2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

AI-enabled Cardiac Chambers Volumetry and Calcified Plaque Characterization in Coronary Artery Calcium (CAC) Scans (AI-CAC) Significantly Improves on Agatston CAC Score for Predicting All Cardiovascular Events: The Multi-Ethnic Study of Atherosclerosis.

Background: Coronary artery calcium (CAC) scans contain valuable information beyond the Agatston Score which is currently reported for predicting coronary heart disease (CHD) only. We examined whether new artificial intelligence (AI) algorithms applied to CAC scans may provide significant improvement in prediction of all cardiovascular disease (CVD) events in addition to CHD, including heart failure, atrial fibrillation, stroke, resuscitated cardiac arrest, and all CVD-related deaths. Methods: We applied AI-enabled automated cardiac chambers volumetry and automated calcified plaque characterization to CAC scans (AI-CAC) of 5830 individuals (52.2% women, age 61.7±10.2 years) without known CVD that were previously obtained for CAC scoring at the baseline examination of the Multi-Ethnic Study of Atherosclerosis (MESA). We used 15-year outcomes data and assessed discrimination using the time-dependent area under the curve (AUC) for AI-CAC versus the Agatston Score. Results: During 15 years of follow-up, 1773 CVD events accrued. The AUC at 1-, 5-, 10-, and 15-year follow up for AI-CAC vs Agatston Score was (0.784 vs 0.701), (0.771 vs. 0.709), (0.789 vs.0.712) and (0.816 vs. 0.729) (p<0.0001 for all), respectively. The category-free Net Reclassification Index of AI-CAC vs. Agatston Score at 1-, 5-, 10-, and 15-year follow up was 0.31, 0.24, 0.29 and 0.29 (p<.0001 for all), respectively. AI-CAC plaque characteristics including number, location, and density of plaque plus number of vessels significantly improved NRI for CAC 1-100 cohort vs. Agatston Score (0.342). Conclusion: In this multi-ethnic longitudinal population study, AI-CAC significantly and consistently improved the prediction of all CVD events over 15 years compared with the Agatston score.

A mixed-methods descriptive study on the role of continuous quality improvement in rural surgical and obstetrical stability: Considering enablers, challenges and impact.

INTRODUCTION: The Rural Surgical Obstetrical Networks (RSON) initiative in BC was developed to stabilize and grow low volume rural surgical and obstetrical services. One of the wrap-around supportive interventions was funding for Continuous Quality Improvement (CQI) initiatives, done through a local provider-driven lens. This paper reviews mixed-methods findings on providers' experiences with CQI and the implications for service stability. BACKGROUND: Small, rural hospitals face barriers in implementing quality improvement initiatives due primarily to lack of resource capacity and the need to prioritize clinical care when allocating limited health human resources. Given this, funding and resources for CQI were key enablers of the RSON initiative and seen as an essential part of a response to assuaging concerns of specialists at higher volume sites regarding quality in lower volume settings. METHODS: Data were derived from two datasets: in-depth, qualitative interviews with rural health care providers and administrators over the course of the RSON initiative and through a survey administered at RSON sites in 2023. FINDINGS: Qualitative findings revealed participants' perceptions of the value of CQI (including developing expanded skillsets and improved team function and culture), enablers (the organizational infrastructure for CQI projects), challenges in implementation (complications in protecting/prioritizing CQI time and difficulty with staff engagement) and the importance of local leadership. Survey findings showed high ratings for elements of team function that relate directly to CQI (team process and relationships). CONCLUSION: Attention to effective mechanisms of CQI through a rural lens is essential to ensure that initiatives meet the contextual realities of low-volume sites. Instituting pathways for locally-driven quality improvement initiatives enhances team function at rural hospitals through creating opportunities for trust building and goal setting, improving communication and increasing individual and team-wide motivation to improve patient care.

Relational Work Is the Work: Virtual Healthcare Transformation for Rural, Remote and First Nations Communities in British Columbia.

The healthcare crisis across unceded First Nations' territories in rural, remote and Indigenous communities in British Columbia (BC) is marked by persistent barriers to accessing care and support close to home. This commentary describes an exceptional story of how technology, trusted partnerships and relationships came together to create an innovative suite of virtual care programs called "Real-Time Virtual Support" (RTVS). We describe key approaches, learnings and future considerations to improve the equity of healthcare delivery for rural, remote and First Nations communities. The key lessons include the following: (1) moving beyond a biomedical model - the collaboration framework for health service design incorporated First Nations' perspective on health and wellness; (2) relational work is the work - the RTVS collaboration was grounded in building connections and relationships to prioritize cultivating trust in the partnership over specific outputs; and (3) aligning to the core values of co-creation - working from a commitment to do things differently and applying an inclusive approach of engagement to integrate perspectives across different sectors and interest groups.

The motivations and experiences of specialists who provide outreach services in rural operating rooms: A survey study from British Columbia.

INTRODUCTION: Outreach care has long been used in Canada to address the lack of access to specialist care in rural settings, but research on the experiences of specialists providing these services is lacking. This descriptive survey study aimed to understand 1) specialists' motivation for engaging in outreach work, (2) their perceptions of the quality of care at their rural outreach hospital, and (3) the supports they receive for their outreach work, in order to create a supportive framework to encourage specialist outreach contributions. METHODS: In July 2022, specialist physicians who provide outreach operating room services at rural hospitals participating in the Rural Surgical and Obstetrical Networks initiative in the province of British Columbia were invited to complete an anonymous survey. RESULTS: 21 of 45 invited outreach specialists completed the survey (47% response rate). Three-quarters of respondents had a surgical specialty. The opportunity to deliver care to underserved patients was the most common motivator for outreach work. Rural hospitals received high ratings from respondents on overall safety and various aspects of communication and teamwork. Postoperative care was a concern for a minority (one-fifth) of respondents, and about half had experienced unnecessary delays between procedures some or most of the time. Generally, respondents felt integrated into rural teams and reported receiving adequate nursing and anesthetic support. The two most common desired additional supports were better/more equipment and space and additional staffing. All 19 respondents not planning to retire soon intended to provide outreach services for at least three more years. CONCLUSION: Specialists providing outreach OR services in small volume rural hospitals in BC usually have altruistic motives for outreach work. For the most part, these specialists have positive experiences in rural hospitals, but they can be better supported through investment in infrastructure and health human resources. Specialists intend to provide outreach services long-term, indicating a stable outreach workforce. More research on the facilitators and barriers of specialist outreach work is needed.

"Food Is Medicine" Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review.

"Food Is Medicine" (FIM) represents a spectrum of food-based interventions integrated into health care for patients with specific health conditions and often social needs. Programs include medically tailored meals, groceries, and produce prescriptions, with varying levels of nutrition and culinary education. Supportive advances include expanded care pathways and payment models, e-screening for food and nutrition security, and curricular and accreditation requirements for medical nutrition education. Evidence supports positive effects of FIM on food insecurity, diet quality, glucose control, hypertension, body weight, disease self-management, self-perceived physical and mental health, and cost-effectiveness or cost savings. However, most studies to date are quasiexperimental or pre/post interventions; larger randomized trials are ongoing. New national and local programs and policies are rapidly accelerating FIM within health care. Remaining research gaps require rigorous, iterative evaluation. Successful incorporation of FIM into health care will require multiparty partnerships to assess, optimize, and scale these promising treatments to advance health and health equity.

Heart failure management at home: a non-randomised prospective case-controlled trial (HeMan at Home).

BACKGROUND/OBJECTIVES: Heart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission. DESIGN/OUTCOMES: A non-randomised prospective case-controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time. RESULTS: Sixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC. CONCLUSIONS: The HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.

Optimizing rural healthcare through improved team function: a case study of the Rural Surgical Obstetrical Networks programme.

We explored enablers and mechanisms of optimal team function within rural hospital teams, and the impact of these factors on health service sustainability in British Columbia. The data were drawn from interviews and focus groups with healthcare providers and administrators (n = 169) who participated in the Rural Surgical Obstetrical Networks (RSON) initiative to support low-volume rural surgical and obstetrical services in British Columbia, Canada. The 5-year programme (2018-2022) provided evidence-based system interventions across eight rural sites with the objective of providing sustainable, quality health services to meet population needs. To explore the impact of RSON interventions on local team function, we performed a scoping review, to assess the current literature surrounding enablers of effective rural hospital teamwork. Through inductive thematic analysis of interview data, we identified five enablers of good team function at RSON sites, including emphasis on local leadership, shared direction, commitment to sustainability, respect and solidarity among colleagues, and meaningful communication. The RSON project led to a shift in team culture in participating sites, improved team function, and contributed to improved clinical processes and patient outcomes. The findings have implications for rural health policy and practice in British Columbia and other jurisdictions with similar health service delivery models and geographic contexts.

Perinatal Outcomes at Rural Hospitals That Participated in the Rural Surgical and Obstetrical Networks (RSON) of British Columbia (2016-2021).

BACKGROUND: The goal of the Rural Surgical and Obstetrical Networks (RSON) of British Columbia was to support safe and appropriate surgery, operative birth, and perinatal care closer to home for rural communities. Family physicians with enhanced obstetrical and/or surgical skills provide cesarean delivery and family practice anesthetists manage anesthesia for labour pain and operative births at RSON-supported hospitals, with the involvement of a local specialist at one site. OBJECTIVES: The objectives of the study were to: (1) compare perinatal outcomes at hospitals participating in the RSON initiative with outcomes at referral hospitals and (2) examine temporal changes in the proportion of childbearing people who resided in RSON communities and gave birth locally. METHODS: Poisson regression analysis was used to model the effect of hospital type (RSON vs. referral) on perinatal outcomes. We restricted the analysis to singleton births and controlled for differences in maternal characteristics, obstetric history, and pregnancy complications. RESULTS: Childbearing people who gave birth at RSON-supported hospitals (n = 3498) had a 10% lower incidence of adverse maternal-newborn outcomes compared to those who gave birth at referral hospitals (n = 14 772), after controlling for referral bias. We found a small increase (3.2 %) in the proportion of local births over the study period. CONCLUSION: Findings provide evidence that childbearing people can safely give birth at smaller rural hospitals in British Columbia and that investments in rural hospitals contribute to service stability. Stabilizing local birth services in rural communities benefits the whole region because it reduces surgical overload in regional referral centres.

You just want a break from the hatred of failure: the lived experience of being a student physiotherapist perfectionist and considerations for educators.

Perfectionism is a personality orientation associated with mental health and adjustment problems. Recent evidence demonstrates that perfectionism is widespread among students and on the rise, with recent generations of students placing increasingly more importance on perfection. Whilst the extant literature is vast, it tends to focus on psychopathology and identification of perfectionism correlates rather than the experience of student perfectionism. Furthermore, the education literature is scant and there is a need to understand the deeper processes and nuances of perfectionism, particularly within health professions education where intense study demands, competition to gain entry to educational programmes, and professional cultures may nurture the problem. This phenomenological study explored the lived experiences of ten physiotherapy students as they wrestled with perfectionism in the various facets of their studies. Semi-structured interviews were undertaken, and participants completed log sheets to document perfectionism-related experiences. Idiographic profiles were composed and interview transcripts were analysed, drawing upon features of both phenomenological and thematic analysis. Perfectionism was found to have toxic consequences for the learning experience. Harmful phenomenological experiences included perpetual and excessive achievement striving, punitive self-criticism and health and wellbeing difficulties. A range of sabotaging learning behaviours such as self-handicapping and feedback avoidance was also illuminated, and cultural and organisational influences perceived to foster perfectionism emerged. Findings are discussed in relation to underlying processes and implications for educators. The prospect of findings transferring to other educational contexts is highlighted.

System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program.

BACKGROUND: The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. METHODS: We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. FINDINGS: Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. CONCLUSION: Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.

Real-time virtual supports improving health equity and access in British Columbia.

In British Columbia (BC) and across the territories of over 200 First Nations and 39 Métis Nation Chartered communities, the COVID-19 pandemic catalyzed a group of partner organizations to rapidly establish seven virtual care pathways under the Real-Time Virtual Support (RTVS) network. They aimed to address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities, and provide pan-provincial services. Mixed-method evaluation assessed implementation, patient and provider experience, quality improvement, cultural safety, and sustainability. Pathways supported 38,905 patient encounters and offered 29,544 hours of peer-to-peer support from April 2020 to March 2021. Mean monthly encounter growth was 178.0% (standard deviation = 252.1%). Ninety percent of patients were satisfied with the care experience; 94% of providers enjoyed delivering virtual care. Consistent growth suggests that the virtual pathways met the needs of providers and patients in rural, remote, and Indigenous communities, and supported virtual access to care in BC.

Multi-disciplinary, simulation-based, standardised trauma team training within the Victorian State Trauma System.

OBJECTIVE: Inconsistency in the structure and function of team-based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. METHODS: The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was site-specific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre-learning, didactic lectures, skill stations and simulated team-based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. RESULTS: The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant-reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7%; P = 0.007]). This finding was independent of clinician experience. CONCLUSIONS: A team-based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant-reported outcomes in clinical confidence and real-life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff-centred outcomes.