Reducing Unnecessary Transfusions of RBCs in Inpatients Admitted Across Niagara Health Community Hospitals.

BACKGROUND AND OBJECTIVES: Blood products are scarce resources. Audits on the use of red blood cells (RBCs) in tertiary centers have repeatedly highlighted inappropriate use. Earlier retrospective audit at our local community hospitals has demonstrated that only 85% and 54% of all requests met Choosing Wisely Canada guidelines for pre-transfusion hemoglobin (Hb) of 80 g/L or less and single unit, respectively.We sought to improve RBC utilization by 15% over a period of 12 months (meeting Choosing Wisely Canada criteria of pre-transfusion Hb ≤80g/L by >80% and single-unit transfusion by >65%). METHODS: Following repeated PDSA (Plan-Do-Study-Act) cycles, we implemented educational strategies, prospective transfusion medicine (TM) technologist-led screening of orders, and an RBC order set. RESULTS: The 3-month median percentages of appropriate RBC use for pre-transfusion Hb and single unit (September-November 2021) across all 3 hospitals were 90% and 71%, respectively. Overall, the rate of appropriate RBCs based on pre-transfusion Hb remained above target (>80%), with minimal improvement across all hospitals (median percentage at pre- and post-technologist screening periods of 87% and 90%, respectively). The median percentage of appropriate RBCs based on single-unit transfusion orders has improved across all Niagara Health hospitals with sustained targets (3-month median percentage at pre- and post-technologist screening and most recent time periods of 54%, 56%, and 71%, respectively). CONCLUSIONS: We have taken a collaborative, multifaceted approach to optimizing utilization of RBCs across the Niagara Health hospitals. The rates of appropriate RBC use were comparable with the provincial and national accreditation benchmark standards. In particular, the TM technologist-led screening was effective in producing sustained improvement with respect to single-unit transfusion. One of the balancing outcomes was increasing workload on technologists. Local and provincial efforts are needed to facilitate recruitment and retention of laboratory technologists, especially in community hospitals.

Examining perceptions of a telemedicine network for pediatric emergency medicine: a mixed-methods pilot study.

Background: Use of telemedicine for healthcare delivery in the emergency department can increase access to specialized care for pediatric patients without direct access to a children's hospital. Currently, telemedicine is underused in this setting. Objectives: This pilot research project aimed to evaluate the perceived effectiveness of a telemedicine program in delivering care to critically ill pediatric patients in the emergency department by exploring the experiences of parents/caregivers and physicians. Methods: Sequential explanatory mixed methods were employed, in which quantitative methods of inquiry were followed by qualitative methods. Data were collected through a post-used survey for physicians, followed by semi-structured interviews with physicians and parents/guardians of children treated through the program. Descriptive statistics were used to analyze the survey data. Reflexive thematic analysis was used to analyze interview data. Results: The findings describe positive perceptions of telemedicine for emergency department pediatric care, as well as barriers and facilitators to its use. The research also discusses implications for practice and recommendations for overcoming barriers and supporting facilitators when implementing telemedicine programming. Conclusion: The findings suggest that a telemedicine program has utility and acceptance among parents/caregivers and physicians for the treatment of critically ill pediatric patients in the emergency department. Benefits recognized and valued by both parents/caregivers and physicians include rapid connection to sub-specialized care and enhanced communication between remote and local physicians. Sample size and response rate are key limitations of the study.

Public health emergency preparedness for infectious disease emergencies: a scoping review of recent evidence.

BACKGROUND: The COVID-19 pandemic continues to demonstrate the risks and profound health impacts that result from infectious disease emergencies. Emergency preparedness has been defined as the knowledge, capacity and organizational systems that governments, response and recovery organizations, communities and individuals develop to anticipate, respond to, or recover from emergencies. This scoping review explored recent literature on priority areas and indicators for public health emergency preparedness (PHEP) with a focus on infectious disease emergencies. METHODS: Using scoping review methodology, a comprehensive search was conducted for indexed and grey literature with a focus on records published from 2017 to 2020 onward, respectively. Records were included if they: (a) described PHEP, (b) focused on an infectious emergency, and (c) were published in an Organization for Economic Co-operation and Development country. An evidence-based all-hazards Resilience Framework for PHEP consisting of 11 elements was used as a reference point to identify additional areas of preparedness that have emerged in recent publications. The findings were analyzed deductively and summarized thematically. RESULTS: The included publications largely aligned with the 11 elements of the all-hazards Resilience Framework for PHEP. In particular, the elements related to collaborative networks, community engagement, risk analysis and communication were frequently observed across the publications included in this review. Ten emergent themes were identified that expand on the Resilience Framework for PHEP specific to infectious diseases. Planning to mitigate inequities was a key finding of this review, it was the most frequently identified emergent theme. Additional emergent themes were: research and evidence-informed decision making, building vaccination capacity, building laboratory and diagnostic system capacity, building infection prevention and control capacity, financial investment in infrastructure, health system capacity, climate and environmental health, public health legislation and phases of preparedness. CONCLUSION: The themes from this review contribute to the evolving understanding of critical public health emergency preparedness actions. The themes expand on the 11 elements outlined in the Resilience Framework for PHEP, specifically relevant to pandemics and infectious disease emergencies. Further research will be important to validate these findings, and expand understanding of how refinements to PHEP frameworks and indicators can support public health practice.

Shaping the future design of paramedicine: A knowledge to action framework to support paramedic system modernization.

BACKGROUND: Over the past two decades, the demands placed on modern paramedic systems has changed. Paramedic services can no longer continue to operate on a traditional response model where more ambulances are deployed to meet the rising demand of patients calling for their health needs. Recent research has explored system design in paramedicine and its relationship with organizational performance. Two subsequent paramedic systems have been identified with one, the Professionally Autonomous paramedic system, being linked to higher performance. Yet, how to operationalize this model for system modernization continues to be a gap in practice. OBJECTIVE: To provide health leaders and policy makers with a framework from which to drive paramedic system modernization. METHODS: This study uses the Knowledge to Action framework to develop an implementation plan for systems that seek to modernize their service delivery model toward that of a Professionally Autonomous paramedic system. RESULTS: A detailed plan of the steps required to undertake system transformation are outlined. Whilst this framework outlines the components required for system modernization, it does not propose an in-depth outline of each of the steps required to achieve each component. Rather, end users are encouraged to develop individual implementation plans tailored to the local context using the comprehensive tools outlined within. CONCLUSION: This knowledge to action framework provides health leaders and policy makers with a uniform roadmap for paramedic system modernization intended to improve health (clinical) outcomes as well as health system outcomes through the Professional Autonomous paramedicine model.

What Factors Increase Odds of Long-Stay Delayed Discharge in Alternate Level of Care Patients?

OBJECTIVE: The objective of this study was to determine the factors that increase the odds of long-stay delayed discharge in alternate level of care (ALC) patients using data collected from the Ontario Wait Time Information System (WTIS) database. DESIGN: Retrospective cohort study utilizing data from Niagara Health's WTIS database. WTIS includes individuals admitted to any of the Niagara Health sites that have been designated as ALC. SETTING AND PARTICIPANTS: Sample consisted of 16,429 ALC patients who received care in Niagara Health hospitals from September 2014 to September 2019 and were recorded in the WTIS database. METHODS: ALC designation of 30 or more days was used as the threshold for a long-stay delayed discharge. This study used binary logistic regression modeling to analyze sex, age, admission source, and discharge destination as well needs/barriers requirements to assess the likelihood of a long-stay delayed discharge among acute care (AC) and post-acute care (PAC) patients given the presence of each variable. Sample sizes calculations and receiver operating characteristic curves were used to verify the validity of the regression model. RESULTS: Overall, 10.2% of the sample were considered long-stay ALC patients. Both AC and PAC long-stay ALC patients were more likely to be male [OR = 1.23, (1.06-1.43); OR = 1.28, (1.03-1.60)] and have a discharge destination of a long-term care bed [OR = 28.68, (22.83-36.04); OR = 6.22, (4.75-8.15)]. AC patients had bariatric [OR = 7.16, (3.45-14.83)], behavioral [OR = 1.89, (1.22-2.91)], infection (isolation) [OR = 2.31, (1.63-3.28)], and feeding [OR = 6.38, (1.82-22.30)] barriers hindering discharge. PAC patients had no significant barriers hindering patient discharge. CONCLUSIONS AND IMPLICATIONS: Shifting the focus from ALC patient designation to short- vs long-stay ALC patients allowed this study to focus on the subset of patients that are disproportionately affecting delayed discharges. Understanding the importance of specialized patient requirements in addition to clinical factors can help hospitals become more prepared in preventing delayed discharges.

The impact of the Caremongering social media movement: A convergent parallel mixed-methods study.

Public health responses to the COVID-19 pandemic, such as business restrictions, social distancing and lockdowns, had social and economic impacts on individuals and communities. Caremongering Facebook groups spread across Canada to support vulnerable individuals by providing a forum for sharing information and offering assistance. We sought to understand the specific impacts of Caremongering groups on individuals 1 year after the pandemic began. We used a convergent parallel mixed-methods approach that included semi-structured interviews with group moderators from 16 Caremongering groups and survey data from 165 group members. We used a constant comparative approach for thematic analysis of interview transcripts and open-ended text responses to the survey. We used source theme tables as joint displays to integrate interview and survey findings. Our results revealed five major themes: providing food, sharing information, supporting health and wellness, acquiring goods and services (non-food), and connecting communities. Respondents of our survey tended to be 35-65 years of age range, but reported helping adults of all ages. Our findings illustrate the potential of using a social media platform to connect with others and provide and access support. The Caremongering initiative demonstrates a community-driven, social media solution to issues such as isolation, loneliness and community health promotion.

Rising through the pandemic: a scoping review of quality improvement in public health during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic generated a growing interest in and need for evidence-based tools to facilitate the implementation of emergency management strategies within public health practice. Quality improvement (QI) is a key framework and philosophy to guide organizational emergency response efforts; however, the nature and extent to which it has been used in public health settings during the COVID-19 pandemic remains unclear. METHODS: We conducted a scoping review of literature published January 2020 - February 2021 and focused on the topic of QI at public health agencies during the COVID-19 pandemic. The search was conducted using four bibliographic databases, in addition to a supplementary grey literature search through custom Google search engines and targeted website search methods. Of the 1,878 peer-reviewed articles assessed, 15 records met the inclusion criteria. An additional 11 relevant records were identified during the grey literature search, for a total of 26 records included in the scoping review. RESULTS: Records were organized into five topics: 1) collaborative problem solving and analysis with stakeholders; 2) supporting learning and capacity building in QI; 3) learning from past emergencies; 4) implementing QI methods during COVID-19; and 5) evaluating performance using frameworks/indicators. CONCLUSIONS: The literature indicates that QI-oriented activities are occurring at the organizational and program levels to enhance COVID-19 response. To optimize the benefits that QI approaches and methodologies may offer, it is important for public health agencies to focus on both widespread integration of QI as part of an organization's management philosophy and culture, as well as project level activities at all stages of the emergency management cycle.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project.

BACKGROUND: Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project. METHODS: A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods. RESULTS: Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses. DISCUSSION: The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.

Using the QI Maturity Tool - Modified Ontario Version to assess the state of QI maturity in Ontario's public health units.

BACKGROUND: Implementation of quality improvement (QI) practices varies considerably among public health units (PHUs) in Ontario. With the emphasis on continuous quality improvement (CQI) in the revised Ontario Public Health Standards (OPHS), there is a need to understand the level of QI maturity in Ontario's PHUs. The objective of this research was to establish a baseline understanding of QI maturity in Ontario's PHUs. METHODS: The QI Maturity Tool - Modified Ontario Version was used to assess the state of QI maturity in 34 PHUs across Ontario. QI maturity was assessed through 23 questions across three dimensions: QI Organizational Culture; QI Capacity and Competency; and QI Perceived Value. QI maturity scores were classified into five stages: Beginning; Emerging; Progressing; Achieving; and Excelling. QI maturity scores were calculated for each of the 34 participating PHUs to determine their stage of QI maturity. Each PHU's score was then used to determine the provincial average for QI maturity. Participants were also asked to answer three questions related to core CQI organizational structures. RESULTS: Across the 34 PHUs, 3503 staff participated in the survey. A review of individual PHU scores indicates that Ontario's PHUs are at varying stages of QI maturity. The average QI maturity score of 4.94 for the 34 participating PHUs places the provincial average in the "Emerging" stage of QI maturity. By QI dimensions, the participating PHUs scored in the "Emerging" stage for QI Organizational Culture (5.09), the "Beginning" stage for QI Competency and Capacity (4.58), and the "Achieving" stage for QI Perceived Value (6.00). CONCLUSION: There is an urgent need for Ontario's PHUs to progress to higher stages of QI maturity. Participants place a high value on QI, but collectively are at less "mature" stages of QI in relation to QI organizational culture and the competency and capacity to engage in QI activities. PHUs should leverage the value that staff place on QI to foster the development of a culture of QI and provide staff with relevant knowledge and skills to engage in QI activities.

The Use of a Palliative Care Screening Tool to Improve Referrals to Palliative Care Services in Community-Based Hospitals: A Quality Improvement Initiative.

Despite efforts to improve access to palliative care services, a significant number of patients still have unmet needs throughout their continuum of care. As such, this project was conducted to increase recognition of patients who could benefit from palliative care, increase referrals, and connect regional sites. This study utilized Plan-Do-Study-Act cycles through a quality improvement approach to develop and test the Palliative Care Screening Tool and aimed to screen 100% of patients within 24 hours who were admitted to selected units by February 2017. The intervention was implemented in 3 different units, each within community hospitals. Patients 18 years or older were screened if they were admitted to one of the selected units for the project, regardless of their diagnosis, age, or comorbidities. The percentage of newly admitted patients who were screened and the total number of palliative care consults were assessed as outcome measures. The tool was met with varying compliance among the 3 sites. However, there was an overall increase in consults across all hospital sites, and an increase in the proportion of noncancer patients was demonstrated. Although the aim was not reached, the tool helped to create a shift in the demographic of patients identified as palliative.

Assessing the Impact of ED Triage Directives on Febrile Oncology Patient Wait Times.

INTRODUCTION: Fever during chemotherapy is a common and potentially severe complication being increasingly evaluated in emergency departments to minimize morbidity and mortality. Streamlining triage of these patients may improve health outcomes and wait times in the health care system. METHODS: A retrospective chart review of febrile patients undergoing chemotherapy was conducted at a local emergency department to assess the impact of nurse-initiated protocols on wait times. RESULTS: We identified 315 patients undergoing current chemotherapy presenting with fever. Of these, 140 (44%) and 87 (28%) were initiated on the sepsis and febrile neutropenia nurse-initiated protocols, respectively. In total, 197 (63%) were admitted. The febrile neutropenia protocol had a shorter wait time from triage to disposition than the sepsis protocol (403 minutes [SD = 23] vs 329 minutes [SD = 19], t = 1.71, P = 0.01). Furthermore, the febrile neutropenia protocol demonstrated shorter times from both triage to lab results reported, in addition to the physician initial assessment in the admitted patient subgroup. DISCUSSION: Decreased wait times from triage associated with the use of a febrile neutropenia protocol could be accounted for by a lower number of lab results required through this protocol in addition to shorter physician assessment times in the admitted population. This study shows that nurse-initiated protocols may influence door-to-antibiotic time for patients undergoing chemotherapy. By having a targeted protocol for the cancer population, health care centers may be able to demonstrate decreased health care expenditure and increased resource availability. Furthermore, as the current population of patients undergoing chemotherapy is at a high risk for neutropenia, prompt management is crucial to minimize mortality.

Assessing Appropriateness of CT and MRI Referrals for Headache and Lumbar: A Canadian Perspective on Patient-Centered Referrals.

BACKGROUND: Inappropriate diagnostic imaging is a burgeoning problem within the Canadian healthcare system and imposes considerable burdens to efficiency and timeliness of care. Low back pain and headaches affect an immense portion of the general population and have become exceedingly common complaints from patients seeking diagnostic imaging from primary care physicians. METHODS: A total of 399 magnetic resonance imaging (MRI) and computed tomography (CT) requisitions for lumbar and head scans were reviewed and assessed for appropriateness in concordance with published Choosing Wisely guidelines for head and lumbar diagnostic imaging. Requisitions were classified as appropriate, inappropriate, or incomplete. Baseline data collection showed 51.6% appropriateness, 12.0% inappropriateness, and 36.3% incompleteness. New patient-centered referral forms containing evidence-based red flags by Choosing Wisely Canada were created for head and lumbar MRI and CT. The aim was to increase awareness and consideration of the guidelines during the referral process. The new referrals were distributed among 149 local family physicians in addition to information pamphlets summarizing the need to reduce unnecessary diagnostic imaging for head and lower back pain. RESULTS AND CONCLUSION: After collection and review of 251 requisitions in the postintervention period, incomplete referrals dropped from 36.3% to 13.15%. Despite insignificant changes in appropriateness, it is promising that the intervention educated local physicians on the information required to complete the CT or MRI forms as further evidence is provided showing the efficacy of the patient-centered referrals. This study provides insight on the importance of appropriate diagnostic imaging and what methods can be used at the primary care level.

Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit.

BACKGROUND: In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). METHODS: All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. RESULTS: There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). CONCLUSION: The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in a Canadian community intensive care unit: a quality improvement study protocol.

BACKGROUND: Pain and agitation are closely linked to the development of delirium, which affects 60%-87% of critically ill patients. Delirium is associated with increased mortality and morbidity. Clinical guidelines that suggest routine assessment, treatment and prevention of pain, agitation and delirium (PAD) is crucial to improving patient outcomes. However, the adoption of and adherence to PAD guidelines remain suboptimal, especially in community hospitals. The aim of this quality improvement study is to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community intensive care unit (ICU). METHODS: This is a quality improvement, uncontrolled, before-and-after study of a multifaceted and multidisciplinary intervention targeting nurses (educational modules, visual reminders), family members (interviews, educational pamphlets and an educational video), physicians (multidisciplinary round script) and the multidisciplinary team as a whole (delirium poster). We will collect data every day for 6 weeks before implementing the intervention. Data collection will include clinical information and information on process of care. We will then implement the intervention. Four weeks after, we will collect data daily for 6 weeks to evaluate the effect of the intervention. On the basis of the volume of the ICU, we expect to enroll approximately 280 patients. We have obtained local ethics approval from the Hamilton Integrated Research Ethics Board (HiREB 18-040-C). INTERPRETATION: The results of this quality improvement study will provide information on adherence to PAD guidelines in a Canadian community ICU setting. They will also supply information on the feasibility of implementing multifaceted and multidisciplinary PAD interventions in community ICUs.

Qualitative descriptive study to explore nurses' perceptions and experience on pain, agitation and delirium management in a community intensive care unit.

OBJECTIVES: The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients. DESIGN: A qualitative descriptive study. SETTING: This study took place in a community hospital ICU located in a medium size Canadian city. PARTICIPANTS: Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated. METHODS: A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns. RESULTS: Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families. CONCLUSIONS: Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.

Attend: A Two-Pronged Trial to Eliminate No Shows in Diagnostic Imaging at a Community-Based Hospital.

PURPOSE: Diagnostic imaging (DI) at Niagara Health, like other hospitals, experiences challenges with patients who do not attend their scheduled appointments, resulting in a "no show." Reducing no show percentages presents an opportunity to improve upon wait lists within specific modalities such as magnetic resonance imaging (MRI) and to reduce the loss of productivity for this high-demand resource. AIM: To reduce the MRI no-show percent in DI at two community hospitals from 6.5% to 5% through patient engagement via mailed reminder letters and education at the primary care level. METHODS: Our two-pronged approach included interventions at community hospitals and at the primary care level. Reminder letters were mailed to patients with their appointment time and other pertinent information to allow for an increased number of patients reminded about appointments and a second means of reminder. At the primary care level, an information package was sent to various independent physicians for distribution to patients requiring an MRI scan, outlining benefits of showing up to the scheduled appointment to educate patients and improve attendance at DI. RESULTS: The mailing letter resulted in a significant reduction from 7.1% to 6.3% in overall no shows across two community hospitals (P = .04). The true effect of the letter was likely masked by increased wait times during the study period, which correlates with increased no-show percentages. The first trial of the information pamphlet among five practices for 1 month resulted in a nonsignificant reduction of no shows from 19% to 3% (P = .125). The second trial among 19 practices for 3 months led to a significant reduction of no shows from 7.7% to 4.2% (P = .007). CONCLUSIONS: Both the methods, the mailing letter and patient-information pamphlet, provide promising results in regard to reducing the no-show percentage among patients seen in DI for MRI appointments.

Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey.

BACKGROUND: Delirium is a common manifestation in the intensive care unit (ICU) that is associated with increased mortality and morbidity. Guidelines suggested appropriate management of pain, agitation and delirium (PAD) is crucial in improving patient outcomes. However, the practice of PAD assessment and management in community hospitals is unclear and the mechanisms contributing to the potential care gap are unknown. OBJECTIVES: This quality improvement initiative aimed to review the practice of PAD assessment and management in a community medical-surgical ICU (MSICU) and to explore the community MSICU nurses' perceived comfort and satisfaction with PAD management in order to understand the mechanisms of the observed care gap and to inform subsequent quality improvement interventions. METHODS: We prospectively collected basic demographic data, clinical information and daily data on PAD process measures including PAD assessment and target Richmond Agitation-Sedation Scale (RASS) score ordered by intensivists on all patients admitted to a community MSICU for >24 hours over a 20-week period. All ICU nurses in the same community MSICU were invited to participate in an anonymous survey. RESULTS: We collected data on a total of 1101 patient-days (PD). 653 PD (59%), 861 PD (78%) and 439 PD (39%) had PAD assessment performed, respectively. Target RASS was ordered by the intensivists on 515 PD (47%). Our nurse survey revealed that 88%, 85% and 41% of nurses were comfortable with PAD assessment, respectively. CONCLUSIONS: Delirium assessment was not routinely performed. This is partly explained by the discomfort nurses felt towards conducting delirium assessment. Our results suggested that improvement in nurse comfort with delirium assessment and management is needed in the community MSICU setting.

Paramedics' Perspectives on Factors Impacting On-Scene Times for Trauma Calls.

IntroductionAccording to Ontario, Canada's Basic Life Support Patient Care Standards, Emergency Medical Services (EMS) on-scene time (OST) for trauma calls should not exceed 10 minutes, unless there are extenuating circumstances. The time to definitive care can have a significant impact on the morbidity and mortality of trauma patients. This is the first Canadian study to investigate why this is the case by giving a voice to those most involved in prehospital care: the paramedics themselves. It is also the first study to explore this issue from a complex, adaptive systems approach which recognizes that OSTs may be impacted by local, contextual features.ProblemResearch addressed the following problem: what are the facilitators and barriers to achieving 10-minute OSTs? METHODS: This project used a descriptive, qualitative design to examine facilitators and barriers to achieving 10-minute OSTs on trauma calls, from the perspective of paramedics. Paramedics from a regional Emergency Services organization were interviewed extensively over the course of one year, using qualitative interviewing techniques developed by experts in that field. All interviews were recorded, transcribed, and entered into NVivo for Mac (QSR International; Victoria, Australia) software that supports qualitative research, for ease of data analysis. Researcher triangulation was used to ensure credibility of the data. RESULTS: Thirteen percent of the calls had OSTs that were less than 10 minutes. The following six categories were outlined by the paramedics as impacting the duration of OSTs: (1) scene characteristics; (2) the presence and effectiveness of allied services; (3) communication with dispatch; (4) the paramedics' ability to effectively manage the scene; (5) current policies; and (6) the quantity and design of equipment. CONCLUSION: These findings demonstrate the complexity of the prehospital environment and bring into question the feasibility of the 10-minute OST standard. LevitanM, LawMP, FerronR, Lutz-GraulK. Paramedics' perspectives on factors impacting on-scene times for trauma calls. Prehosp Disaster Med. 2018;33(3):250-255.

Engaging Nurses in Optimizing Antimicrobial Use in ICUs: A Qualitative Study.

Antimicrobial stewardship programs (ASPs) have predominately involved infectious diseases physicians and pharmacists with little attention to the nurses. To achieve optimal success of ASPs, engagement of nurses to actively participate in initiatives, strategies, and solutions to combat antibiotic resistance across the health care spectrum is required. In this context, the experiences of local ASP teams engaging nurses in appropriate antimicrobial use were explored to inform future strategies to enhance their involvement in ASPs.

The Varying Roles of Nurses During Interfacility Care Transitions.

This study explored health care professionals' perceptions and experiences associated with the role of point-of-care nurses during care transitions from an acute care hospital to a rehabilitation setting to being discharged home. We used a qualitative exploratory design and semistructured interviews. Content analysis revealed 3 themes that point to the ambiguity related to the roles that nurses enact with older patients during care transitions. We suggest ways to better support nurses to engage in quality care transitions.