Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis.

PURPOSE: The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada. MATERIAL AND METHODS: We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record. RESULTS: 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events. CONCLUSIONS: An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial.

OBJECTIVES: The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. METHODS: The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. RESULTS: We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. CONCLUSIONS: In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. CLINICAL TRIAL REGISTRATION NUMBER: anzctr.org.au identifier: ACTRN12616000481471.

Atividade física para saúde, covid-19 e mídias sociais: o quê, onde e por quê? / Actividad física para la salud, covid-19 y medios sociales: ¿qué, dónde y por qué? / Physical activity for health, covid-19 and social media: what, where and why?

Resumo Este estudo concentra-se no uso de mídias sociais por professores de Educação Física (EF) para o ensino de atividade física para saúde durante a pandemia de covid-19. Com base na pesquisa apreciativa e utilizando uma metodologia de teoria fundamentada em dados (Grounded Theory), a análise de duas entrevistas e uma tarefa digital permitem apresentar três principais temas: (1) Mídias Sociais como Ferramenta de Ensino; (2) Um Legado Digital Duradouro?, e; (3) Desigualdade do Aprendizado Remoto. Esses temas destacam a urgência em utilizar mídias sociais quando os espaços físicos da EF foram removidos, o reconhecimento de que o ensino poderia ser diferente no futuro e os desafios inerentes aos espaços digitais. Em conclusão: (1) defendemos a efetiva formação inicial e continuada de professores e no uso positivo de tecnologias digitais; (2) sugerimos que atividades on-line futuras incorporadas ao aprendizado, e; (3) exigir aos governos ações para nivelar as desigualdades tecnológicas.

Resumen Este estudio se centra en el uso de los medios sociales por parte de los profesores de Educación Física (EF) para enseñar actividad física para la salud durante la pandemia de covid-19. Con base en la investigación apreciativa y utilizando una metodología teórica fundamentada en datos (Grounded Theory), el análisis de dos entrevistas y una tarea digital permiten presentar tres temas principales: (1) Medios Sociales como Herramienta de Enseñanza, (2) ¿Un Legado Digital Duradero?, y (3) Desigualdad del Aprendizaje Remoto. Estos temas destacan la urgencia de utilizar medios sociales cuando los espacios físicos de la EF fueron suspendidos, el reconocimiento de que la enseñanza podría ser diferente en el futuro y los desafíos inherentes a los espacios digitales. En conclusión, (1) abogamos por la efectiva formación inicial y continua de profesores en el uso positivo de las tecnologías digitales, (2) sugerimos que actividades online futuras sean incorporadas al aprendizaje, y (3) demandar a los gobiernos acciones para nivelar las desigualdades tecnológicas.

Abstract This study focuses on Physical Education (PE) teachers' use of social media to teach physical activity for health during the covid-19 pandemic. Drawing on appreciative inquiry and utilising a grounded theory methodology, analysis of two interviews and a digital task allow us to present three main themes: (1) Social Media as a Teaching Tool, (2) A Lasting Digital Legacy?, and (3) Inequity of Remote Learning. These themes highlight the rush to utilise social media when the physical spaces of PE were removed, the recognition that teaching could be different in the future, and challenges inherent to digital spaces. In concluding we: (1) advocate for effective initial teacher education and ongoing professional development in the positive use of digital technologies, (2) suggest that future online activities incorporate learning, and (3) urge governments to do more in terms of levelling out technological inequalities.

Prevalence of sudden cardiac death in dogs with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is associated with increased risk of sudden cardiac death (SCD) in humans, independent of secondary risk factors such as thrombogenic disorders. In dogs, SCD is described in a number of heart diseases, but an association between AF and SCD is unreported. HYPOTHESIS: (a) A higher proportion of dogs with AF will experience SCD, and (b) SCD will be associated with complex ventricular arrhythmias. ANIMALS: One-hundred forty-two dogs with AF, and 127 dogs without AF. METHODS: Retrospective, multicenter, case-control study. Dogs included in the AF group were compared to a control group of dogs in sinus rhythm, matched for echocardiographic diagnosis. Descriptive statistics were used to identify proportions of each group suffering SCD, compared using chi-squared testing. Risk factors for SCD in dogs with AF were evaluated at the univariable and multivariable level using binary logistic regression. Significance was P < .05. RESULTS: A significantly higher proportion of dogs with AF suffered SCD than dogs in the control group (14.8% vs 5.5%; P = .01). Younger age at diagnosis, larger left atrial size, and a history of syncope all were independent predictors of SCD in dogs with AF (χ2 , 16.3; P = .04). CONCLUSIONS AND CLINICAL IMPORTANCE: Atrial fibrillation was associated with a higher prevalence of SCD in dogs. A history of syncope may be a useful predictor of SCD risk.

Prompting Pedagogical Change through Promoting Active Lifestyles Paradoxes.

This study explored approaches to promoting active lifestyles (PAL) in schools which aimed to inform and develop physical education (PE) trainees and teachers' health-related philosophies and pedagogies. Thirty-two secondary school PE trainees and teachers involved in a University-based Initial Teacher Education partnership in England participated in this study during the period 2015-2019. The participants were involved in professional development which included an introduction to research-informed PAL 'paradoxes' associated with promoting active lifestyles. Participants were asked to review their own health-related philosophies and practices in light of these paradoxes and were encouraged to use them to influence their own pedagogies as well as those of colleagues/peers. Participants found the PAL paradoxes interesting, surprising and perplexing; expressed a keen desire to address and solve them; and experienced the joys and challenges of influencing colleagues'/peers' health-related philosophies and pedagogies. The findings suggest that this innovative low-cost, flexible and accessible approach to pedagogical change has the potential to engage PE teachers, increase their effectiveness as promoters of physical activity, and to greatly enhance the subject's contribution to public health. This is significant, given calls for new pedagogical approaches and teachers' previously reported lack of engagement in professional development in this area.

An Evaluation of the Implementation of a UK School-Based Running Program.

The adoption of school-based running programs has rapidly increased over the last five years in the UK and globally. However, there is currently a lack of information on how these initiatives are implemented, and whether they are generalizable and/or sustainable. This study evaluated the implementation (including reach, fidelity, and dose) of a school-based running program over seven months to inform future delivery. This observational study used a mixed-method, single-group, before-and-after design strengthened by multiple interim measurements to evaluate the implementation of an optional school-based running program. Five state-funded primary schools in Leicestershire, UK, participated, with 17 teachers and 189 (81 boys (47.4%) and 90 girls (52.6%)) Year 5 pupils (aged 9-10 years) from eight classes. During the 2016/2017 academic year, data were collected via several measures (including interviews, focus groups, observations, questionnaires, and teacher implementation logs) at multiple levels (i.e., school and individual) and at multiple time points during implementation. Follow up qualitative data were also collected during 2017/2018. The school-based running program achieved good reach, with 100% of pupils opting to participate at some point during the academic year. All schools implemented the program with good fidelity, although the level of implementation varied between schools and over time. The average number of sessions held per week ranged from 0.94-3.89 with the average distance accumulated per pupil per week ranging from 0.02 to 2.91 kilometers and boys being more likely than girls to be classed as high-level participators. Despite an initial drop off in participation over time, all schools remained engaged in the program and continued to implement it until the end of the school year. Contextual features (e.g., staff capacity and resources) differed between schools and influenced the quality of implementation and the frequency of delivery. The school-based running program is simple, inexpensive, and versatile and can be implemented by schools with relative ease. However, schools are diverse settings, with unique challenges to ongoing delivery. Thus, planned adaptations, specific to each school's context, are likely necessary to sustain participation in the longer term and should be considered prior to implementation.

"I Just Like the Feeling of It, Outside Being Active": Pupils' Experiences of a School-Based Running Program, a Qualitative Study.

INTRODUCTION: School-based running programs that promote daily (or regular) walking/jogging/running are an emerging public health initiative. However, evaluation of these programs has predominantly used quantitative measures that limit understanding and explanations of contextual influences on pupil participation. Therefore, the aim of this study was to qualitatively explore pupils' experiences of participating in a primary-school-based running program (Marathon Kids) to provide relevant insights and inform program developments. METHODS: Nine semistructured focus groups were conducted with a purposeful sample of 50 pupils (26 girls and 24 boys) between 6 and 10 years of age from 5 primary schools in England. All schools had delivered the running program for 5-9 months during the 2015-16 academic year. Transcripts were analyzed using an inductive thematic approach. RESULTS: Pupils identified a range of organizational, interpersonal, and intrapersonal factors that they believed influenced their participation in the program. Six themes were identified as being important to pupils' experiences: Marathon Kids as an enabling program, pupils' autonomy to participate, peer influence on participation (e.g., development of social cohesion), teacher influence on delivery (e.g., fidelity of implementation), logistics and suitability of the school environment, and appropriateness of program resources. CONCLUSIONS: School-based running programs can offer an enjoyable physical activity experience for children; however, it is important to understand how current delivery approaches influence pupils' participation. Aspects that were believed to facilitate enjoyment included pupil autonomy to participate, perceived benefits of participation (including psychosocial outcomes), and a supportive school environment. Further research is required to identify the type and level of support required by schools to sustain pupil participation in running programs so that their perceived value is maintained.

Does Use of Electronic Alerts for Systemic Inflammatory Response Syndrome (SIRS) to Identify Patients With Sepsis Improve Mortality?

PURPOSE: The objective of this study was to assess whether earlier antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) and evidence of organ dysfunction identified through electronic alerts improves patient mortality. METHODS: This is a retrospective observational cohort study of adult patients admitted across 5 acute-care hospitals. Mortality, Premier CareScienceTM Analytics Expected Mortality Score, and clinical and demographic variables were obtained through the electronic medical record and Premier (Premier Healthcare Solutions, Inc, Charlotte NC) reports. Patients with 2 SIRS criteria and organ dysfunction were identified through an automated alert. Univariate and multivariate logistic regression was performed. RESULTS: Of those with SIRS and organ dysfunction, 8146 patients were identified through the electronic Best Practice Alert (BPA). Overall 30-day mortality rate was 8.7%. There was no significant association between time to antibiotic administration from BPA alert and mortality (P = 0.21) after adjusting for factors that could influence mortality, including age, heart rate, blood pressure, plasma lactate levels, creatinine, bilirubin levels, and the CareScienceTM Predicted Mortality Risk Score. Female gender (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.63) and facility were also independently associated with mortality. CONCLUSION: The use of alerts in the electronic medical record may misclassify patients with SIRS as having sepsis. Time to antibiotic administration in patients meeting SIRS criteria and evidence of end-organ dysfunction through BPA alerts did not affect 30-day mortality rates across a health system. Patient severity of illness, gender, and facility also independently predicted mortality. There were higher rates of antibiotic use and Clostridioides difficile infection in patients with BPA alerts.

A retrospective qualitative evaluation of barriers and facilitators to the implementation of a school-based running programme.

BACKGROUND: There is growing interest in school-based interventions which deliver opportunities for additional physical activity time outside of physical education (PE). A practical and cost-effective approach may be school running programmes. Consequently, many school-based running initiatives are currently being implemented in a grass-roots style movement across the UK. However, research on the implementation of physical activity programmes in schools is notably underdeveloped. Therefore, this qualitative study aimed to better understand the barriers and facilitators to the implementation of a running programme, Marathon Kids (MK), within primary schools in England. METHODS: Two sets of semi-structured interviews were conducted, the first with each of the three core members of staff responsible for MK, and the second with each of the MK school staff Champions from 20 primary schools. Also, nine focus groups were conducted with 55 pupils (6-10 years) from five of the schools; all were analysed using thematic analysis. RESULTS: Three themes were identified surrounding the barriers and facilitators to implementation: features of the programme (e.g. ethos and resources), school climate (e.g. culture; whole school engagement; PE and physical activity policies and goals; and physical environment) and programme implementation decisions (e.g. aspirations and planning and sustainability). CONCLUSION: Findings suggest that the barriers and facilitators to implementation are wide-ranging and include programme, organisational and system-level factors. Collectively pointing towards the need for a preparation period before implementation to understand schools' readiness to implement and context-specific factors, both regarding organisational capacity and programme specific capacity.

Marathon Kids UK: study design and protocol for a mixed methods evaluation of a school-based running programme.

INTRODUCTION: Schools are promising settings for physical activity promotion; however, they are complex and adaptive systems that can influence the quality of programme implementation. This paper presents an evaluation of a school-based running programme (Marathon Kids). The aims of this study are (1) to identify the processes by which schools implement the programme, (2) identify and explain the contextual factors affecting implementation and explications of effectiveness and (3) examine the relationship between the level of implementation and perceived outcomes. METHODS: Using a realist evaluation framework, a mixed method single-group before-and-after design, strengthened by multiple interim measurements, will be used. Year 5 (9-10 years old) pupils and their teachers will be recruited from six state-funded primary schools in Leicestershire, UK.Data will be collected once prior to implementation, at five discrete time points during implementation and twice following implementation. A weekly implementation log will also be used. At time point 1 (TP1) (September 2016), data on school environment, teacher and pupil characteristics will be collected. At TP1 and TP6 (July 2017), accelerometry, pupil self-reported physical activity and psychosocial data (eg, social support and intention to be active) will be collected. At TP2, TP3 and TP5 (January, March and June 2017), observations will be conducted. At TP2 and TP5, there will be teacher interviews and pupil focus groups. Follow-up teacher interviews will be conducted at TP7 and TP8 (October 2017 and March 2018) and pupil focus group at TP8. In addition, synthesised member checking will be conducted (June 2018) with a mixed sample of schools. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained through Loughborough University Human Participants Ethics Subcommittee (R16-P032 & R16-P116). Findings will be disseminated via print, online media and dissemination events as well as practitioner and/or research journals.

Healthcare Antibiotic Resistance Prevalence - DC (HARP-DC): A Regional Prevalence Assessment of Carbapenem-Resistant Enterobacteriaceae (CRE) in Healthcare Facilities in Washington, District of Columbia.

OBJECTIVE Carbapenem-resistant Enterobacteriaceae (CRE) are a significant clinical and public health concern. Understanding the distribution of CRE colonization and developing a coordinated approach are key components of control efforts. The prevalence of CRE in the District of Columbia is unknown. We sought to determine the CRE colonization prevalence within healthcare facilities (HCFs) in the District of Columbia using a collaborative, regional approach. DESIGN Point-prevalence study. SETTING This study included 16 HCFs in the District of Columbia: all 8 acute-care hospitals (ACHs), 5 of 19 skilled nursing facilities, 2 (both) long-term acute-care facilities, and 1 (the sole) inpatient rehabilitation facility. PATIENTS Inpatients on all units excluding psychiatry and obstetrics-gynecology. METHODS CRE identification was performed on perianal swab samples using real-time polymerase chain reaction, culture, and antimicrobial susceptibility testing (AST). Prevalence was calculated by facility and unit type as the number of patients with a positive result divided by the total number tested. Prevalence ratios were compared using the Poisson distribution. RESULTS Of 1,022 completed tests, 53 samples tested positive for CRE, yielding a prevalence of 5.2% (95% CI, 3.9%-6.8%). Of 726 tests from ACHs, 36 (5.0%; 95% CI, 3.5%-6.9%) were positive. Of 244 tests from long-term-care facilities, 17 (7.0%; 95% CI, 4.1%-11.2%) were positive. The relative prevalence ratios by facility type were 0.9 (95% CI, 0.5-1.5) and 1.5 (95% CI, 0.9-2.6), respectively. No CRE were identified from the inpatient rehabilitation facility. CONCLUSION A baseline CRE prevalence was established, revealing endemicity across healthcare settings in the District of Columbia. Our study establishes a framework for interfacility collaboration to reduce CRE transmission and infection. Infect Control Hosp Epidemiol 2017;38:921-929.

Time to Change Dosing of Inactivated Quadrivalent Influenza Vaccine in Young Children: Evidence From a Phase III, Randomized, Controlled Trial.

BACKGROUND.: Children under 3 years of age may benefit from a double-dose of inactivated quadrivalent influenza vaccine (IIV4) instead of the standard-dose. METHODS.: We compared the only United States-licensed standard-dose IIV4 (0.25 mL, 7.5 µg hemagglutinin per influenza strain) versus double-dose IIV4 manufactured by a different process (0.5 mL, 15 µg per strain) in a phase III, randomized, observer-blind trial in children 6-35 months of age (NCT02242643). The primary objective was to demonstrate immunogenic noninferiority of the double-dose for all vaccine strains 28 days after last vaccination. Immunogenic superiority of the double-dose was evaluated post hoc. Immunogenicity was assessed in the per-protocol cohort (N = 2041), and safety was assessed in the intent-to-treat cohort (N = 2424). RESULTS.: Immunogenic noninferiority of double-dose versus standard-dose IIV4 was demonstrated in terms of geometric mean titer (GMT) ratio and seroconversion rate difference. Superior immunogenicity against both vaccine B strains was observed with double-dose IIV4 in children 6-17 months of age (GMT ratio = 1.89, 95% confidence interval [CI] = 1.64-2.17, B/Yamagata; GMT ratio = 2.13, 95% CI = 1.82-2.50, B/Victoria) and in unprimed children of any age (GMT ratio = 1.85, 95% CI = 1.59-2.13, B/Yamagata; GMT ratio = 2.04, 95% CI = 1.79-2.33, B/Victoria). Safety and reactogenicity, including fever, were similar despite the higher antigen content and volume of the double-dose IIV4. There were no attributable serious adverse events. CONCLUSIONS.: Double-dose IIV4 may improve protection against influenza B in some young children and simplifies annual influenza vaccination by allowing the same vaccine dose to be used for all eligible children and adults.

A Case of Localized, Unilateral (Cephalic) Wound Botulism.

We describe a rare presentation of botulism originally presenting with exclusively unilateral cranial nerve deficits following a puncture wound to the face. Cephalic tetanus was initially suspected but laboratory testing confirmed botulism. Botulism caused by local diffusion of toxin from a contaminated head wound can be confused with cephalic tetanus.

Private sector leads the way in looking after older nurses.

The NHS needs to look after its ageing workforce and help older nurses who want to continue working (features February 4).

More than 10 years after "the horse is dead . . .": surely it must be time to "Dismount"?!

This article represents a response to an editorial piece written in Pediatric Exercise Science over 10 years ago by Thomas Rowland in which he debated fitness testing and asked whether the "horse" of fitness testing in schools was dead. Here, the authors revisit the debate and consider the progress that has been made with regard to fitness testing in schools in recent years. On the basis of findings from the literature and some of their research, the authors suggest that accepting the fact that the horse is dead would not be a bad thing. Their advice is certainly to pull tightly on the reigns, slow the horse down, and not allow fitness testing to dominate schools' efforts to promote physical activity.

Infection control in pediatric extended care facilities.

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools. Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.