Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone.

OBJECTIVE: Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN. METHODS: In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons. RESULTS: Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN. CONCLUSION: ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others

Endothelial selectins and pulmonary gas exchange in female aerobic athletes

Demonstration of a greater elevation in the (ideal) alveolar/arterial oxygen difference in habitually active female subjects with exercise-induced arterial hypoxemia, at equivalent submaximal levels of oxygen uptake compared to inactive controls, suggests functional or structural compromise of the blood-gas interface may occur with chronic-recurrent intensive exercise. Mechanical and/or chemically mediated pulmonary endothelial dysfunction during heavy exercise may alter vascular tone and permeability, leading to interstitial edema and accentuation of ventilation-perfusion mismatch and/or diffusion limitation. Elevated plasma levels of soluble endothelial cell adhesion molecules E- and Pselectin have been demonstrated in acute lung injury and have been used as indirect markers of endothelial activation or injury. Therefore, plasma levels of these selectins were measured by enzyme immunoassay in fourteen habitually active, eumenorrheic female subjects (mean±SD: age = 28.9±5.51; VO₂[sub peak] = 49.4±8.2 ml.kg⁻¹.min⁻¹, range 32.3 to 63.7 ml.kg⁻¹.min⁻¹; TLC = 5.41±0.68 L, 101±9.3% predicted) before and after an incremental maximal exercise test during the follicular phase of their menstrual cycle (cycle day = 6.2±1.2, serum progesterone = 80+100 pmol.L⁻¹). Arterial partial pressure of oxygen (PaO₂) was measured and corrected for esophageal temperature, arterial oxyhemoglobin saturation (%Sa0₂) was calculated from blood gas variables and measured with pulse oximetry, and the (ideal) alveolar/arterial oxygen gradient was calculated from the ideal gas equation. Pulmonary gas exchange efficiency was maintained at peak exercise in ten subjects, while decrements in arterial partial pressure of oxygen during exercise of greater than 1.3 kilopascals (10 mmHg) were seen in three of the remaining four subjects. One subject displayed a minimal %Sa0₂ of 94% and was included in the mild hypoxemia group. Maximum likelihood ANOVA procedures, used on account of missing data, showed significant differences between groups averaged over time for Pa0₂ (p<0.01) and %Sa02 (p=0.04), while the group by time interaction for the (ideal) A-aD0₂ approached significance (p=0.07). Averaged over time, changes in alveolar P0₂ , arterial PC0₂ , pH and temperature were not significantly different between groups. Plasma concentrations of soluble E-selectin were not significantly different before or after exercise (p=0.16), but plasma concentrations of P-selectin rose significantly (mean increase ± SD; 21.5±24.8 ngmL'1, p=0.007). No significant group by time interaction was noted in pre-post exercise concentrations of either E-selectin (p=0.74) or P-selectin (p=0.42) between subjects who demonstrated normal gas exchange and subjects who displayed mild to moderate exercise-induced gas exchange impairment. The correlation between absolute (ngmL⁻¹) and relative (%) change in soluble E- and P-selectin, and VO₂[sub peak], maximal A-aD0₂ and PaC0₂ was not significant, nor was the correlation between minimal exercise Pa02 and either absolute (r=0.16, p=0.61) or relative (r=0.18, p=0.57) change in soluble E-selectin. However, absolute change in plasma concentration of soluble P-selectin was significantly correlated with minimal Pa0₂ (r=-0.60, p=0.04), while the correlation between the relative change in P-selectin and minimal Pa0₂ approached significance (r=-0.46, p=0.14). The increase in plasma P-selectin induced by heavy exercise may represent platelet and/or endothelial activation. Correlation with impairment of arterial oxygenation is compatible with the hypothesis that pulmonary endothelial dysfunction may occur during intense exercise in some habitually active female subjects.Education, Faculty ofKinesiology, School ofGraduat

Creating safety in an emergency department

Hospital emergency departments (EDs) are complex, high-hazard sociotechnical systems with distinction as sites of the highest proportion of preventable patient harm. Patient safety is threatened by abbreviated and uneven care in an interrupted environment marked by uncertainty, multiple transitions over space and time, and mismatch between demand and resources. Recommendations for reporting systems, standardization, and ‘safety culture’ are at the forefront of local, national, and international strategies to improve patient safety. British Columbia is currently implementing a provincial electronic Patient Safety Learning System to enhance reporting and learning, and to facilitate a culture of safety. However, the concept of ‘safety culture’, while popular and political, remains problematic and theoretically underspecified. Moreover, there is lack of clear evidence about how emergency care providers conceptualize, make sense of, and learn from patient safety incidents, and limited evidence to guide an effective safety learning strategy for providers and staff in a busy ED. In this multi-perspective, multi-method, practice-based ethnographic inquiry conducted at an inner city, tertiary care ED, I explore how ED practitioners and staff create safety in patient care in their everyday practice. In this context, ‘safety’ is an emergent phenomenon of collective joint action, enacted dialogically by multiple actors, within a resilient system imbued with multiple social, cultural and political meanings. I claim that patient safety within an ED (and likely in other health care settings) is most effectively created through dialogic storying, resilience, and phronesis. I present an alternative account to the dominant “medical error” and bureaucratic “measure and manage” discourse, and propose an approach to creating safety, including an open communicative space to facilitate sharing stories and learning about patient safety incidents, a safety action team charged with systems analysis and empowered to enact change, and an inter-professional simulation learning environment to enhance dialogic sensemaking and innovation, that offers more to facilitate safety and resilience in everyday practice. I advocate for a pragmatic practice-based account of patient harm within an ongoing reflective conversation about safety and performance, and for foresight and resilience in anticipating and responding to the complexities of everyday emergency care.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Understanding resilient clinical practices in emergency department ecosystems

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Unintended Medication Discrepancies Associated with Reliance on Prescription Databases for Medication Reconciliation on Admission to a General Medical Ward

ABSTRACT Background: In a recent study, 50% of the patients who were admitted to a hospital’s general medicine ward had at least one error in medication orders at the time of admission related to inaccuracies in the medication history. The use of computerized prescription databases has been suggested as a way to improve medication reconciliation at the time of admission.Objective: To quantify and describe unintended discrepancies between a best possible medication history and medications ordered on admission to the general medicine ward in a hospital with routine access to a provincial outpatient prescription database (British Columbia’s PharmaNet).Methods: This prospective study involved 20 patients who were regularly using at least 4 prescription medications before admission to hospital. The best possible medication history for each patient (based on a review of the medical chart and the PharmaNet record and an interview with the patient) was compared with the physician’s admission orders to identify any discrepancies. The frequency and perceived severity of discrepancies, graded independently by 3 physicians, were compared with observations from a similar study conducted at a hospital where a prescription database was not available.Results: The 20 patients were recruited between September 2005 and January 2006. For 8 patients (40%), information in the PharmaNet database was consistent with the prescription medication list obtained during the best possible medication history at the time of admission. For the other 12 patients, a total of 30 unintended discrepancies were identified, 13 (43%) of which were classified as having potential for moderate or severe harm. The proportion of patients with unintended discrepancies was similar to that for the comparison cohort (60% versus 54%). Although the percentage of discrepancies involving omissions was lower than in the comparison population (37% versus 46%), these results were offset by a higher proportion of commission discrepancies (27% versus 0%).Conclusion: Unintended discrepancies were frequent, despite use of the PharmaNet database at the time of admission. Inconsistencies between the PharmaNet record and patients’ actual medication use, coupled with failure to verify PharmaNet data with patients, were likely contributing factors.RÉSUMÉ Contexte : Dans une récente étude, 50 % des patients admis à une unité de médecine générale avaient au moment de leur admission au moins une erreur d’ordonnance de médicament liée à une histoire médicamenteuse inexacte. Il a été suggéré de recourir à des bases de données informatisées sur les ordonnances comme moyen d’améliorer le bilan comparatif des médicaments à l’admission.Objectif : Quantifier et décrire les différences accidentelles entre le meilleur schéma thérapeutique possible et les ordonnances de médicaments rédigées à l’admission à l’unité de médecine générale en ayant un accès courant à la base de données provinciale sur les ordonnances externes (PharmaNet, en Colombie-Britannique).Méthodes : Il s’agit d’une étude prospective de 20 patients qui prenaient couramment au moins quatre médicaments d’ordonnance avant leur admission à l’hôpital. Le meilleur schéma thérapeutique possible pour chaque patient (établi grâce à l’étude du dossier médical et du registre PharmaNet et à un entretien avec le patient) a été comparé aux ordonnances rédigées à l’admission par le médecin pour détecter toute différence. La fréquence et l’importance perçue des disparités classées indépendamment par trois médecins ont été comparées aux observations tirées d’une étude similaire menée dans un hôpital où il n’y avait pas d’accès à une telle base de données.Résultats : Les 20 patients ont été recrutés entre septembre 2005 et janvier 2006. Chez huit patients (40 %), l’information dans la base de données PharmaNet concordait avec la liste de médicaments d’ordonnance obtenue du meilleur schéma thérapeutique possible relevé au moment de l’admission. Pour les 12 autres patients, on a noté un total de 30 différences accidentelles, dont 13 (43 %) ont été classées comme ayant un potentiel délétère modéré à grave. La proportion de patients chez qui on a observé des différences accidentelles était similaire à celle de la cohorte de référence (60 % contre 54 %). Bien que le pourcentage de différences impliquant des omissions était plus faible que celui de la cohorte de référence (37 % contre 46 %), ces résultats ont été contrebalancés par une proportion plus élevée de différences de commission (27 % contre 0 %).Conclusion : Les différences accidentelles étaient fréquentes malgré le recours à la base de données PharmaNet au moment de l’admission. Des disparités entre le registre PharmaNet et les médicaments réels du patient, jumelées à l’absence de vérification des données tirées de PharmaNet avec les patients, constituaient vraisemblablement des facteurs contribuant à de telles différences accidentelles

Influence of inhaled nitric oxide on gas exchange during normoxic and hypoxic exercice in highly trained cyclists

Une étude sur les effets de l'inhalation d'oxyde nitrique (20 ppm) sur les échanges gazeux au cours d'un exercice normoxique et hypoxique chez 7 cyclistes entrainés. Evaluation et comparaison de la consommation d'oxygène et du taux de saturation artérielle d'oxyhémoglobine en condition hypoxique et normoxique

Influence of inhaled nitric oxide on gas exchange during normoxic and hypoxic exercice in highly trained cyclists

Une étude sur les effets de l'inhalation d'oxyde nitrique (20 ppm) sur les échanges gazeux au cours d'un exercice normoxique et hypoxique chez 7 cyclistes entrainés. Evaluation et comparaison de la consommation d'oxygène et du taux de saturation artérielle d'oxyhémoglobine en condition hypoxique et normoxique

Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU Participatory Action Research Project (PICU-PAR)

Background: Despite considerable efforts, engaging staff to lead quality improvement activities in practice settings is a persistent challenge. At British Columbia Children’s Hospital (BCCH), the pediatric intensive care unit (PICU) undertook a new phase of quality improvement actions based on the Community of Practice (CoP) model with Participatory Action Research (PAR). This approach aims to mobilize the PICU ‘community’ as a whole with a focus on practice; namely, to create a ‘community of practice’ to support reflection, learning, and innovation in everyday work. Methodology: An iterative two-stage PAR process using mixed methods has been developed among the PICU CoP to describe the environment (stage 1) and implement specific interventions (stage 2). Stage 1 is ethnographic description of the unit’s care practice. Surveys, interviews, focus groups, and direct observations describe the clinical staff’s experiences and perspectives around bedside care and quality endeavors in the PICU. Contrasts and comparisons across participants, time and activities help understanding the PICU culture and experience. Stage 2 is a succession of PAR spirals, using results from phase 1 to set up specific interventions aimed at building the staff’s capability to conduct QI projects while acquiring appropriate technical skills and leadership capacity (primary outcome). Team communication, information, and interaction will be enhanced through a knowledge exchange (KE) and a wireless network of iPADs. Relevance: Lack of leadership at the staff level in order to improve daily practice is a recognized challenge that faces many hospitals. We believe that the PAR approach within a highly motivated CoP is a sound method to create the social dynamic and cultural context within which clinical teams can grow, reflect, innovate and feel proud to better serve patients.Anthropology, Department ofArts, Faculty ofEmergency Medicine, Department ofMedicine, Faculty ofPediatrics, Department ofOther UBCNon UBCReviewedFacult