Interprofessional primary care: indispensable for family physicians yet invisible to older patients.

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

Designing and Implementing a Zero Harm Falls Prevention Program: A Quality Improvement Study.

BACKGROUND: Inpatient falls with harm have severe implications on patients and the health care system. PURPOSE: We implemented a zero harm approach to falls prevention, which aimed to reduce falls with injury by 25% within 1 year. METHODS: We implemented a multifaceted and multidisciplinary quality improvement falls prevention strategy that included facilitating organization-wide education, adopting the Morse Fall Risk Assessment tool, displaying real-time unit-specific falls rates, and implementing a transparent root-cause analysis process after falls. Our outcome measure was falls with injury per 1000 patient-days. RESULTS: We observed a decrease in the rate of patient falls with injury from 2.03 (baseline period) to 1.12 (1 year later) per 1000 patient-days. We also observed increases in awareness around falls prevention and patient safety incident reporting. CONCLUSIONS: Our zero harm approach reduced falls with injury while improving our patient safety culture.

A scoping review of barriers, facilitators and tools to escalation of care processes in the emergency department.

INTRODUCTION: Escalation of care is the timely recognition and communication of deterioration in a previously stable patient. Delays in escalating care may lead to unnecessary patient morbidity and mortality. There is currently a paucity of synthesis of work focused on the initiation of escalation of care in the emergency department (ED), where unique challenges may be present. We sought to complete a scoping review to investigate: (1) factors (barriers and/or facilitators) affecting clinicians in escalating care in the ED; and (2) tools that support clinicians in ED escalation of care processes. METHODS: We conducted a scoping review guided by the Arksey & O'Malley framework, and in accordance with PRISMA Scoping Reviews (PRISMA-ScR) checklist. Searches were conducted in MEDLINE, EMBASE and CINAHL on November 30th, 2020. Extracted data was analyzed via qualitative content analysis. Review and data abstraction were completed by two independent reviewers. Discrepancies were resolved via consensus meetings with a third reviewer. RESULTS: Of the 4527 unique records identified, 13 studies met our inclusion criteria. Studies described standard escalation practices including detection, reporting, and response. Factors influencing escalation of care were described on individual (confidence, comfort, and expertise), interpersonal (communication and the nurse-physician relationship), organizational (workload and staffing), and environmental (distractions and layout) levels. Four ED-specific tools for escalation of care were also identified. CONCLUSION: This scoping review identified 13 studies that contained information on processes, factors influencing and/or tools used to facilitate escalation of care in the ED. They may serve as valuable starting points for ED clinicians and administrators who are building or reforming local escalation of care processes.

RéSUMé: INTRODUCTION: L'escalade des soins est la reconnaissance et la communication en temps opportun de la détérioration chez un patient auparavant stable. Les retards dans l'intensification des soins peuvent entraîner une morbidité et une mortalité inutiles chez les patients. Il existe actuellement peu de synthèse des travaux axés sur l'initiation de l'escalade des soins dans les services d'urgence (SU), où des défis uniques peuvent être présents. Nous avons cherché à réaliser une revue de la portée afin d'étudier : (1) les facteurs (obstacles et/ou facilitateurs) affectant les cliniciens dans l'escalade des soins à l'urgence ; et (2) les outils qui soutiennent les cliniciens dans les processus d'escalade des soins à l'urgence. MéTHODES: Nous avons effectué une revue de la portée de l'étude guidée par le cadre d'Arksey & O'Malley, et conformément à la liste de contrôle PRISMA Scoping Reviews (PRISMA-ScR). Des recherches ont été effectuées dans MEDLINE, EMBASE et CINAHL le 30 novembre 2020. Les données extraites ont été analysées au moyen d'une analyse qualitative du contenu. La révision et l'abstraction des données ont été effectuées par deux réviseurs indépendants. Les divergences ont été résolues au moyen de réunions de consensus avec un troisième examinateur. RéSULTATS: Sur les 4527 dossiers uniques recensés, 13 études répondaient à nos critères d'inclusion. Des études ont décrit les pratiques d'escalade standard, y compris la détection, le signalement et la réponse. Les facteurs influençant l'escalade des soins ont été décrits sur les niveaux individuel (confiance, confort et expertise), interpersonnel (communication et relation infirmière-médecin), organisationnel (charge de travail et dotation) et environnemental (distractions et aménagement). Quatre outils spécifiques aux services d'urgence pour l'escalade des soins ont également été identifiés. CONCLUSION: Cet examen de la portée a permis de recenser 13 études qui contenaient de l'information sur les processus, les facteurs influençant et/ou les outils utilisés pour faciliter l'escalade des soins à l'urgence. Ils peuvent servir de point de départ précieux aux cliniciens et administrateurs des services d'urgence qui mettent en place ou réforment les processus locaux d'escalade des soins.

The involvement of trauma survivors in hospital-based injury prevention, violence intervention and peer support programs: A scoping review.

BACKGROUND: Despite decades-long involvement of trauma survivors in hospital-based program delivery, their roles and impact on trauma care have not been previously described. We aimed to characterize the literature on trauma survivor involvement in hospital-based injury prevention, violence intervention and peer support programs to map what is currently known and identify future research opportunities. METHODS: A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology. Articles were identified through electronic databases and gray literature. Included articles described hospital-based injury prevention programs, violence intervention programs and peer support programs that involved trauma survivors leveraging their injury experiences to counsel others. Studies were screened and data were abstracted in duplicate. Data were synthesized generally and by program type. RESULTS: Thirty-six published articles and four program reports were included. Peer support programs were described in 21 articles, mainly involving trauma survivors as mentors or peer supporters. Peer support programs' most commonly reported outcome was participant satisfaction (n = 6), followed by participant self-efficacy (n = 5), depression (n = 4), and community integration (n = 3). Eleven injury prevention studies were included, all involving trauma survivors as speakers in youth targeted programs. Injury prevention studies commonly reported outcomes of participants' risk behaviors and awareness (n = 9). Violence intervention programs were included in four articles involving trauma survivors as intervention counsellors. Recidivism rate was the most commonly reported outcome (n = 3). Variability exists across and within program types when reporting on involved trauma survivors' gender, age, selection and training, duration of involvement and number of survivors involved. Outcomes related to trauma survivors' own experiences and the impacts to them of program involvement were under-studied. CONCLUSIONS: Significant opportunity exists to fill current knowledge gaps in trauma survivors' involvement in trauma program delivery. There is a need to describe more fully who involved trauma survivors are to inform the development of effective future interventions.

Toward Zero Harm: Mackenzie Health's Journey Toward Becoming a High Reliability Organization and Eliminating Avoidable Harm.

OBJECTIVES: In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years. METHODS: We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organization-specific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards. RESULTS: In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care. CONCLUSIONS: This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.

Experiences of healthcare providers with a novel emergency response intubation team during COVID-19.

OBJECTIVES: In the early stages of the COVID-19 pandemic, there were significant concerns about the infectious risks of intubation to healthcare providers. In response, a dedicated emergency response intubation team (ERIT) consisting of anesthesiologists and allied health providers was instituted for our emergency department (ED). Given the high-risk nature of intubations and the new interprofessional team dynamics, we sought to assess health-care provider experiences and potential areas of improvement. METHODS: Surveys were distributed to healthcare providers at the University Health Network, a quaternary healthcare centre in Toronto, Canada, which includes two urban EDs seeing over 128,000 patients per year. Participants included ED physicians and nurses, anesthesiologists, anesthesia assistants, and operating room nurses. The survey included free-text questions. Responses underwent thematic analysis using grounded theory and were independently coded by two authors to generate descriptive themes. Discrepancies were resolved with a third author. Descriptive themes were distilled through an inductive, iterative process until fewer main themes emerged. RESULTS: A total of 178 surveys were collected (68.2% response rate). Of these, 123 (69%) participated in one or more ERIT activations. Positive aspects included increased numbers of staff to assist, increased intubation expertise, improved safety, and good team dynamics within the ERIT team. Challenges included a loss of scope (primarily ED physicians and nurses) and unfamiliar workflows, perceived delays to ERIT team arrival or patient intubation, role confusion, handover concerns, and communication challenges between ED and ERIT teams. Perceived opportunities for improvement included interprofessional training, developing clear guidelines on activation, inter-team role clarification, and guidelines on handover processes post-intubation. CONCLUSIONS: Healthcare providers perceived that a novel interprofessional collaboration for intubations of COVID-19 patients presented both benefits and challenges. Opportunities for improvement centred around interprofessional training, shared decision making between teams, and structured handoff processes.

RéSUMé: OBJECTIFS: Aux premiers stades de la pandémie de COVID-19, les risques infectieux de l'intubation pour les prestataires de soins de santé ont suscité de vives inquiétudes. En réponse, une équipe d'intervention d'urgence en intubation (emergency response intubation team ERIT), composée d'anesthésistes et de prestataires de services paramédicaux, a été mise en place dans notre service d'urgence. Compte tenu de la nature à haut risque des intubations et de la nouvelle dynamique d'équipe interprofessionnelle, nous avons cherché à évaluer les expériences des prestataires de soins et les domaines d'amélioration potentiels. MéTHODES: Les questionnaires ont été distribués aux prestataires de soins de santé du University Health Network, un centre de soins de santé quaternaire de Toronto, au Canada, qui comprend deux urgences urbaines accueillant plus de 128 000 patients par an. Les participants comprenaient des médecins et des infirmiers des urgences, des anesthésistes, des assistants en anesthésie et des infirmiers de salle d'opération. Les réponses ont fait l'objet d'une analyse thématique fondée sur la théorie de la base et ont été codées indépendamment par deux auteurs afin de générer des thèmes descriptifs. Les divergences ont été résolues avec un troisième auteur. Les thèmes descriptifs ont été distillés par un processus inductif et itératif jusqu'à ce qu'un nombre réduit de thèmes principaux émerge. RéSULTATS: Au total, 178 sondages ont été recueillis (taux de réponse de 68,2 %). Parmi ceux-ci, 123 (69 %) ont participé à une ou plusieurs activations d'ERIT. Les aspects positifs comprenaient un nombre accru de personnel pour aider, une expertise accrue en matière d'intubation, une sécurité améliorée et une bonne dynamique d'équipe au sein de l'équipe ERIT. Parmi les difficultés rencontrées, citons la perte du champ d'action (principalement les médecins et les infirmières des services d'urgence) et les flux de travail non familiers, les retards perçus dans l'arrivée de l'équipe d'ERIT ou l'intubation du patient, la confusion des rôles, les problèmes de transfert et les difficultés de communication entre les équipes des services d'urgence et d'ERIT. Les possibilités d'amélioration perçues comprennent la formation interprofessionnelle, l'élaboration de directives claires sur l'activation, la clarification des rôles entre les équipes et les directives sur les processus de transfert après l'intubation. CONCLUSIONS: Les prestataires de soins de santé ont perçu qu'une nouvelle collaboration interprofessionnelle pour les intubations des patients COVID-19 présentait à la fois des avantages et des défis.