Come aboard the Magnet Journey.

In 2007, Diane Ream Rourke published in this journal, the history and explanation for Baptist Hospital in Florida to include its library on its successful Magnet journey. This article draws heavily from American Nursing Credentialing Center (ANCC) Magnet Information pages. It begins with a quick review of the history of the Program, further suggestions for a librarian's contribution to obtain Magnet Recognition and a brief current literature review on the values Magnet Recognition brings to a hospital's economics, patient care, and nursing staff. The quick history review and suggestions on the librarian contribution to the Magnet journey are based on an invited CE course by this author. The literature review on the values Magnet Recognition brings to a hospital's economics, patient care, and nursing staff was part of a presentation this author prepared for the Chief of Nursing. This author was a Magnet Champion and Magnet exemplar when Virtua Health first earned its first Magnet designation.

COVID-19 and Innovation in Medical Library Services: A Scoping Review of Case Studies.

The services of medical libraries and information centers has changed due to the COVID-19 pandemic. This study aims to identify the innovative services of medical libraries and information centers during the COVID-19 pandemic. In this scoping review, PubMed, Web of Science (WOS), Scopus, ProQuest, Library, Information Science & Technology Abstracts (LISTA) databases were searched to identify case studies and case series. After screening the identified studies, 18 studies were selected. The results showed that the main users of medical libraries and information centers during COVID-19 were health care providers and recipients, researchers, organizational staff, and ordinary library users. Innovative services during the COVID-19 were also provided in these libraries, including distance education services, virtual information services, virtual guidelines, providing information resources, and evidence-based response to treatment teams. To provide these new services, medical libraries used traditional, semi-traditional, and modern information and communication technologies such as telephone, email, online library platforms, e-learning, and social networks. Medical libraries and information centers changed the way they provide services in the face of the COVID-19 crisis. Analyzing the services provided during this period can provide a model for policymakers, and medical librarians and information professionals to improve their services. The information presented here can be used to inform library services during future, similarly critical situations.

[Exposures to fruit plants in Germany from 2010-2019 : Analysis of the Erfurt joint poison information center database]. / Expositionen mit Fruchtpflanzen in Deutschland im Zeitraum 2010­2019 : Auswertung der Datenbank des Gemeinsamen Giftinformationszentrums Erfurt (GGIZ).

BACKGROUND: Inquiries about fruit plants are a frequent reason for consultation with poison information centers, although it should be emphasized that there are no large systematic studies on toxicity based on exposure data. The aim of this work is to determine the risk of poisoning by fruit plants in Germany. METHODS: Retrospective study of data from the Erfurt Joint Poison Information Center on poisoning inquiries regarding fruit plants (2010-2019) with a detailed presentation of interim results, a tabular handout, plant photos as identification aids, and trend analyses. RESULTS: From 16,088 plant exposures with 16,700 plants, 214 different fruit plant species were identified. Forty-five fruit plant species (21%) turned out to be relevant (≥ 30 inquiries) and of these, 6 (2.8%) turned out to be highly relevant (≥ 300 inquiries). All relevant plants were assigned a defined risk category (RC): RC 0 (2; 4.4%), RC 1 (26; 57.8%), RC 2 (12; 26.7%), and RC 3 (5; 11.1%). Regarding the inquiries, 6% (459/7607) were related to RC 0; 47.9% (3645/7607) to RC 1; 39.3% to RC 2 (2986/7607); and 6.8% (517/7607) to RC 3. Of the inquiries, 69.5% (5284/7607) were related to young children (1 to < 6 years). Exposure outcomes for all age groups were asymptomatic in 82%, mild in 14.7%, moderate in 3%, and severe in 0.3%, with severe poisoning caused by seven plant species. Interventions were initiated in 66.8% (5079) of the inquiries. Inquiries were most frequently related to Taxus baccata, Ligustrum vulgare, Physalis alkekengi, Prunus laurocerasus, Convallaria majalis, Mahonia spec., Sambucus spec., Lonicera spec., Sorbus aucuparia, Thuja spec., Hedera helix, and Cotoneaster spec. DISCUSSION: Poisoning by fruit plants in Germany is rare. However, there is a great need for information and education.

Mouse resources at the RIKEN BioResource Research Center and the National BioResource Project core facility in Japan.

The RIKEN BioResource Research Center (BRC) was established in 2001 as a comprehensive biological resource center in Japan. The Experimental Animal Division, one of the BRC infrastructure divisions, has been designated as the core facility for mouse resources within the National BioResource Project (NBRP) by the Japanese government since FY2002. Our activities regarding the collection, preservation, quality control, and distribution of mouse resources have been supported by the research community, including evaluations and guidance on advancing social and research needs, as well as the operations and future direction of the BRC. Expenditure for collection, preservation, and quality-control operations of the BRC, as a national core facility, has been funded by the government, while distribution has been separately funded by users' reimbursement fees. We have collected over 9000 strains created mainly by Japanese scientists including Nobel laureates and researchers in cutting-edge fields and distributed mice to 7000 scientists with 1500 organizations in Japan and globally. Our users have published 1000 outstanding papers and a few dozen patents. The collected mouse resources are accessible via the RIKEN BRC website, with a revised version of the searchable online catalog. In addition, to enhance the visibility of useful strains, we have launched web corners designated as the "Mouse of the Month" and "Today's Tool and Model." Only high-demand strains are maintained in live colonies, while other strains are cryopreserved as embryos or sperm to achieve cost-effective management. Since 2007, the RIKEN BRC has built up a back-up facility in the RIKEN Harima branch to protect the deposited strains from disasters. Our mice have been distributed with high quality through the application of strict microbial and genetic quality control programs that cover a globally accepted pathogens list and mutated alleles generated by various methods. Added value features, such as information about users' publications, standardized phenotyping data, and genome sequences of the collected strains, are important to facilitate the use of our resources. We have added and disseminated such information in collaboration with the NBRP Information Center and the NBRP Genome Information Upgrading Program. The RIKEN BRC has participated in international mouse resource networks such as the International Mouse Strain Resource, International Mouse Phenotyping Consortium, and Asian Mouse Mutagenesis and Resource Association to facilitate the worldwide use of high-quality mouse resources, and as a consequence it contributes to reproducible life science studies and innovation around the globe.

Hand sanitizer-related calls at the National Poisons Information Centre, India during the lockdown period of the Covid-19 pandemic.

Background Hand sanitizer (HS) has been increasingly used during the Covid-19 pandemic. We compared the telephonic calls received by the National Poisons Information Centre (NPIC), New Delhi, India, related to its unsafe exposure and inappropriate use during the lockdown and prelockdown periods. Methods We analysed and compared telephonic call records of 3 months of pre-lockdown and 3 months of the lockdown and HS-related calls in different age groups and zones during these periods. Results The centre received 4000 calls; of these 1583 (40%) were related to household products of which only 63 (4%) were related to HS. There was an 8-fold increase in the number of calls received at the NPIC during the lockdown compared to the pre-lockdown period seeking medical attention following unsafe exposure or inappropriate use of HS. More calls were received from the south and north zones and, in the majority of these cases, HS was ingested accidentally. In some cases, HS was ingested intentionally for suicide during the lockdown. Conclusions Our study shows that unsafe exposure of HS is common under conditions of stress as seen during the lockdown period of the Covid-19 pandemic. It should be kept out of reach of small children. Further, providing psychological help and counselling to older age groups under conditions of stress are important issues of concern.

e-Health for COVID-19 Epidemic: The Arizona Poison and Drug Information Center Experience.

Background: A significant challenge of the COVID-19 epidemic was the dissemination of accurate and timely information to the public, health care providers, and first responders. We describe the expansion of the Arizona Poison and Drug Information Center (APDIC) to fill such a need for residents of Arizona. Methodology: The original mission of the APDIC was recognition and management of chemical exposure, poisoning, envenomation, and drug-related medical problems. In response to COVID-19, APDIC expanded its personnel and facilities to accommodate telephone calls and teleconsults regarding COVID-19. Thirteen different topics dealing with COVID-19 were addressed and tracked and included: testing information, isolation, prevention, personal protective equipment, travel, vaccines, therapies, antibody testing, contact tracing, exposure to the virus and what to do in businesses, at work or at school regarding isolation and quarantine. Results: Responding to the public health needs, APDIC accepted >320,000 telephone calls and completed 48,346 teleconsults from March 3, 2020 to March 3, 2021. This represented a 15-fold increase in calls and twice the number of consults over 2019. Upon release of the vaccine, calls increased sharply with >7,000 calls in 1 day (February 7, 2021). Conclusion: In conclusion, the APDIC, rapidly expanded to address urgent public health information needs surrounding COVID-19 while still accomplishing its founding mission.

[Illicit Drug Exposures Reported to the Poisons Information Centre Erfurt (2011 to 2020)]. / Illegale Drogenexpositionsfälle im Einzugsbereich des Giftnotrufs Erfurt (2011 bis 2020).

AIM OF THE STUDY: Because of significant changes in recent years, cases of illicit drug exposure reported to the Poisons Information Centre (PIC) Erfurt during the last 10 years were investigated. METHODS: Retrospective analysis of above-mentioned cases from 2011 to 2020 according to substance classes, symptom severity, age groups, and gender. RESULTS: Cases of illicit drug exposure (4,963, 2.8% of all exposures) increased from 316 in 2011 to 614 in 2015, decreased to 514 in 2017, and rose again to 578 in 2019. In 2020, a drop to 549 cases was observed. The ratio of multiple to single drug exposure cases, however, increased from 1.0 to 1.7 in 2020. Cases of exposure to psychostimulants almost doubled from 168 in 2011 to 319 in 2020. Cases of exposure to new psychoactive substances (NPS) rose from 21 in 2011 to 126 in 2015 and fell to 16 in 2020. 320 cases (6.5%) of illicit drug exposures resulted in severe, 1902 cases (38.3%) in moderate and 2139 cases (43.1%) in minor or no symptoms. Age groups mainly involved were adults of middle age (72.7%) and unknown age (12.7%) as well as adolescents (12.1%). Men (69.9%) were more often involved than women (26.9%). CONCLUSIONS: Illicit drug exposures reported to the Poisons Information Centre (PIC) Erfurt discontinuously increased from 2011 to 2020 mainly by increase in mixed consumption. The intermittent decrease in 2016 and 2017 was caused by the fall of NPS exposures. Data of substance abuse from PICs could supplement official annual drug reports in aspects of Clinical Toxicology.

Genetic and Rare Diseases Information Center (GARD).

The Genetic and Rare Diseases Information Center (GARD) is a database dedicated to aiding anyone who may be seeking assistance and knowledge regarding rare diseases. This public health resource was put into motion by the Rare Diseases Act of 2002, and uses Translational Science to enhance research procedures. People can use this resource to find support, disease facts, ongoing research information, and available treatments. The GARD database is an excellent guide for anyone wanting to increase their knowledge of rare diseases and how to help those who have a rare disorder.

Exposures to psycholeptics, psychoanaleptics, and cardiovascular drugs reported to the PIC erfurt during heat waves from 2003 to 2018.

Psycholeptics, psychoanaleptics, and cardiovascular drugs alter individual tolerance to extreme heat. To explore the influence of heat waves on their toxicity in acute overdose, we retrospectively analyzed all human exposures to psycholeptics and psychoanaleptics (PLAexp) as well as cardiovascular drugs (CVDexp) registered by the Poisons Information Center (PIC) Erfurt between June to September of the years 2003 to 2018 for frequency, age groups, sex, circumstances of exposure, and symptom severity. The results of the non-heat years (NHY) 2004-2005 and 2007-2014 (average air temperature June-September 16.2 °C) were compared to the results of the heat years (HY) 2003, 2006 and 2015-2018 (average air temperature June-September 17.5 °C). In total, 13,191 cases (HY 5,117; NHY 8,074) of PLAexp and 2,960 cases (HY 1,168; NHY 1,792) of CVDexp were registered. During HY, accidental PLAexp (11.2% versus 9.7%) and CVDexp (40.6% versus 36.8%) were more often seen. Severe symptoms were less frequent in PLAexp (4.4% versus 6.3%) and CVDexp (3.3% versus 4.9%). Although in HY, no higher rates of moderate or severe PLAexp and CVDexp were detected than in NHY, patients with these medications should be observed carefully during heat waves because of affected body's usual cooling mechanisms.

Vitamin and mineral supplement exposures: cases reported to Australia's largest Poisons Information Centre, 2014-2015 to 2018-2019.

Vitamin and mineral supplements (VMS) are widely available and commonly used. Little is known about patterns of poisoning exposures to VMS in the Australian population. We performed a retrospective study of calls to the New South Wales Poisons Information Centre (NSWPIC), July 2014-June 2019. NSWPIC is Australia's largest PIC, taking approximately 100 000 calls/year (50 % of Australian poisoning calls) from healthcare professionals and members of the public. We conducted additional analyses on Fe exposures due to their high risk of acute toxicity. There were 10 944 VMS exposures reported to NSWPIC during the study period, increasing 9·6 % per annum over a 5-year period (95 % CI, 7·2, 12·1 %). Toddlers (1-4 years) accounted for 41·5 % (4546) of cases. Agents most commonly involved were multivitamins (n 3610), vitamin D (n 2080), Fe (n 1533) and Mg (n 804). In 17·7 % (1934) of cases, the call originated from hospital or the patient was referred to hospital by NSWPIC. Fe exposures increased by 14·0 % per year (95 % CI, 9·5, 18·5 %), and most were associated with high-strength products (> 45 mg elemental Fe per unit dose, n 1036). Fe exposures were hospitalised in 38 % of cases (n 583). We conclude that VMS exposures are increasing in Australia. Although most exposures can be managed at home, many required hospitalisation. Fe exposures are increasing and had higher rates of hospitalisation than other agents. VMS are often considered safe and without the potential for adverse effects, highlighting the importance of public education into the potential risks of misuse of these products.

Iatrogenic medication errors reported to the Victorian Poisons Information Centre.

BACKGROUND: Iatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system. AIMS: To examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through the analysis of referrals to a state Poisons Information Centre (PIC). METHODS: A retrospective review of iatrogenic medication errors reported to the Victorian PIC (VPIC) from community and hospital healthcare settings from January 2015 to December 2019. RESULTS: Over a 5-year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. Five percent (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded poisoning severity score, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15). CONCLUSIONS: Iatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs.

Opioid exposures in children under 5 years of age (2004-2019): A retrospective study of calls to Australia's largest poisons information centre.

AIM: To describe time trends in opioid exposures in children under 5 years, and to describe patient demographics, the medicines involved, the reasons for exposure and disposition. METHODS: A retrospective analysis of paediatric (<5 years of age) opioid exposure calls to the New South Wales Poisons Information Centre (NSWPIC, Australia's largest poison centre), 2004-2019. Joinpoint regression analysis was used to examine temporal trends. RESULTS: There were 4807 cases of paediatric opioid exposure during the 16 year study period, with an average of 300 exposures per year. Exposures increased, 2004-2007, with an annual percentage change (APC) of 14.6% (95% CI = 4.3 to 26.0%), then decreased, 2007-2016, APC -3.4% (95% CI = -5.3 to -1.3%). A steeper decrease was observed after 2016, APC -14.1% (95% CI = -21.8 to -5.6%). The overall APC was -2.3% (95% CI = -4.7 to 0.2%), 2004-2019. Accidental exposures accounted for 86% of calls (4137). The majority of calls were from family members regarding exposures that happened at home, highlighting the need for safety initiatives. The preparations most frequently involved were paracetamol/opioid combination products (primarily codeine), 53% (2566) and ibuprofen/opioid combinations 14% (650). Twenty-two percent of cases were referred to a hospital (1062), and a further 15% (719) of calls originated from hospital staff. CONCLUSION: Opioid exposures in young Australian children continue to occur; however, the rate has declined since 2007. Safe storage and parent education initiatives could further reduce the burden of paediatric opioid poisoning in Australia.

Integrating e-collections following the merger of two specialist hospital libraries: a case study.

BACKGROUND: Birmingham Women's and Children's NHS Foundation Trust was formed in February 2017 following an acquisition. The Library and Knowledge Services (LKS) merged while operating across two hospital sites. A priority for the merged Library and Knowledge Service was to integrate e-collections. A literature review identified six papers reporting health libraries that had merged and integrated e-collections. OBJECTIVES: A priority for the merged Library and Knowledge Service was to integrate e-collections. METHODS: To ensure equitable and cost-effective access to an extended collection, an audit of pre-existing e-collections was conducted. Electronic licence agreements enabling cross-site access were negotiated. A new OpenAthens ID was created. RESULTS: The integration of e-collections enabled Trust staff access to a greater number of e-journals and additional e-content, and an overall cost-saving was achieved. DISCUSSION: This case study supports existing literature stating that integrating collections increases the number of e-journals. It further identifies cost-difference in acquiring cross-site access to e-journals compared to databases providing full-text e-journals and additional e-content. CONCLUSION: Integrating e-collections enables equity of access and value. A national co-ordinated approach to procurement of e-collections will further support equity and best value throughout NHS LKS.

Appropriateness evaluation of Drug Information Center's Facebook page for evidence-based drug information dissemination.

OBJECTIVE: To assess the characteristics of an unpaid Facebook page for drug information (DI) and its reachability to users. METHODS: In this retrospective observational study over a 6-month duration, a Facebook page for the DI Center was created. One drug-related clinical question recently asked in the DI Center by a hospital clinician and its evidence-based answer along with the appropriate references were framed in a scenario and posted on the Facebook page on working days. The Facebook page likes, consumption, reach, engagement, impressions, and total number of followers were obtained from Facebook insights. The monthly averages of these parameters were assessed using the augmented Dickey-Fuller (ADF) test. RESULTS: The cointegration (ADF) test revealed a statistically significant time-dependent correlation trend between the mean engaged users and mean monthly reach (ADF, -4.904; P = 0.01). Similarly, a statistically significant time-dependent correlation trend was observed with mean engaged users and mean monthly impressions (ADF, -5.456; P = 0.01). CONCLUSION: The knowledge gap between quality DI and evidence-based medicine practice in a developing country can be bridged with a novel DI Center Facebook page initiative.

Popping up in Unexpected Places: Posing a Pop-Up Library to Healthcare Staff.

Pop-up libraries have been a trending form of outreach by public and academic libraries during recent years but they are still a novel concept in clinical and hospital settings. Engaging with healthcare staff in common spaces with an inviting temporary display provides an opportunity to proactively raise awareness of library resources and services to non-library users while also piquing interest in a timely topic or special theme. Mayo Clinic librarians describe how a pop-up library was implemented as a unique form of outreach at the Rochester, Minnesota campus in early 2020.

[Service rendered's assessment of a pharmaceutical information center on patients care]. / Évaluation du service rendu d'un centre d'information pharmaceutique sur la prise en charge des patients.

The Question-Answer (Q/R) service of Lyon's teaching hospital, offers reliable and updated information for healthcare professionals (HP). The impact of Q/R activity on patient outcome was measured by using a survey to assess user's satisfaction and impact on HP knowledge and/or patients cares. The compatibility of this tool with daily use had been assessed too. MATERIALS AND METHODS: The survey was sent prospectively, for 9 months in 2018, to all HP whose enquiry was linked to a particular patient's care. The survey was posted 24-48h after the answer had been provided. RESULTS: 41 survey over 55 sent were returned (74.5%). The level of satisfaction measured is mostly good or excellent on all evaluated items. The HP surveyed consider that the responses provided have a potential positive impact on their professional knowledge and practices (97.6%), on the patient's care (n=36/37) and patient outcome (n=22/23). CONCLUSION: High level of satisfaction with the Q/R service and positive impact of this specialized Q/R service on improvement of HP knowledge and patient's care. This tool can be used in daily practice.

A Review of Baclofen Overdoses in Australia: Calls to a Poisons Information Centre and a Case Series.

AIM: to describe trends in baclofen reports to Australia's largest Poisons Information Centre (PIC) and present a case series detailing severity of overdoses. SHORT SUMMARY: PBS data demonstrates baclofen use is increasing in Australia, while calls to NSWPIC illustrate an increase in number of exposures associated with toxicity. Baclofen toxicity may require prolonged intensive care admission. To minimize harms associated, especially with off-label baclofen prescribing for AUD, prescribers should pay careful attention to psychiatric comorbidities, and closely monitor treatment and dispensing. METHODS: this is a retrospective observational study of baclofen overdoses reported to New South Wales PIC (NSWPIC) from January 1 2004 to 31 December 2016. In addition, referrals to a metropolitan toxicology service relating to baclofen toxicity from 2014 to 2017 were analysed. The number of Pharmaceutical Benefit Scheme (PBS) claims for baclofen were also reviewed. RESULTS: during the 13-year study period, 403 cases of baclofen toxicity were reported to NSWPIC. There was a 230% increase in annual exposures over this period, 71% of patients were symptomatic, with 77% requiring hospitalization. Coingestants were reported in 53%, with 57% being psychoactive medications (including alcohol). An increase in number of baclofen dispensing episodes was also noted. From the five cases of deliberate self-harm reported to the metropolitan toxicology service, three obtained baclofen for management of alcohol use disorder (AUD) and required prolonged treatment in the intensive care unit (ICU). CONCLUSIONS: NSWPIC data shows an increase in number of calls regarding intentional baclofen exposures in parallel with increase the number of baclofen PBS claims. These closely parallel the increase in dispensing of baclofen since 2008. Case studies presented reinforce the severity of baclofen toxicity. Together, they demonstrate the potential risk of harm of baclofen prescribing, and the greater need for caution. Baclofen should be considered carefully in patients high risk of overdose or be used only in specialist services with close monitoring.

Drug information centres and their provision of decision support: The Scandinavian experience.

WHAT IS KNOWN AND OBJECTIVE: Appraisal of drug information centres (DICs) is mainly by word of mouth communication and surveys of overall user satisfaction. Efforts to study the impact of this type of informatics and decision support systematically are generally lacking within the healthcare system. COMMENT: Scandinavian DICs question-answering databases are relevant sources for identifying recurring problems in pharmacotherapy, including drug safety questions, and for re-use of previous answers. Recent studies in this setting have shown that high-quality answers demand easily accessible literature sources, skills in literature search and critical assessment of the retrieved documentation. Furthermore, patient-specific advice in clinical cases presented within a requested time frame is appraised by clinicians. WHAT IS NEW AND CONCLUSIONS: Effective decision support by Scandinavian DICs depends on skills among staff and technological resources. Our experience could motivate further studies investigating methods and evaluating the impact of DICs in the healthcare system.

How One Library's Health Information Center Expanded Its Marketing Plan.

When Preston Medical Library moved inside the Medical Center in September 2014, the new patient library, called the Health Information Center (HIC), was added. This addition is a patient focused, consumer health library that, among other things, offers health information and books. After the initial marketing plan was implemented, a task force was created to focus specifically on marketing the consumer health library and its resources. This article discusses how the task force revamped the marketing strategy to include outreach into the medical center's waiting rooms and other opportunities for collaboration.

Project to improve storage, access and incorporation of advance care plans in a regional Australian hospital.

PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent. DESIGN: Quality improvement study. SETTING: A Western Australian regional hospital. KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care. STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education. EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described. LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.