Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: a scoping review

Geduld, C, Muller, H., Saunders, C. J

Introduction: The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners.

Method: We performed a focused scoping review of published literature on the prehospital use of clinical spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis.

Results: Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low-resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting.

Conclusion: This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Reproduced with permission.

Temperature control parameters are important: earlier pre-induction is associated with improved outcomes following out-of-hospital cardiac arrest

Rachel Beekman, Noah Kim; Christine Nguyen; George McGinniss, Yanhong Deng, Eva Kitlen; Gabriella Garcia, Charles Wira, Akhil Khosla, Jennifer Johnson, P. Elliott Miller, Sarah M. Perman, Kevin N. Sheth, David M. Greer, Emily J. Gilmore

Study objective: Temperature control trials in cardiac arrest patients have not reliably conferred neuroprotective benefit but have been limited by inconsistent treatment parameters. To evaluate the presence of a time dependent treatment effect, we assessed the association between preinduction time and clinical outcomes.

Methods: In this retrospective, single academic centre study between 2014 and 2022, consecutive out-of-hospital cardiac arrest (OHCA) patients treated with temperature control were identified. Preinduction was defined as the time from hospital arrival to initiation of a closed-loop temperature feedback device (door to temperature control initiation time), and early door to temperature control device time was defined a priori as <3 hours. We assessed the association between good neurologic outcome (cerebral performance category 1–2) and door to temperature control device time using logistic regression. The proportion of patients who survived to hospital discharge was evaluated as a secondary outcome. A sensitivity analysis using inverse probability treatment weighting, created using a propensity score, was performed to minimise measurable confounding.

Results: Three hundred and forty-seven OHCA patients were included; the early door to temperature control device cohort included 75 (21.6%) patients with a median (IQR) door to temperature control device of 2.50 (2.03–2.75) hours, while the late door to temperature control device cohort included 272 (78.4%) patients with a median (IQR) door to temperature control device of 5.18 (4.19–6.41) hours. In the multivariable logistic regression model, early door to temperature control device was associated with improved good neurologic outcome and survival before (adjusted OR (95% CI) 2.36 (1.16–4.81) and 3.02 (1.54–6.02)) and after (adjusted OR (95% CI) 1.95 (1.19–3.79) and 2.14 (1.33–3.36)) inverse probability treatment weighting, respectively.

Conclusion: In our study of OHCA patients, a shorter preinduction time for temperature control was associated with improved good neurologic outcome and survival. This finding may indicate that early initiation in the emergency department will confer benefit. Our findings are hypothesis generating and need to be validated in future prospective trials.

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Women at the top: a qualitative study of women in leadership positions in emergency medicine in Canada

Molly Allen, Janelle Lazor, Konika Nirmalanathan & Anna Nowacki

Objectives: For the last two decades, more than half of Canadian medical students have been women, with an increasing number of medical trainees choosing emergency medicine as their careers. Despite a proportional increase of women in full-time faculty positions in emergency medicine, women are still underrepresented in leadership. The purpose of this study is to explore the experiences of women leaders in emergency medicine to identify common themes that may have contributed to their acquisition of leadership roles.

Methods: Participants included women emergency medicine physicians in Canada who currently or previously held a leadership position. Data were collected through semistructured interviews. Inductive thematic analysis was performed on the interview transcripts. Transcribed data were coded and categorised into recurrent themes. A narrative summary of the most impactful themes was presented.

Results: Twenty participants were interviewed. Most participants perceived career opportunities were due to chance, related to personal skill set or required additional training. Participants highlighted the importance of mentorship and sponsorship. Gender expectations and traditional gender roles were perceived as having a negative impact on career leadership success. Participants acknowledged the need for women in leadership to empower younger generations of women to become leaders. For future emergency medicine leaders, participants suggested applying for leadership positions early, networking and seeking mentorship. Potential supportive changes to leadership structures included explicit parental leave policies, flexible scheduling and job sharing to encourage women leaders.

Conclusion: To date, there has been no Canadian specific study exploring the factors contributing to the success of women leaders in emergency medicine. This study examines career advancement of women leaders in emergency medicine and provides useful insight to those aspiring to grow their careers as well as to mentors and sponsors of women in emergency medicine.

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Comparing accuracy of clinical prediction rules to predict pneumonia in children and adolescents with acute febrile respiratory illness

Wu YH, Chiu JH, Tse CF, Chan YY, Poon KM, Lui CT

Background: It is a common challenge for emergency physicians to differentiate pneumonia from simple upper respiratory tract infections. Several clinical prediction rules exist to assist the diagnosis process and guide the clinical decisions of ordering investigations such as chest X-ray (CXR).

Objective: This study aims to validate and compare the accuracy of various prediction rules in the setting of children and adolescents presenting with acute febrile respiratory illness (AFRI).

Method: This was a prospective multicentre study. Three hundred and fifty-five patients, aged 6–18 years, were recruited. Patients with immunocompromised state or hypoxia were excluded. Pneumonia was defined as diagnosis by CXR or subsequent diagnosis of pneumonia on reattendance within 7 days. Clinical rules including Diehr rule, Heckerling rule, Bilkis simpler rule, the AFRI rule, the paediatric AFRI (PAFRI) were compared in terms of accuracy of predicting pneumonia in the recruited subjects and presented as receiver operating characteristic curves.

Results: Five patients were excluded. In the 350 patients included, 38 were diagnosed as pneumonia by CXR and 1 was subsequently diagnosed as pneumonia on reattendance. The area under the receiver operating characteristic curve of Diehr rule, Heckerling rule, Bilkis simpler rule, AFRI rule and PAFRI rule was 0.703, 0.565, 0.59, 0.807 and 0.846, respectively. The PAFRI rule is superior to other prediction rules in terms of diagnostic accuracy. At the cut-off of PAFRI ≥0, the rule has high sensitivity of 97.44% and negative predictive value of 99.09%.

Conclusion: Among the rules compared, the PAFRI rule has the highest diagnostic accuracy in assisting emergency physicians to identify pneumonia among children and adolescents aged 6–18 years presenting with AFRI.

Reproduced with permission.