The PoET (Prevention of Error-Based Transfers) Project.

The PoET (Prevention of Error-based Transfers) Project is one of the Ethics Quality Improvement Projects (EQIPs) taking place at William Osler Health System. This specific project is designed to reduce transfers from long-term care to hospital that are caused by legal and ethical errors related to consent, capacity and substitute decision-making. The project is currently operating in eight long-term care homes in the Central West Local Health Integration Network and has seen a 56% reduction in multiple transfers before death in hospital.

Six Change Ideas that Significantly Minimize Alternate Level of Care (ALC) Days in Acute Care Hospitals.

A significant issue affecting the healthcare system across Ontario is the number of patients admitted to hospitals that are then subsequently being designated alternate level of care (ALC). In 2016, 14.5% of Ontario in-patient beds were occupied by ALC-designated patients. Contributing to this phenomenon are ethical errors that can affect decision-making around discharge. Since 2012, William Osler Health System has redesigned their discharge process to eliminate ethical errors and align more fully with the Health Care Consent Act (HCCA) and the Public Hospitals Act (PHA). Through quality improvement processes including the use of scripting, education, checklists, mentoring and role clarity, Osler's ALC days are currently the lowest in the province of Ontario. The elimination of such errors also decreased patient confusion and improved the discharge experience.

Transfers of LTC residents to hospital EDs: an ethics quality improvement project to minimize non-beneficial and unwanted hospital transfers and maximize system efficiency.

We know that errors related to consent, capacity and substitute decision-making can lead to transfers from long-term care to hospital that seniors do not want and cannot benefit from. Three ethics quality improvement projects were launched to minimize errors in decision-making to work towards providing care residents want and can benefit from. We learned that there is a systemic barrier, namely the level-of-care form that undermines the efforts made by long-term care staff to meet their ethical and legal obligations. Because of the use of these forms, residents can receive treatment that they do not want or could not benefit from, including transfer to hospital.

Evaluating the Association between the Implementation of the PoET (Prevention of Error-Based Transfers) Southwest Spread Project and Palliative Care Provision: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data.

OBJECTIVES: The PoET (Prevention of Error-based Transfers) project seeks to align long-term care (LTC) home informed consent practices to existing legislation, thereby reducing consent-related error-based transfers to acute care. We sought to measure changes in resident-level palliative care provision after participating in the PoET Southwest Spread Project (PSSP), and to identify patient and LTC home characteristics associated with palliative care provision. DESIGN: Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data. SETTING: Sixty LTC homes (PSSP = 30; Control = 30) in Ontario, Canada, from November 2019 to December 2021. METHODS: We matched 30 PSSP to 30 control homes and described incidence rates for resident-level palliative care provision (ie, physician palliative care encounters and palliative medication prescriptions) during the 7-month postimplementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and palliative care provision during the postimplementation period. We adjusted for resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent subcohort to measure palliative care provision patterns during the last 2 months of life. RESULTS: We captured a matched cohort of 8894 residents (PSSP = 4103; Control = 4791). Incidence rates of palliative care encounters increased during the postimplementation period for PSSP (82.6 to 85.4 per 100 person-months) but not for control residents (68.8 to 65.3 per 100 person-months). After adjusting for key covariates, PSSP exposure was associated increased palliative care provision (incidence rate ratio 2.47, 95% CI 2.31-2.64) and palliative care medication prescription (1.16, 95% CI 1.12-1.20). Larger home size, certain health regions, and higher number of comorbidities were associated with increased physician palliative care encounters. CONCLUSIONS AND IMPLICATIONS: By promoting correct informed consent practices in LTC, PSSP participation increased palliative care provision for PSSP LTC residents across all settings.

Ethical Issues in Long-term Care in Low-, Middle- and High-Income Countries During the COVID-19 Pandemic.

Long-term care (LTC) centers experienced an unprecedented emergency involving exponential mortality during the COVID-19 pandemic. Individuals residing in long-term care were particularly vulnerable to the effects of COVID-19, placing residents, staff, families, and organizations in a precarious position. Complex issues surrounding how to manage vulnerable populations during the pandemic have highlighted the importance of gathering information on ethical issues that require effective policy and decision-making. This project sought to identify the ethical issues faced in long-term care by residents, families, staff, and organizations from stakeholders themselves. A total of 305 participants from 45 countries responded, highlighting numerous ethical issues in long-term care during COVID-19. While numerous issues were mentioned, there was an overlap in the themes of responses between stakeholders. Visitation, isolation, harm, staff well-being, and the overall enforcement of policies during the pandemic represented the most often discussed issues. As a preliminary study of this issue, future research is necessary in order to effectively guide pandemic policymaking moving forward.

Evaluating the Association between the Implementation of the PoET Southwest Spread Project and Reductions in Acute Care Transfers from Long-Term Care: A Quasi-Experimental Matched Cohort Study Using Population-Level Health Administrative Data.

OBJECTIVES: To measure changes in resident-level acute care transfer rates after the PoET Southwest Spread Project (PSSP), and to identify patient and long-term care (LTC) home characteristics associated with acute care transfers after program launch. DESIGN: Quasi-experimental matched (1:1 ratio) cohort study design using linked population-based health administrative data. SETTING: Sixty publicly funded LTC homes (PSSP = 30; control = 30) in Ontario, Canada, from November 2019 to December 2021. METHODS: We matched 30 PSSP homes to 30 control homes with similar characteristics and described incidence rates for resident-level acute care transfers during the 7-month post-implementation period. We used generalized linear mixed models to evaluate the association between PSSP implementation and acute care transfers during the post-implementation period. We adjusted resident-level characteristics (ie, age, sex, comorbidity status) and home-level characteristics (ie, rurality status, profit model, COVID-19 impact). We identified a decedent sub-cohort to measure transfer patterns during the last 2 months of life. RESULTS: A matched cohort of 8894 residents (PSSP = 4103; control = 4791) was captured. Incidence rates of transfers increased during the post-implementation period for both PSSP (78.8 to 80.9 transfers per 1000 person-months) and control residents (66.9 to 67.9 transfers per 1000 person-months). After adjusting for covariates of interest, PSSP exposure was associated with a reduction in acute care transfers during the post-implementation period after adjusting for covariates (incidence rate ratio, 0.73; 95% CI, 0.62-0.87; P = .0002). Older age and select health regions were associated with reduced transfers, whereas higher comorbidity status and higher COVID-19 outbreak days were associated with increases. Similar patterns persisted for transfers during the last 2 months of life. CONCLUSIONS AND IMPLICATIONS: This study systematically evaluated the impact of an ethics-based health care intervention in LTC using health care utilization databases. PoET implementation is associated with reduced acute care transfer rates, especially in the last 2 months of life in LTC.

To share or not to share: a randomized trial of consent for data sharing in genome research.

PURPOSE: Despite growing concerns toward maintaining participants' privacy, individual investigators collecting tissue and other biological specimens for genomic analysis are encouraged to obtain informed consent for broad data sharing. Our purpose was to assess the effect on research enrollment and data sharing decisions of three different consent types (traditional, binary, or tiered) with varying levels of control and choices regarding data sharing. METHODS: A single-blinded, randomized controlled trial was conducted with 323 eligible adult participants being recruited into one of six genome studies at Baylor College of Medicine in Houston, Texas, between January 2008 and August 2009. Participants were randomly assigned to one of three experimental consent documents (traditional, n = 110; binary, n = 103; and tiered, n = 110). Debriefing in follow-up visits provided participants a detailed review of all consent types and the chance to change data sharing choices or decline genome study participation. RESULTS: Before debriefing, 83.9% of participants chose public data release. After debriefing, 53.1% chose public data release, 33.1% chose restricted (controlled access database) release, and 13.7% opted out of data sharing. Only one participant declined genome study participation due to data sharing concerns. CONCLUSION: Our findings indicate that most participants are willing to publicly release their genomic data; however, a significant portion prefers restricted release. These results suggest discordance between existing data sharing policies and participants' judgments and desires.

Effects of reducing attentional demands on performance of reading comprehension tests by third graders.

The researchers examined the effects of reducing attentional demands on reading comprehension test scores. Third grade students (N=939) completed two forms (T & S) of the Stanford 9 Reading Comprehension Test (54 items, 50 min.) in the spring of 1999. Form T (state-mandated) was administered following standardized procedures in one session. Form S (alternate) was administered in multiple, divided-time sessions, that is, the total test time and items were divided in halves and thirds per session to lessen attentional demands. A repeated-measure analysis of variance yielded significant effects for average and low readers. A resource match explanation and a metacognitive explanation are offered for the results, and educational implications are discussed.

Exploring the ELSI universe: critical issues in the evolution of human genomic research.

A report on the National Human Genome Research Institute's Ethical, Legal, and Social Implications Research Program 2011 Congress, 'Exploring the ELSI Universe', Chapel Hill, North Carolina, USA, 12-14 April 2011.

Evaluation of artificial dermis neovascularization in an avascular wound.

Soft tissue coverage for avascular wounds is necessary in reconstructive surgery. Several authors have demonstrated successful treatment of problem wounds using artificial dermis. This study evaluates in an animal model the potential for neovascularization of artificial dermis in devascularized and avascular wound beds. Forty rats were assigned to four groups: (1) control, full-thickness skin graft was replaced on the vascular wound bed; (2) Integra, Integra placed over the full-thickness wound; (3) fascia, the spinotrapezius fascia exposed and Integra placed over the wound; and (4) fascia/Parafilm, a Parafilm layer placed under the raised fascia with Integra over the fascia. Laser Doppler readings were taken at baseline over the intact skin and then over the created wound beds. Biopsies of the full-thickness skin graft and the neodermis were obtained on postoperative day 14 and histologically evaluated for neovascularization. The laser Doppler readings confirmed the nature of the surgically created, poorly vascularized and avascular wound beds. Subsequent biopsies of the artificial dermis in these wound beds, however, demonstrated active neovascularization. This study demonstrates that Integra artificial dermis can serve as an effective dermal substitute in avascular wounds. Lateral ingrowth of capillaries into the dermal substitute may explain the successful integration of this artificial dermis.