BC Guidelines

Minor revisions to the Chronic Obstructive Pulmonary Disease (COPD) guideline to reflect new PharmaCare regular benefit coverage for Tiotropium.

The Tobacco Use Disorder (TUD) guideline provides evidence-based recommendations for primary care practitioners on managing tobacco use disorder (TUD). This guideline also addresses vaping. While the guideline focuses on TUD in adults (ages ≥ 19), there are some recommendations addressing the youth population (ages 12-18).

• Tobacco use disorder (TUD) (defined in the DSM-5-TR), like other substance use disorders, is a chronic and often relapsing condition. Document smoking history by number of years spent smoking (now considered a better risk indicator than “pack years”). Ask regularly about smoking status and document tobacco use in the patient medical record, including number of cessation attempts.
• Acknowledge that relapse is common and can be expected. If a patient has resumed tobacco use, offer education and review and adjust their smoking cessation plan.
• Continue to provide brief interventions (BI), which are effective when routinely repeated. Consider a motivational interviewing (MI) approach with all patients, including those not yet ready to stop smoking.
• The most effective way to stop smoking is a combination of both pharmacotherapy and counselling. Treatment plans should be individually and collaboratively tailored.
  • Medications: Encourage first-line pharmacotherapy, including nicotine replacement therapy (NRT), varenicline, and bupropion.
  • Counselling: Smoking cessation programs provide support to those who plan to quit smoking. Encourage patients to connect with QuitNow or to the FNHA’s Talk Tobacco Program.
• Ask regularly about and document vaping use (including youth). Advise and support efforts to quit vaping.

• ANA testing is only indicated if the diagnosis of a CTD (i.e., systemic lupus erythematosus, scleroderma, polymyositis/dermatomyositis, Sjögren’s syndrome) is a significant clinical possibility.
• ANA testing is not indicated:
  • as a screening test to evaluate fatigue, back pain, or other musculoskeletal pain without other clinical indications
  • to confirm a diagnosis of rheumatoid arthritis or osteoarthritis.
  • to monitor lupus flares.
• ANA testing need only be ordered once in most cases.
• When the ANA test result is:
  • Positive: Repeat or serial testing is not indicated, as changes in ANA titres do not correlate with disease activity.
  • Negative: Repeat testing may be indicated only if the clinical presentation has changed.

The Concussion / Mild Traumatic Brain Injury (mTBI) guideline provides recommendations for the primary care assessment, diagnosis, and management of concussion/mild traumatic brain injury (mTBI) for patients of all ages. This guideline is not appropriate for use with moderate or severe brain injuries.

Key Recommendations

Assessment and Diagnosis

• Assess all individuals suspected of concussion as soon as possible, ideally within 72 hours, and before potential re-exposure to head trauma.
• Triage patients with red flags for emergency department evaluation.
• Screen patients to identify those at risk of persisting symptoms.
• Routine neuroimaging is not recommended unless specific red flags are present.
• Evaluate patients for other relevant conditions (e.g., mental health or mood disorders, attention-deficit/hyperactivity disorder (ADHD), chronic headache, substance use). Manage these while also treating for concussion.

Management

• Counsel all patients to observe relative rest for 24-48 hours.
• Reassure patients of likelihood of good prognosis but highlight importance of early recognition and management of persisting symptoms.
• Advise patients that they can gradually return to activities even in the presence of mild symptoms. This should be at a pace with no more than mild and brief symptom exacerbation.
• Advise patients to avoid activities that risk reoccurrence of head trauma until medically cleared.
• Prescribe aerobic exercise interventions to decrease concussion-related symptoms and reduce the risk of persistent symptoms. Begin with 55% max heart rate then progress to 70%.
• Focus early management strategies on 1) headache, 2) sleep, and 3) mood.
• Conduct a follow-up assessment, ideally within two weeks of diagnosis.
• Refer patients at risk of or experiencing persisting symptoms to interdisciplinary care.
• Provide patient education in verbal and written formats.
• Where possible, co-manage patients

Special Considerations

• Consider interpersonal violence and child abuse/neglect with trauma-related presentations. Report and refer as required.
• Consider specialist involvement to assess/manage patients with neurological conditions or injuries (e.g., Parkinson’s disease, multiple sclerosis, spinal cord injury).
• Maintain a high index of suspicion for mental health sequelae, screen and manage appropriately.

Extended Learning Document: Primary Care Approaches to Addressing the Impacts of Trauma and Adverse Childhood Experiences (ACEs)

All individuals experience trauma throughout their lives. These traumatic experiences may be previous events, or they may be current. The health care community’s understanding of trauma’s impacts on our health continues to evolve, particularly in the context of the In Plain Sight Report  highlighting the experiences of Indigenous peoples in Canada, the ongoing toxic drug crisis, and mass traumatic events, such as natural disasters, warfare and genocide. Primary care providers are encouraged to learn how trauma affects an individual's and community’s health, as well as their utilization of the health care services, and health care experiences.

This extended learning document seeks to introduce primary care providers to the concept of trauma-informed practice (TIP). It provides information about tools including, but not limited to, the Adverse Childhood Experiences (ACEs) questionnaire. This document also provides additional resources for ongoing learning and professional/ personal development. 

This is not a clinical practice guideline as research in this area is still evolving, especially the evidence for the use of the ACEs questionnaire in clinical practice. The focus of the document is on adults. While some resources are referenced for the pediatric population, history taking and management of adverse childhood experiences in children and adolescents are outside the scope of this guideline.

Key Learnings

• Build a strong, ongoing, consistent, and trusting relationship with patients. This is important to successfully address difficult topics in a culturally safe way and to support an individual’s ability to make positive changes over time. This enables primary care practitioners providing longitudinal care to better support their patients to improve their well-being, address past experiences, and give hope. While an ongoing relationship is important, there will be episodic encounters where practicing in a trauma-informed way will be imperative, to ensure patients return to seek care (e.g., walk-in or emergency department setting).

• Recognize and respect the prevalence of historical, intergenerational and current trauma, as well as the many ways that trauma can be experienced. See Indian Hospitals in Canada to learn more.

• Be sensitive to trauma-informed principles in patient interactions.

• Practice a reflective, continuous commitment to ongoing education, which is an important aspect of trauma-informed practice (TIP).

• Practice trauma-informed care, including considerations for staff and clinicians who have experienced trauma in their own lives. This trauma may come from personal experiences, or it could be secondary trauma experienced during exposure to another individual's traumatic experiences.

• It is important that healthcare providers build an informal system of peer support that they can draw on or contribute to. Skills, such as “The Four Cs,” can support care providers’ well-being while delivering TIP. The Physician Health Program (PHP) offers a confidential 24-hour intake and crisis support line (1-800-663-6729).

• It is not enough to have cultural awareness and cultural sensitivity to improve access and quality of health care services.  It is imperative that all these concepts are applied in practice as practitioners continue their cultural safety and humility journey and learning.