Risk Factors and Modifiers for Cardiovascular Disease Assessment of Patients with Heterozygous Familial Hypercholesterolaemia.

Background: The assessment of the risk of cardiovascular disease (CVD) in patients with heterozygous familial hypercholesterolemia (HeFH) is determined by conventional risk factors. However, factors modifying CVD, or risk modifiers, beyond conventional risk factors may inform their CVD risk assessment and the subsequent use of new therapies. This work identifies and characterises patients within a lipid clinic cohort with regards to conventional CVD risk factors and risk modifiers with a focus on those with HeFH. Methods: A study of consecutive adult patients attending our specialist lipid clinic was performed over a six-month period. The patient data recorded included demographics, clinical characteristics, risk factors and risk modifiers, biochemical profiles and genetic testing results. Risk modifiers were identified based on ESC/EAS guidance, and those with HeFH were compared to those without. Results: A total of 370 patients were included. Of these, 98 HeFH patients were identified (26%). Then, 52% of HeFH patients were stratified into the very-high risk category due to the presence of CVD risk factors. Risk modifiers were present in 73%. These included a family history of premature CVD (56%), obesity (28%), a sedentary lifestyle (13%) and a major psychiatric disorder (12%). Compared to the rest of the cohort, those with HeFH were less likely to have hypertension and more likely to have a family history of premature CVD. Conclusions: Half of patients with HeFH are categorised as having very high CV risk. Consideration of risk modifiers, particularly a family history of premature CV disease, increases this very-high-risk category further. This may have implications for the clinical application and access to novel treatments.

An exploration of patient experiences of transitioning to a remote day programme following inpatient treatment in an adult eating disorder service.

WHAT IS KNOWN ON THE SUBJECT?: Traditionally, treatment for eating disorders (EDs) has been provided on an inpatient or outpatient basis, but more recently other levels of treatment provision to include, day care (DC) and community outreach programmes, have been developed. There is limited research exploring the experience of patients who have transitioned from inpatient ED treatment to a remote DC treatment. This lack of knowledge can impact mental health nurses' understanding of what that experience is like for patients and hence may influence the efficacy of collaboration and inclusion between patients and nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This research addresses this dearth of knowledge and adds to our understanding of patients' experiences of attending a remote DC programme following a period of inpatient treatment for an ED. This is an important study for nurses and other mental health professionals working with people in ED treatment, as it highlights the specific challenges and anxieties of transitioning from inpatient to a remote DC programme and the individualized supports advisable during this process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research provides a basis on which nurses can understand and address the challenges experienced by patients after transitioning to a less intensive supportive ED programme. The understanding of these experiences will enhance the therapeutic alliance between the nurse and patient, which will in turn support the patient in increasing agency as they progress through their recovery. This research provides a foundation on which to develop specific supports that need to be in place to help patients manage the anxieties they experience as they transition to a less intense and remote treatment. Findings from these lived experiences can be used to support the development of similar DC programmes for EDs in other settings. ABSTRACT: INTRODUCTION: Day care (DC) treatment for people with an eating disorder (ED) provides for an easier transition from hospital to home, along with a treatment milieu where patients can maintain occupational and social functioning and allow for the transfer of newly acquired skills to everyday life. AIM: To explore patients' experiences of attending a remote day programme following intense inpatient treatment in an adult ED service. METHOD: A qualitative descriptive methodology informed the study. In-depth semi-structured interviews were conducted with 10 consenting patients. A thematic analysis framework was used to guide the process of data analysis. RESULTS: Three themes reflected participants' experiences: 'Moving On: Preparing for Change', 'Navigating a New Support System' and 'Increasing Agency'. DISCUSSION: An underlying issue for participants was an ongoing but changing experience of anxiety. While anticipatory anxiety is evident in preparing for discharge, this is replaced with a real-time anxiety as they endeavour to negotiate an effective support network. IMPLICATIONS FOR PRACTICE: The findings from this study provide a basis on which mental health nurses can develop timely and effective treatment and support systems with patients who are transitioning from a high support inpatient ED programme to a less intensive ED remote DC programme.

Abbreviated lipid guidelines for clinical practice : Based on ESC lipid guidelines 2019 and ESC cardiovascular disease prevention in clinical practice guidelines 2021.

BACKGROUND: Lipid disorders are now considered causal for atherosclerotic cardiovascular disease (ASCVD) which remains one of the most important contributors to morbidity and mortality in the developed world. Identification and early treatment of lipid disarrays remains the cornerstone of good clinical practice to prevent, halt and even reverse ASCVD. Guidelines for lipid management are imperative to help promote good clinical practice. Given the detail involved in comprehensive guidelines and the multiple areas of knowledge required by clinical practitioners, abbreviated, easy to understand, practical versions of guidelines are required to ensure dissemination of the most important information. The recent ESC lipid guidelines 2019 and the ESC guidelines on CVD prevention in clinical practice 2021 (1,2), provide an excellent detailed summary of all the latest evidence supporting lipid interventions that reduce ASCVD. METHOD: We therefore developed a single-page document with hyperlinks to help practitioners gain easy access to practical information on lipid management. It has been developed for future electronic use in clinical practice. CONCLUSION: It is presented here in a tabular format together with printable versions of the associated hyperlinks that provide the additional information required in decision making. It is hoped to audit the impact of this approach to help guide future ways of disseminating the latest clinical guideline updates.

The DA VINCI study: is Ireland achieving ESC/EAS guideline-directed LDL-C goals?

BACKGROUND: The EU-wide, cross-sectional observational study of lipid-lowering therapy (LLT) use in secondary and primary care (DA VINCI) assessed the proportion of patients achieving low-density lipoprotein cholesterol (LDL-C) goals recommended by the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines and provided an insight into regional use of LLT in Europe, including Ireland. AIMS: This analysis focuses on data from patients in Ireland who participated in the DA VINCI study. METHODS: The DA VINCI study enrolled patients receiving LLT at primary and secondary care sites across 18 European countries between June 2017 and November 2018. The study assessed the achievement of risk-based 2016 and 2019 ESC/EAS LDL-C goals. This subgroup analysis aimed to evaluate LDL-C goal attainment in an Irish cohort of primary and secondary care patients. RESULTS: In total, 198 patients from Ireland were enrolled from three primary care and three secondary care centres. Most patients were White and male, and were receiving moderate- or high-intensity statin therapy (most frequently atorvastatin or rosuvastatin). Few patients (< 10%) were receiving combination therapy of statin and ezetimibe. Approximately 60% of patients achieved their 2016 ESC/EAC LDL-C goals while less than half the patients achieved their 2019 ESC/EAS goals. Approximately half of secondary prevention patients achieved their 2016 ESC/EAS goals and only 20% of secondary prevention patients achieved their 2019 ESC/EAS goals. CONCLUSIONS: These results highlight the disparity between dyslipidaemia management in clinical practice in Ireland and guideline recommendations. TRIAL REGISTRATION: ENCePP; EU PAS 22,075; date registered 06 February 2018.

Clinical characteristics of two groups commonly referred to an Irish hypertension service-patients with resistant hypertension and young adults with hypertension.

BACKGROUND: The management of hypertension is primarily performed in primary care settings in many health systems. However, two groups of patients often require specialist input: patients with resistant hypertension (RH) and young adults with hypertension. AIMS: To elucidate these groups by examining the characteristics of patients attending an Irish hypertension service, thus informing future management of hypertension. METHODS: Patients were recruited at consecutive hypertension clinics at St James Hospital, Dublin from July to September 2019. Following patient consent, patient data were recorded to identify patient characteristics as well as the results of investigations, blood pressure (BP) measurements and the anti-hypertensive treatment of the study participants which were then analysed. RESULTS: Two hundred thirty-six patients were included in the study. Compared to those without RH, the RH group were more likely to be obese (OR 2.59 [95% CI 1.06 to 6.33]), to have cardiovascular disease (OR 3.07 [95% CI 1.56 to 6.02]) and to have a non-dipping BP pattern (OR 3.86 [95% CI 1.57 to 9.47]). Young adults comprised 27% of the cohort. Forty-seven percent of these patients were obese, 15.9% had hypertension in pregnancy and 22.2% had chronic headaches. Despite being prescribed less anti-hypertensives (1.41 vs 2.28; p < 0.05), the majority of young patients had a BP less than 140/90 mmHg, comparing favourably with older patients (OR 2.25 [95% CI 1.20 to 4.27]). CONCLUSION: This contemporary study highlights the high prevalence of obesity among RH patients and young adults with hypertension. Findings suggest that programs to combat hypertension must include interventions to address obesity.

Referrals to, and characteristics of patients attending a specialist hypertension clinic.

The management of hypertension is suboptimal in Ireland and internationally. The role of a specialist hypertension clinic is not always defined but an analysis of the reasons for referral are likely informative. Also, a description of the clinical characteristics of patients with hypertension will inform requirements for comprehensive hypertension management in the community and secondary care. Patients were recruited at consecutive hypertension clinics at St James Hospital, Dublin from July to September 2019. Reasons for referral, clinical characteristics of patients, their investigations and treatment were analyzed. 236 patients were included in the study. The majority of patients, 83%, were obese or overweight. A family history of hypertension was a frequent finding with 70.8% of patients reporting same. 26.7% of patients were under the age of 40. 78% of referrals were from primary care and the most referrals were to investigate secondary causes of hypertension or because the patient was ≤40 years of age. Calcium channel blockers were the treatment most frequently prescribed (51.7%). Clinic blood pressure for the cohort was 137/81 mmHg and this was replicated by their ambulatory BP. This insight into the contemporary management of hypertension highlights the frequency of obesity and a positive family history in those with hypertension. Most referrals were consistent with international guidance though deviations were evident. Findings suggest a national program for hypertension with greater focus on public health interventions and better resourcing of primary care is required.

Levels of Prebeta-1 High-Density Lipoprotein Are a Strong Independent Positive Risk Factor for Coronary Heart Disease and Myocardial Infarction: A Meta-Analysis.

Background We previously showed that levels of prebeta-1 high-density lipoprotein (HDL), the principal acceptor of cholesterol effluxed from cells, including artery wall macrophages, are positively associated with coronary heart disease (CHD) and myocardial infarction (MI) risk. Methods and Results In a multiethnic follow-up cohort of 1249 individuals from University of California-San Francisco clinics, we determined the degree to which prebeta-1 HDL levels, both absolute and percentage of apolipoprotein AI, are associated with CHD and history of MI. Independent, strong, positive associations were found. Meta-analysis revealed for the absolute prebeta-1 HDL for the top tertile versus the lowest, unadjusted odds ratios of 1.90 (95% CI, 1.40-2.58) for CHD and 1.79 (95% CI, 1.35-2.36) for MI. For CHD, adjusting for established risk factors, the top versus bottom tertiles, quintiles, and deciles yielded sizable odds ratios of 2.37 (95% CI, 1.74-3.25, P<0.001), 3.20 (95% CI, 2.07-4.94, P<0.001), and 4.00 (95% CI, 2.11-7.58, P<0.001), respectively. Men and women were analyzed separately in a combined data set of 2507 individuals. The odds ratios for CHD and MI risk were similar. Higher levels of prebeta-1 HDL were associated with all 5 metabolic syndrome features. Addition of prebeta-1 HDL to these 5 features resulted in significant improvements in risk-prediction models. Conclusions Analysis of 2507 subjects showed conclusively that levels of prebeta-1 HDL are strongly associated with a history of CHD or MI, independently of traditional risk factors. Addition of prebeta-1 HDL can significantly improve clinical assessment of risk of CHD and MI.

Partners' experiences of living with a person with an eating disorder: A grounded theory study.

AIM: To explore the experiences of intimate partners of people with an eating disorder. DESIGN: Qualitative grounded theory study. METHODS: In-depth interviews were conducted with 18 partners of people with an eating disorder from 2013-2016. Data were analysed using the principles of classic grounded theory including, concurrent data collection and analysis, theoretical sampling, constant comparative analysis and memo writing. RESULTS: Partners encounter disruptions to their lives when their significant other experiences an eating disorder. As a result, partners engage in a four-stage cyclical process involving: encountering a disruption; becoming an informed self; countering the disruption and reclaimed livability. By engaging in this process partners learn to support their significant other, remain committed to the relationship and recover their own lives. The process is drawn together and defined as the theory of 'Reconstructing Livability'. CONCLUSION: The theory of 'Reconstructing Livability' provides a unique conceptualization of the experiences of partners who are living with a person with an eating disorder. It highlights the challenges faced by partners when supporting the recovery of their significant other and the intimate relationship, while reclaiming their own lives. IMPACT: This study addresses the dearth of knowledge and understanding of partners' experiences. Partners engage in a process to enable them support recovery of their significant other and their own lives, but this is hindered by the challenges and unmet needs they experience. The theory provides a basis on which nurses can provide effective and timely supports to partners.

The Leadership and Organizational Context Required to Support Patient Partnerships.

Healthcare providers and managers typically design programs based on what they believe patients need and want. Yet patients have knowledge and insight into how the system can be changed to better meet their needs, improve outcomes and reduce costs. We describe challenges in creating a culture of patient partnerships and the leadership actions and organizational context required now and in the future to support engagement-capable environments at the organizational and policy levels in Canada. Case examples illustrate the need for leaders to set clear expectations, develop the infrastructure to support patient partnerships and provide education to staff, physicians and patient partners.

Levels of prebeta-1 high-density lipoprotein are elevated in 3 phenotypes of dyslipidemia.

BACKGROUND: Prebeta-1 high-density lipoprotein (HDL) is a small subspecies of HDL that functions as the HDL quantum particle and is the principal acceptor of cholesterol effluxed from macrophages through the ATP-binding cassette transporter, ABCA1. High levels of prebeta-1 HDL are associated with increased risk of structural coronary artery disease and myocardial infarction. OBJECTIVE: We aimed to compare prebeta-1 HDL levels in normal subjects and in 3 phenotypes of dyslipidemia. METHODS: We studied 2435 individuals (1388 women; 1047 men). Of these, 2018 were not taking lipid-lowering medication when enrolled: 392 were normolipidemic controls; 713 had elevated levels of low-density lipoprotein cholesterol; 623 had combined hyperlipidemia; and 290 had hypertriglyceridemia. RESULTS: Relative to controls, prebeta-1 HDL levels were increased in all 3 dyslipidemic phenotypes, particularly the combined and hypertriglyceridemia groups. This increase possibly reflects increased acceptor capacity of apolipoprotein B-100 containing lipoproteins for entropically driven transfer of cholesteryl esters from HDL via cholesteryl ester transfer protein. Multiple regression analysis revealed that the main predictor variables significantly associated with prebeta-1 HDL levels were apolipoprotein A-I (apoA-1) (ß = 0.500), triglyceride (ß = 0.285), HDL-C (ß = -0.237), and age (ß = -0.169). There was an interaction between apoA-1 and sex (female vs male; ß = -0.110). Among postmenopausal women, estrogenized subjects had a similar level of prebeta-1 HDL compared to those not receiving estrogens. CONCLUSIONS: Prebeta-1 HDL levels are elevated in the 3 most common types of hyperlipidemia and are most strongly influenced by the levels of apoA-1, triglyceride, and HDL-C.

Physical Assessment Techniques in Nursing Education: A Replicated Study.

BACKGROUND: It has been nearly a decade since findings revealed that a sample of U.S. nurses routinely used only 30 physical assessment techniques in clinical practice. In a time of differentiating nice-to-know from need-to-know knowledge and skills, what has changed in nursing education? METHOD: This cross-sectional, descriptive study examines the physical assessment skills taught and used among nursing students at one baccalaureate nursing education program located in the midwestern United States. RESULTS: Findings highlight the similarities and differences from previous studies and offer insight as to how closely nursing education mirrors the skills needed for clinical practice. CONCLUSION: Nurse educators must continue to discriminate content taught in prelicensure nursing education programs and should consider the attainment of competency of those essential skills that most lend to optimal patient outcomes. [J Nurs Educ. 2017;56(5):287-291.].

Healthcare for the Aging Citizen and the Aging Citizen for Healthcare: Involving Patient Advisors in Elder-Friendly Care Improvement.

With an aging population and a healthcare system that is overly reliant on providing expensive and sometimes problematic hospital-based care for older Canadians, driving improvements that promote elder-friendly care has never been more critical. The Acute Care for Elders (ACE) Strategy at Toronto's Mount Sinai Hospital is the focus of a pan-Canadian collaborative delivered by the Canadian Foundation for Healthcare Improvement in partnership with the Canadian Frailty Network. The intent is to spread the ACE Strategy's elder-friendly models of care and practices to 18 participating healthcare delivery organizations. A key element of the ACE Collaborative is the inclusion of patient advisors as members of the 18 teams. This article considers the development of elder-friendly care models and practices, with lessons for patient advisors and organizations on the necessary skill-mix, as well as lessons for providers and managers on ways to more effectively engage patient advisors in health system improvement to better serve an aging population.

The Effects of the Transforming Care at the Bedside Program on Perceived Team Effectiveness and Patient Outcomes.

The objective of the study was to document the impact of Transforming Care at the Bedside (TCAB) program on health care team's effectiveness, patient safety, and patient experience. A pretest and posttest (team effectiveness) and a time-series study design (patient experience and safety) were used. The intervention (the TCAB program) was implemented in 8 units in a multihospital academic health science center in Montreal, Quebec, Canada. The impact of TCAB interventions was measured using the Team Effectiveness (TCAB teams, n = 50), and Clostridium difficile-associated diarrhea and vancomycin-resistant Enterobacter rates (patient safety) and Hospital Consumer Assessment of Healthcare Providers and Systems (patient experience; n = 551 patients). The intervention was composed of 4 learning modules, each lasting 12 to 15 weeks of workshops held at the start of each module, combined with hands-on learning 1 day per week. Transforming Care at the Bedside teams also selected 1 key safety indicator to improve throughout the initiative. Pretest and posttest differences indicate improvement on the 5 team effectiveness subscales. Improvement in vancomycin-resistant Enterococcus rate was also detected. No significant improvement was detected for patient experience. These findings call to attention the need to support ongoing quality improvement competency development among frontline teams.

Development and validation of an instrument to assess job satisfaction in eye-care personnel.

PURPOSE: The aim was to develop and validate an instrument to measure job satisfaction in eye-care personnel and assess the job satisfaction of one-year trained vision technicians in India. METHODS: A pilot instrument for assessing job satisfaction was developed, based on a literature review and input from a public health expert panel. Rasch analysis was used to assess psychometric properties and to undertake an iterative item reduction. The instrument was then administered to vision technicians in vision centres of Andhra Pradesh in India. Associations between vision technicians' job satisfaction and factors such as age, gender and experience were analysed using t-test and one-way analysis of variance. RESULTS: Rasch analysis confirmed that the 15-item job satisfaction in eye-care personnel (JSEP) was a unidimensional instrument with good fit statistics, measurement precisions and absence of differential item functioning. Overall, vision technicians reported high rates of job satisfaction (0.46 logits). Age, gender and experience were not associated with high job satisfaction score. Item score analysis showed non-financial incentives, salary and workload were the most important determinants of job satisfaction. CONCLUSIONS: The 15-item JSEP instrument is a valid instrument for assessing job satisfaction among eye-care personnel. Overall, vision technicians in India demonstrated high rates of job satisfaction.

The Experience of Patients Engaged in Co-designing Care Processes.

This article presents the experiences of patients engaged in co-designing care under a program entitled, "Transforming Care at the Bedside," based at an academic health sciences center. This descriptive, qualitative study collected data through individual interviews. Participants included patients from 5 units in an academic health sciences center in Quebec, Canada. A total of 6 individual interviews were conducted in November 2014, 15 months after the Transforming Care at the Bedside work began in September 2013. Content analysis was used to analyze the qualitative data. Being listened to and informed gave patients an opportunity to better understand patient needs and the complexity of care in the unit and in the organization. The experience enabled patients to better translate the patient experience for the team's benefit and influence the team's perspective and decisions. Through this experience, several patients felt motivated and empowered and that they afforded consideration through this experience. This study highlights the importance of creating opportunities for patients and health care providers to share their unique experiences and expertise to better understand each other's reality. In this context, they developed a more comprehensive understanding of the issues and worked together to implement realistic changes on behalf of the patients.

Expanding patient engagement in quality improvement and health system redesign: Three Canadian case studies.

Healthcare organizations face growing pressures to increase patient-centred care and to involve patients more in organizational decisions. Yet many providers worry that such involvement requires additional time and resources and do not see patients as capable of contributing meaningfully to decisions. This article discusses three efforts in four organizations to engage patients in quality improvement efforts. McGill University Health Centre, Saskatoon Health Region, and Vancouver Coastal and Fraser Health Regions all engaged patients in quality improvement and system redesign initiatives that were successful in improving care processes, outcomes, and patient experience measures. Patient involvement in redesigning care may provide a way to demonstrate the value of patients' experiences and inputs into problem-solving, building support for their involvement in other areas. Further study of these cases and a broader survey of organizational experiences with patient involvement may help elucidate the factors that support greater patient engagement.

Clinical Competency of 1-Year Trained Vision Technicians in Andhra Pradesh, India.

PURPOSE: To assess clinical competency of 1-year trained vision technicians (VTs) in detecting and referring causes of visual impairment in India. METHODS: Eye examination results and management plans for 328 patients examined by 24 VTs in 24 vision centers of LV Prasad Eye Institute in Andhra Pradesh were compared with those of a standard optometrist who examined the same patients. Eye examinations included retinoscopy and subjective refraction, slit lamp examination, applanation tonometry and undilated direct ophthalmoscopy. Data were analyzed for level of concordance in retinoscopy, spectacle prescription, disease detection and referral. RESULTS: VTs demonstrated moderate to good levels of agreement in refraction, disease detection and referral. Sensitivity and specificity for ocular pathology identification were 77.4% (95% confidence interval, CI, 69.4-84.2%) and 86.6% (95% CI 81.1-91.1%), respectively. The highest sensitivity was demonstrated in detecting significant cataract (91.5%) and refractive error (83.0%). VT spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. VT sensitivity in detecting posterior segment abnormalities was low (18.5%) resulting in failure to detect retinal conditions such as diabetic retinopathy and maculopathy. Despite lack of recognition of the specific pathology, referral decisions were correct in 78.4% of cases. CONCLUSION: VTs in India competently detect and manage or refer the two most common causes of visual impairment; uncorrected refractive error and cataract. Over two-thirds of patients received accurate and appropriate services from VTs, suggesting that they are a useful and competent cadre for rural and remote eye care.

Intraoperative radiocolloid injection for sentinel node biopsy postneoadjuvant chemotherapy.

BACKGROUND: This study sought to determine significance of radiocolloid injection timing for sentinel node biopsy (SNB) after neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS: A retrospective comparison of intraoperative (IRCI) and preoperative (PRCI) radiocolloid injection for SNB was performed in breast cancer patients who had completed NAC. The sentinel node identification rate (SNIDR) was tested for noninferiority by a two-proportion z-test. The differences between clinical demographics, pathologic demographics, and SNIDR were evaluated by Fisher exact test. The difference in the number of sentinel nodes removed was analyzed by two-sample t-test. RESULTS: In the 6-y study period, 120 SNB were performed after NAC: 84 received PRCI and 36 received IRCI. The two groups were similar except there were fewer clinical T2 and more clinical T3 and T4 with IRCI (P = 0.0008). The SNIDR was 92.9% with PRCI and 80.6% with IRCI. By two-proportion z-test, IRCI was not "noninferior" (P = 0.5179). By Fisher exact test, the SNIDR of the two groups did not differ. The SNIDR differs only in patients who experience T downstaging (100% versus 80%, P = 0.0173). The mean number of lymph nodes removed was higher with IRCI: 3.38 versus 2.49 nodes (P = 0.0068). There were more positive SNB with IRCI: 32.1% versus 55.2%, (P = 0.0432). The incidence of nontherapeutic axillary dissection was similar between the two groups (3.6% for PRCI versus 5.6% for IRCI). CONCLUSIONS: IRCI for SNB after NAC may be inferior to PRCI.

Effective Strategies to Spread Redesigning Care Processes Among Healthcare Teams.

PURPOSE: The purpose of this study was to describe how spread strategies facilitate the successful implementation of the Transforming Care at the Bedside (TCAB) program and their impact on healthcare workers and patients in a major Canadian healthcare organization. DESIGN: This study used a qualitative and descriptive design with focus groups and individual interviews held in May 2014. Participants included managers and healthcare providers from eight TCAB units in a university health center in Quebec, Canada. The sample was composed of 43 individuals. METHODS: The data were analyzed using NVivo according to the method proposed by Miles and Huberman. FINDINGS: The first two themes that emerged from the analysis are related to context (organizational transition requiring many changes) and spread strategies for the TCAB program (senior management support, release time and facilitation, rotation of team members, learning from previous TCAB teams, and engaging patients). The last theme that emerged from the analysis is the impact on healthcare professionals (providing front-line staff and managers with the training they need to make changes, team leadership, and increasing receptivity to hearing patients' and families' needs and requests). CONCLUSIONS: This study describes the perspectives of managers and team members to provide a better understanding of how spread strategies can facilitate the successful implementation of the TCAB program in a Canadian healthcare organization. CLINICAL RELEVANCE: Spread strategies facilitate the implementation of changes to improve the quality and safety of care provided to patients.