Uncovering the wider impact of COVID-19 measures on the lives of children with complex care needs and their families: A mixed-methods study protocol.

Existing barriers to care were exacerbated by the development and implementation of necessary public health restrictions during the COVID-19 pandemic. Children with complex care needs and their families represent a small portion of the paediatric population, and yet they require disproportionately high access to services. Little is known about the impact of COVID-19 public health measures on this population. This study will generate evidence to uncover the wider impact of COVID-19 measures on the lives of children with complex care needs and their families in relation to policy and service changes. This multi-site sequential mixed methods study will take place across the Canadian Maritime provinces and use an integrated knowledge translation approach. There are two phases to this study: 1) map COVID-19 public health restrictions and service changes impacting children with complex care needs by conducting an environmental scan of public health restrictions and service changes between March 2020 and March 2022 and interviewing key informants involved in the development or implementation of restrictions and service changes, and 2) explore how children with complex care needs and their families experienced public health restrictions and service changes to understand how their health and well-being were impacted.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review.

BACKGROUND: People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings. METHODS: A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature. FINDINGS: The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives. CONCLUSION: This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

What implementation strategies and outcome measures are used to transform healthcare organizations into learning health systems? A mixed-methods review protocol.

BACKGROUND: A learning health system (LHS) framework provides an opportunity for health system restructuring to provide value-based healthcare. However, there is little evidence showing how to effectively implement a LHS in practice. OBJECTIVE: A mixed-methods review is proposed to identify and synthesize the existing evidence on effective implementation strategies and outcomes of LHS in an international context. METHODS: A mixed-methods systematic review will be conducted following methodological guidance from Joanna Briggs Institute (JBI) and PRISMA reporting guidelines. Six databases (CINAHL, Embase, MEDLINE, PAIS, Scopus and Nursing & Allied Health Database) will be searched for terms related to LHS, implementation and evaluation measures. Three reviewers will independently screen the titles, abstracts and full texts of retrieved articles. Studies will be included if they report on the implementation of a LHS in any healthcare setting. Qualitative, quantitative or mixed-methods study designs will be considered for inclusion. No restrictions will be placed on language or date of publication. Grey literature will be considered for inclusion but reviews and protocol papers will be excluded. Data will be extracted from included studies using a standardized extraction form. One reviewer will extract all data and a second will verify. Critical appraisal of all included studies will be conducted by two reviewers. A convergent integration approach to data synthesis will be used, where qualitative and quantitative data will be synthesized separately and then integrated to present overarching findings. Data will be presented in tables and narratively. CONCLUSION: This review will address a gap in the literature related to implementation of LHS. The findings from this review will provide researchers with a better understanding of how to design and implement LHS interventions. This systematic review was registered in PROSPERO (CRD42022293348).

Tackling overutilization of hospital tests and treatments: Lessons learned from a grassroots approach.

Recent data suggest unnecessary medical testing and treatment is relatively common in Canada. A number of harms to patients can arise as a result of unnecessary tests and treatments. In addition to patient harm, unnecessary tests and treatments add to the cost of medical care. Inspired by the Choosing Wisely campaign, St. Michael's Hospital in Toronto, Ontario, developed a hospital-wide program to address many different forms of overutilization at our hospital. The program prioritizes harm reduction over cost-containment and aims to create sustainable change through grassroots clinician engagement. This article will review important lessons learned from the St. Michael's experience.

CAEP 2015 Academic Symposium: Leadership within the emergency medicine academic community and beyond.

OBJECTIVES: A panel of emergency medicine (EM) leaders endeavoured to define the key elements of leadership and its models, as well as to formulate consensus recommendations to build and strengthen academic leadership in the Canadian EM community in the areas of mentorship, education, and resources. METHODS: The expert panel comprised EM leaders from across Canada and met regularly by teleconference over the course of 9 months. From the breadth of backgrounds and experience, as well as a literature review and the development of a leadership video series, broad themes for recommendations around the building and strengthening of EM leadership were presented at the CAEP 2015 Academic Symposium held in Edmonton, Alberta. Feedback from the attendees (about 80 emergency physicians interested in leadership) was sought. Subsequently, draft recommendations were developed by the panel through attendee feedback, further review of the leadership video series, and expert opinion. The recommendations were distributed to the CAEP Academic Section for further feedback and updated by consensus of the expert panel. RESULTS: The methods informed the panel who framed recommendations around four themes: 1) leadership preparation and training, 2) self-reflection/emotional intelligence, 3) academic leadership skills, and 4) gender balance in academic EM leadership. The recommendations aimed to support and nurture the next generation of academic EM leaders in Canada and included leadership mentors, availability of formal educational courses/programs in leadership, self-directed education of aspiring leaders, creation of a Canadian subgroup with the AACEM/SAEM Chair Development Program, and gender balance in leadership roles. CONCLUSIONS: These recommendations serve as a roadmap for all EM leaders (and aspiring leaders) to build on their success, inspire their colleagues, and foster the next generation of Canadian EM academic leaders.

Medication-related emergency department visits in pediatrics: a prospective observational study.

BACKGROUND AND OBJECTIVE: There are few data on the rate and characterization of medication-related visits (MRVs) to the emergency department (ED) in pediatric patients. We sought to evaluate the frequency, severity, preventability, and classification of MRVs to the ED in pediatric patients. METHODS: We performed a prospective observational study of pediatric patients presenting to the ED over a 12-month period. A medication-related ED visit was identified by using pharmacist assessment, emergency physician assessment, and an independent adjudication committee. RESULTS: In this study, 2028 patients were enrolled (mean age, 6.1 ± 5.0 years; girls, 47.4%). An MRV was found in 163 patients (8.0%; 95% confidence interval [CI]: 7.0%-9.3%) of which 106 (65.0%; 95% CI: 57.2%-72.3%) were deemed preventable. Severity was classified as mild in 14 cases (8.6%; 95% CI: 4.8%-14.0%), moderate in 140 cases (85.9%; 95% CI: 79.6%-90.8%), and severe in 9 cases (5.5%; 95% CI: 2.6%-10.2%). The most common events were related to adverse drug reactions 26.4% (95% CI: 19.8%-33.8%), subtherapeutic dosage 19.0% (95% CI: 13.3%-25.9%), and nonadherence 17.2% (95% CI: 11.7%-23.9%). The probability of hospital admission was significantly higher among patients with an MRV compared with those without an MRV (odds ratio, 6.5; 95% CI: 4.3-9.6) and, if admitted, the median (interquartile range) length of stay was longer (3.0 [5.0] days vs 1.5 [2.5] days, P = .02). CONCLUSIONS: A medication-related cause was found in ∼1 of every 12 ED visits by pediatric patients, of which two-thirds were deemed preventable. Pediatric patients who present to the ED with an MRV are more likely to be admitted to hospital and when admitted have a longer length of stay.

Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review.

OBJECTIVE: To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN: A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS: We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION: Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Making interprofessional education work: the strategic roles of the academy.

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.

STUDY OBJECTIVE: We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change. METHODS: This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes. RESULTS: At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED. CONCLUSION: Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.