Lifting the curtain on the emergency department crisis: a multi-method reception study of Larry Saves the Canadian Healthcare System.

BACKGROUND: Despite growing evidence of the potential of arts-based modalities to translate knowledge and spark discussion on complex issues, applications to health policy are rare. This study explored the potential of a research-based theatrical video to increase public capacity and motivation to engage with the complex issues that make Emergency Department wait times such an intractable problem. METHODS: Larry Saves the Canadian Healthcare System is a digital musical micro-series developed from extensive research examining system-level causes of Emergency crowding and the ineffectiveness of prevailing approaches. We released individual episodes and a revised full-length version on YouTube, using organic promotion strategies and paid advertising. We used YouTube Analytics to track views, engagement and viewer demographics, and content-analyzed viewer comments. We also conducted five university-based screenings; 92 students completed questionnaires, rating Larry on 16 descriptors using a 7-point Likert scale. RESULTS: From June 2022 through May 2023, Larry garnered over 100,000 views (76,752 of the full-length version, 35,535 of episodes), 1329 likes, 2780 shares, and 139 comments. Views and watch time were higher among women and positively associated with age. Among YouTube comments, the predominating themes were praise for the video and criticism of the healthcare system. Many commenters applauded the show's accuracy, humor, and/or resonance with their experience; several shared healthcare horror stories. Students overwhelmingly agreed with all positive and disagreed with all negative descriptors, and nearly unanimously deemed the video informative, thought-provoking, and entertaining. Most also affirmed that it had increased their knowledge, interest, and confidence to participate in discussions about healthcare issues. Neither gender, primary language, nor employment in healthcare predicted ratings, but graduate students and those 25+ years old evaluated the video most positively. DISCUSSION: These findings highlight the promise of research-informed musical satire to inform and invigorate discourse on an urgent health policy problem. Larry has reached tens of thousands of viewers, garnered excellent feedback, and received high student ratings. Further research should directly assess educational and behavioural outcomes and explore what facilitative strategies could maximize this knowledge translation product's potential to foster informed, impactful policy dialogue.

Developing a set of emergency department performance measures to evaluate delirium care quality for older adults: a modified e-Delphi study.

BACKGROUND: Older adults are at high risk of developing delirium in the emergency department (ED); however, it is under-recognized in routine clinical care. Lack of detection and treatment is associated with poor outcomes, such as mortality. Performance measures (PMs) are needed to identify variations in quality care to help guide improvement strategies. The purpose of this study is to gain consensus on a set of quality statements and PMs that can be used to evaluate delirium care quality for older ED patients. METHODS: A 3-round modified e-Delphi study was conducted with ED clinical experts. In each round, participants rated quality statements according to the concepts of importance and actionability, then their associated PMs according to the concept of necessity (1-9 Likert scales), with the ability to comment on each. Consensus and stability were evaluated using a priori criteria using descriptive statistics. Qualitative data was examined to identify themes within and across quality statements and PMs, which went through a participant validation exercise in the final round. RESULTS: Twenty-two experts participated, 95.5% were from west or central Canada. From 10 quality statements and 24 PMs, consensus was achieved for six quality statements and 22 PMs. Qualitative data supported justification for including three quality statements and one PM that achieved consensus slightly below a priori criteria. Three overarching themes emerged from the qualitative data related to quality statement actionability. Nine quality statements, nine structure PMs, and 14 process PMs are included in the final set, addressing four areas of delirium care: screening, diagnosis, risk reduction and management. CONCLUSION: Results provide a set of quality statements and PMs that are important, actionable, and necessary to a diverse group of clinical experts. To our knowledge, this is the first known study to develop a de novo set of guideline-based quality statements and PMs to evaluate the quality of delirium care older adults receive in the ED setting.

Managing intergroup silos to improve patient flow.

BACKGROUND: Health care managers face the critical challenge of overcoming divisions among the many groups involved in patient care, a problem intensified when patients must flow across multiple settings. Surprisingly, however, the patient flow literature rarely engages with its intergroup dimension. PURPOSE: This study explored how managers with responsibility for patient flow understand and approach intergroup divisions and "silo-ing" in health care. METHODOLOGY/APPROACH: We conducted in-depth interviews with 300 purposively sampled senior, middle, and frontline managers across 10 Canadian health jurisdictions. We undertook thematic analysis using sensitizing concepts drawn from the social identity approach. RESULTS: Silos, at multiple levels, were reported in every jurisdiction. The main strategies for ameliorating silos were provision of formal opportunities for staff collaboration, persuasive messages stressing shared values or responsibilities, and structural reorganization to redraw group boundaries. Participants emphasized the benefits of the first two but described structural change as neither necessary nor sufficient for improved collaboration. CONCLUSION: Silos, though an unavoidable feature of organizational life, can be managed and mitigated. However, a key challenge in redefining groups is that the easiest place to draw boundaries from a social identity perspective may not be the best place from one of system design. Narrowly defined groups forge strong identities more easily, but broader groups facilitate coordination of care by minimizing the number of boundaries patients must traverse. PRACTICE IMPLICATIONS: A thoughtfully designed combination of strategies may help to improve intergroup relations and their impact on flow. It may be ideal to foster a "mosaic" identity that affirms group allegiances at multiple levels.

Can facility-based transitional care improve patient flow? Lessons from four Canadian regions.

Units providing transitional, subacute, or restorative care represent a common intervention to facilitate patient flow and improve outcomes for lower acuity (often older) inpatients; however, little is known about Canadian health systems' experiences with such "transition units." This comparative case study of diverse units in four health regions (48 interviews) identified important success factors and pitfalls. A fundamental requirement for success is to clearly define the unit's intended population and design the model around its needs. Planners must also ensure that the unit be resourced and staffed to deliver truly restorative care. Finally, streamlined processes must be developed to help patients access and move through the unit. Units that were perceived as more effective appeared to have satisfactorily addressed these population, capacity, and process issues, whereas those perceived as less effective continued to struggle with them. Findings suggest principles to support optimal design and implementation of transition units.

The stipulation-stimulation spiral: A model of system change.

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Advancing the evaluation of integrated knowledge translation.

BACKGROUND: Integrated knowledge translation (IKT) flows from the premise that knowledge co-produced with decision-makers is more likely to inform subsequent decisions. However, evaluations of manager/policy-maker-focused IKT often concentrate on intermediate outcomes, stopping short of assessing whether research findings have contributed to identifiable organisational action. Such hesitancy may reflect the difficulty of tracing the causes of this distal, multifactorial outcome. This paper elucidates how an approach based on realistic evaluation could advance the field. MAIN TEXT: Realistic evaluation views outcomes as a joint product of intervention mechanisms and context. Through identification of context-mechanism-outcome configurations, it enables the systematic testing and refinement of 'mid-range theory' applicable to diverse interventions that share a similar underlying logic of action. The 'context-sensitive causal chain' diagram, a tool adapted from the broader theory-based evaluation literature, offers a useful means of visualising the posited chain from activities to outcomes via mechanisms, and the context factors that facilitate or disrupt each linkage (e.g. activity-mechanism, mechanism-outcome). Drawing on relevant literature, this paper proposes a context-sensitive causal chain by which IKT may generate instrumental use of research findings (i.e. direct use to make a concrete decision) and identifies an existing tool to assess this outcome, then adapts the chain to describe a more subtle, indirect pathway of influence. Key mechanisms include capacity- and relationship-building among researchers and decision-makers, changes in the (perceived) credibility and usability of findings, changes in decision-makers' beliefs and attitudes, and incorporation of new knowledge in an actual decision. Project-specific context factors may impinge upon each linkage; equally important is the organisation's absorptive capacity, namely its overall ability to acquire, assimilate and apply knowledge. Given a sufficiently poor decision-making environment, even well-implemented IKT that triggers important mechanisms may fall short of its desired outcomes. Further research may identify additional mechanisms and context factors. CONCLUSION: By investigating 'what it is about an intervention that works, for whom, under what conditions', realistic evaluation addresses questions of causality head-on without sacrificing complexity. A realist approach could contribute greatly to our ability to assess - and, ultimately, to increase - the value of IKT.

Planning without action and action without planning? Examining a regional health system's efforts to improve patient flow, 1998-2013.

Most health care organizations engage in formal and informal planning, yet their improvement initiatives may remain disjointed and reactive. Research on organizational decision-making has found that the "discovery" approach (seek and assess multiple options before selecting one) outperforms "idea imposition" (identify 1 option, then gather information to [dis]confirm it), yet is observed relatively infrequently. Might this imply that discovery frequently collapses before fruition? This qualitative study sought to better understand the planning-action disjunction, as observed in 1 organization, by comparing its planning processes against the discovery approach. It focused on a Canadian regional health system's recurrent, unsuccessful attempts to improve patient flow. Through extensive document review supplemented by interviews with 62 managers, it identified all relevant regional plans/reports produced during a 15-year period and followed each recommendation forward in time to discover its fate. Each report presented a lengthy, unprioritized list of disparate recommendations, few of which progressed to full implementation. It appeared that decision-makers repeatedly embarked on a discovery approach, but rapidly allowed it to splinter into multiple idea-imposition approaches; numerous options were generated, but never evaluated against each other. Thus, the product of each planning process was not a coherent strategy but a list of disconnected actions.

The three paradoxes of patient flow: an explanatory case study.

BACKGROUND: Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow. METHODS: This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels. RESULTS: Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole. CONCLUSION: An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes.

BACKGROUND: Timely access to orthopedic trauma surgery is essential for optimal outcomes. Regionalization of some types of surgery has shown positive effects on access, timeliness and outcomes. We investigated how the consolidation of orthopedic surgery in 1 Canadian health region affected patients requiring hip fracture surgery. METHODS: We retrieved administrative data on all regional emergency department visits for lower-extremity injury and all linked inpatient stays from January 2010 through March 2013, identifying 1885 hip-fracture surgeries. Statistical process control and interrupted time series analysis controlling for demographics and comorbidities were used to assess impacts on access (receipt of surgery within 48-h benchmark) and surgical outcomes (complications, in-hospital/30-d mortality, length of stay). RESULTS: There was a significant increase in the proportion of patients receiving surgery within the benchmark. Complication rates did not change, but there appeared to be some decrease in mortality (significant at 6 mo). Length of stay increased at a hospital that experienced a major increase in patient volume, perhaps reflecting challenges associated with patient flow. CONCLUSION: Regionalization appeared to improve the timeliness of surgery and may have reduced mortality. The specific features of the present consolidation (including pre-existing interhospital performance variation and the introduction of daytime slates at the referral hospital) should be considered when interpreting the findings.

CONTEXTE: En traumatologie, l'accès rapide à la chirurgie orthopédique est essentiel pour l'obtention de résultats optimaux. La régionalisation de certains types de chirurgie a eu des effets positifs sur l'accès aux soins, leur rapidité et leurs résultats. Nous avons vérifié l'effet qu'a eu la consolidation des soins chirurgicaux orthopédiques dans une région sanitaire canadienne sur les patients qui ont eu recours à la chirurgie pour une fracture de la hanche. MÉTHODES: Nous avons obtenu les données administratives concernant toutes les consultations dans les services d'urgence régionaux pour des blessures aux membres inférieurs et nous les avons corrélées avec les séjours hospitaliers de janvier 2010 à mars 2013. Nous avons ainsi recensé 1885 chirurgies pour fracture de la hanche. Nous avons utilisé la maîtrise statistique des procédés et le modèle chronologique interrompu et nous avons tenu compte des caractéristiques démographiques et des comorbidités pour évaluer les impacts sur l'accès aux interventions (attente limite de 48 h pour obtenir la chirurgie) et leurs résultats (complications, mortalité perhospitalière à 30 j et durée des séjours). RÉSULTATS: On a noté une augmentation significative de la proportion de patients traités par chirurgie à l'intérieur des délais. Les taux de complications n'ont pas varié, mais il semble y avoir eu une certaine diminution de la mortalité (significative à 6 mois). La durée des séjours a augmenté dans un hôpital qui a connu un accroissement majeur de sa clientèle, témoignant peut-être de difficultés liées à l'afflux de patients. CONCLUSION: La régionalisation a semblé améliorer l'accès rapide à la chirurgie et pourrait avoir réduit la mortalité. Il faut tenir compte des caractéristiques spécifiques de la présente consolidation (y compris la variation préexistante du rendement interhospitalier et la création de listes de jour à l'hôpital de référence) avant d'interpréter ces conclusions.

What if implementation is not the problem? Exploring the missing links between knowledge and action.

Given all the available knowledge about effective implementation, why do many organizations continue to have-or appear to have-an implementation problem? Analysis of a 7-year corpus of reports by a Canadian health region's "embedded" research and evaluation unit sought to discover the source of the region's intractable difficulty implementing improvement. Findings suggested that the problem was neither a lack of knowledge (decision-makers displayed sophisticated understanding of fundamental issues) nor an inability to take action (there existed sufficient capacity to implement change). However, managers' high-level knowledge was not made actionable, and micro-level decision-making often produced piecemeal actions inadequately informed by existing knowledge. The problem arose at the stage of "operationalization"-the identification of concrete, executable actions fully informed by knowledge of complex, system-level issues. Yet this crucial phase is a focus of neither the implementation nor knowledge translation (KT) literatures. The organizational decision-making literature reveals how decision-makers initiate operationalization (i.e., by setting the direction for a discovery approach) but not how they can ensure its successful completion. The focus of KT research and practice should expand to explicating and improving decision-making, lest KT become an exercise of infusing content into a broken process. Copyright © 2014 John Wiley & Sons, Ltd.

Patient characteristics associated with longer emergency department stay: a rapid review.

BACKGROUND: Prolonged emergency department (ED) stays make a disproportionate contribution to ED overcrowding, but the factors associated with longer stays have not been systematically reviewed. OBJECTIVE: To identify the patient characteristics associated with ED length of stay (LOS) and ascertain whether a predictive model existed. METHODS: This rapid systematic review included published, English-language studies that assessed at least one patient-level predictor of ED LOS (defined as a continuous or dichotomous variable) in an adult or mixed adult/paediatric population within an Organization for Economic Cooperation and Development country. Findings were synthesised narratively. RESULTS: We identified 35 relevant studies; most included multiple predictors, but none developed a predictive model. The factors most commonly associated with long ED LOS were need for admission (10 of 10 studies) and older age (which may be a proxy for age-related differences in health condition and severity; 9 of 10), receipt of diagnostic tests or consults (8 of 8) and ambulance arrival (4 of 5). Acuity often showed a bell-shaped relationship with LOS (ie, patients with moderate acuity stayed longest). LIMITATIONS: Methodological choices made in the interests of rapidity limited the review's comprehensiveness and depth. CONCLUSIONS: Despite a sizeable body of literature, the available information is insufficiently precise to inform clinical or service-planning decisions; there is a need for a predictive model, including specific patient complaints. Deeper understanding of the determinants of ED LOS could help to identify patients and/or populations who require special intervention or resources to prevent a protracted stay.

Assessing the organizational impact of patient involvement: a first STEPP.

Purpose - Patient involvement in the design and improvement of health services is increasingly recognized as an essential part of patient-centred care. Yet little research, and no measurement tool, has addressed the organizational impacts of such involvement. The paper aims to discuss these issues. Design/methodology/approach - The authors developed and piloted the scoresheet for tangible effects of patient participation (STEPP) to measure the instrumental use of patient input. Its items assess the magnitude of each recommendation or issue brought forward by patients, the extent of the organization's response, and the apparent degree of patient influence on this response. In collaboration with teams (staff) from five involvement initiatives, the authors collected interview and documentary data and scored the STEPP, first independently then jointly. Feedback meetings and a "challenges log" supported ongoing improvement. Findings - Although researchers' and teams' initial scores often diverged, the authors quickly reached consensus as new information was shared. Composite scores appeared to credibly reflect the degree of organizational impact, and were associated with salient features of the involvement initiatives. Teams described the STEPP as easy to use and useful for monitoring and accountability purposes. The tool seemed most suitable for initiatives in which patients generated novel, concrete recommendations; less so for broad public consultations of which instrumental use was not a primary goal. Originality/value - The STEPP is a promising, first-in-class tool with potential usefulness to both researchers and practitioners. With further research to better establish its reliability and validity, it could make a valuable contribution to full mixed-methods evaluation of patient involvement.

The politics of patient-centred care.

BACKGROUND: Despite widespread belief in the importance of patient-centred care, it remains difficult to create a system in which all groups work together for the good of the patient. Part of the problem may be that the issue of patient-centred care itself can be used to prosecute intergroup conflict. OBJECTIVE: This qualitative study of texts examined the presence and nature of intergroup language within the discourse on patient-centred care. METHODS: A systematic SCOPUS and Google search identified 85 peer-reviewed and grey literature reports that engaged with the concept of patient-centred care. Discourse analysis, informed by the social identity approach, examined how writers defined and portrayed various groups. RESULTS: Managers, physicians and nurses all used the discourse of patient-centred care to imply that their own group was patient centred while other group(s) were not. Patient organizations tended to downplay or even deny the role of managers and providers in promoting patient centredness, and some used the concept to advocate for controversial health policies. Intergroup themes were even more obvious in the rhetoric of political groups across the ideological spectrum. In contrast to accounts that juxtaposed in-groups and out-groups, those from reportedly patient-centred organizations defined a 'mosaic' in-group that encompassed managers, providers and patients. CONCLUSION: The seemingly benign concept of patient-centred care can easily become a weapon on an intergroup battlefield. Understanding this dimension may help organizations resolve the intergroup tensions that prevent collective achievement of a patient-centred system.

The rules of engagement: physician engagement strategies in intergroup contexts.

PURPOSE: Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques. This paper seeks to address this issue. DESIGN/METHODOLOGY/APPROACH: The authors examined how four disparate organisations engaged physicians in change. Qualitative methods included interviews (109 managers and physicians), observation, and document review. FINDINGS: Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members' identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing "systemness" with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates. RESEARCH LIMITATIONS/IMPLICATIONS: The authors cannot confirm the accuracy of managers perceptions of the inter-group context or the efficacy of particular strategies. Nonetheless, the findings suggested the fruitfulness of social identity thinking in approaching physician engagement. PRACTICAL IMPLICATIONS: Attention to inter-group dynamics may help organisations engage physicians more effectively. ORIGINALITY/VALUE: This study illuminates and explains variation in the way different organisations engage physicians, and offers a theoretical basis for selecting engagement strategies.

Impact of a regional acute care surgery model on patient access and outcomes.

BACKGROUND: The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. METHODS: Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14,713). RESULTS: Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. CONCLUSION: Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.

CONTEXTE: Le regroupement des services chirurgicaux d'urgence (SCU) dans 3 hôpitaux sur 6 d'une région sanitaire canadienne visait à contrer une relative pénurie de chirurgiens capables d'effectuer les interventions d'urgence. Nous en avons analysé l'impact sur l'accessibilité des services et sur les résultats chez les patients. MÉTHODES: À l'aide du modèle linéaire généralisé et d'un contrôle statistique des procédés, nous avons analysé les cas adressés aux SCU entre 39 mois précédant et 17 mois suivant l'entrée en vigueur du regroupement des services (n = 14 713). RÉSULTANTS: L'intervalle avant l'intervention chirurgicale s'est allongé après le regroupement des services. Les temps d'attente ont principalement augmenté pour les patients qui consultaient dans un hôpital de premier recours d'où ils étaient susceptibles d'être réorientés vers un hôpital de référence. Même si les équipes des SCU ont permis aux hôpitaux de référence de gérer un volume beaucoup plus important de patients sans augmentation du temps d'attente à l'hôpital même, le temps d'attente dans son ensemble s'est prolongé à l'échelle du système en raison de l'accroissement du nombre de transferts. Les temps d'attente pour les hospitalisations ont été difficiles à interpréter parce qu'on avait tendance à admettre les patients directement aux SCU, en contournant les services d'urgences. Pour les patients qui passaient par les urgences, les temps d'attente pour une hospitalisation ont augmenté après le regroupement; toutefois, cette tendance a été compensée par l'attente pour ainsi dire nulle des patients qui contournaient les services d'urgence. La régionalisation n'a exercé aucun impact sur la durée du séjour, les réadmissions, la mortalité ou les complications. CONCLUSIONS: Le regroupement a permis à la région d'assurer une couverture chirurgicale adéquate sans nuire aux patients. La nécessité de réorienter des patients vers les hôpitaux de référence a contribué à prolonger les temps d'attente.

A critical appraisal and recommendation synthesis of delirium clinical practice guidelines relevant to the care of older adults in the emergency department: An umbrella review.

RATIONALE: Older adults are at high risk of developing delirium in the emergency department (ED); however, it is often missed or undertreated. Improving ED delirium care is challenging in part due to a lack of standards to guide best practice. Clinical practice guidelines (CPGs) translate evidence into recommendations to improve practice. AIM: To critically appraise and synthesize CPG recommendations for delirium care relevant to older ED patients. METHODS: We conducted an umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations were critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) instruments. A threshold of 70% or greater in the AGREE-II Rigour of Development domain was used to define high-quality CPGs. Delirium recommendations from CPGs meeting this threshold were included in the synthesis and narrative analysis. RESULTS: AGREE-II Rigour of Development scores ranged from 37% to 83%, with 5 of 10 CPGs meeting the predefined threshold. AGREE-REX overall calculated scores ranged from 44% to 80%. Recommendations were grouped into screening, diagnosis, risk reduction, and management. Although none of the included CPGs were ED-specific, many recommendations incorporated evidence from this setting. There was agreement that screening for nonmodifiable risk factors is important to define high-risk populations, and those at risk should be screened for delirium. The '4A's Test' was the recommended tool to use in the ED specifically. Multicomponent strategies were recommended for delirium risk reduction, and for its management if it occurs. The only area of disagreement was for the short-term use of antipsychotic medication in urgent situations. CONCLUSION: This is the first known review of delirium CPGs including a critical appraisal and synthesis of recommendations. Researchers and policymakers can use this synthesis to inform future improvement efforts and research in the ED. REGISTRATION: This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6OSF.IO/TG7S6.

Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in health care.

CONTEXT: One of health care's foremost challenges is the achievement of integration and collaboration among the groups providing care. Yet this fundamentally group-related issue is typically discussed in terms of interpersonal relations or operational issues, not group processes. METHODS: We conducted a systematic search for literature offering a group-based analysis and examined it through the lens of the social identity approach (SIA). Founded in the insight that group memberships form an important part of the self-concept, the SIA encompasses five dimensions: social identity, social structure, identity content, strength of identification, and context. FINDINGS: Our search yielded 348 reports, 114 of which cited social identity. However, SIA-citing reports varied in both compatibility with the SIA's metatheoretical paradigm and applied relevance to health care; conversely, some non-SIA-citers offered SIA-congruent analyses. We analyzed the various combinations and interpretations of the five SIA dimensions, identifying ten major conceptual currents. Examining these in the light of the SIA yielded a cohesive, multifaceted picture of (inter)group relations in health care. CONCLUSIONS: The SIA offers a coherent framework for integrating a diverse, far-flung literature on health care groups. Further research should take advantage of the full depth and complexity of the approach, remain sensitive to the unique features of the health care context, and devote particular attention to identity mobilization and context change as key drivers of system transformation. Our article concludes with a set of "guiding questions" to help health care leaders recognize the group dimension of organizational problems, identify mechanisms for change, and move forward by working with and through social identities, not against them.

Interpretations of integration in early accountable care organizations.

CONTEXT: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? METHODS: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. FINDINGS: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. CONCLUSIONS: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. "Soft integration" may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations.

A critical appraisal of delirium clinical practice guidelines relevant to the care of older adults in the emergency department with a synthesis of recommendations: an umbrella review protocol.

BACKGROUND: Up to 35% of older adults present to the emergency department (ED) with delirium or develop the condition during their ED stay. Delirium associated with an ED visit is independently linked to poorer outcomes such as loss of independence, increased length of hospital stay, and mortality. Improving the quality of delirium care for older ED patients is hindered by a lack of knowledge and standards to guide best practice. High-quality clinical practice guidelines (CPGs) have the power to translate the complexity of scientific evidence into recommendations to improve and standardize practice. This study will identify and synthesize recommendations from high-quality delirium CPGs relevant to the care of older ED patients. METHODS: We will conduct a multi-phase umbrella review to retrieve relevant CPGs. Quality of the CPGs and their recommendations will be critically appraised using the Appraisal of Guidelines, Research, and Evaluation (AGREE)-II; and Appraisal of Guidelines Research and Evaluation - Recommendations Excellence (AGREE-REX) instruments, respectively. We will also synthesize and conduct a narrative analysis of high-quality CPG recommendations. DISCUSSION: This review will be the first known evidence synthesis of delirium CPGs including a critical appraisal and synthesis of recommendations. Recommendations will be categorized according to target population and setting as a means to define the bredth of knowledge in this area. Future research will use consensus building methods to identify which are most relevant to older ED patients. TRIAL REGISTRATION: This study has been registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/TG7S6 .

Conceptualizing the Organization of Surgical Services Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries".

According to Iverson and colleagues' thoughtful analysis, decisions to decentralize or regionalize surgical services must take into account contextual realities that may impede the safe execution of certain delivery models in low-and middle-income countries (LMICs), and should be governed by procedure-related considerations (specifically, volume, patient acuity, and procedure complexity). This commentary suggests that, by shifting attention to the mechanisms whereby (de)centralization may exert beneficial impacts, it is possible to generate guidance applicable to countries across the socioeconomic spectrum. Four key mechanisms can be identified: decentralization (1) minimizes the need for patients to travel for care and, (2) obviates certain system-induced delays once patients present; centralization (3) facilitates the maintenance of a workforce with sufficient expertise to offer services safely, and (4) conserves resources by limiting the number of sites. The commentary elucidates how context- and procedure-related factors determine the importance of each mechanism, allowing planners to prioritize among them. Although some context factors have special relevance to LMICs, most can also appear in high-income countries (HICs), and the procedure-related factors are universal. Thus, evidence from countries at all income levels might be fruitfully combined into an integrated body of context-sensitive guidance.