Publications by authors named "Janette Baird"

115 Publications

Introduction of an Electronic Mobile Device Version of an Alcohol Impairment Scale (the Hack's Impairment Index Score) Does Not Impair Nursing Assessment of Patients in Emergency Departments.

Curr Ther Res Clin Exp 2021 29;94:100630. Epub 2021 Mar 29.

Dept of EM Brown Physicians Inc. Brown university, Providence, RI.

Background: There is no formal assessment to determine level of disability in the millions of patients with alcohol-induced impairment who present to emergency departments annually. Hack's Impairment Index (HII) is a standardized, serializable clinical tool designed to quantify ability. Nursing staff members at this center perform the HII and determine a score using paper prompts.

Objective: We developed an HII electronic application and investigated whether or not an electronic version on a mobile device would affect nursing performance.

Methods: A chart review-based quality improvement project compared the number, repetitions, and completeness of HII score documentation performed by nurses over 6.5 months. Group 1: paper-based HII scores for the 90-day period before intervention; group 2: iPad-based HII scores for the 90 days after intervention. There was a 2-week period for staff training and electronic version feedback between groups. Informal, ad hoc interviews were performed with nurses at investigation termination.

Results: Group 1: 476 emergency department patients with alcohol-induced impairment had HII scores ordered; 339 (71.2%; 95% CI, 67.1, 75.3%) had HII assessments with a total of 539 HII scores documented. An average (SD) 1.60 (0.01) serial assessments occurred per patient, 5 (1.1%; 95% CI, (0, 2.2%) scores were incomplete. Group 2: 569 alcohol-induced impairment emergency department patients were seen and had HII scores ordered; 420 (73.8%; 95% CI, (70.2, 77.4%) had HII assessments with a total of 639 HII scores documented. An average (SD) 1.52 (0.03) serial assessments occurred per patient, 4 (0.9%; 95% CI, (0.81, 0.99%) had incomplete HII scores.

Conclusions: Although our study took place at 1 center, was a chart review, and not directly observed, we found that the mobile device-based HII application to determine a score did not interfere with nursing performance. Specifically, the repetition and completeness of nursing assessments of emergency department patients with impairment from alcohol use was not altered when comparing paper chart documentation with electronic format documentation. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).
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http://dx.doi.org/10.1016/j.curtheres.2021.100630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296087PMC
March 2021

Prediction of anemia and estimation of hemoglobin concentration using a smartphone camera.

PLoS One 2021 14;16(7):e0253495. Epub 2021 Jul 14.

Department of Emergency Medicine, Brown University, Providence, Rhode Island, United States of America.

Anemia, defined as a low hemoglobin concentration, has a large impact on the health of the world's population. We describe the use of a ubiquitous device, the smartphone, to predict hemoglobin concentration and screen for anemia. This was a prospective convenience sample study conducted in Emergency Department (ED) patients of an academic teaching hospital. In an algorithm derivation phase, images of both conjunctiva were obtained from 142 patients in Phase 1 using a smartphone. A region of interest targeting the palpebral conjunctiva was selected from each image. Image-based parameters were extracted and used in stepwise regression analyses to develop a prediction model of estimated hemoglobin (HBc). In Phase 2, a validation model was constructed using data from 202 new ED patients. The final model based on all 344 patients was tested for accuracy in anemia and transfusion thresholds. Hemoglobin concentration ranged from 4.7 to 19.6 g/dL (mean 12.5). In Phase 1, there was a significant association between HBc and laboratory-predicted hemoglobin (HBl) slope = 1.07 (CI = 0.98-1.15), p<0.001. Accuracy, sensitivity, and specificity of HBc for predicting anemia was 82.9 [79.3, 86.4], 90.7 [87.0, 94.4], and 73.3 [67.1, 79.5], respectively. In Phase 2, accuracy, sensitivity and specificity decreased to 72.6 [71.4, 73.8], 72.8 [71, 74.6], and 72.5 [70.8, 74.1]. Accuracy for low (<7 g/dL) and high (<9 g/dL) transfusion thresholds was 94.4 [93.7, 95] and 86 [85, 86.9] respectively. Error trended with increasing HBl values (slope 0.27 [0.19, 0.36] and intercept -3.14 [-4.21, -2.07] (p<0.001) such that HBc tended to underestimate hemoglobin in higher ranges and overestimate in lower ranges. Higher quality images had a smaller bias trend than lower quality images. When separated by skin tone results were unaffected. A smartphone can be used in screening for anemia and transfusion thresholds. Improvements in image quality and computational corrections can further enhance estimates of hemoglobin.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253495PLOS
July 2021

The age-old question: Thematic analysis of focus groups on physician experiences of aging in emergency medicine.

J Am Coll Emerg Physicians Open 2021 Aug 5;2(4):e12499. Epub 2021 Jul 5.

Department of Emergency Medicine, Warren Alpert Medical School Brown University Providence Rhode Island USA.

Objectives: Emergency medicine has a demanding work environment. Characteristics influencing longevity among older physicians in emergency medicine have been the subject of ongoing discussion. The American College of Emergency Physicians (ACEP) released a policy statement in 2009 suggesting accommodating emergency physicians in preretirement years. We engaged emergency physicians to determine awareness of the ACEP policy and issues faced in preretirement years.

Methods: We conducted a series of online focus group discussions with a purposive sample of emergency physicians, age ≥ 50 years. The discussion guide was developed from the ACEP policy statement and relevant literature. Groups were audio recorded, transcribed, and analyzed with a thematic coding system developed iteratively by the 4-person team. Emerging themes were identified, organized, and presented with illustrative quotations.

Results: A total of 28 emergency physicians participated in 4 focus groups, with between 6 and 9 participants in each group. These physicians had between 17 and 35 years of clinical experience (median = 27), 6 were female (21%), and the majority (n = 26, 93%) worked in academic emergency medicine. Only 1 emergency physician was fully aware of the ACEP policy. Three principal content areas were identified: workload demands that change as physicians age, wellness and physician social equity, and senior emergency physician value. Interwoven across all of these was the focus on leadership and solutions to issues. Issues facing emergency physicians in their preretirement years were identified; commitment from emergency medicine site and national leadership and buy-in from junior colleagues was emphasized. Generational conflicts in recognizing the contribution and needs of preretirement emergency physicians was a major barrier to solutions.

Conclusions: Workload demands, wellness and physician social equity, and concerns about value as a senior physician are major themes confronting preretirement emergency physicians. Generational divides, deficits in local and national leadership, and the health detriments of rotating schedules and night shifts are barriers to longevity in emergency medicine. Further research on the value of senior physicians and the impact of hospital and departmental financial models on adopting accommodations for senior emergency physicians is needed.
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http://dx.doi.org/10.1002/emp2.12499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256805PMC
August 2021

Facilitators and barriers to post-overdose service delivery in Rhode Island emergency departments: A qualitative evaluation.

J Subst Abuse Treat 2021 Apr 14;130:108411. Epub 2021 Apr 14.

Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 South Main Street, Providence, RI 02903, United States.

Background: Emergency departments (EDs) in the US have increasingly incorporated interventions that seek to reduce opioid-related morbidity and mortality. However, many of these interventions are underutilized. This study examined ED provider-identified barriers and facilitators to policy-prescribed service provision for patients treated for an opioid overdose in Rhode Island EDs, and opportunities to improve care delivery.

Methods: Semi-structured qualitative interviews were conducted with 55 ED providers (management and clinical staff) across Rhode Island EDs from November 2019 to July 2020. Thematic analysis of interviews focused on gaps and best practices in post-overdose care delivery, including social and structural factors driving access to, and uptake of, services.

Results: Participants highlighted how automatic service delivery (opt out vs. opt in) and the integration of peer-based services enhanced post-overdose service provision. However, social and structural factors (e.g. insurance barriers, limited outpatient treatment resources) and gaps in provider knowledge of medications for opioid use disorder created barriers to care. Addressing long ED wait times and establishing dedicated care teams for patients following an overdose were seen as critical to improving ED service delivery.

Conclusion: Our findings suggest that post-overdose service delivery within EDs is a useful approach for connecting patients to services, particularly when peer support specialists are involved. However, standardizing service delivery approaches and improving provider education of harm reduction services must be prioritized alongside state-level policy changes to improve access to care for ED patients.
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http://dx.doi.org/10.1016/j.jsat.2021.108411DOI Listing
April 2021

The role of salivary vesicles as a potential inflammatory biomarker to detect traumatic brain injury in mixed martial artists.

Sci Rep 2021 Apr 14;11(1):8186. Epub 2021 Apr 14.

Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA.

Traumatic brain injury (TBI) is of significant concern in the realm of high impact contact sports, including mixed martial arts (MMA). Extracellular vesicles (EVs) travel between the brain and oral cavity and may be isolated from salivary samples as a noninvasive biomarker of TBI. Salivary EVs may highlight acute neurocognitive or neuropathological changes, which may be particularly useful as a biomarker in high impact sports. Pre and post-fight samples of saliva were isolated from 8 MMA fighters and 7 from controls. Real-time PCR of salivary EVs was done using the TaqMan Human Inflammatory array. Gene expression profiles were compared pre-fight to post-fight as well as pre-fight to controls. Largest signals were noted for fighters sustaining a loss by technical knockout (higher impact mechanism of injury) or a full match culminating in referee decision (longer length of fight), while smaller signals were noted for fighters winning by joint or choke submission (lower impact mechanism as well as less time). A correlation was observed between absolute gene information signals and fight related markers of head injury severity. Gene expression was also significantly different in MMA fighters pre-fight compared to controls. Our findings suggest that salivary EVs as a potential biomarker in the acute period following head injury to identify injury severity and can help elucidate pathophysiological processes involved in TBI.
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http://dx.doi.org/10.1038/s41598-021-87180-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047010PMC
April 2021

Player age and initial helmet contact among American football players.

Am J Emerg Med 2021 Mar 18;47:115-118. Epub 2021 Mar 18.

Georgetown University School of Medicine, Washington, DC, USA.

Objective: Concussions and chronic traumatic encephalopathy (CTE) related to professional football has received much attention within emergency care and sports medicine. Research suggests that some of this may be due to a greater likelihood of initial helmet contact (IHC), however this association has not been studied across all age groups. This study aims to investigate the association between player age and IHC in American football.

Methods: Retrospective review of championship games between 2016 and 2018 at 6 levels of amateur tackle football as well as the National Football League (NFL). Trained raters classified plays as IHC using pre-specified criteria. A priori power analysis established the requisite impacts needed to establish non-inferiority of the incidence rate of IHC across the levels of play.

Results: Thirty-seven games representing 2912 hits were rated. The overall incidence of IHC was 16% across all groups, ranging from 12.6% to 18.9%. All but 2 of the non-NFL divisions had a statistically reduced risk of IHC when compared with the NFL, with relative risk ratios ranging from 0.55-0.92. IHC initiated by defensive participants were twice as high as offensive participants (RR 2.04, p < 0.01) while 6% [95% CI 5.4-7.2] of all hits were helmet-on-helmet contact.

Conclusions: There is a high rate of IHC with a lower relative risk of IHC at most levels of play compared to the NFL. Further research is necessary to determine the impact of IHC; the high rates across all age groups suggests an important role for education and prevention.
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http://dx.doi.org/10.1016/j.ajem.2021.03.039DOI Listing
March 2021

Demographics and Career Intentions of Graduates of Combined Baccalaureate-MD Programs, 2010-2017: An Analysis of AAMC Graduation Questionnaire Data.

Acad Med 2021 01;96(1):108-112

B. Clyne is associate professor of emergency medicine and vice chair for education, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Purpose: Combined baccalaureate-MD programs exist to fulfill a variety of educational missions, including to promote the development of physician-scientists, increase workforce diversity, promote primary care careers, and meet the needs of underserved patients. The authors sought to determine the demographics of combined program graduates, as well as their intention to practice in primary care (IPPC) and intention to work with the medically underserved (IWMU), as compared with graduates of traditional MD programs.

Method: Data from the 2010-2017 Association of American Medical Colleges Graduation Questionnaire, a national survey of graduating medical students, were recategorized (e.g., as combined program or traditional program) before analysis. Logistic regression models on the 2 primary outcomes (IPPC and IWMU) were conducted to estimate odds ratios for the effects of covariates and predictors (e.g., gender, underrepresented in medicine [URM] group member, type of medical degree program).

Results: Data from a total of 109,028 respondents were included (3,182 from combined and 105,846 from traditional programs). Compared with students in traditional programs, those in combined programs were more likely to be younger (age at graduation ≤ 29: 3,143, 98.8% vs 89,688, 84.7%) and female (1,813, 57.0% vs 52,013, 49.1%) but less likely to identify as a URM group member (276, 8.7% vs 14,757, 13.9%). In an adjusted logistic regression model, graduating from a combined program, identifying as female, and IWMU predicted significantly greater odds of IPPC, while identifying as a URM, identifying as female, and having debt predicted significantly greater odds of IWMU. Graduating medical students who indicated family medicine as a career specialty were more likely to indicate an IWMU.

Conclusions: Medical students graduating from combined programs were more likely to indicate an IPPC but were no more likely to indicate an IWMU than traditional program graduates.
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http://dx.doi.org/10.1097/ACM.0000000000003576DOI Listing
January 2021

The Impact of COVID-19 on Service Provision for Emergency Department Patients Post-Opioid Overdose: A Field Report.

J Addict Med 2020 Nov 16. Epub 2020 Nov 16.

Department of Epidemiology, School of Public Health, Brown University, Providence, RI (ABC, FLB), Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI (FLB, EAS, RW, JB), Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI (FLB).

Background: To minimize the spread of COVID-19, health and ancillary care providers altered service delivery patterns. These changes included an increase in reliance on telemedicine modalities, a reduction in services or hours of operation, and prohibiting guests and nonessential personnel from healthcare settings. We describe a rapid environmental assessment with senior emergency department (ED) practitioners in Rhode Island to understand how COVID-related procedural changes impact the provision of post-overdose care in ED.

Methods: Semi-structured interviews were conducted with 14 senior healthcare practitioners in EDs across Rhode Island from June to July 2020. Interviews were part of a larger, ongoing study examining the implementation and effectiveness of post-opioid overdose care in EDs and sought to understand how COVID-19 had impacted the provision of services for people who use drugs (PWUD).

Results: COVID-related policy changes challenged the provision of services to PWUD in the ED, and extended challenges in connecting people with OUD to services in the community. Specifically, challenges included transitions to telehealth modalities, required COVID tests for treatment services, and gaps in community resources.

Conclusions: This study underscores opportunities to improve the delivery of services amid overlapping public health crises for PWUD, including bolstering the use of telemedicine in EDs and across the care continuum.
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http://dx.doi.org/10.1097/ADM.0000000000000779DOI Listing
November 2020

Screening Adolescent Trauma Patients for Substance Use at 10 Pediatric Trauma Centers.

J Trauma Nurs 2020 Nov/Dec;27(6):313-318

Departments of Emergency Medicine (Drs Mello, Zonfrillo, and Baird and Ms Bromberg), Psychiatry and Human Behavior (Dr Spirito), and Surgery (Dr Wills), Alpert Medical School of Brown University, Providence, Rhode Island; Departments of Health Services, Policy and Practice (Dr Mello) and Behavioral and Social Sciences (Drs Becker and Scott), Brown University School of Public Health, Providence, Rhode Island; Injury Prevention Center of Rhode Island Hospital-Hasbro Children's Hospital, Providence, Rhode Island (Drs Mello, Wills, Zonfrillo, and Baird and Mss Bromberg and Nimaja); Dell Children's Trauma and Injury Research Center, Dell Children's Medical Center, Austin, Texas (Dr Barczyk); Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts (Dr Lee); Division of Pediatrics, Intermountain Primary Children's Hospital, Salt Lake City, Utah (Dr Pruitt); Department of Pediatrics, Harborview Medical Center, Seattle, Washington (Dr Ebel); Department of Pediatrics, Hennepin County Medical Center, Minneapolis, Minnesota (Dr Kiragu); Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, Maryland (Dr Nasr); Department of Pediatric Surgery, UMass Memorial Medical Center, Worcester, Massachusetts (Dr Aidlen); and Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock (Dr Maxson).

Background: The American College of Surgeons Committee on Trauma recommends universal alcohol screening be part of the evaluation of admitted trauma patients. Yet, suboptimal screening rates have been reported for admitted adult and adolescent trauma patients. This lack of screening, in turn, has limited the ability of trauma services to provide patients with brief interventions during their hospital admission and subsequent referrals to treatment after discharge. The primary aim of this study was to examine current rates of alcohol and other drug screening with admitted injured adolescents across a national cohort of 10 pediatric trauma centers.

Methods: This retrospective observational study was nested within a larger adolescent screening, brief intervention, and referral to treatment implementation study (Clinicaltrials.gov NCT03297060). Ten pediatric trauma centers participated in a retrospective chart review of a random sample of adolescent trauma patients presenting for care between March 1, 2018, and November 30, 2018.

Results: Three hundred charts were abstracted across the 10 participating trauma centers (n = 30 per site). Screening rates varied substantially across centers from five (16.7%) to 28 (93.3%) of the 30 extracted charts. The most frequent screening type documented was blood alcohol concentration (BAC) (N = 80, 35.2% of all screens), followed by the CRAFFT (N = 79, 26.3%), and then the urine drug screen (UDS) (N = 77, 25.6%). The BAC test identified 11 patients as positive for recent alcohol use. The CRAFFT identified 11 positive patients.

Conclusions: Alcohol and drug screening is underutilized for adolescents admitted to pediatric trauma centers. More research is warranted on how best to utilize the teachable moment of the pediatric trauma visit to ensure comprehensive screening of adolescent alcohol or other drug (AOD) use.
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http://dx.doi.org/10.1097/JTN.0000000000000537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682252PMC
November 2021

Pediatric Airway Assessment Tool (PAAT): A Rating Tool to Assess Resident Proficiency in Simulated Pediatric Airway Skills Performance.

MedEdPORTAL 2020 10 19;16:10997. Epub 2020 Oct 19.

Associate Professor, Departments of Emergency Medicine & Pediatrics, Division of Pediatric Emergency Medicine, Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Director, Brown Emergency Medicine Medical Education Research Fellowship.

Introduction: The Accreditation Council for Graduate Medical Education has identified the need for assessment of core skills for pediatric and emergency medicine residents, which includes pediatric airway management. Although there are standard courses for pediatric airway management, there is no validated tool to assess basic and advanced pediatric airway skills performance. Our objective was to develop a simulation-based tool for the formative assessment of resident pediatric airway skills performance that was concise, yet comprehensive, and to evaluate the evidence supporting the argument for the tool's validity.

Methods: We developed a pediatric airway assessment tool (PAAT) to assess six major domains of pediatric airway skills performance: basic airway maneuvers, airway adjuncts, bag-valve mask ventilation, advanced airway equipment preparation, direct laryngoscopy, and video laryngoscopy. This tool consisted of a 72-item pediatric airway skills assessment checklist to be used in simulation. We enrolled 12 subjects at four different training levels to participate. Assessment scores were rated by two independent expert raters.

Results: The interrater agreement was high, ranging from 0.92 (adult bagging rate) to 1 (basic airway maneuvers). There was a significant trend of increasing scores with increased training level.

Discussion: The PAAT demonstrated excellent interrater reliability and provided evidence of the construct's validity. Although further validation of this assessment tool is needed, these results suggest that the PAAT may eventually be useful for assessment of resident proficiency in pediatric airway skills performance.
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http://dx.doi.org/10.15766/mep_2374-8265.10997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586756PMC
October 2020

Healthcare-Experience Survey Assessment in the Rhode Island Cambodian Community.

J Immigr Minor Health 2021 Apr 20;23(2):409-413. Epub 2020 Oct 20.

Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA.

The Cambodian community is the largest Southeast Asian cultural identity in Rhode Island (RI) with high poverty rates and limited healthcare access. Investigators conducted a cross-sectional observational survey study from 2016 to 2017 on eligible Cambodians to better understand their healthcare experiences. Questions were reviewed by the RI Cambodian Society for cultural sensitivity. 123 surveys were collected; 98 respondents had medical providers. Respondents with providers reported difficulty understanding of their providers (59%) and limited access to medical interpreters (50%). The non-provider group were less likely to have medical insurance (54.2% vs. 88.8%, p = .0001) and more likely to visit the emergency department (47.1% vs. 15.3%; p < .0001). Language barrier and lack of medical interpreters and healthcare insurance were the major barriers to healthcare for surveyed Cambodians. Future studies are needed to assess whether native-language specific community healthcare resources can positively affect their access to care.
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http://dx.doi.org/10.1007/s10903-020-01110-6DOI Listing
April 2021

A Battery of Easily Accessible, Simple Tools for the Assessment of Concussion in Children.

J Pediatr 2021 02 14;229:232-239.e1. Epub 2020 Oct 14.

Department of Pediatrics, Hasbro Children's Hospital/Rhode Island Hospital, Alpert School of Medicine at Brown University, Providence, RI; Department of Orthopedics, Hasbro Children's Hospital/Rhode Island Hospital, Alpert School of Medicine at Brown University, Providence, RI.

Objective: To determine whether a non-proprietary, novel testing battery can identify recently concussed children within 8 weeks of injury.

Study Design: In total, 568 clinic outpatients aged 10-18 years were sorted into 3 groups: 316 had never been concussed, 162 had ever been concussed before 8 weeks earlier, and 90 had been recently concussed within 8 weeks. At initial and any subsequent visits, a neurologic examination and 4 procedures were performed: Stick Drop, Wall Ball, Sharpened Modified Romberg (SMR), and Animal Naming. Analysis included inter-group and intra-person performance differences using a series of t tests on the Stick Drop, Wall Ball, SMR, and Animal Naming.

Results: The recently concussed group performed worse (P < .01 for all) on Stick Drop, total Wall Ball bounces and drops, and SMR compared with never-concussed and ever-concussed groups. This effect for Stick Drop, SMR, and Wall Ball but not Animal Naming persisted beyond the 4 weeks commonly stated to define recovery. Of 59 recently concussed subjects who returned for ≥1 visit, there were improvements in Stick Drop average (P = .004) and maxima (P = .02) as well as SMR (P = .01) but not Animal Naming between initial and subsequent visits.

Conclusions: This novel, rapid testing battery distinguished groups of children ages 10-18 years who had and had not experienced a recent concussion. A view that physical concussion symptoms resolve within a month of injury may be incomplete. Deployment of this readily available, inexpensive and non-proprietary battery should be compared with other tools and studied further in serial assessments.
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http://dx.doi.org/10.1016/j.jpeds.2020.10.012DOI Listing
February 2021

Modified Delphi Method Derivation of the FAMILY (Family Assessment of Medical Interventions & Liaisons with the Young) EMS Instrument.

Prehosp Emerg Care 2020 Oct 28:1-8. Epub 2020 Oct 28.

Department of Pediatrics, Yale Pediatric Emergency Medicine, New Haven, Connecticut (MXC); Brown University Warren Alpert Medical School, Providence, Rhode Island (LB, JB); Yale School of Medicine, New Haven, Connecticut (MA); University of Colorado School of Medicine, Aurora, Colorado (KA).

Background: Though family satisfaction with prehospital care is a surrogate for quality and patient outcomes, there are no tools available to measure family satisfaction.

Objective: To develop the EMS Family Assessment of Medical Interventions & Liaisons with the Young (FAMILY) instrument.

Methods: Components of family experiences with pediatric prehospital care were identified with a modified Delphi method. The expert panel included Emergency Medical Technicians, paramedics, family representatives, and EMS leaders from Colorado, Connecticut, and Rhode Island. An online survey was used to assess proposed questions from each of five candidate domains from national guidelines, including Safety, Communication, Family Presence, Cultural Awareness, Children with Special Healthcare Needs and Overall Satisfaction. Round-1 items were scored on a five-point Likert scale. Inclusion in the final instrument required 70% agreement ranking items as "" or "." In Round-2, participants assessed proposed refinements. This resulted in FAMILY Version-1, with sections for family members and EMS care providers. EMSC Family Action Network (FAN) representatives evaluated the FAMILY, leading to Version-2. Suggestions from the national FAN about content, clarity, and whether the instrument captured their experiences with pediatric EMS care led to the final FAMILY version. Bilingual speakers translated the instrument into Spanish, while assessing the content for semantic, idiomatic, experiential, and conceptual equivalence between the English and Spanish versions.

Results: There were 22 experts in Round-1, and 20 continued into Round-2 .The Delphi process yielded 12 questions in six domains with 14 recommended modifications. Two questions were excluded. Five domains reached 70% agreement in Round-1. Cultural Awareness reached 75% agreement after Round-2. Six FAN representatives evaluated Version-1, leading to changes for clarity, content and cultural sensitivity. Seventeen FAN representatives evaluated Version-2 leading to additional refinement. The assessment of the equivalence between the English and Spanish survey versions resulted in changes in the Spanish language content for equivalent meaning.

Conclusion: A panel of EMS and family stakeholders successfully developed an instrument to assess family satisfaction with pediatric EMS care. Further validation is required in a large respondent population. Assessing family satisfaction with pediatric EMS encounters is an important step toward improving prehospital care.
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http://dx.doi.org/10.1080/10903127.2020.1824052DOI Listing
October 2020

Boarding is Associated with Reduced Emergency Department Efficiency that is not Mitigated by a Provider in Triage.

West J Emerg Med 2020 Apr 21;21(3):647-652. Epub 2020 Apr 21.

Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island.

Introduction: Boarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects.

Methods: We performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]).

Results: Implementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p < 0.01), and 18 minutes (31%) at the CED (p < 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (p<0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p < 0.01), and every four minutes of boarding increased median LOSD by one minute (p < 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p < 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p < 0.01).

Conclusion: In this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact.
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http://dx.doi.org/10.5811/westjem.2020.2.45728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234689PMC
April 2020

Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches.

J Am Pharm Assoc (2003) 2020 Sep - Oct;60(5):740-749. Epub 2020 Apr 23.

Objectives: Pharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake.

Design: Eight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island.

Setting And Participants: Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.

Outcome Measures: The FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings.

Results: A total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist-partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received.

Conclusions: Experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone.
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http://dx.doi.org/10.1016/j.japh.2020.03.005DOI Listing
June 2021

Core Content for Pediatric Emergency Medicine Ultrasound Fellowship Training: A Modified Delphi Consensus Study.

AEM Educ Train 2020 Apr 12;4(2):130-138. Epub 2019 Jul 12.

University of Ottawa Ottawa Ontario Canada.

Background: Pediatric emergency medicine (PEM) point-of-care ultrasound (POCUS) fellowships exist to provide learners with expertise in ultrasound (US) education, administration, and research oversight. Currently, there are no standardized goals or objectives for these programs, resulting in considerable variability in PEM POCUS fellowship training.

Methods: A modified Delphi survey of PEM and general emergency medicine (EM) POCUS experts in Canada and the United States was conducted to obtain consensus regarding the most important curricular components of a PEM POCUS fellowship training program. Participants were solicited from the P2 Network mailing list and from PEM and EM POCUS fellowship directors listed on the Society of Clinical Ultrasound Fellowships and the Canadian Society of POCUS-EM Fellowships websites. Curricular components considered as part of the survey included US skills, educational skills, administrative skills, and research requirements. Consensus was considered to have been reached when ≥80% of respondents agreed to either include or exclude the component in fellowship training.

Results: Round 1 of the survey was sent to 311 participants. A total of 118 (37.9%) completed eligibility for the survey, and 92 (78.0%) met eligibility criteria. Of those, 80 (67.8% of eligible participants) completed the first round of the survey. Round 2 of the survey was sent to those who completed part 1, and 64 (80.0%) completed that round. During Round 1, consensus was achieved for 15 of 75 US applications, seven of seven educational skills, nine of 11 administrative skills, and four of six research requirements. In Round 2 of the survey, consensus was reached on two additional US skills, but no additional administrative skills or research requirements.

Conclusions: With a consensus-building process, the core content for PEM POCUS fellowship training was defined. This can help POCUS educators formulate standardized curricula to create consistent training in POCUS fellowship graduates.
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http://dx.doi.org/10.1002/aet2.10365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163196PMC
April 2020

Pharmacy on-site overdose protocols and prevention of overdose.

Subst Abus 2020 Mar 18:1-5. Epub 2020 Mar 18.

Department of Emergency Medicine, Injury Prevention Center, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

: Opioid overdose is a preventable injury leading to high morbidity and premature mortality in communities across the United States. Overdoses take place where people use drugs, including commercial and public locations like community pharmacies, and necessitate swift detection and response to avoid harm and, even more seriously, death. The presence of emergency and safety protocols improves occupational health and safety for all in the workplace. The aim of this study was to assess the prevalence of experience with on-site pharmacy overdose and to explore pharmacist and site characteristics associated with having a known protocol for responding to on-site overdose emergencies. : An anonymous, online survey about naloxone provision and opioid safety was delivered by email, through professional pharmacy associations and continuing education attendance lists, to 3,100 pharmacists in Massachusetts and Rhode Island between October 2017 and January 2018. Survey items gauged socio-demographics, practice site characteristics, safer opioid dispensing and naloxone provision. Summary statistics and bivariate analyses were conducted to describe characteristics associated with items pertaining to on-site overdose policy awareness. : Of the 357 respondents (11.5% response rate), 154 (5.0%) answered the questions of interest: 17.5% reported having at least one suspected overdose on-site at their practice location, while 42.9% reported that they were knowledgeable about and could locate at their practice location an on-site overdose protocol detailing how to respond to an overdose. Pharmacists who were knowledgeable about protocols were also more likely to offer naloxone to patients ( = 0.02) and did not practice at a chain pharmacy ( = 0.01). : Community pharmacies that stock and distribute naloxone are key parts of community efforts to address the opioid crisis. Pharmacies and other healthcare settings should develop and implement on-site overdose response protocols and cultivate a norm of naloxone provision to patients.
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http://dx.doi.org/10.1080/08897077.2020.1736236DOI Listing
March 2020

A Novel Tool to Facilitate Communication of Pain Quality: "Pain Blocks".

Clin Ther 2020 02 3;42(2):286-294.e1. Epub 2020 Feb 3.

Alpert Medical School, Department of Emergency Medicine, Research, Rhode Island Hospital, Providence, RI, USA.

Purpose: Assessment of pain is difficult for many reasons, including the inability of patients to translate a subjective experience into words, and it is challenging for health care providers to create a shared understanding of what is being described. Physical representations exist to facilitate the objective scaling of "severity" or "intensity" of pain, but none exist to enable communication of pain quality. The objective of this proof-of-concept study was to develop, introduce, and evaluate consistency of participant interpretation of a novel kinesthetic tool set (Pain Blocks) that was designed to represent qualities of pain.

Methods: A prospective convenience sampling of participants approached in nonmedical settings over 9 months was queried to assess 6 randomly ordered Pain Blocks during structured interviews. The subjects were directed to associate each Pain Block with a pain quality from a list of 12 suggestions or use a free-text area for "other" descriptors. During the study, Pain Blocks were removed and replaced based on consistency of response at interval assessments. In part 2, participants were asked if any of the Pain Blocks accurately characterized the quality of their last severe pain.

Findings: A convenience sample of 220 participants was enrolled in the study and assessed 6 Pain Blocks. They interpreted and applied a pain quality to each of the blocks. Using interval assessments, a final selection of 6 Pain Blocks was derived that had consistent high association with specific pain qualities, either individually or with synonyms: Block 1 (stretching and tearing), 81.8%; Block 3 (crampy and throbbing), 90.4%; Block 4 (sharp and stabbing), 99.1%; Block 6 (crushing and dull), 94.1%; Block 7 (twisting), 95.8%; and Block 8b (burning), 100%. There were no differences in consistency of block interpretation between sexes or in terms of past experience of pain.

Implications: We were able to create a group of physical objects (Pain Blocks) that were consistently and persistently interpreted, with a high degree of reliability, to represent specific pain qualities across ages and sexes. Although this proof-of-concept article was limited by the inclusion of English-speaking patients only and voluntary participants not currently in pain, the results support further investigation into tools to create a shared understanding of pain sensations between provider and participant.
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http://dx.doi.org/10.1016/j.clinthera.2019.12.013DOI Listing
February 2020

A Statewide Cross-Sectional Survey of School Nurses' Knowledge and their Role in the Management of Concussed Students.

R I Med J (2013) 2020 Feb 3;103(1):42-45. Epub 2020 Feb 3.

Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, RI; Mayo Clinic, Department of Emergency Medicine, Rochester, MN.

The school nurse plays a vital role in reintegrating the concussed student into the academic environment. The objective of our survey study was to understand the self- reported level of knowledge of school nurses regarding the diagnosis and management of patients presenting with symptoms of concussion, what responsibilities they have to the concussed student, and to identify the educational resources used. We had a 91.7% response rate and found that most school nurses did not learn about concussions in nursing school; 85% used the CDC HEADS UP website as their educational resource, and the majority reported their knowledge level as fair and wanted more information. Furthermore, 81% took care of at least one concussed student during the past 3 months, 78% had managed the return-to- learn protocol, and 40% managed the return-to-play protocol. Areas for improvement are highlighted and preferred methods to educate were surveyed.
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February 2020

Pharmacy leaders' beliefs about how pharmacies can support a sustainable approach to providing naloxone to the community.

Res Social Adm Pharm 2020 10 18;16(10):1493-1497. Epub 2020 Jan 18.

Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Department of Epidemiology, Alpert Medical School of Brown University, Providence, RI, USA; Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Department of Emergency Medicine, Boston, MA, USA.

Background: Naloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication.

Objective: The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone.

Methods: In-depth interviews were conducted with 12 pharmacy leaders in Massachusetts and Rhode Island. Participants were recruited from three types of community pharmacies: (1) chain; (2) independent; and (3) hospital outpatient. Theory-driven immersion crystallization, using Brownlee et al.'s model of healthcare quality improvement, was used to inform coding of the interview data, with predetermined categories of staff; organization; and process.

Results: Five main themes were identified: (1) Importance of staff training to increase comfort; (2) Strength through coordination of efforts; (3) Pharmacy as a community leader in the opioid crisis; (4) Persisting stigma; and (5) Ongoing workflow challenges.

Conclusions: The results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.
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http://dx.doi.org/10.1016/j.sapharm.2020.01.006DOI Listing
October 2020

Pharmacist attitudes toward pharmacy-based naloxone: A cross-sectional survey study.

J Am Pharm Assoc (2003) 2020 Mar - Apr;60(2):304-310. Epub 2019 Dec 20.

Objective: The aim of this study was to evaluate pharmacist attitudes regarding recommending pharmacy-based naloxone (PBN). The influence of gender, practice setting, the number of years of practice, state, and PBN involvement were explored. Barriers to, and facilitators of, provision of PBN were also assessed.

Design: A 71-question survey was designed to assess experience with, and attitudes toward, PBN. We employed a cross-sectional study design and utilized the online survey site Qualtrics (Qualtrics International Inc, Provo, UT).

Setting And Participants: The survey was e-mailed to approximately 2900 licensed pharmacists from all practice settings in Massachusetts (approximately 1400) and Rhode Island (approximately 1500) and was open from April 5, 2016, until July 13, 2016.

Outcome Measures: Attitudes toward opioid overdose prevention (12 questions) were used to develop the Opioid Overdose Prevention Attitude (OOPA) scale which consisted of 3 subscales: Opioid Overdose Prevention Attitude, Public Health Attitude, and Naloxone Dispensing Attitude.

Results: Of the approximately 2900 pharmacists who received the survey, 402 responded (13%), and 245 (137 from Massachusetts and 108 from Rhode Island) were included in the analyses. The majority (79%) identified as White or Caucasian, and 127 (51.8%) stated they had ever dispensed naloxone. Of those, 85 (67%) had done so in the past 30 days. We examined differences in the OOPA subscales by pharmacists' characteristics and pharmacy practice settings. Working in a pharmacy that had a standing order or collaborative practice agreement allowing pharmacists to dispense naloxone without a physician's prescription, or in a pharmacy that stocked naloxone resulted in more positive attitudes toward opioid overdose prevention and public health prevention.

Conclusion: Respondents who practiced in a pharmacy with a standing order or collaborative practice agreement were more likely to have dispensed naloxone. Both stocking naloxone and ever having dispensed naloxone were associated with higher OOPA scores. More research is needed to better understand how pharmacist attitudes influence the distribution of naloxone.
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http://dx.doi.org/10.1016/j.japh.2019.11.004DOI Listing
June 2021

Rurality and differences in pharmacy characteristics and community factors associated with provision of naloxone in the pharmacy.

Int J Drug Policy 2020 11 15;85:102602. Epub 2019 Nov 15.

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA.

Background: Pharmacies are the most accessible healthcare settings across urban, suburban, and rural areas of the United States and, thus a key venue in the overdose risk environment. Pharmacy dispensing of naloxone is part of the public health response to the opioid overdose crisis, yet little is known about the pharmacy- and community-level characteristics with which naloxone provision is associated.

Methods: We conducted a longitudinal analysis of pharmacy-level quarterly naloxone dispensed from one large US community pharmacy chain from the 1st quarter of 2013 to the 2nd quarter of 2017, examining associations between naloxone provision and pharmacy-level characteristics and community factors in two US states, Rhode Island and Massachusetts. Rurality was defined using the rural urban commuting area (RUCA) scale scores, calculated based on US 2010 Census variables. Pharmacy-level characteristics (e.g., 24 h store, average daily volumes of total prescriptions, nonprescription syringe sales, buprenorphine prescriptions) derived from the pharmacy chain; community factors (e.g., RUCA score, ZIP-code level age, race distributions, and median household income) were obtained from the decennial census files. The linear mixed effects methods modeled dispensing history and the number of naloxone doses dispensed through binomial and negative binomial distributions respectively, accounting for trend and covariates.

Results: Adjusted analyses of dispensing data from 449 pharmacies in two states indicated that more rural pharmacies (i.e., stores in areas with higher RUCA scores), pharmacies with higher volumes of all prescriptions and of buprenorphine, that sell more nonprescription syringes, that have drive-throughs and longer weekend hours, and that are located in communities with younger age distributions were associated with increased likelihood of ever dispensing naloxone and a greater number of naloxone doses dispensed (all p<.05).

Conclusion: Pharmacies are a key evolving element in the overdose risk environment, striving to develop reputations as sources of wellness, prevention, and harm reduction supplies, like naloxone. Pharmacy naloxone dispensing may be an especially effective strategy to alter the overdose risk environment in rural communities.
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http://dx.doi.org/10.1016/j.drugpo.2019.11.010DOI Listing
November 2020

Dedicated MRI in the emergency department to expedite diagnostic management of hip fracture.

Emerg Radiol 2020 Feb 15;27(1):41-44. Epub 2019 Oct 15.

Department of Emergency Medicine, Brown University, Providence, RI, USA.

Purpose: To determine the effect on time to diagnosis of making MRI imaging for hip fractures available directly in the emergency department (ED).

Methods: We conducted a retrospective observational study of patients with MRI imaging of the hip for suspected occult fracture, comparing time to diagnosis and time to disposition of populations imaged in the year preceding and the year following installation of an MRI scanner in the ED.

Results: Time to diagnosis of hip fractures was 709 min before installation of a dedicated ED MRI scanner and 280 min after, a 60% reduction. Including the MRI in the diagnostic workup did not increase ED throughput time, and we were able to save 48% of the patients who had an ED-based MRI from an admission to the hospital.

Conclusion: Implementation of an MRI scanner for dedicated emergency department use enables faster hip fracture diagnosis and surgical consultation, or definitive disposition without increasing ED throughput time.
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http://dx.doi.org/10.1007/s10140-019-01729-5DOI Listing
February 2020

An Electronic Sexual Health Module for Hospitalized Adolescent Girls.

Hosp Pediatr 2019 11 9;9(11):880-887. Epub 2019 Oct 9.

Departments of Pediatrics and.

Objectives: To evaluate the acceptability and feasibility of an electronic sexual health module for inpatient adolescent girls and assess the preliminary effect on uptake of sexual health services.

Methods: We recruited girls 14 to 18 years old admitted to the hospitalist service of 1 academic children's hospital from January 2016 to October 2016. Participants completed an electronic sexual health module that included a sexual health assessment, tailored feedback (randomized for half of the participants only), and a questionnaire to request sexual health services. Participation and completion rates, along with effects of tailored feedback, risk perception, age group, and sexual activity on uptake of services, were examined.

Results: Seventy-seven percent of eligible participants who were approached enrolled in the study ( = 66 of 86). The completion rate was 100%. Fifty-three percent ( = 35) requested some form of sexual health service; of these, 83% ( = 29) requested to watch a contraception video. There was no statistically significant difference in the frequency of requests for those who received tailored feedback and for those who did not (57% vs 48%; = .48). Younger teens and those without sexual experience made requests similar to older and sexually experienced girls except regarding sexually transmitted infection testing, which was significantly higher in the latter populations.

Conclusions: This pilot study demonstrated reasonable feasibility and acceptability of a standardized sexual health module for adolescent girls admitted to the general pediatric wards. Videos focused on adolescent health were of particular interest to this population. Further study should examine the impact of such a module on long-term sexual health behaviors.
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http://dx.doi.org/10.1542/hpeds.2018-0276DOI Listing
November 2019

Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians.

J Am Pharm Assoc (2003) 2019 Nov - Dec;59(6):824-831. Epub 2019 Sep 30.

Objectives: There is limited research on the attitudes of pharmacy technicians toward pharmacy naloxone provision, despite their widespread role in the pharmacy. We examined attitudes and perceptions of pharmacy technicians in the provision of naloxone in a sample of Massachusetts pharmacies.

Design: Thirty-nine community retail pharmacies from 1 U.S. chain were purposely sampled in 13 municipalities across Massachusetts. Pharmacies were divided into high-risk municipalities (HRMs) versus low-risk municipalities (LRMs) based on the state average opioid-related death rate from 2011 to 2015.

Setting And Participants: A pharmacy technician working in each pharmacy was administered an in-person survey. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone.

Outcome Measures: Closed-ended responses were analyzed by Mann-Whitney U, Fisher exact, and chi-square tests. Open-ended responses were summarized for themes and then contrasted by municipality risk status.

Results: Technician participation was 100% (n = 39). Technicians in both groups believed they could identify patient groups at risk of overdose in their practice, but HRM technicians recognized the need for naloxone for more of their at-risk patients (81% in HRM vs. 33% in LRM believed > 25% of patients need naloxone, P < 0.01). A willingness to provide naloxone was high (> 89%) in both groups. Open-ended responses revealed commonalities between groups, including the belief that patients need lower-cost naloxone, and a lack of patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs.

Conclusion: Pharmacy technicians would benefit from overdose prevention training and are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone. Among technicians, there is a high willingness to be involved in implementing broader naloxone access in pharmacies.
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http://dx.doi.org/10.1016/j.japh.2019.08.009DOI Listing
September 2020

Evaluation of a Safer Opioid Prescribing Protocol (SOPP) for Patients Being Discharged From a Trauma Service.

J Trauma Nurs 2019 May/Jun;26(3):113-120

Department of Emergency Medicine (Dr Mello), The Warren Alpert School of Medicine of Brown University (Drs Green and Baird); Division of Trauma and Surgical Critical Care, Department of Surgery (Dr Adams and Ms Bohlen), Injury Prevention Center, Rhode Island Hospital, Providence (Drs Baird and Mello); Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Faul); Department of Emergency Medicine, Boston Medical Center Injury Prevention Center, Boston University School of Medicine, Boston, Massachusetts (Drs Green and Howland); Rhode Island Hospital, University Surgical Associates, Inc., Providence (Ms Hodne); and Department of Health Services, Practice and Policy, Brown University School of Public Health, Providence, Rhode Island (Dr Mello).

The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose.
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http://dx.doi.org/10.1097/JTN.0000000000000435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727973PMC
March 2020

Documentation of Tobacco, Alcohol, and Drug Screening in Hospitalized Adolescents.

Hosp Pediatr 2019 09 14;9(9):719-723. Epub 2019 Aug 14.

Warren Alpert Medical School, Brown University, Providence, Rhode Island; and.

Objectives: To examine the frequency of documented screening for tobacco, alcohol, and drug use in hospitalized adolescents on the pediatric hospitalist service.

Patients And Methods: This was a retrospective chart review of adolescents aged 14 to 17 years hospitalized at a large urban academic children's hospital in the Northeast from 2013 to 2015. Only patients admitted directly to the hospitalist service and only the first admission (if multiple occurred) were included. Patients presenting for psychiatric illness, ingestions, or impaired neurologic functioning were excluded. Admission history and physical (H&P) notes were reviewed to identify documented screening for tobacco, alcohol, and drug use. χ tests and 95% confidence intervals (CIs) were used to compare screenings for each substance and assess for associations of patient and encounter characteristics.

Results: A total of 443 charts met criteria for inclusion. The majority of adolescents were girls ( = 286; 64.6%), and mean age was 15.6 years (SD: 1.1). The H&P notes included notation of screening for tobacco use in 75.4% (95% CI: 71.1%-79.3%), alcohol use in 56.4% (95% CI: 51.7%-61.1%), and drug use in 37.9% (95% CI: 33.4%-42.6%) of charts. Girls were 1.4 times more likely to have of documented screening for alcohol use than boys. The admission diagnosis category was significantly associated with documentation of alcohol screening. Tobacco and drug screening frequency did not differ on the basis of sex, age, or diagnosis category.

Conclusions: Documentation of substance use screening was not universal in admission H&P notes. These discrepancies suggest a need for improvements in screening protocols and documentation methods.
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http://dx.doi.org/10.1542/hpeds.2018-0252DOI Listing
September 2019

Pilot Study of the Effect of a Protocol of 30 Minutes of Scene Care in Out-of-Hospital Cardiac Arrest in Rhode Island.

R I Med J (2013) 2019 May 1;102(4):30-33. Epub 2019 May 1.

Director of Senior Resident EMS Education, Assistant Professor of Emergency Medicine, Clinician Education, Alpert Medical School of Brown University.

Background: Improved outcomes in out-of-hospital cardiac arrest (OHCA) have been demonstrated with increased focus on high-quality CPR. In 2017, the RI Department of Health mandated 30 minutes of on-scene CPR for atraumatic cardiac arrest victims. The effects of this intervention are unknown.

Methods: An EMR query was performed to identify OHCA cases presenting to a Lifespan hospital during the months of March 2016 (pre-intervention) and March 2017 (post-intervention) with an estimated severity index of 1 or cardiac arrest. Primary Results: 63 cases of OHCA were identified. ROSC at ED presentation increased in the post-intervention period, though it was not statistically significant (12% vs 22%, CI = -0.01,0.25 vs. 0.09,0.35). Endotracheal intubation and ACLS medication use increased as well.

Conclusions: This pilot study of a protocol emphasizing on-scene CPR in urban Rhode Island resulted in changes in pre-hospital OHCA management and there was a trend toward increased ROSC in the post-intervention period.
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May 2019

Substance use screening, brief intervention, and referral to treatment training for emergency medicine trainees.

Adv Med Educ Pract 2019 14;10:71-76. Epub 2019 Feb 14.

Department of Emergency Medicine, The Warren Alpert Medical School, Brown University, Providence, RI, USA,

Introduction: Emergency medicine (EM) providers are in an opportunistic position to identify and intervene with patients at risk for alcohol misuse and related problems. However, alcohol screening, brief intervention, and referral to treatment (SBIRT) services are underutilized within the emergency department. Providing SBIRT training to trainees may help to increase utilization of these valuable services in the future. An SBIRT training program for EM faculty and trainees was developed and delivered to increase trainees' skills and practice of SBIRT services.

Methods: The SBIRT training program included unique tracks for medical students, physician assistant (PA) students, EM residents and faculty preceptors. Faculty and trainees completed performance measures at the end of each training session, 30 days post-training and 12 months later.

Results: SBIRT training was provided to 238 trainees and 65 faculty members. At all follow-up time points, satisfaction of training and usefulness varied by trainee type with PA students rating constructs higher than both medical students and EM residents. At the 12-month follow-up survey, there was no significant difference in ratings of sharing the information (χ (2)=0.38, =0.33) between these trainees, with the majority of all trainees (96% of PA students, 83% of residents and 68% of medical students) responding that they had applied what they learned in the training to their work.

Conclusion: An SBIRT training curriculum for EM trainees was delivered successfully and utilized 12 months after implementation.
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http://dx.doi.org/10.2147/AMEP.S186502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386202PMC
February 2019

Corrigendum to "Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes" [J. Subst. Abus. Treat. 94 (2018 Nov) 29-34].

J Subst Abuse Treat 2019 Apr 16;99. Epub 2019 Jan 16.

Department of Emergency Medicine, Alpert Medical School of Brown University, 55 Claverick Street, Suite 100, Providence, RI, United States; Injury Prevention Center, Rhode Island Hospital, 55 Claverick Street, 2nd Floor, Providence, RI, United States.

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http://dx.doi.org/10.1016/j.jsat.2019.01.008DOI Listing
April 2019
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