bluuebunny/crossref_metadata_2025_split huggingface dataset:
Regional needs assessment for emergency physician audit and feedback
Authors: Gupta Rakesh , Mercuri Mathew , McCulloch Amy , Monteiro Sandra , Mastoras George , Krywenky Ashley , Chan Teresa , Mondoux Shawn 
Published: May 2020

ABSTRACTObjectivesAudit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region.MethodsWe conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups.ResultsA total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners.ConclusionThis study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.
Just the Facts: What are the roles of oxygen escalation and noninvasive ventilation in COVID-19?
Authors: Long Brit , Liang Stephen Y. , Hicks Christopher , Gottlieb Michael 
Published: May 2020

A 37-year-old female presents with cough, fever, dyspnea, and myalgias for five days after recent contact with a family member with confirmed 2019 coronavirus disease (COVID-19). Her vital signs include T 38.3° C, HR 108, BP 118/70 mm Hg, RR 26 breaths per minute, and oxygen saturation 67% on room air. She is not in respiratory distress currently and is protecting her airway. Her chest X-ray reveals bilateral airspace opacities. You plan to immediately intervene and address her hypoxia.
LO17: Major adverse cardiac events in patients ruled-out by a validated high-sensitivity troponin algorithm for acute myocardial infarction
Authors: O'Rielly C. , Andruchow J. , McRae A. 
Published: May 2020

Introduction: Chest pain and symptoms of acute coronary syndrome are a leading cause of emergency department (ED) visits in Canada. Validated 2-hour high-sensitivity troponin algorithms can rapidly and accurately rule-in or rule-out myocardial infarction (MI) in most patients. The objective of this study was to quantify the incidence and timing of major adverse cardiac events (MACE: MI, death, or urgent revascularization) in the 30-days following the index ED encounter among patients who had MI ruled out using a 2-hour high-sensitivity troponin T (hs-cTnT) algorithm. We also sought to identify patient characteristics associated with very low risk of MACE. Methods: This was a secondary analysis of data prospectively collected from adult patients presenting with a primary complaint of chest pain or symptoms of ACS. This analysis focused on patients who had an MI ruled out using a validated 2-hour serial hs-cTnT diagnostic algorithm. Incidence of 30-day MACE was quantified. Sex-specific Kaplan-Meier curves were constructed to describe timing of MACE events after MI rule-out. Demographic and clinical variables of patients who did or did not have MACE were compared using simple bivariable analyses. Results: This analysis included 550 patients with serial 2h hs-cTnT testing. Of these, MI was ruled out in 344 (62.5% of patients), ruled in 67 (12.2%), and 139 (25.3%) had nondiagnostic hs-cTnT results. Among the 344 patients who had MI ruled out, 11 (3.2%) experienced a MACE in the 30 days following their index ED encounter. These included 10 (2.9%) unplanned revascularizations and 1 (0.3%) fatal MI. MACE occurred at a median of 5 days (range: 0-23 days) after the index ED encounter. Of the 11 patients experiencing MACE, 9 (81.8%) had a normal ECG at their index ED encounter. None of the 93 (27.0%) ruled-out patients under the age of 50 experienced a MACE in the follow-up period. Patients experiencing MACE were more likely to have a history of coronary disease and multiple vascular risk factors compared to those not experiencing MACE. Conclusion: The validated 2h hs-cTnT AMI algorithm ruled-out MI in a large proportion of patients. The 30-day MACE incidence after MI rule-out was 3%. Most MACE events were unplanned revascularizations. We determined that age < 50 was associated with event-free survival and may be of value in identifying patients who do not need additional cardiac testing after MI has been ruled out using high-sensitivity troponin testing.
LO28: Innovating for overcrowding: analyzing the impact of a novel emergency physician role on patient flow
Authors: Green-Harrison L. , Polsky Z. , Fung T. , Lang E. , Patocka C. 
Published: May 2020

Introduction: Overcrowding in the Emergency Department (ED) results in delays in care, and increased patient morbidity and mortality. Innovative departmental approaches have the potential to make patient flow through the ED more efficient and reduce overcrowding by improving patient throughput. The Calgary zone ED recently piloted a new physician role, the Emergency Physician Lead (EPL), a senior physician working closely with the charge nurse and consulting services to provide physician leadership, and to troubleshoot flow issues and safety breeches such as EMS offload delays and long emergency inpatient (EIP) stays. The objective of this study was to evaluate the efficacy of the EPL by determining its effect on key metrics of patient flow, and by identifying which specific EPL interventions were most effective at improving patient throughput. Methods: A retrospective cohort design was used to compare Foothills Medical Centre (FMC) ED patients seen by the EPL from March-June 2019 (n = 1343 patients) with a control group from the same period in 2018 (n = 5530). An EMR search was used to collect patient data and generate descriptive statistics, which were compared between groups by Mann-Whitney U-test. Patient handover notes left by the EPL were also collected and analyzed by two independent assessors to develop a list of actions taken by the EPL. Each patient was then coded based on the actions in the handover note, and means for each coded group were compared to control to find correlations between action and changes in key flow metrics. Results: Patients whose care involved the EPL had a 40% shorter average ED length of stay (ELOS) compared to control (515 vs 865 min, p < 0.001). The EPL was especially effective for patients with ELOS above the 90th percentile, with a 58% relative reduction. EPL patients also had lower average times from first contact with the department to first order being placed (79 vs 143 min, p < 0.001), and spent less time as EIPs after being admitted (390 vs 515 mins, p < 0.001). EPL actions aimed at early ordering of investigations or early management showed the largest relative reductions in ELOS, followed by actions related to resolving issues with consulting services (56% and 48% respectively, p < 0.001). Conclusion: The EPL role appears to be associated with improvements in several key metrics of patient flow. Specific EPL actions were correlated with marked decreases in length of stay. The EPL may be an effective strategy to improve patient throughput and combat ED overcrowding.
LO29: Interventions at triage to improve emergency department throughput: a systematic review
Authors: Grant K. , Bayley C. , Lang E. , Innes G. 
Published: May 2020

Introduction: Emergency Department (ED) crowding is the primary threat to emergency care quality. Input and outflow factors are important factors, but EDs must optimize throughput efficiency by improving internal processes from triage to disposition, and triage is the first throughput phase. Triage throughput interventions exclude strategies that direct patients away from the ED (these modify input rather than throughput). Previous research has described physicians in triage, team triage, telemedical triage, and nurse practitioner (NP) or physician assistant (PA) led triage, but their impact has never been systematically evaluated. Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without the use of filters or language restrictions of all triage interventions that effected ED throughput (PROSPERO:CRD42019125651). Two independent reviewers screened studies. Study quality was assessed using the Cochrane Risk of Bias tool (version 2) for randomized controlled trials, and the National Heart, Lung, and Blood Institute quality assessment tool for other designs. Results: 18 studies met inclusion criteria (Cohen's k = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. Studies were grouped into physician led, NP or PA led, and team triage interventions. Six physician in triage interventions reported LOS changes between -82 and + 18 minutes. Five NP/PA led triage interventions resulted in LOS changes of -106 to + 19 minutes. Five team triage interventions reported LOS reductions of 4 to 34 minutes. One telemedicine triage study reported a non-significant 8 minute increase in LOS. Six physician at triage interventions yielded significant LWBS rate improvement (relative risk {RR}= 0.29-0.82). Team triage interventions generated LWBS rate changes ranging from meaningful improvement (RR = 0.58) to substantial deterioration (RR = 1.68). Five studies have low risk of bias, 11 studies have some risk of bias, and 2 studies have high risk of bias (Cohen's kappa = 0.58). Conclusion: Fourteen of 18 triage interventions reduced EDLOS and/or LWBS rate. Physician, NP and PA led triage were the most effective triage interventions. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.
LO35: A province-wide quality improvement collaborative for treatment of children's pain in Alberta's emergency departments
Authors: Thull-Freedman J. , Pols E. , McFetridge A. , Libbey S. , Lonergan K. , Lethebe B. , Ali S. , Stang A. 
Published: May 2020

Background: Pediatric pain is often under-treated in emergency departments (EDs), causing short and long-term harm. In Alberta EDs, children's pain outcomes were unknown. A recent quality improvement collaborative (QIC) led by our team improved children's pain care in 4 urban EDs. We then spread to all EDs in Alberta using the Institute for Healthcare Improvement Framework for Going to Full Scale. Aim Statement: To increase the proportion of children <12 years who receive topical anesthetic before needle procedures from 11% to 50%; and for children <17 years with fractures: to 1) increase the proportion receiving analgesia from 31% to 50%; 2) increase the proportion with pain score documentation from 24% to 50%, and 3) reduce time to analgesia from 60 to 30 minutes, within 1 year. Measures & Design: All 97 EDs in Alberta that treat children were invited. Each was asked to form a project team, attend webinars, develop key driver diagrams and perform PDSA tests of change. Sites were given a monthly list of randomly selected charts for audit and entered data in REDCap for upload to a provincial run chart dashboard. Baseline performance measurement informed aims. Measures included proportion of children <12 years undergoing a lab test who received topical anesthetic, and for children <17 years with fracture, the proportion with a pain score, proportion receiving analgesia and median minutes to analgesia. Length of stay and use of opioids were balancing measures. Control charts were used to detect special cause. Interrupted time series (ITS) was performed to assess significance and trends. Evaluation/Results: 36 sites (37%) participated, including rural and urban sites from all regions. 8417 visits were audited. 23/36 sites completed audits before and after tests of change and were analyzed. Special cause occurred for all aims. The proportion receiving topical anesthetic increased from 11% to 30% (ITS p < 0. 001). For children with fractures, the proportion with pain scores increased from 24% to 34% (ITS p = 0.21, underlying trend present), proportion receiving analgesic medication increased from 31% to 39% (ITS p = 0.41, underlying trend present) and minutes to analgesia decreased from 60 to 28 (ITS p < 0. 01). There was no increase in length of stay or use of opioid medications. Discussion/Impact: A pragmatic approach encouraging locally led change was well-received and key to success. The QIC method shows promise for improving outcomes in diverse EDs across large geographic areas. Next steps include further spread and sustainability measurement.
LO37: Reducing hemolysis of coagulation blood samples in the emergency department
Authors: Weatherby H. , Woolner V. , Chartier L. , Casey S. , Ong C. , Gaylord E. 
Published: May 2020

Background: Hemolysis of blood samples is the leading cause of specimen rejection from hospital laboratories. It contributes to delays in patient care and disposition decisions. Coagulation tests (prothrombin time/international normalized ratio [PT/INR] and activated partial thromboplastin time [aPTT]) are especially problematic for hemolysis in our academic hospital, with at least one sample rejected daily from the emergency department (ED). Aim Statement: We aimed to decrease the monthly rate of hemolyzed coagulation blood samples sent from the ED from a rate of 2.9% (53/1,857) to the best practice benchmark of less than 2% by September 1st, 2019. Measures & Design: Our outcome measure was the rate of hemolyzed coagulation blood samples. Our process measure was the rate of coagulation blood tests sent per 100 ED visits. Our balancing measure was the number of incident reports by clinicians when expected coagulation testing did not occur. We used monthly data for our Statistical Process Control (SPC) charts, as well as Chi square and Mann-Whitney U tests for our before-and-after evaluation. Using the Model for Improvement to develop our project's framework, we used direct observation, broad stakeholder engagement, and process mapping to identify root causes. We enlisted nursing champions to develop our Plan-Do-Study-Act (PDSA) cycles/interventions: 1) educating nurses on hemolysis and coagulation testing; 2) redesigning the peripheral intravenous and blood work supply carts to encourage best practice; and 3) removing PT/INR and aPTT from automatic inclusion in our electronic chest pain bloodwork panel. Evaluation/Results: The average rate of hemolysis remained unchanged from baseline (2.9%, p = 0.83). The average rate of coagulation testing sent per 100 ED visits decreased from 41.5 to 28.8 (absolute decrease 12.7 per 100, p < 0.05), avoiding $4,277 in monthly laboratory costs. The SPC chart of our process measure showed special cause variation with greater than eight points below the centerline. Discussion/Impact: Our project reduced coagulation testing, without changing hemolysis rates. Buy-in from frontline nurses was integral to the project's early success, prior to implementing our electronic approach – a solution ranked higher on the hierarchy of intervention effectiveness – to help sustainability. This resource stewardship project will now be spread to a nearby institution by utilizing similar approaches.
Kicking the Crusaders out of the Caucasus: Deconstructing the 200-Year-Old Meme that the Khevsurs Descended from a Lost Band of Medieval Knights
Authors: Sherman Ryan Michael 
Published: May 2020

AbstractThe region of Khevsureti in Georgia is the historic home of a group of Kartvelian highlanders known as Khevsurs. As Khevsureti’s popularity as a mountain tourist destination has grown, so too has the popularity of an old story that asserts the Khevsurs are the descendants of a lost band of Crusaders. For 200 years, this meme has manifested itself in books about the region, newspaper articles, the work of a few scholars, and now much Internet discussion. The growing collection of cases has created the illusion of an unconsolidated quantity of evidence and many commentators have since taken the story to be a credible theory or actual legend. A systematic deconstruction and analysis of this story shows how this set of details initially formed, grew, and spread based on a few unreliable accounts in circulation beginning in the early 19th century. This article offers a case study of how such memes form and propagate; it provides an additional example of a Western tendency to romanticize and project elements of their own ethnicities into the Caucasus; and it examines this false history in terms of cultural appropriation and the relationship between ethnicity and narrative, adding to the literature on invented histories and pseudoarchaeology. Finally, this careful deconstruction and repudiation will help remove this story from serious discussions of cultural heritage in Khevsureti and show how historical memes and popular examples of pseudoarcheology spread and capture imaginations.
The Don and Kuban Regions During Famine: The Authorities, the Cossacks, and the Church in 1921–1922 and 1932–1933
Authors: Krinko Evgeny , Skorik Alexander , Shadrina Alla 
Published: May 2020

AbstractThis article studies the famine of 1921–1922 and 1932–1933 in the Southern Russian regions. Famine as a socio-historical phenomenon is considered in the context of the relationship of state power, the Cossacks, and the Church. The authors reveal the general and special features of the famine emergence and analyze the differences in the state policies of 1921–1922 and 1932–1933. Considerable attention is paid to the survival strategies of the Don, Kuban and Terek populations. Slaughtering and eating draft animals, transfer from the state places of work to the private campaigns and cooperatives, moving to shores and banks, and eating river and sea food became widespread methods of overcoming famine. Asocial survival strategies included cannibalism, abuse of powers, bribery, and more. In 1921–1922, the Russian Orthodox Church fought actively against the famine. In 1932–1933, the Church was weakened and could not provide significant assistance to the starving population. The article was written based on declassified documents from the state and departmental archives, including criminal investigations and analytical materials of the Obedinjonnoe gosudarstvennoe politicheskoe upravlenie [Joint State Political Directorate] (OGPU) recording the attitudes of minds. Also used are personal stories—namely, interviews with eyewitnesses of the famine of 1932–1933, recorded by the Kuban folklorists in the territory of the Krasnodar and Stavropol Krai.
A new method for quantifying heterochrony in evolutionary lineages
Authors: Lamsdell James C. 
Published: May 2020

AbstractThe occupation of new environments by evolutionary lineages is frequently associated with morphological changes. This covariation of ecotype and phenotype is expected due to the process of natural selection, whereby environmental pressures lead to the proliferation of morphological variants that are a better fit for the prevailing abiotic conditions. One primary mechanism by which phenotypic variants are known to arise is through changes in the timing or duration of organismal development resulting in alterations to adult morphology, a process known as heterochrony. While numerous studies have demonstrated heterochronic trends in association with environmental gradients, few have done so within a phylogenetic context. Understanding species interrelationships is necessary to determine whether morphological change is due to heterochronic processes; however, research is hampered by the lack of a quantitative metric with which to assess the degree of heterochronic traits expressed within and among species. Here I present a new metric for quantifying heterochronic change, expressed as a heterochronic weighting, and apply it to xiphosuran chelicerates within a phylogenetic context to reveal concerted independent heterochronic trends. These trends correlate with shifts in environmental occupation from marine to nonmarine habitats, resulting in a macroevolutionary ratchet. Critically, the distribution of heterochronic weightings among species shows evidence of being influenced by both historical, phylogenetic processes and external ecological pressures. Heterochronic weighting proves to be an effective method to quantify heterochronic trends within a phylogenetic framework and is readily applicable to any group of organisms that have well-defined morphological characteristics, ontogenetic information, and resolved internal relationships.
Sex differences in associations of socioemotional dispositions measured in childhood and adolescence with brain white matter microstructure 12 years later
Authors: Lahey Benjamin B. , Hinton Kendra E. , Meyer Francisco Calvache , Villalta-Gil Victoria , Van Hulle Carol A. , Applegate Brooks , Yang Xiaochan , Zald David H. 
Published: May 2020

AbstractPredictive associations were estimated between socioemotional dispositions measured at 10–17 years using the Child and Adolescent Dispositions Scale (CADS) and future individual differences in white matter microstructure measured at 22–31 years of age. Participants were 410 twins (48.3% monozygotic) selected for later neuroimaging by oversampling on risk for psychopathology from a representative sample of child and adolescent twins. Controlling for demographic covariates and total intracranial volume (TICV), each CADS disposition (negative emotionality, prosociality, and daring) rated by one of the informants (parent or youth) significantly predicted global fractional anisotropy (FA) averaged across the major white matter tracts in brain in adulthood, but did so through significant interactions with sex after false discovery rate (FDR) correction. In females, each 1 SD difference in greater parent-rated prosociality was associated with 0.43 SD greater FA (p< 0.0008). In males, each 1 SD difference in greater parent-rated daring was associated with 0.24 SD lower FA (p< 0.0008), and each 1 SD difference in greater youth-rated negative emotionality was associated with 0.18 SD greater average FA (p< 0.0040). These findings suggest that CADS dispositions are associated with FA, but associations differ by sex. Exploratory analyses suggest that FA may mediate the associations between dispositions and psychopathology in some cases. These associations over 12 years could reflect enduring brain–behavior associations in spite of transactions with the environment, but could equally reflect processes in which dispositional differences in behavior influence the development of white matter. Future longitudinal studies are needed to resolve the causal nature of these sex-moderated associations.