The effectiveness of a multifaceted, group-facilitated audit and feedback intervention to increase tranexamic acid use during total joint arthroplasty.

PURPOSE: Intraoperative tranexamic acid (TXA) is used to reduce blood loss and the need for transfusions following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite evidence in literature and local practice protocols supporting TXA as a part of standard of care for joint arthroplasty, TXA administration is underutilized. We aimed to use group-facilitated audit and feedback as the foundation of a knowledge translation strategy to increase TXA use for THA and TKA procedures. METHODS: Anesthesiologists consented to receive two data reports summarizing their individual rates of TXA use and postoperative blood transfusions compared with site peers. Variables collected included patient demographics, TXA usage, and the frequency and volume of red blood cell transfusions administered in the 72-hr postoperative period. The facilitated feedback session discussed report findings and focused on factors contributing to local practice patterns and opportunities for change. RESULTS: Tranexamic acid use increased for THA procedures at the intervention site from 66.6 to 74.4% (absolute change, 7.9%; 95% confidence interval [CI], 2.4 to 13.3). Likewise, TXA use for TKA procedures increased from 62.4 to 82.3% (absolute change, 19.9%; 95% CI 15.0 to 25.0). CONCLUSIONS: Physicians and their teams were able to review their practice data on TXA utilization, reflect on differences compared with evidence-based guidelines, discuss findings with peers, and identify opportunities for improvement. The intervention increased the use of TXA for both TKA and THA and shifted the dosage to better align with evidence-based practice guidelines.

RéSUMé: OBJECTIF : L'acide tranexamique (ATX) peropératoire est utilisé pour réduire les pertes sanguines et les besoins transfusionnels après les arthroplasties totales de la hanche (ATH) et du genou (ATG). Malgré les données probantes et les protocoles de pratique locaux appuyant l'utilisation d'ATX dans le cadre de la norme de soins en cas d'arthroplastie, l'administration de cet agent est sous-utilisée. Notre objectif était d'utiliser l'audit et la rétroaction facilités par le groupe comme base d'une stratégie d'application des connaissances afin d'accroître l'utilisation de l'ATX lors des ATH et ATG. MéTHODE: Les anesthésiologistes ont consenti à recevoir deux rapports de données résumant leurs taux individuels d'utilisation d'ATX et de transfusions sanguines postopératoires par rapport à leurs pairs au sein du même établissement. Les variables recueillies comprenaient les données démographiques des patients, l'utilisation d'ATX et la fréquence et le volume des transfusions d'érythrocytes administrées au cours d'une période postopératoire de 72 heures. La séance de rétroaction facilitée a porté sur les conclusions du rapport et s'est concentrée sur les facteurs contribuant aux habitudes de pratique locales et aux possibilités de changement. RéSULTATS: L'utilisation d'acide tranexamique a augmenté pour les procédures d'ATH au site d'intervention, passant de 66,6 % à 74,4 % (variation absolue, 7,9 %; intervalle de confiance [IC] à 95 %, 2,4 à 13,3). De même, l'utilisation d'ATX pour les procédures d'ATG est passée de 62,4 % à 82,3 % (variation absolue, 19,9 %; IC 95 %, 15,0 à 25,0). CONCLUSION: Les médecins et leurs équipes ont pu passer en revue leurs données de pratique sur l'utilisation d'ATX, réfléchir aux différences par rapport aux lignes directrices fondées sur des données probantes, discuter des résultats avec leurs pairs et identifier les possibilités d'amélioration. L'intervention a augmenté l'utilisation d'ATX pour l'ATG et l'ATH et a modifié la posologie pour mieux s'aligner sur les lignes directrices de pratique fondées sur des données probantes.

Do Low-Risk Patients With Dyspepsia Need a Gastroscopy? Use of Gastroscopy for Otherwise Healthy Patients With Dyspepsia.

BACKGROUND: Choosing Wisely Canada (CWC) recommends not to perform gastroscopy for dyspepsia in otherwise healthy adults less than 55 years of age (2014). The aim of this study was to evaluate the use of gastroscopy in a young, healthy population with uncomplicated dyspepsia. METHODS: A retrospective review of gastroscopies completed during 3-month periods in 2015, 2016, and 2017 identified all patients undergoing gastroscopy for the primary indication of dyspepsia. Low-risk patients for dyspepsia were defined as adults, aged 18 to 54 years without alarm symptoms, comorbidities and/or abnormal imaging findings or laboratory values. Gastroscopy and pathology reports were reviewed to identify clinically actionable findings. Clinical outcomes were followed to December 31, 2018 including gastroenterology referrals, emergency room visitation and hospitalization. RESULTS: Among 1358 patients having a gastroscopy for dyspepsia, 480 (35%) were low-risk patients. Sixteen patients 3.3% (16/480) had a clinically actionable result found on gastroscopy or biopsy. No malignant lesions were detected. Low-risk patients were followed up for an average of 2.75 years, 8% (39/480) visited the emergency department (ED), 1% (3/480) of patients were admitted to hospital and 12% (59/480) of patients were re-referred for a dyspepsia-related concern. INTERPRETATION: A high rate of low yield, high cost, invasive endoscopic investigations were performed in this population of otherwise healthy patients under age 55 years. These data suggest limited uptake of current recommendations against the routine use of gastroscopy to investigate dyspepsia.

Just the Facts: Risk stratifying non-traumatic back pain for spinal epidural abscess in the emergency department.

A 65-year-old male with a history of hypertension presents to the emergency department (ED) with new onset of non-traumatic back pain. The patient is investigated for life-threatening diagnoses and screened for "red flag symptoms," including fever, neurologic abnormalities, bowel/bladder symptoms, and a history of injectiondrug use (IVDU). The patient is treated symptomatically and discharged home but represents to the ED three additional times, each time with new and progressive symptoms. At the time of admission, he is unable to ambulate, has perineal anesthesia, and 500 cc of urinary retention. Whole spine magnetic resonance imaging (MRI) confirms a thoracic spinal epidural abscess. This case, and many like it, prompts the questions: when should emergency physicians consider the diagnosis of a spinal epidural abscess, and what is the appropriate evaluation of these patients in the ED? (Figure 1).

Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department.

OBJECTIVE: Despite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians. METHODS: Our cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts. RESULTS: Seventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: -15.5%; 95% CI: -19.8% to -11.2%) and 78.9% to 64.4% (absolute difference: -14.5%; 95% CI: -21.9% to -7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged. CONCLUSION: The combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.

De-implementing wisely: developing the evidence base to reduce low-value care.

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

How do emergency departments and emergency leaders catalyze positive change through quality improvement collaborations?

OBJECTIVES: Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration. METHODS: An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback. RESULTS: Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program. CONCLUSION: A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

OBJECTIF: L'amélioration de la qualité et la sécurité des patients (AQSP) joue un rôle important dans la correction des lacunes observées dans la prestation optimale de soins. Toutefois, les équipes de soins au service des urgences (SU) disposent de peu de documentation sur la conception de leurs propres programmes d'AQSP. L'étude avait donc pour objectif l'élaboration de recommandations conçues à l'intention des chefs de file, nouveaux ou confirmés, au SU, et présentées comme une voie à emprunter pour améliorer les soins aux patients, par l'application d'activités programmatiques d'AQSP, tout d'abord au sein du service, puis entre services, grâce à la collaboration. MÉTHODE: Un groupe d'experts composé de 10 cliniciens en médecine d'urgence, ayant des compétences particulières en AQSP et en pouvoir d'influence, a été mis sur pied. Un examen de cadrage a été entrepris à la recherche de publications sur l'établissement de programmes d'AQSP et de cadres de travail s'y rapportant, en soins de santé. Des consultations ont été menées avec les parties intéressées parmi les chefs de file en soins de santé au Canada, et le groupe d'experts a rédigé une version préliminaire de recommandations fondées sur l'ensemble de l'information recueillie. Celles-ci ont été examinées et améliorées durant le Symposium sur les affaires universitaires 2018 de l'ACMU, à Calgary, à la suite de rétroactions communiquées en personne ou par voie électronique. RÉSULTATS: Les recommandations portaient sur : l'éveil d'un sentiment d'urgence à l'égard de l'amélioration; la mobilisation d'intervenants et de chefs de file compétents; la mise sur pied d'un comité local structuré d'AQSP; l'obtention de financement et de ressources; la disponibilité de données locales pour orienter le travail; le soutien de la formation des membres d'équipe en AQSP; la promotion de la collaboration entre professions, entre services et avec les patients; l'utilisation d'un cadre de travail d'AQSP déjà établi afin d'orienter le travail; l'élaboration d'un système de récompenses et de structures incitatives; la possibilité d'entreprendre, au début, des initiatives à petite échelle, soit des projets plutôt que des programmes. CONCLUSION: Les dix recommandations ont été présentées à titre de principes directeurs en vue de l'élaboration d'activités d'AQSP et de leur mise en œuvre durable dans les SU, au Canada et ailleurs dans le monde. Les chefs de file dans les SU sont invités à appliquer ces recommandations dans le but d'améliorer les soins aux patients.

The Calgary Audit and Feedback Framework: a practical, evidence-informed approach for the design and implementation of socially constructed learning interventions using audit and group feedback.

BACKGROUND: Audit and feedback interventions may be strengthened using social interaction. The Calgary office of the Alberta Physician Learning Program (CPLP) developed a process for audit and group feedback for physicians. This paper extends previous work in which we developed a conceptual model of physician responses to audit and group feedback based on a qualitative analysis of six audit and group feedback sessions. The present study explored the mediating factors for successfully engaging physician groups in change planning through audit and group feedback. METHODS: To understand why some groups were more interactive than others, we completed a comparative case analysis of the six audit and group feedback projects from the prior study. We used framework analysis to build the case studies, triangulated our observations across data sources to validate findings, compared the case studies for similarities and differences that influenced social interaction (mediating factors), and thematically categorized mediating factors into an organizing framework. RESULTS: Mediating factors for socially interactive AGFS were a pre-existing relationship between the program team and the physician group, projects addressing important, actionable questions, easily interpretable data visualization in the reports, and facilitation of the groups that included reflective questioning. When these factors were in place (cases 1, 2A, 3), the audit and group feedback sessions were dynamic, with physicians sharing and comparing practices, and raising change cues (such as declaring commitments to de-prescribing, planning educational interventions, and improving documentation). In cases 2C-D, the mediating factors were less well established and in these cases, the sessions showed little physician reflection or change planning. We organized the mediating factors into a framework linking the factors for successful sessions to the conceptual model of physician behaviors which these mediating factors drive. CONCLUSIONS: We propose the Calgary Audit and Feedback Framework as a practical tool to help foster socially constructed learning in audit and group feedback sessions. Ensuring that the four factors, relationship, question choice, data visualization, and facilitation, are considered for design and implementation of audit and group feedback will help physicians move from reactions to their data towards planning for change.

How do physicians behave when they participate in audit and feedback activities in a group with their peers?

BACKGROUND: Audit and feedback interventions may be strengthened using social interaction. With this in mind, the Calgary office of the Alberta Physician Learning Program developed a process for audit and group feedback for physician groups. As a part of a larger project to develop a practical approach to the design and implementation of audit and group feedback projects, we explored patterns of physician behavior during facilitated audit and group feedback sessions. METHODS: Six audit and group feedback sessions were recorded, transcribed, and analyzed thematically to derive a conceptual model of physicians' behaviors during audit and group feedback sessions. RESULTS: A predictable cycle of behaviors emerged from audit and group feedback sessions. This cycle would repeat with discussion of each new data element: reacting to the data, questioning and understanding the data, justifying and contextualizing, sharing and reflecting on the data and relevant guidelines, and planning for change. "Change cues" that emerged within groups reliably pivoted the discussion towards action planning. CONCLUSIONS: In audit and group feedback sessions, physicians display a predictable series of behaviors as they move towards commitment to change. Establishing the meaning and credibility of the data is a necessary precursor to reflection. Group reflection leads to "change cues" triggered by group members, which stimulate action planning.

Association of out-of-hospital advanced airway management with outcomes after traumatic brain injury and hemorrhagic shock in the ROC hypertonic saline trial.

OBJECTIVE: Prior studies suggest adverse associations between out-of-hospital advanced airway management (AAM) and patient outcomes after major trauma. This secondary analysis of data from the Resuscitation Outcomes Consortium Hypertonic Saline Trial evaluated associations between out-of-hospital AAM and outcomes in patients suffering isolated severe traumatic brain injury (TBI) or haemorrhagic shock. METHODS: This multicentre study included adults with severe TBI (GCS ≤8) or haemorrhagic shock (SBP ≤70 mm Hg, or (SBP 71-90 mm Hg and heart rate ≥108 bpm)). We compared patients receiving out-of-hospital AAM with those receiving emergency department AAM. We evaluated the associations between airway strategy and patient outcomes (28-day mortality, and 6-month poor neurologic or functional outcome) and airway strategy, adjusting for confounders. Analysis was stratified by (1) patients with isolated severe TBI and (2) patients with haemorrhagic shock with or without severe TBI. RESULTS: Of 2135 patients, we studied 1116 TBI and 528 shock; excluding 491 who died in the field, did not receive AAM or had missing data. In the shock cohort, out-of-hospital AAM was associated with increased 28-day mortality (adjusted OR 5.14; 95% CI 2.42 to 10.90). In TBI, out-of-hospital AAM showed a tendency towards increased 28-day mortality (adjusted OR 1.57; 95% CI 0.93 to 2.64) and 6-month poor functional outcome (1.63; 1.00 to 2.68), but these differences were not statistically significant. Out-of-hospital AAM was associated with poorer 6-month TBI neurologic outcome (1.80; 1.09 to 2.96). CONCLUSIONS: Out-of-hospital AAM was associated with increased mortality after haemorrhagic shock. The adverse association between out-of-hospital AAM and injury outcome is most pronounced in patients with haemorrhagic shock.

Use of the Ottawa Ankle Rules in children: a survey of physicians' practice patterns.

INTRODUCTION: A number of studies have assessed the diagnostic accuracy of the Ottawa Ankle Rules (OAR) in children; however, the role of the OAR in guiding physician radiograph use is unclear. OBJECTIVES: The primary purpose of this study was to determine the extent to which Canadian pediatric emergency physicians report using the OAR. Secondary goals included determining current diagnostic and management strategies for Salter-Harris 1 (SH-1) injuries of the ankle and which fractures physicians deem to be clinically significant. METHODS: A self-administered piloted survey was distributed by mail to 215 Canadian pediatric emergency physicians using a modified Dillman technique. Participants were selected through Pediatric Emergency Research Canada (PERC), a national network of health care professionals with an interest in pediatric emergency medicine research. RESULTS: Of 209 surveys, 144 were returned, for a response rate of 68.9%. Of those, 87.5% (126 of 144) reported applying the OAR in children to determine the need for radiographs in acute ankle or midfoot injuries. Of those, 65.1% reported using the OAR always or usually, and 64.5% (93 of 144) of physicians stated that they believe all ankle fractures are clinically significant. Although physicians report that they most commonly order the radiographs, 36.2% of participants indicated that radiographs were requisitioned by nurses or other health care providers at their facilities. SH-1 fractures were reported to be most commonly managed by immobilization (83.3%; 120 of 144), with most patients going on to follow-up with an orthopedic surgeon. CONCLUSIONS: The majority of Canadian pediatric emergency physicians indicate that they use the OAR when assessing children with acute ankle and midfoot injuries. Most physicians believe that all ankle fractures, including SH-1, are clinically significant and have a management preference for immobilization and orthopedic follow-up.