CT PE (-23%, 95% CI = -31% to -14%, p < 0.001). For all three studies, the average utilizers did not change their usage practices. For CT brain, the low utilizers also did not increase usage but for CT C-spine and CT PE usage was increased (+29%, 95% CI = 10% to 52%, p = 0.003; and +46%, 95% CI = 26% to 70%, p < 0.001, respectively)., Conclusion: Embedded clinical decision support is associated with decreased overall utilization of high-cost imaging, especially among higher utilizers. It also affected low utilizers, increasing their usage consistent with improved adherence to guidelines, but this effect did not offset the overall decreased utilization for CT brain or CT C-spine. Thus, integrating clinical decision support into the provider workflow promotes usage of validated tools across providers, which can standardize the delivery of care and improve compliance with evidence-based guidelines., (© 2017 by the Society for Academic Emergency Medicine.)

The Reevaluation of Systemic Early Neuromuscular Blockade (ROSE) trial is a multicenter, randomized trial designed to assess the efficacy and safety of early neuromuscular blockade in patients with moderate to severe acute respiratory distress syndrome. This document provides background for interpretation of the trial results, and highlights unique design approaches that may inform future trials of acute illness. We describe the process by which ROSE was chosen as the inaugural trial of the multidisciplinary Prevention and Early Treatment of Acute Lung Injury Network, provide the trial methodology using the Consolidated Standards of Reporting Trials framework, and discuss key design challenges and their resolution. Four key design issues proved challenging-feasibility, choice of sedation depth in the control group, impact of emphasizing early treatment on enrollment criteria and protocol execution, and choice of positive end-expiratory pressure strategy. We used literature, an iterative consensus model, and internal surveys of current practice to inform design choice. ROSE will provide definitive, Consolidated Standards of Reporting Trials adherent data on early neuromuscular blockade for future patients with acute respiratory distress syndrome. Our multidisciplinary approach to trial design may be of use to other trials of acute illness. Clinical trial registered with www.clinicaltrials.gov (NCT02509078).