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BACKGROUND: Dentists serve a crucial role in managing treatment complications for patients with head and neck cancer, including post-radiation caries and oral infection. To date, dental services for head and neck cancer patients in Ontario, Canada have not been well characterized and considerable disparities in allocation, availability, and funding are thought to exist. The current study aims to describe and assess the provision of dental services for head and neck cancer patients in Ontario. METHODS: A mixed methods scoping assessment was conducted. A purposive sample of dentist-in-chiefs at each of Ontario's 9 designated head and neck cancer centres (tertiary centres which meet provincially-set quality and safety standards) was invited to participate. Participants completed a 36-item online survey and 60-minute semi-structured interview which explored perceptions of dental services for head and neck cancer patients at their respective centres, including strengths, gaps, and inequities. If a centre did not have a dentist-in-chief, an alternative stakeholder who was knowledgeable on that centre's dental services participated instead. Thematic analysis of the interview data was completed using a mixed deductive-inductive approach. RESULTS: Survey questionnaires were completed at 7 of 9 designated centres. A publicly funded dental clinic was present at 5 centres, but only 2 centres provided automatic dental assessment for all patients. Survey data from 2 centres were not captured due to these centres' lack of active dental services. Qualitative interviews were conducted at 9 of 9 designated centres and elicited 3 themes: (1) lack of financial resources; (2) heterogeneity in dentistry care provision; and (3) gaps in the continuity of care. Participants noted concerning under-resourcing and limitations/restrictions in funding for dental services across Ontario, resulting in worse health outcomes for vulnerable patients. Extensive advocacy efforts by champions of dental services who have sought to mitigate current disparities in dentistry care were also described. CONCLUSIONS: Inequities exist in the provision of dental services for head and neck cancer patients in Ontario. Data from the current study will broaden the foundation for evidence-based decision-making on the allocation and funding of dental services by government health care agencies.
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Caries Dental , Neoplasias de Cabeza y Cuello , Enfermedades de la Boca , Humanos , Ontario , Atención a la Salud , Caries Dental/terapia , Atención OdontológicaRESUMEN
BACKGROUND: Older adults (aged ≥ 65 yr) account for a substantial proportion of hospital admissions for severe injury, yet little is known about their care experiences and views regarding outcomes. We sought to characterize the acute care and early recovery experiences of older adults who had been discharged after traumatic injury, with a long-term goal to inform the selection of patient-centred process and outcome measures in geriatric trauma. METHODS: From June 2018 to September 2019, we conducted telephone interviews with adults aged 65 years or older who had been discharged after traumatic injury within 6 months from Sunnybrook or London Health Sciences Centres in Ontario, Canada. Using interpretive description and thematic analysis, we drew on social science theories of illness and aging for data interpretation. We analyzed data to the point of theoretical saturation. RESULTS: We interviewed 25 trauma survivors aged 65-88 years. Most were injured in a fall. Four themes characterized participants' experiences, as follows: "I don't feel like a senior" (i.e., participants disliked being viewed as a senior or as needing senior-specific care); "don't bother telling him anything" (i.e., participants perceived ageist assumptions and treatment in acute care processes); getting back to normal (i.e., participants emphasized their active lifestyles and functional recovery as goals of care); "I have lost control of my life" (i.e., substantial social and personal losses linked to participants' experiences and adaptations to aging generally). INTERPRETATION: Findings suggest that older adults experience social and personal loss after injury, and underscore how implicit age bias may influence care experiences and outcomes. This can inform improvements in injury care and guide providers in the selection of patient-centred outcome measures.
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Alta del Paciente , Sobrevivientes , Masculino , Humanos , Anciano , OntarioRESUMEN
Objectives: To address the knowledge gap in the practice of compassionate healthcare by elucidating patient perspectives on compassion, empathy, and sympathy. Methods: Semi-structured telephone interviews were conducted at two time points with patients undergoing head and neck cancer treatment. Questions explored participants' understanding of compassion, sympathy, and empathy, as they relate to each other and to healthcare. Interviewers manually recorded responses. Qualitative exploratory methods were used to analyze data; inductive line-by-line coding was conducted to develop primary codes. Themes emerged through categorization of codes. Results: Ninety-five interviews conducted with 63 participants across two time points revealed four major themes - Compassion-vs-Empathy-vs-Sympathy, Coping Methods, Showing Care, and Nature of Interaction - encompassing seven categories, with a total of 24 codes. Codes were consistent across time points, except for two new codes, "positivity" and "personalized" emerging during follow-up interviews. Conclusions: Patient narrative from this study supported the concept that compassion is multidimensional and enabled several dimensions to be identified, highlighting the importance of patient perspectives in improving the provision of compassionate healthcare. Findings should be considered in future training and practice.
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BACKGROUND: End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities. METHODS: A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects. RESULTS: Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life. CONCLUSION: This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.
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Planificación Anticipada de Atención , Calidad de Vida , Adolescente , Adulto , Comunicación , Muerte , Toma de Decisiones , HumanosRESUMEN
OBJECTIVE: The aim of this study was to examine the effect of surgeon-anesthesiologist sex discordance on postoperative outcomes. SUMMARY BACKGROUND DATA: Optimal surgical outcomes depend on teamwork, with surgeons and anesthesiologists forming two key components. There are sex and sex-based differences in interpersonal communication and medical practice which may contribute to patients' perioperative outcomes. METHODS: We performed a population-based, retrospective cohort study among adult patients undergoing 1 of 25 common elective or emergent surgical procedures from 2007 to 2019 in Ontario, Canada. We assessed the association between differences in sex between surgeon and anesthesiologists (sex discordance) on the primary endpoint of adverse postoperative outcome, defined as death, readmission, or complication within 30âdays following surgery using generalized estimating equations. RESULTS: Among 1,165,711 patients treated by 3006 surgeons and 1477 anesthesiologists, 791,819 patients were treated by sex concordant teams (male surgeon/male anesthesiologist: 747,327 and female surgeon/female anesthesiologist: 44,492), whereas 373,892 were sex discordant (male surgeon/female anesthesiologist: 267,330 and female surgeon/male anesthesiologist: 106,562). Overall, 12.3% of patients experienced >1 adverse postoperative outcomes of whom 1.3% died. Sex discordance between surgeon and anesthesiologist was not associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio 1.00, 95% confidence interval 0.97-1.03). CONCLUSIONS: We did not demonstrate an association between intraoperative surgeon and anesthesiologist sex discordance on adverse postoperative outcomes in a large patient cohort. Patients, clinicians, and administrators may be reassured that physician sex discordance in operating room teams is unlikely to clinically meaningfully affect patient outcomes after surgery.
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Cirujanos , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Ontario/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: Recently immigrated and ethnic minority patients in Ontario, Canada are more likely to receive aggressive life-prolonging treatment at the end of life in comparison to other patients. To explore this finding further, this survey-based observational study aimed to evaluate satisfaction with the quality of end-of-life care for patients from diverse ethnocultural backgrounds. METHODS: The End-of-Life Satisfaction Survey was used to measure satisfaction with the quality of inpatient end-of-life care from the perspective of next-of-kin of recently deceased patients at Sunnybrook Health Sciences Centre in Toronto, Ontario (between March 2012 to May 2019). The primary outcome was the global rating of satisfaction. Associations with patient ethnicity, patient religion, level of religiosity/spirituality, language/communication barriers, and location of death were assessed using univariable and multivariable modified Poisson regression. Secondary outcomes included differences in satisfaction and rates of dying in intensive care units (ICU) among patient population subgroups, and identification of high priority areas for quality-of-care improvement. RESULTS: There were 1,543 respondents. Patient ethnicities included Caucasian (68.2%), Mediterranean (10.5%), East Asian (7.6%), South Asian (3.5%), Southeast Asian (2.1%) and Middle Eastern (2.0%); religious affiliations included Christianity (66.6%), Judaism (12.3%) and Islam (2.1%), among others. Location of death was most commonly in ICU (38.4%), hospital wards (37.0%) or long-term care (20.0%). The mean(SD) rating of satisfaction score was 8.30(2.09) of 10. After adjusting for other covariates, satisfaction with quality of end-of-life care was higher among patients dying in ICU versus other locations (relative risk [RR] 1.51, 95%CI 1.05-2.19, p=0.028), lower among those who experienced language/communication barriers (RR 0.49 95%CI 0.23-1.06, p=0.069), and lower for Muslim patients versus other religious affiliations (RR 0.46, 95%CI 0.21-1.02, p=0.056). Survey items identified as highest priority areas for quality-of-care improvement included communication and information giving; illness management; and healthcare provider characteristics such as emotional support, doctor availability and time spent with patient/family. CONCLUSION: Satisfaction with quality-of-care at the end of life was higher among patients dying in ICU and lower among Muslim patients or when there were communication barriers between families and healthcare providers. These findings highlight the importance of measuring and improving end-of-life care across the ethnocultural spectrum.
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Satisfacción Personal , Cuidado Terminal , Etnicidad , Humanos , Islamismo , Grupos Minoritarios , Ontario , Satisfacción del PacienteRESUMEN
OBJECTIVES: Follow-up colonoscopy rates among persons with positive fecal occult blood test results (FOBT + ) remain suboptimal in many jurisdictions. In Ontario, Canada, primary care providers (PCPs) are responsible for arranging follow-up colonoscopies. The objectives were to understand the reasons for a lack of follow-up colonoscopy and any action plans to address follow-up. METHODS: Semi-structured interviews were conducted with 30 FOBT+ persons and 30 PCPs in Ontario. Eligible FOBT+ persons were identified through administrative databases and included those aged 50-74, with a 6-12 month old FOBT+, no follow-up colonoscopy, and no prior colorectal cancer diagnosis or colectomy. Eligible PCPs had ≥1 rostered FOBT+ person without follow-up colonoscopy. Transcripts were analyzed inductively using Nvivo 11 (QSR International Pty Ltd., 2015). RESULTS: Reasons for lack of follow-up colonoscopy were: person and/or provider believed the FOBT + was a false positive; person was afraid of colonoscopy; person had other health issues; and breakdown in communication of FOBT+ results or colonoscopy appointments. PCPs who initially recommended follow-up colonoscopy did not change the minds of the persons who dismissed the FOBT+ as a false positive and/or who were afraid of the procedure. These FOBT+ persons negotiated an alternative follow-up action plan including repeating the FOBT or not following-up. CONCLUSIONS: PCPs may not adequately counsel FOBT+ persons who believe the FOBT+ is a false positive and/or fear colonoscopy. PCPs may lack fail-safe systems to communicate FOBT+ results and colonoscopy appointments. Using navigators may help address these barriers and increase follow-up rates.
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Colonoscopía/psicología , Neoplasias Colorrectales/diagnóstico , Pacientes no Presentados/psicología , Sangre Oculta , Médicos de Atención Primaria/psicología , Anciano , Colonoscopía/estadística & datos numéricos , Consejo , Detección Precoz del Cáncer/métodos , Detección Precoz del Cáncer/psicología , Detección Precoz del Cáncer/estadística & datos numéricos , Reacciones Falso Positivas , Miedo , Femenino , Humanos , Masculino , Tamizaje Masivo/métodos , Tamizaje Masivo/estadística & datos numéricos , Persona de Mediana Edad , Pacientes no Presentados/estadística & datos numéricos , Ontario , Educación del Paciente como Asunto , Relaciones Médico-Paciente , Médicos de Atención Primaria/estadística & datos numéricos , Investigación CualitativaRESUMEN
BACKGROUND: Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact. OBJECTIVE: This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery. METHODS: An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery. RESULTS: Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001). CONCLUSIONS: Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.
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Colon/cirugía , Vías Clínicas , Procedimientos Quirúrgicos del Sistema Digestivo , Hospitales de Enseñanza/organización & administración , Atención Perioperativa/métodos , Recto/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Adhesión a Directriz , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Estados UnidosRESUMEN
: Limited recent data exist regarding intended retirement plans for general surgeons (GS). We sought to understand when and why surgeons decide to stop operating as primary surgeon and stop all clinical work.A paper-based survey of practicing GS in the province of Ontario, Canada, was conducted. A questionnaire was developed using a systematic approach of item generation and reduction. Face and content validity were tested. The survey was administered via mail, with a planned reminder.Overall response rate was 33.5% (242/723). The median age at which respondents planned to/did stop operating was 65 (interquartile range 60-67.5). The median age at which respondents planned to/did retire from all clinical work was 70 (interquartile range 65-72.5). Career satisfaction (97%), sense of identity (90%), and financial need (69%) were factors that influenced the decision to continue operating. Enjoyment of work (79%), camaraderie with surgical colleagues (66%), and financial need (45%) were reasons to continue working after ceasing to operate as the primary surgeon. On multivariate analysis, younger respondents (36-50 years old) perceived they were less likely to continue operating past age 65 (odds ratio 0.13), and academic surgeons were more likely to stop operating after age 65 (odds ratio 2.39). Call coverage by nonstaff surgeons was not associated with retirement age.Overall, GS plan to stop operating at age 65, and to cease all clinical activities at age 70. Younger, nonacademic surgeons plan to stop operating earlier. Career satisfaction, sense of identity, and financial need are the principal reported motivations to continue operating.
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Empleo , Cirugía General , Satisfacción en el Trabajo , Jubilación/estadística & datos numéricos , Cirujanos , Factores de Edad , Anciano , Empleo/estadística & datos numéricos , Femenino , Cirugía General/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Ontario , Estudios Retrospectivos , Cirujanos/estadística & datos numéricos , Encuestas y Cuestionarios , Recursos HumanosRESUMEN
OBJECTIVE: The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS). METHODS: Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively. RESULTS: Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07-0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20-0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66-0.82; p < 0.0001) and 5 vs 8 days following rectal procedures (RR 0.54, 95% CI 0.49-0.59; p < 0.001). CONCLUSION: Early removal of urinary catheters is associated with a decreased risk of UTI and LOS.
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Infecciones Relacionadas con Catéteres/prevención & control , Remoción de Dispositivos/normas , Adhesión a Directriz/estadística & datos numéricos , Cuidados Posoperatorios/normas , Complicaciones Posoperatorias/prevención & control , Catéteres Urinarios , Infecciones Urinarias/prevención & control , Adulto , Anciano , Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/etiología , Colon/cirugía , Remoción de Dispositivos/estadística & datos numéricos , Procedimientos Quirúrgicos del Sistema Digestivo , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Ontario , Cuidados Posoperatorios/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Recto/cirugía , Resultado del Tratamiento , Cateterismo Urinario/instrumentación , Cateterismo Urinario/normas , Infecciones Urinarias/epidemiología , Infecciones Urinarias/etiologíaRESUMEN
BACKGROUND: Failure to follow-up post-bariatric surgery has been associated with higher postoperative complications, lower percentage weight loss and poorer nutrition. OBJECTIVE: This study aimed to understand the patient follow-up experience in order to optimize follow-up care within a comprehensive bariatric surgery program. METHODS: Qualitative telephone interviews were conducted in patients who underwent surgery through a publically funded multidisciplinary bariatric surgery program in 2011, in Ontario, Canada. Inductive thematic analysis was used. RESULTS: Of the 46 patients interviewed, 76.1 % were female, mean age was 50, and 10 were lost to follow-up within 1 year postsurgery. Therapeutic continuity was the most important element of follow-up care identified by patients and was most frequently established with the dietician, as this team member was highly sought and accessible. Patients who attended regularly (1) appreciated the specialized care, (2) favoured ongoing monitoring and support, (3) were committed to the program and (4) felt their family doctor had insufficient experience/knowledge to manage their follow-up care. Of the 36 people who attended the clinic regularly, 8 were not planning to return after 2 years due to (1) perceived diminishing usefulness, (2) system issues, (3) confidence that their family physician could continue their care or (4) higher priority personal/health issues. Patients lost to follow-up stated similar barriers. CONCLUSION: Patients believe the follow-up post-bariatric surgery is essential in providing the support required to maintain their diet and health. More personalized care focusing on continuity and relationships catering to individual patient needs balanced with local healthcare resources may redefine and reduce attrition rates.
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Cirugía Bariátrica/rehabilitación , Cuidados a Largo Plazo/organización & administración , Obesidad Mórbida/cirugía , Atención Dirigida al Paciente/organización & administración , Adulto , Instituciones de Atención Ambulatoria/organización & administración , Manejo de la Enfermedad , Femenino , Estudios de Seguimiento , Accesibilidad a los Servicios de Salud/organización & administración , Investigación sobre Servicios de Salud/métodos , Humanos , Perdida de Seguimiento , Masculino , Persona de Mediana Edad , Ontario , Grupo de Atención al Paciente/organización & administración , Satisfacción del Paciente , Complicaciones Posoperatorias/prevención & control , Investigación CualitativaRESUMEN
OBJECTIVE: To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication. DESIGN: Retrospective cohort study. SETTING: General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada. PARTICIPANTS: All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured. RESULTS: Communication priority was assigned by 2 independent reviewers-low (121+ min), medium (31-120min), high (6-30min), and immediate (0-5min) priority. Overall, 2 independent reviewers analyzed pages' content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing. CONCLUSIONS: Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.
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Educación de Postgrado en Medicina/métodos , Cirugía General/educación , Comunicación Interdisciplinaria , Internado y Residencia/organización & administración , Centros Médicos Académicos , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Evaluación de Necesidades , Ontario , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
Optimal interprofessional communication (IPC) is broadly viewed as a prerequisite to providing quality patient care. In this study, we explored the enablers and barriers to IPC between surgical trainees and ward nurses with a view towards improving IPC and the quality of surgical patient care. We conducted an ethnography in two academic centres in Canada totalling 126 hours of observations and 32 semi-structured interviews with trainees and nurses. Our findings revealed constraints on IPC between trainees and nurses derived from contested meanings of space and time. Trainees experienced the contested spatial boundaries of the surgical ward when they perceived nurses to project a sense of territoriality. Nurses expressed difficulty getting trainees to respond and attend to pages from the ward, and to have a poor understanding of the nurses' role. Contestations over time spent in training and patient care were found in trainee-nurse interactions, wherein trainees perceived seasoned nurses to devalue their clinical knowledge on the ward. Nurses viewed the limited time that trainees spent in clinical rotation in the ward as adversely affecting communication. This study underscores that challenges to enhancing IPC at academic health centres are rooted in team and professional cultures. Efforts to improve IPC should therefore: identify and target the social and cultural dimensions of healthcare team member relations; recognise how power is deployed and experienced in ways that negatively impact IPC; and enhance an understanding and appreciation in the temporal and spatial dimensions of IPC.
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Cirugía General/educación , Comunicación Interdisciplinaria , Relaciones Interprofesionales , Personal de Enfermería en Hospital , Estudiantes de Medicina , Femenino , Humanos , Entrevistas como Asunto , Masculino , Investigación CualitativaRESUMEN
This ethnography explores communication around critically ill surgical patients in three surgical intensive care units (ICUs) in Canada. A boundary framework is used to articulate how surgeons', intensivists', and nurses' communication practices shape and are shaped by their respective disciplinary perspectives and experiences. Through 50 hours of observations and 43 interviews, these health care providers are found to engage in seven communication behaviors that either mitigate or magnify three contested symbolic boundaries: expertise, patient ownership, and decisional authority. Where these boundaries are successfully mitigated, experiences of collaborative, high-quality patient care are produced; by contrast, boundary magnification produces conflict and perceptions of unsafe patient care. Findings reveal that high quality and safe patient care are produced through complex social and cultural interactions among surgeons, intensivists, and nurses that are also expressions of knowledge and power. This enhances our understanding of why current quality improvement efforts targeting communication may be ineffective.
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Comunicación , Cuidados Críticos , Unidades de Cuidados Intensivos , Cultura Organizacional , Mejoramiento de la Calidad , Antropología Cultural , Cuidados Críticos/organización & administración , Humanos , Unidades de Cuidados Intensivos/organización & administración , Relaciones Interprofesionales , Grupo de Atención al Paciente/organización & administración , Seguridad del Paciente , Mejoramiento de la Calidad/organización & administraciónRESUMEN
This systematic review explores the sociodemographic factors associated with the utilization of bariatric surgery among eligible patients. Electronic databases were searched for population-based studies that explored the relationship between sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Twelve retrospective cohort studies were retrieved, of which the results of 9 studies were pooled using a random effects model. Patients who received bariatric surgery were significantly more likely to be white versus non-white (OR 1.54; 95% CI 1.08, 2.19), female versus male (OR 2.80; 95% CI 2.46, 3.22), and have private versus government or public insurance (OR 2.51; 95% CI 1.04, 6.05). Prospective cohort studies are warranted to further determine the relative effect of these factors, adjusting for confounding factors.
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Cirugía Bariátrica/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Masculino , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Estudios Prospectivos , Factores SocioeconómicosRESUMEN
BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. OBJECTIVE: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. METHODS: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. RESULTS: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. CONCLUSIONS: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.
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Adhesión a Directriz/estadística & datos numéricos , Atención Perioperativa/métodos , Guías de Práctica Clínica como Asunto , Canadá , Hospitales Universitarios , Humanos , Tiempo de Internación/estadística & datos numéricos , Auditoría Médica , Readmisión del Paciente/estadística & datos numéricos , Atención Perioperativa/normas , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad , Estudios RetrospectivosRESUMEN
BACKGROUND: Bariatric surgery is the only weight-loss treatment available that results in both sustained weight loss and improvements of obesity-related comorbidities. Individuals who meet the eligibility criteria for bariatric surgery are generally older, come from racial or ethnic minorities, are economically disadvantaged, and have low levels of education. However, the population who actually receives bariatric surgery does not reflect the individuals who need it the most. The objective is to conduct a systematic review of the literature exploring the inequities to the access of bariatric surgery. METHODS/DESIGN: EMBASE and Medline databases will be searched for observational studies that compared at least one of the PROGRESS-PLUS sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Articles published in the year 1980 to present with no language restrictions will be included. For inclusion, studies must only include adults (≥18 years old) who meet National Institutes of Health (NIH) eligibility criteria for bariatric surgery defined as having either (1) a body mass index (BMI) of 40 kg/m² or greater; or (2) BMI of 35 kg/m² or greater with significant weight-related comorbidities. Eligible interventions will include malabsorptive, restrictive, and mixed bariatric procedures. DISCUSSION: There appears to be inequities in access to bariatric surgery. In order to resolve the health inequity in the treatment of obesity, a synthesis of the literature is needed to explore and identify barriers to accessing bariatric surgery. It is anticipated that the results from this systematic review will have important implications for advancing solutions to minimize inequities in the utilization of bariatric surgery. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004920.