CJEM最新文献

Background: In some emergency departments (EDs), pharmacists review and follow-up on microbiological test results for recently discharged patients, intervening when empiric therapy is missing or inadequate to ensure appropriate antimicrobial use. Currently, this practice is not well described in Canada. Characterizing these ED pharmacist activities can help identify antimicrobial stewardship opportunities and allow for more tailored education and training.

Objectives: The primary objective of this study was to describe culture review and follow-up pharmacy practice in terms of antimicrobial stewardship interventions. Secondary objectives included describing the types of cultures being managed and the antimicrobials prescribed empirically and post-culture review.

Methods: A retrospective chart review was conducted using pharmacist workload tracking documentation to identify patients with eligible cultures from six EDs in Alberta.

Results: Three hundred cultures were included in this study, and one hundred twenty-nine interventions (40.7% of all cultures reviewed) were performed by ED pharmacists. Initiation of therapy was the most common (33.3%), followed by tailoring therapy (21.7%). Urine cultures were predominant (55.7%), and the antibiotics most prescribed, empirically, and post-culture for urine, were cefixime (44%) and trimethoprim-sulfamethoxazole (34%), respectively. Five patients with asymptomatic bacteriuria were treated with antibiotics. Five patients with skin and soft tissue infections were treated with dual oral antibiotics when culture and sensitivity results indicated monotherapy would have been sufficient. Eight extra days of cefixime therapy were prescribed due to unaccounted doses administered in the ED.

Conclusion: This study highlights the critical role of ED pharmacists in culture review and follow-up activities and their contributions to antimicrobial stewardship. By characterizing culture review and follow-up practices, several opportunities for minimizing unnecessary antimicrobial use were identified. These findings will help inform the development of targeted education and training programs to help strengthen the stewardship capabilities of ED pharmacists and prescribers.

Objective: Topical non-steroidal anti-inflammatory drugs (NSAIDs) effectively treat acute musculoskeletal pain in adults, but evidence in children is limited. This scoping review aims to summarize current evidence for use in children and identify literature gaps to inform future research.

Methods: We conducted a scoping review following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines. Our electronic search included published studies across six databases, grey literature, and unpublished or ongoing trials. Studies involving children (< 18 years) with acute musculoskeletal pain treated with topical NSAIDs in Emergency Department (ED), urgent care, or ambulatory settings were included. We extracted data on study methodology, participant characteristics, clinical outcomes, adverse events, and rescue analgesia use. We performed critical appraisal using Joanna Briggs Institute tools.

Results: Three studies met inclusion criteria: two randomized-controlled trials and one non-randomized trial, totaling 467 participants aged 6-18 years. Interventions included ketoprofen gel, methyl salicylate/1-menthol patch, and diclofenac epolamine patch for ankle sprains or minor soft tissue injuries. Treatment durations ranged from 30 minutes to 14 days. Studies varied in design, intervention protocols, outcome measures, and reporting quality. Common outcomes included pain reduction, rescue medication use, and adverse events. Overall, findings suggest topical NSAIDs may be effective and well tolerated for managing acute musculoskeletal pain in children. However, the available evidence has low credibility with high risk of bias and methodological heterogeneity. No studies compared topical with oral NSAIDs, and few assessed long-term safety, functional recovery, or participant-centered outcomes such as satisfaction or adherence.

Conclusion: Topical NSAIDs may be a potential option for relief of acute musculoskeletal pain in children, although evidence is grossly limited. High-quality randomized-controlled trials are needed to evaluate the efficacy and safety of topical NSAIDs in children before recommendations for use in clinical practice can be made.

Purpose: Canadian hospitals often plan to use an alternate triage tool, opposed to the standard Canadian Triage Acuity Scale (CTAS), in the event of a mass casualty incident despite lack of study or validation for this setting. It is not known whether these alternate triage strategies have ever been utilized by hospitals during disaster response. We sought to identify the type and frequency of alternate triage tools used during Canadian mass casualty incident responses.

Methods: A scoping review of scientific databases and the gray literature was conducted to find information regarding the triage strategy employed during real mass casualty incidents in Canada from January 1, 1983 to December 31, 2024. A survey of healthcare providers was conducted if data could not be obtained through literature review.

Results: The literature reviews yielded 358 reports: four met inclusion criteria. Twenty-two incidents were identified from media reports and contacts for 15 of these events were surveyed; data were retrieved regarding six events. In total, data were collected for nine separate mass casualty incidents. Five (55.5%) cited a plan to use an alternate triage tool during a disaster, but only 1 (11.1%) utilized it (triage tags) during real-time response. The remaining used CTAS, with or without clinician judgment.

Conclusions: Secondary disaster triage may not require an alternate algorithm, potentially saving time and financial resources associated with training. We strongly suggest the increased publication of reports either in peer-reviewed journals or through the creation of a national repository as available data on this subject are very limited.

Background: A code stroke activation involves mobilization of finite health care resources. We evaluated the proportion of activations that were non-compliant with code stroke criteria, and the acute treatments and healthcare use after these activations in two urban comprehensive stroke centres.

Methods: We conducted a multicentre health records review of adult patients seen in the context of code stroke activations in the emergency departments (ED) at two comprehensive stroke centres in Toronto, Canada, between January 1 and December 31, 2022. Code strokes activated in the field by paramedics, or by physicians or nurses in the ED were included. The primary outcome was the proportion of non-compliant activations, defined as an activation that did not meet institutional criteria. Secondary outcomes were receipt of thrombolysis or thrombectomy in code stroke activations that were non-compliant vs. compliant.

Results: A total of 1028 code strokes were included, of which 768 (74.7%) were paramedic-initiated. Overall, 314 (30.5%) were non-compliant: 19.6% paramedic-initiated and 70.7% ED-staff initiated. Incorrect determination of the last seen normal time was the most common cause of non-compliant activations. Although a small number of patients received reperfusion therapy despite non-compliant activation (n = 26, 8.2%), most of these patients were less likely to receive these treatments or be admitted to a stroke unit compared to patients with compliant activations.

Conclusion: One in three code stroke activations were non-compliant to activation criteria. Quality improvement strategies such as increasing adherence to code stroke protocols by simplifying the protocol, use of simulation exercises, and involving stroke team for borderline cases could help reduce non-compliant activation and conserve healthcare resources.