Daniel Grigat - Academia.edu (original) (raw)

Papers by Daniel Grigat

Canadian Journal of Emergency Medicine

Background In 2016, based on recommendations of the American Association of Blood Banks (AABB), C... more Background In 2016, based on recommendations of the American Association of Blood Banks (AABB), Choosing Wisely Canada released transfusion guidelines for patients with Iron Deficiency Anemia. The goal of the present study was to examine the number of transfusions given in Calgary emergency departments (EDs) before and after the release of these guidelines. Methods We analyzed 11,786 anemia encounters from January 2014 to December 2019. A transfusion was considered potentially avoidable if the patient's hemoglobin was > 70 g/L and if the patient was hemodynamically stable. We used time-series analyses to examine change in rate of total and potentially avoidable transfusions quarterly over the total and pre and post intervention periods. Results In total, 1409/11,786 (12.0%) of the encounters received transfusions; 80.0% (1127/1409) were indicated while 19.9% (281/1409) were potentially avoidable. In the pre-intervention period, the rate of potentially avoidable transfusions was 21.5% (133/618) and in the post-intervention period, the rate of potentially avoidable transfusions was 18.7% (148/791). The rate of potentially avoidable transfusions decreased quarterly at a rate of 0.3% which did not reach statistical significance (p = 0.06). Discussion Our data suggest that the number of potentially avoidable transfusions has not decreased since the release of Choosing Wisely Canada guidelines and local educational initiatives. This may be due to the fact that there is a pre-existing down trend in the number of transfusions provided. Keywords Knowledge translation • Clinical practice guidelines • Quality improvement Résumé Contexte En 2016, sur la base des recommandations de l'AABB (Association américaine des banques de sang) Choisir avec soin Canada a publié des directives sur la pratique transfusionnelle pour les patients atteints d'anémie ferriprive. Le but de la présente étude était d'examiner le nombre de transfusions administrées dans les services d'urgence (SU) de Calgary avant et après la publication de ces directives. Méthodes Nous avons analysé 11 786 cas d'anémie entre janvier 2014 et décembre 2019. Une transfusion était jugée comme potentiellement évitable si l'hémoglobine du patient était > 70 g/L et si le patient était stable sur le plan hémodynamique. Nous avons utilisé des analyses de séries chronologiques pour examiner trimestriellement le changement du taux de transfusions totales et potentiellement évitables au cours de l'ensemble des périodes, y compris avant et après l'intervention.

Canadian Journal of Emergency Medicine

Objectives Clinical decision support may facilitate evidence-based imaging, but most studies to d... more Objectives Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). Methods Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. Results A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. Conclusion Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.

BACKGROUND Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient qual... more BACKGROUND Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient quality of life continues to be significantly impacted. OBJECTIVE To assess the impact of IBD on patients and families with regard to leisure, relationships, mental well-being and financial security, and to evaluate the quality and availability of IBD information. METHODS An online survey was advertised on the Crohn's and Colitis Canada website, and at gastroenterology clinics at the University of Alberta Hospital (Edmonton, Alberta) and University of Calgary Hospital (Calgary, Alberta). RESULTS The survey was completed by 281 IBD patients and 32 family members. Among respondents with IBD, 64% reported a significant or major impact on leisure activities, 52% a significant or major impact on interpersonal relationships, 40% a significant or major impact on financial security, and 28% a significant or major impact on planning to start a family. Patient information needs emphasized understa...

Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states:... more Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states: “Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule)”. In order to provide patients with information on the risks and benefits of computed tomography (CT) scans in minor traumatic brain injuries (mTBI) and to encourage discussions between patients and their doctor, we designed a patient-focused mTBI infographic for the emergency department (ED). Methods Stakeholders worked with content experts to co-design the infographic, which was posted in two emergency department (ED) waiting rooms. A survey was administered to evaluate whether the infographic influenced patient beliefs about the risks and benefits of CT scans and to gauge patient willingness to have a discussion with their doctor about the necessity of a scan. Results One hundred fifteen patients completed the survey. Prior to pa...

Long term care (LTC) facilities provide health services and assist residents with daily care. At ... more Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and...

Cureus, 2020

This study describes the protocol for a systematic review and meta-analysis. The primary objectiv... more This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.

Background In 2017 the Emergency Strategic Clinical Network (ESCN) and Addiction and Mental Hea... more Background In 2017 the Emergency Strategic Clinical Network (ESCN) and Addiction and Mental Health Strategic Clinical Network (AMH SCN) of Alberta Health Services (AHS) launched a survey to understand the experience of young people seeking help in an Emergency Department (ED) for a mental health concern. Over 1500 surveys were completed, and qualitative results were analyzed thematically and interpreted in partnership with focus groups. A major theme of the responses was the feeling of being stigmatized when seeking help for a mental health concern, and that health care professionals’ understanding, empathy, and competencies with youth mental health needs to be improved. In response to this finding, a nurse education workshop has been developed and is being piloted and evaluated. Implementation The ESCN and the AMH SCN are working together to develop, pilot, and evaluate new training for ED nurses. The education will debunk common misperceptions and associated stigma about the...

Academic Emergency Medicine, 2015

Researchers have attempted to optimize imaging utilization by describing which clinical variables... more Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference....

Past Imperfect, 2008

Joan of Arc has exercised a hold on the imagination, both medieval and modern, far exceeding her ... more Joan of Arc has exercised a hold on the imagination, both medieval and modern, far exceeding her limited military achievements. It is perhaps for this reason that the trial of Joan on charges of heresy, culminating in her conviction and execution, is typically interpreted in a cynical light. The primary theme of the literature is that the she was brought to trial and convicted for challenging the institutionalized power of state and church. The issue of gender transgression, which is repeated throughout the transcripts of Joan's trial, is either ignored or dismissed as irrelevant. It is typical of the medieval narrative that belief systems no longer accepted today are not taken seriously, and this is done through reducing them to familiar categories. This paper aims to take the trial of Joan of Arc seriously by arguing that Joan really was a heretic because she was different from orthodox Christians in that she transgressed traditional gender roles. This issue played a major role in Joan's trial and one can scarcely read two paragraphs of the record without issues of gender transgression being raised and denounced. Furthermore, gender transgression was explicitly identified as amounting to heresy, and theological arguments were given by learned experts to justify this connection. This is not to deny that Joan was a heretic on other grounds; her obstinate refusal to submit herself to the Church militant and insistence on her ability to interpret her own revelations are crucial issues. Likewise, we do not intend to deny the political aspect of her trial, but rather to argue that the defense and reinforcement of traditional authority structures cannot be demarcated from the issue of heresy and gender transgression.

CJEM, Jan 5, 2018

CLINICIAN'S CAPSULE What is known about the topic? Age-adjusted D-dimer thresholds have been ... more CLINICIAN'S CAPSULE What is known about the topic? Age-adjusted D-dimer thresholds have been proposed to improve specificity of diagnostic testing for thromboembolism in patients ages 50 and over. What did this study ask? What is the diagnostic accuracy of an age-adjusted D-dimer threshold in a population of patients undergoing investigations for suspected pulmonary embolism (PE)? What did this study find? Age-adjusted D-dimer cut-offs improved specificity but at the expense of a slightly higher risk of missed PE. Why does this study matter to clinicians? Use of age adjusted D-dimer thresholds, in combination with validated risk scores, may reduce CT utilization in older patients.

Canadian Journal of Emergency Medicine

Background In 2016, based on recommendations of the American Association of Blood Banks (AABB), C... more Background In 2016, based on recommendations of the American Association of Blood Banks (AABB), Choosing Wisely Canada released transfusion guidelines for patients with Iron Deficiency Anemia. The goal of the present study was to examine the number of transfusions given in Calgary emergency departments (EDs) before and after the release of these guidelines. Methods We analyzed 11,786 anemia encounters from January 2014 to December 2019. A transfusion was considered potentially avoidable if the patient's hemoglobin was > 70 g/L and if the patient was hemodynamically stable. We used time-series analyses to examine change in rate of total and potentially avoidable transfusions quarterly over the total and pre and post intervention periods. Results In total, 1409/11,786 (12.0%) of the encounters received transfusions; 80.0% (1127/1409) were indicated while 19.9% (281/1409) were potentially avoidable. In the pre-intervention period, the rate of potentially avoidable transfusions was 21.5% (133/618) and in the post-intervention period, the rate of potentially avoidable transfusions was 18.7% (148/791). The rate of potentially avoidable transfusions decreased quarterly at a rate of 0.3% which did not reach statistical significance (p = 0.06). Discussion Our data suggest that the number of potentially avoidable transfusions has not decreased since the release of Choosing Wisely Canada guidelines and local educational initiatives. This may be due to the fact that there is a pre-existing down trend in the number of transfusions provided. Keywords Knowledge translation • Clinical practice guidelines • Quality improvement Résumé Contexte En 2016, sur la base des recommandations de l'AABB (Association américaine des banques de sang) Choisir avec soin Canada a publié des directives sur la pratique transfusionnelle pour les patients atteints d'anémie ferriprive. Le but de la présente étude était d'examiner le nombre de transfusions administrées dans les services d'urgence (SU) de Calgary avant et après la publication de ces directives. Méthodes Nous avons analysé 11 786 cas d'anémie entre janvier 2014 et décembre 2019. Une transfusion était jugée comme potentiellement évitable si l'hémoglobine du patient était > 70 g/L et si le patient était stable sur le plan hémodynamique. Nous avons utilisé des analyses de séries chronologiques pour examiner trimestriellement le changement du taux de transfusions totales et potentiellement évitables au cours de l'ensemble des périodes, y compris avant et après l'intervention.

Canadian Journal of Emergency Medicine

Objectives Clinical decision support may facilitate evidence-based imaging, but most studies to d... more Objectives Clinical decision support may facilitate evidence-based imaging, but most studies to date examining the impact of decision support have used non-randomized designs which limit the conclusions that can be drawn from them. This randomized trial examines if decision support can reduce computed tomography (CT) utilization for patients with mild traumatic brain injuries and suspected pulmonary embolism in the emergency department. This study was funded by a competitive public research grant and registered on ClinicalTrials.gov (NCT02410941). Methods Emergency physicians at five urban sites were assigned to voluntary decision support for CT imaging of patients with either head injuries or suspected pulmonary embolism using a cluster-randomized design over a 1-year intervention period. The co-primary outcomes were CT head and CT pulmonary angiography utilization. CT pulmonary angiography diagnostic yield (proportion of studies diagnostic for acute pulmonary embolism) was a secondary outcome. Results A total of 225 physicians were randomized and studied over a 2-year baseline and 1-year intervention period. Physicians interacted with the decision support in 38.0% and 45.0% of eligible head injury and suspected pulmonary embolism cases, respectively. A mixed effects logistic regression model demonstrated no significant impact of decision support on head CT utilization (OR 0.93, 95% CI 0.79-1.10, p = 0.31), CT pulmonary angiography utilization (OR 0.98, 95% CI 0.88-1.11, p = 0.74) or diagnostic yield (OR 1.23, 95% CI 0.96-1.65, p = 0.10). However, overall CT pulmonary diagnostic yield (17.7%) was almost three times higher than that reported by a recent large US study, suggesting that selective imaging was already being employed. Conclusion Voluntary decision support addressing many commonly cited barriers to evidence-based imaging did not significantly reduce CT utilization or improve diagnostic yield but was limited by low rates of participation and high baseline rates of selective imaging. Demonstrating value to clinicians through interventions that improve workflow is likely necessary to meaningfully change imaging practices.

BACKGROUND Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient qual... more BACKGROUND Despite improvements in therapies for inflammatory bowel diseases (IBDs), patient quality of life continues to be significantly impacted. OBJECTIVE To assess the impact of IBD on patients and families with regard to leisure, relationships, mental well-being and financial security, and to evaluate the quality and availability of IBD information. METHODS An online survey was advertised on the Crohn's and Colitis Canada website, and at gastroenterology clinics at the University of Alberta Hospital (Edmonton, Alberta) and University of Calgary Hospital (Calgary, Alberta). RESULTS The survey was completed by 281 IBD patients and 32 family members. Among respondents with IBD, 64% reported a significant or major impact on leisure activities, 52% a significant or major impact on interpersonal relationships, 40% a significant or major impact on financial security, and 28% a significant or major impact on planning to start a family. Patient information needs emphasized understa...

Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states:... more Introduction The first Choosing Wisely Canada (CWC) recommendation for Emergency Medicine states: “Don’t order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule)”. In order to provide patients with information on the risks and benefits of computed tomography (CT) scans in minor traumatic brain injuries (mTBI) and to encourage discussions between patients and their doctor, we designed a patient-focused mTBI infographic for the emergency department (ED). Methods Stakeholders worked with content experts to co-design the infographic, which was posted in two emergency department (ED) waiting rooms. A survey was administered to evaluate whether the infographic influenced patient beliefs about the risks and benefits of CT scans and to gauge patient willingness to have a discussion with their doctor about the necessity of a scan. Results One hundred fifteen patients completed the survey. Prior to pa...

Long term care (LTC) facilities provide health services and assist residents with daily care. At ... more Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community. We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and...

Cureus, 2020

This study describes the protocol for a systematic review and meta-analysis. The primary objectiv... more This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.

Background In 2017 the Emergency Strategic Clinical Network (ESCN) and Addiction and Mental Hea... more Background In 2017 the Emergency Strategic Clinical Network (ESCN) and Addiction and Mental Health Strategic Clinical Network (AMH SCN) of Alberta Health Services (AHS) launched a survey to understand the experience of young people seeking help in an Emergency Department (ED) for a mental health concern. Over 1500 surveys were completed, and qualitative results were analyzed thematically and interpreted in partnership with focus groups. A major theme of the responses was the feeling of being stigmatized when seeking help for a mental health concern, and that health care professionals’ understanding, empathy, and competencies with youth mental health needs to be improved. In response to this finding, a nurse education workshop has been developed and is being piloted and evaluated. Implementation The ESCN and the AMH SCN are working together to develop, pilot, and evaluate new training for ED nurses. The education will debunk common misperceptions and associated stigma about the...

Academic Emergency Medicine, 2015

Researchers have attempted to optimize imaging utilization by describing which clinical variables... more Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference....

Past Imperfect, 2008

Joan of Arc has exercised a hold on the imagination, both medieval and modern, far exceeding her ... more Joan of Arc has exercised a hold on the imagination, both medieval and modern, far exceeding her limited military achievements. It is perhaps for this reason that the trial of Joan on charges of heresy, culminating in her conviction and execution, is typically interpreted in a cynical light. The primary theme of the literature is that the she was brought to trial and convicted for challenging the institutionalized power of state and church. The issue of gender transgression, which is repeated throughout the transcripts of Joan's trial, is either ignored or dismissed as irrelevant. It is typical of the medieval narrative that belief systems no longer accepted today are not taken seriously, and this is done through reducing them to familiar categories. This paper aims to take the trial of Joan of Arc seriously by arguing that Joan really was a heretic because she was different from orthodox Christians in that she transgressed traditional gender roles. This issue played a major role in Joan's trial and one can scarcely read two paragraphs of the record without issues of gender transgression being raised and denounced. Furthermore, gender transgression was explicitly identified as amounting to heresy, and theological arguments were given by learned experts to justify this connection. This is not to deny that Joan was a heretic on other grounds; her obstinate refusal to submit herself to the Church militant and insistence on her ability to interpret her own revelations are crucial issues. Likewise, we do not intend to deny the political aspect of her trial, but rather to argue that the defense and reinforcement of traditional authority structures cannot be demarcated from the issue of heresy and gender transgression.

CJEM, Jan 5, 2018

CLINICIAN'S CAPSULE What is known about the topic? Age-adjusted D-dimer thresholds have been ... more CLINICIAN'S CAPSULE What is known about the topic? Age-adjusted D-dimer thresholds have been proposed to improve specificity of diagnostic testing for thromboembolism in patients ages 50 and over. What did this study ask? What is the diagnostic accuracy of an age-adjusted D-dimer threshold in a population of patients undergoing investigations for suspected pulmonary embolism (PE)? What did this study find? Age-adjusted D-dimer cut-offs improved specificity but at the expense of a slightly higher risk of missed PE. Why does this study matter to clinicians? Use of age adjusted D-dimer thresholds, in combination with validated risk scores, may reduce CT utilization in older patients.