Interventions on gender equity in the workplace: a scoping review.

BACKGROUND: Various studies have demonstrated gender disparities in workplace settings and the need for further intervention. This study identifies and examines evidence from randomized controlled trials (RCTs) on interventions examining gender equity in workplace or volunteer settings. An additional aim was to determine whether interventions considered intersection of gender and other variables, including PROGRESS-Plus equity variables (e.g., race/ethnicity). METHODS: Scoping review conducted using the JBI guide. Literature was searched in MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, ERIC, Index to Legal Periodicals and Books, PAIS Index, Policy Index File, and the Canadian Business & Current Affairs Database from inception to May 9, 2022, with an updated search on October 17, 2022. Results were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension to scoping reviews (PRISMA-ScR), Sex and Gender Equity in Research (SAGER) guidance, Strengthening the Integration of Intersectionality Theory in Health Inequality Analysis (SIITHIA) checklist, and Guidance for Reporting Involvement of Patients and the Public (GRIPP) version 2 checklist. All employment or volunteer sectors settings were included. Included interventions were designed to promote workplace gender equity that targeted: (a) individuals, (b) organizations, or (c) systems. Any comparator was eligible. Outcomes measures included any gender equity related outcome, whether it was measuring intervention effectiveness (as defined by included studies) or implementation. Data analyses were descriptive in nature. As recommended in the JBI guide to scoping reviews, only high-level content analysis was conducted to categorize the interventions, which were reported using a previously published framework. RESULTS: We screened 8855 citations, 803 grey literature sources, and 663 full-text articles, resulting in 24 unique RCTs and one companion report that met inclusion criteria. Most studies (91.7%) failed to report how they established sex or gender. Twenty-three of 24 (95.8%) studies reported at least one PROGRESS-Plus variable: typically sex or gender or occupation. Two RCTs (8.3%) identified a non-binary gender identity. None of the RCTs reported on relationships between gender and other characteristics (e.g., disability, age, etc.). We identified 24 gender equity promoting interventions in the workplace that were evaluated and categorized into one or more of the following themes: (i) quantifying gender impacts; (ii) behavioural or systemic changes; (iii) career flexibility; (iv) increased visibility, recognition, and representation; (v) creating opportunities for development, mentorship, and sponsorship; and (vi) financial support. Of these interventions, 20/24 (83.3%) had positive conclusion statements for their primary outcomes (e.g., improved academic productivity, increased self-esteem) across heterogeneous outcomes. CONCLUSIONS: There is a paucity of literature on interventions to promote workplace gender equity. While some interventions elicited positive conclusions across a variety of outcomes, standardized outcome measures considering specific contexts and cultures are required. Few PROGRESS-Plus items were reported. Non-binary gender identities and issues related to intersectionality were not adequately considered. Future research should provide consistent and contemporary definitions of gender and sex. TRIAL REGISTRATION: Open Science Framework https://osf.io/x8yae .

Recent innovations in long-term care coverage and financing: a rapid scoping review.

OBJECTIVES: To identify, chart and analyse the literature on recent initiatives to improve long-term care (LTC) coverage, financial protection and financial sustainability for persons aged 60 and older. DESIGN: Rapid scoping review. DATA SOURCES: Four databases and four sources of grey literature were searched for reports published between 2017 and 2022. After using a supervised machine learning tool to rank titles and abstracts, two reviewers independently screened sources against inclusion criteria. ELIGIBILITY CRITERIA: Studies published from 2017-2022 in any language that captured recent LTC initiatives for people aged 60 and older, involved evaluation and directly addressed financing were included. DATA EXTRACTION AND ANALYSIS: Data were extracted using a form designed to answer the review questions and analysed using descriptive qualitative content analysis, with data categorised according to a prespecified framework to capture the outcomes of interest. RESULTS: Of 24 reports, 22 were published in peer-reviewed journals, and two were grey literature sources. Study designs included quasi-experimental study, policy analysis or comparison, qualitative description, comparative case study, cross-sectional study, systematic literature review, economic evaluation and survey. Studies addressed coverage based on the level of disability, income, rural/urban residence, employment and citizenship. Studies also addressed financial protection, including out-of-pocket (OOP) expenditures, copayments and risk of poverty related to costs of care. The reports addressed challenges to financial sustainability such as lack of service coordination and system integration, insufficient economic development and inadequate funding models. CONCLUSIONS: Initiatives where LTC insurance is mandatory and accompanied by commensurate funding are situated to facilitate ageing in place. Efforts to expand population coverage are common across the initiatives, with the potential for wider economic benefits. Initiatives that enable older people to access the services needed while avoiding OOP-induced poverty contribute to improved health and well-being. Preserving health in older people longer may alleviate downstream costs and contribute to financial sustainability.

Integrating health geography and behavioral economic principles to strengthen context-specific behavior change interventions.

The long-term economic viability of modern health care systems is uncertain, in part due to costs of health care at the end of life and increasing health care utilization associated with an increasing population prevalence of multiple chronic diseases. Control of health care spending and sustaining delivery of health care services will require strategic investments in prevention to reduce the risk of disease and its complications over an individual's life course. Behavior change interventions aimed at reducing a range of harmful and risky health-related behaviors including smoking, physical inactivity, excess alcohol consumption, and excess weight, are one approach that has proven effective at reducing risk and preventing chronic disease. However, large-scale efforts to reduce population-level chronic diseases are challenging and have not been very successful at reducing the burden of chronic diseases. A new approach is required to identify when, where, and how to intervene to disrupt patterns of behavior associated with high-risk factors using context-specific interventions that can be scaled. This paper introduces the need to integrate theoretical and methodological principles of health geography and behavioral economics as opportunities to strengthen behavior change interventions for the prevention of chronic diseases. We discuss how health geography and behavioral economics can be applied to expand existing behavior change frameworks and how behavior change interventions can be strengthened by characterizing contexts of time and activity space.

Behavior change interventions are challenged by lack of information about the contexts influencing decisions patients make as part of their daily routine such as when, where, and how health behaviors occur. A new approach is required to strengthen behavior change interventions by integrating contexts of time and activity space so that strategies can be scaled across populations to influence how individuals make decisions about improving their health behaviors. Incorporating ideas from health geography and behavioral economics into the design of behavior change interventions provides an opportunity to collect and investigate individual-level health information characterizing contexts of individuals' activities across space, connections to place, time management, and patterns in behavior over time. By visualizing and characterizing key spatiotemporal contexts about an individual's day-to-day routine, insight can be gained about where and for how long activities occur and what opportunities exist for adapting day-to-day routines. This paper will discuss how theory from health geography could be applied to understand contexts influencing behaviors and how spatiotemporal information could be applied for the purpose of tailoring behavioral economic strategies to strengthen the design of behavior change interventions.

Global evidence of gender equity in academic health research: a scoping review.

OBJECTIVES: To chart the global literature on gender equity in academic health research. DESIGN: Scoping review. PARTICIPANTS: Quantitative studies were eligible if they examined gender equity within academic institutions including health researchers. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes related to equity across gender and other social identities in academia: (1) faculty workforce: representation of all genders in university/faculty departments, academic rank or position and salary; (2) service: teaching obligations and administrative/non-teaching activities; (3) recruitment and hiring data: number of applicants by gender, interviews and new hires for various rank; (4) promotion: opportunities for promotion and time to progress through academic ranks; (5) academic leadership: type of leadership positions, opportunities for leadership promotion or training, opportunities to supervise/mentor and support for leadership bids; (6) scholarly output or productivity: number/type of publications and presentations, position of authorship, number/value of grants or awards and intellectual property ownership; (7) contextual factors of universities; (8) infrastructure; (9) knowledge and technology translation activities; (10) availability of maternity/paternity/parental/family leave; (11) collaboration activities/opportunities for collaboration; (12) qualitative considerations: perceptions around promotion, finances and support. RESULTS: Literature search yielded 94 798 citations; 4753 full-text articles were screened, and 562 studies were included. Most studies originated from North America (462/562, 82.2%). Few studies (27/562, 4.8%) reported race and fewer reported sex/gender (which were used interchangeably in most studies) other than male/female (11/562, 2.0%). Only one study provided data on religion. No other PROGRESS-PLUS variables were reported. A total of 2996 outcomes were reported, with most studies examining academic output (371/562, 66.0%). CONCLUSIONS: Reviewed literature suggest a lack in analytic approaches that consider genders beyond the binary categories of man and woman, additional social identities (race, religion, social capital and disability) and an intersectionality lens examining the interconnection of multiple social identities in understanding discrimination and disadvantage. All of these are necessary to tailor strategies that promote gender equity. TRIAL REGISTRATION NUMBER: Open Science Framework: https://osf.io/8wk7e/.

Programmes to support transitions in community care for children with complex care needs: a scoping review.

OBJECTIVE: This scoping review aimed to map the range of programmes in the literature to support children and youth with complex care needs and their families during transitions in care in the community. DESIGN: A scoping review of the literature. CONTEXT: This review included programmes that supported the transition in care to home and between settings in the community. DATA SOURCES: We implemented our strategy to search five databases: (1) PubMed; (2) CINAHL; (3) ERIC; (4) PyscINFO and (5) Social Work Abstracts. The search was last implemented on 29 April 2021. STUDY SELECTION: Our search results were imported into Covidence Systematic Review Software. First, two reviewers assessed titles and abstracts against our eligibility criteria. Relevant articles were then retrieved in full and reviewed by two reviewers for inclusion. Disagreements were resolved by a third reviewer. DATA EXTRACTION: Relevant data were extracted related to population, concept, context, methods and key findings pertinent to our review objective. RESULTS: A total of 2482 records were identified. After our two-stage screening process, a total of 27 articles were included for analysis. Articles ranged in the type of transitions being supported and target population. The most common transition reported was the hospital-to-home transition. Intervention components primarily consisted of care coordination using a teams-based approach. The most reported barriers and enablers to implementing these transition care programmes were related to physical opportunities. LIMITATIONS: Included articles were limited to English and French. CONCLUSIONS: This review identified important gaps within the literature, as well as areas for future consideration to ensure the effective development and implementation of programmes to support children and youth with complex care needs during transitions in care.

Identifying children with medical complexity in administrative datasets in a Canadian context: study protocol.

INTRODUCTION: Children with medical complexity and their families are an important population of interest within the Canadian healthcare system. Despite representing less than 1% of the paediatric population, children with medical complexity require extensive care and account for one third of paediatric healthcare expenditures. Opportunities to conduct research to assess disparities in care and appropriate allocation of health resources relies on the ability to accurately identify this heterogeneous group of children. This study aims to better understand the population of children with medical complexity in the Canadian Maritimes, including Nova Scotia (NS), New Brunswick (NB) and Prince Edward Island (PEI). This will be achieved through three objectives: (1) Evaluate the performance of three algorithms to identify children with medical complexity in the Canadian Maritimes in administrative data; then using the 'best fit' algorithm (2) Estimate the prevalence of children with medical complexity in the Canadian Maritimes from 2003 to 2017 and (3) Describe patterns of healthcare utilisation for this cohort of children across the Canadian Maritimes. METHODS AND ANALYSIS: The research will be conducted in three phases. In Phase 1, an expert panel will codevelop a gold-standard definition of paediatric medical complexity relevant to the Canadian Maritime population. A two-gate validation process will then be conducted using NS data and the gold-standard definition to determine the 'best fit' algorithm. During phase 2 the 'best fit' algorithm will be applied to estimate the prevalence of children with medical complexity in NS, NB and PEI. Finally, in phase 3 will describe patterns of healthcare utilisation across the Canadian Maritimes. ETHICS AND DISSEMINATION: Ethics approval for this protocol was granted by the institutional research ethics board at the IWK Health Centre (REB # 1026245). A waiver of consent was approved. This study will use an integrated knowledge translation approach, where end users are involved in each stage of the project, which could increase uptake of the research into policy and practice. The findings of this research study will be submitted for publication and dissemination through conference presentations and with our end users.

Using the Theoretical Domains Framework to Identify Barriers and Enablers to Implementing a Virtual Tertiary-Regional Telemedicine Rounding and Consultation for Kids (TRaC-K) Model: Qualitative Study.

BACKGROUND: Inequities in access to health services are a global concern and a concern for Canadian populations living in rural areas. Rural children hospitalized at tertiary children's hospitals have higher rates of medical complexity and experience more expensive hospitalizations and more frequent readmissions. The 2 tertiary pediatric hospitals in Alberta, Canada, have already been operating above capacity, but the pediatric beds at regional hospitals are underused. Such imbalance could lead to poor patient safety and increased readmission risk at tertiary pediatric hospitals and diminish the clinical exposure of regional pediatric health care providers, erode their confidence, and compel health systems to further reduce the capacity at regional sites. A Telemedicine Rounding and Consultation for Kids (TRaC-K) model was proposed to enable health care providers at Alberta Children's Hospital to partner with their counterparts at Medicine Hat Regional Hospital to provide inpatient clinical care for pediatric patients who would otherwise have to travel or be transferred to the tertiary site. OBJECTIVE: The aim of this study is to identify perceived barriers and enablers to implementing the TRaC-K model. METHODS: This study was guided by the Theoretical Domains Framework (TDF) and used qualitative methods. We collected qualitative data from 42 participants from tertiary and regional hospitals through 31 semistructured interviews and 2 focus groups. These data were thematically analyzed to identify major subthemes within each TDF domain. These subthemes were further aggregated and categorized into barriers or enablers to implementing the TRaC-K model and were tabulated separately. RESULTS: Our study identified 31 subthemes in 14 TDF domains, ranging from administrative issues to specific clinical conditions. We were able to merge these subthemes into larger themes and categorize them into 4 barriers and 4 enablers. Our findings showed that the barriers were lack of awareness of telemedicine, skills to provide virtual clinical care, unclear processes and resources to support TRaC-K, and concerns about clear roles and responsibilities. The enablers were health care providers' motivation to provide care closer to home, supporting system resource stewardship, site and practice compatibility, and motivation to strengthen tertiary-regional relationships. CONCLUSIONS: This systematic inquiry into the perceived barriers and enablers to the implementation of TRaC-K helped us to gain insights from various health care providers' and family members' perspectives. We will use these findings to design interventions to overcome the identified barriers and harness the enablers to encourage successful implementation of TRaC-K. These findings will inform the implementation of telemedicine-based interventions in pediatric settings in other parts of Canada and beyond. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12913-018-3859-2.

Global evidence of gender inequity in academic health research: a living scoping review protocol.

OBJECTIVE: The objective of this review is to describe the global evidence of gender inequity among individuals with appointments at academic institutions that conduct health research, and examine how gender intersects with other social identities to influence outcomes. INTRODUCTION: The gender demographics of universities have shifted, yet the characteristics of those who lead academic health research institutions have not reflected this change. Synthesized evidence will guide decision-making and policy development to support the progress of gender and other under-represented social identities in academia. INCLUSION CRITERIA: This review will consider any quantitative, qualitative, or mixed methods primary research that reports outcome data related to gender equity and other social identities among individuals affiliated with academic or research institutions that conduct health research, originating from any country. METHODS: The JBI Manual for Evidence Synthesis and the Cochrane Collaboration's guidance on living reviews will inform the review methods. Information sources will include electronic databases, unpublished literature sources, reference scanning of relevant systematic reviews, and sources provided by experts on the research team. Searches will be run regularly to monitor the development of new literature and determine when the review will be updated. Study selection and data extraction will be conducted by two reviewers working independently, and all discrepancies will be resolved by discussion or a third reviewer. Data synthesis will summarize information using descriptive frequencies and simple thematic analysis. Results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension to scoping reviews. REGISTRATION: Open Science Framework: https://osf.io/8wk7e/.

Designing an intervention to improve sexual health service use among university undergraduate students: a mixed methods study guided by the behaviour change wheel.

INTRODUCTION: University undergraduate students are within the population at highest risk for acquiring sexually transmitted infections, unplanned pregnancy, and other negative health outcomes. Despite the availability of sexual health services at university health centres, many students delay or avoid seeking care. In this study, we describe how the Behaviour Change Wheel was used as a systematic approach to design an intervention to improve sexual health service use among university undergraduate students. METHODS: This paper describes the intervention development phase of a three-phased, sequential explanatory mixed methods study. Phases one and two included a quantitative and qualitative study that aimed to better understand students' use of sexual health services. In phase three, we followed the Behaviour Change Wheel to integrate the quantitative and qualitative findings and conduct stakeholder consultation meetings to select intervention strategies, including intervention functions and behaviour change techniques. RESULTS: Key linkages between opportunity and motivation were found to influence students' access of sexual health services. Stakeholders identified six intervention functions (education, environmental restructuring, enablement, modelling, persuasion, and incentivization) and 15 behaviour change techniques (information about health consequences, information about social and environmental consequences, feedback on behaviour, feedback on outcomes of behaviour, prompts/cues, self-monitoring of behaviour, adding objects to the environment, goal setting, problem solving, action planning, restructuring the social environment, restructuring the physical environment, demonstration of the behaviour, social support, credible source) as relevant to include in a toolbox of intervention strategies to improve sexual health service use. CONCLUSIONS: This study details the use of the Behaviour Change Wheel to develop an intervention aimed at improving university students' use of sexual health services. The Behaviour Change Wheel provided a comprehensive framework for integrating multiple sources of data to inform the selection of intervention strategies. Stakeholders can use these strategies to design and implement sexual health service interventions that are feasible within the context of their health centre. Future research is needed to test the effectiveness of the strategies at changing university students' sexual health behaviour.

Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework.

BACKGROUND: The scope of pharmacist practice has expanded in many jurisdictions, including Nova Scotia, Canada, to include prescribing of medications. OBJECTIVE: To identify the relationship between barriers and facilitators to pharmacist prescribing and self-reported prescribing activity using the Theoretical Domains Framework version 2 (TDF(v2)). METHODS: The study was a self-administered electronic survey of all registered pharmacists (approximately 1300) in Nova Scotia, Canada. The questionnaire was developed using a consensus process that mapped facilitators and barriers to prescribing with the 14 domains of the TDF(v2). The questionnaire captured information about the type and rate of pharmacists' prescribing activities, pharmacists' perceptions of their prescribing role at the patient, pharmacist, pharmacy organization and health system level, and pharmacist demographics and practice settings. A 5-point Likert scale was used for most TDF(v2) domains. Cronbach's alpha was used to study the internal consistency of responses within each of the TDF(v2) domains and simple logistic regression was used to measure the relationship between TDF(v2) domain responses and self-reported prescribing activity. Open-ended questions were analyzed separately. RESULTS: Eighty-seven pharmacists completed the questionnaire. The majority of respondents were female (70 %), staff pharmacists (52 %) practicing pharmacy for a mean of 18 years. The three domains that respondents most positively associated with prescribing were Knowledge (84 %), Reinforcement (81 %) and Intentions (78 %). The largest effect on prescribing activity was the Skills domain (OR 4.41, 95% CI, 1.34-14.47). CONCLUSIONS: We determined the TDF(v2) domains associated with pharmacist self-reported prescribing behaviours. This understanding can assist the development of policy and program interventions at the pharmacist, pharmacy, and health system levels, to increase the uptake of pharmacist prescribing. Further work is needed to develop and implement interventions based on the domains identified, and to test these in pilot settings and then in large-scale interventions.

Protocol for a mixed studies systematic review on the implementation of the recovery approach in adult mental health services.

INTRODUCTION: Recovery is integral to mental health planning in G-8 countries including Canada. A recovery-oriented approach to care aims to promote personal empowerment, illness self-management and a life beyond services for people with serious mental illness (SMI), while reducing the financial burden associated with mental illness. Although there is a growing body of literature on recovery, no synthesis of research on the implementation of recovery into mental health services exists. OBJECTIVES: The objective is to conduct a mixed studies systematic review on the operationalisation of recovery into mental health services for adults with SMI. It will inform the transformation of Canadian services to a recovery orientation, but may be applicable to other countries. METHODS AND ANALYSIS: Seven databases including PubMed, Ovid Medline, Ovid Embase, Ovid PsycInfo, CINAHL, the Cochrane Library and Scopus will be searched for peer-reviewed empirical studies published from 1998 to December 2016. Systematic reviews and studies using quantitative, qualitative and mixed methodologies will be included. Secondary searches will be conducted in reference lists of all selected full text articles. Handsearches will also be performed in the tables of contents of three recovery-focused journals for the last 5 years. International experts in the field will be contacted for comments and advice. Data extraction will include identification and methodological synthesis of each study; definition of recovery; information on recovery implementation; facilitators and barriers and study outcomes. A quality assessment will be conducted on each study. The data will be synthesised and a stepwise thematic analysis performed. ETHICS AND DISSEMINATION: Ethics approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) a 1-day symposium; (2) presentations in national and international conferences and to local stakeholders; (3) publications in peer-reviewed journals; (4) posts on the organisational websites.

Strategies to support transitions from hospital to home for children with medical complexity: A scoping review.

BACKGROUND: Children with medical complexity constitute a small but resource-intensive subgroup of children with special health care needs. Their medical fragility and resource-intensive needs put them at greater risk for inadequate transitions from hospital to home-based care, and subsequent adverse outcomes and hospital re-admissions. OBJECTIVE: This scoping literature review was conducted to map empirically researched interventions, frameworks, programs or models that could inform or support the transition from hospital to home for children with medical complexity. DESIGN: We conducted a scoping review using the methodology outlined by the Joanna Briggs Institute. DATA SOURCES: In consultation with an experienced librarian, we searched PubMed, EMBASE and CINAHL for English-language articles published from the date of origin to February 2016. We also hand-searched four high impact journals and searched the reference lists of relevant articles. REVIEW METHODS: Two reviewers independently screened the literature results according to inclusion criteria. Empirically designed studies that targeted children <18years old who were specifically defined as medically complex or fragile and transitioning from acute care to home were included. Data were extracted using a predefined tool. Quality appraisal of the articles was conducted using the mixed methods appraisal tool (MMAT). Thematic analysis was carried out to identify existing patterns or trends in the included studies. RESULTS: Of the 2088 abstracts retrieved, 14 studies met the inclusion criteria. Following analysis, we identified three major categories of interventions: Comprehensive care plans (n=3), Complex Care Programs (n=8) and Integrated delivery models (n=3). The overall quality of included studies was moderate, with 21% (n=3) scoring 0.25, 29% (n=4) scoring 0.50, 43% (n=6) scoring 0.75, and 7% (n=1) scoring 1.0. CONCLUSIONS: In the absence of evidence-based guidelines to ensure adequate transitions from hospital to home for children with medical complexity, identification of potential models to support this transition is imperative. We identified interventions, frameworks, models and programs in the literature that might inform the development of such guidelines; however, there is a need for consensus around the definition for children with medical complexity and the limited number of these studies and lack of high quality of evidence signals the need for further research to improve the transition from hospital to home and ultimately, improve patient and family outcomes.

Effectiveness and safety of short-stay units in the emergency department: a systematic review.

OBJECTIVES: Overcrowding is a serious and ongoing challenge in Canadian hospital emergency departments (EDs) that has been shown to have negative consequences for patient outcomes. The American College of Emergency Physicians recommends observation/short-stay units as a possible solution to alleviate this problem. However, the most recent systematic review assessing short-stay units shows that there is limited synthesized evidence to support this recommendation; it is over a decade old and has important methodologic limitations. The aim of this study was to conduct a more methodologically rigorous systematic review to update the evidence on the effectiveness and safety of short-stay units, compared with usual care, on hospital and patient outcomes. METHODS: A literature search was conducted using MEDLINE, the Cochrane Library, Embase, ABI/INFOM, and EconLit databases and gray literature sources. Randomized controlled trials of ED short-stay units (stay of 72 hours or less) were compared with usual care (i.e., not provided in a short-stay unit), for adult patients. Risk-of-bias assessments were conducted. Important decision-making (gradable) outcomes were patient outcomes, quality of care, utilization of and access to services, resource use, health system-related outcomes, economic outcomes, and adverse events. RESULTS: Ten reports of five studies were included, all of which compared short-stay units with inpatient care. Studies had small sample sizes and were collectively at a moderate risk of bias. Most outcomes were only reported by one study and the remaining outcomes were reported by two to four studies. No deaths were reported. Three of the four included studies reporting length of stay found a significant reduction among short-stay unit patients, and one of the two studies reporting readmission rates found a significantly lower rate for short-stay unit patients. All four economic evaluations indicated that short-stay units were a cost-saving intervention compared to inpatient care from both hospital and health care system perspectives. Results were mixed for outcomes related to quality of care and patient satisfaction. CONCLUSIONS: Insufficient evidence exists to make conclusions regarding the effectiveness and safety of short-stay units, compared with inpatient care.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial.

BACKGROUND: The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. DESIGN/METHODS: We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. DISCUSSION: This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01815710.

A systematic review of crisis interventions used in the emergency department: recommendations for pediatric care and research.

OBJECTIVE: In this systematic review, we evaluated the effectiveness of emergency department (ED)-based management interventions for mental health presentations with an aim to provide recommendations for pediatric care. METHODS: A search of electronic databases, references, key journals, and conference proceedings was conducted, and primary authors were contacted. Experimental and observational studies that evaluated ED crisis care with pediatric and adult patients were included. Adult-based studies were evaluated for potential translation to pediatric investigation. Pharmacological-based studies were excluded. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data, and a second checked for completeness and accuracy. Presentation of study outcomes included odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CI). Meta-analysis was deferred due to clinical heterogeneity in intervention, patient population, and outcome. RESULTS: Twelve observational studies were included in the review with pediatric (n = 3), and adult or unknown (n = 9) aged participants. Pediatric studies supported the use of specialized care models to reduce hospitalization (OR, 0.45; 95% CI, 0.33-0.60), return ED visits (OR, 0.60; 95% CI, 0.28-1.25), and length of ED stay (MD, -43.1 minutes; 95% CI, -63.088 to -23.11 minutes). In an adult study, reduced hospitalization was reported in a comparison of a crisis intervention team to standard care (OR, 0.59; 95% CI, 0.43-0.82). Five adult-based studies assessed triage scales; however, little overlap in the scales investigated, and the outcomes measured limited comparability and generalizability for pediatrics. In a comparison of a mental health scale to a national standard, a study demonstrated reduced ED wait (MD, -7.7 minutes; 95% CI, -12.82 to -2.58 minutes) and transit (MD, -17.5 minutes; 95% CI, -33.00 to -1.20 minutes) times. Several studies reported a shift in triage scores of psychiatric patients dependent on the scale or nurse training (psychiatric vs emergency), but linkage to system- or patient-based outcomes was not made, limiting clinical interpretation. CONCLUSIONS: Pediatric studies have demonstrated that the use of specialized care models for mental health care can reduce hospitalization, return ED visits, and length of ED stay. Evaluation of these models using more rigorous study designs and the inclusion of patient-based outcomes will improve this evidence base. Adult-based studies provided recommendations for pediatric research including a focus on triage and restraint use.

Bridging the gap: knowledge seeking and sharing in a virtual community of emergency practice.

Disparities exist between rural and urban emergency departments with respect to knowledge resources such as online journals and clinical specialists. As knowledge is a critical element in the delivery of quality care, a web-based learning project was proposed to address the knowledge needs of emergency clinicians. One objective of this project was to evaluate the effectiveness of the online environment for knowledge exchange among rural and urban emergency clinicians. Descriptive and content analysis of the online discussion board revealed 202 postings with rural participants contributing the largest number of postings (75%; 152/202). Postings were used to establish a clinical presence (87/202), seek clinical information (52/202), and share clinical information (63/202). Postintervention survey results indicate that this modality introduced participants to new clinical experts and resources. The results provide direction for design of a virtual community of practice, which may reduce current knowledge resource disparities.