Emergency department triage decision-making by registered nurses: An instrument development study.

AIM: To develop and psychometrically test the triage decision-making instrument, a tool to measure Emergency Department Registered Nurses decision-making. DESIGN: Five phases: (1) defining the concept, (2) item generation, (3) face validity, (4) content validity and (5) pilot testing. METHODS: Concept definition informed by a grounded theory study from which four domains emerged. Items relevant to the four domains were generated and revised. Face validity was established using three focus groups. The target population upon which the reliability and validity of the triage decision-making instrument was explored were triage registered nurses in emergency departments. Three expert judges assessed 89 items for content and domain designation using a 4-point scale. Psychometric properties were assessed by exploratory factor analysis, following which the names of the four domains were modified. RESULTS: The triage decision-making instrument is a 22-item tool with four factors: clinical judgement, managing acuity, professional collaboration and creating space. Focus group data indicated support for the domains. Expert review resulted in 46 items with 100% agreement and 13 with 66% agreement. Fifty-nine items were distributed to a convenience sample of 204 triage nurses from six hospitals in 2019. The Kaiser-Meyer-Olkin measures indicated that the data were sufficient for exploratory factor analysis. Bartlett's test indicated patterned relationships among the items (X2 (231) = 1156.69). An eigenvalue of >1.0 was used and four factors explained 48.64% of the variance. All factor loadings were ≥0.40. Internal consistency was demonstrated by Cronbach's alphas of .596 factor 1, .690 factor 2, .749 factor 3 and .822 for factor 4. CONCLUSION: The triage decision-making instrument meets the criteria for face validity, content validity and internal consistency. It is suitable for further testing and refinement. IMPACT: The instrument is a first step in quantifying triage decision-making in real-world clinical environments. The triage decision-making instrument can be used for targeted triage interventions aimed at improving throughput and staff education. STATISTICAL SUPPORT: Dr. Tak Fung who is a member of the research team is a statistician. STATISTICAL METHODS: Development, validation and assessment of instruments/scales. Descriptive statistics. REPORTING METHOD: STROBE cross-sectional checklist. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The TDI makes the complexity of triage decision-making visible. Identifying the influence of decision-making factors in addition to acuity that affect triage decisions will enable nurse managers and educators to develop targeted interventions and staff development initiatives. By extension, this will enhance patient care and safety.

An Environmental Scan and Appraisal of Patient Online Resources for Managing Rheumatoid Arthritis Flares.

OBJECTIVE: To conduct an environmental scan and appraisal of online patient resources to support rheumatoid arthritis (RA) flare self-management. METHODS: We used the Google search engine (last search March 2023) using the terms "rheumatoid arthritis" and "flare management." Additional searches targeted major arthritis organizations, as well as regional, national, and international resources. Appraisal of the resources was conducted by 2 research team members and 1 patient partner to assess the understandability and actionability of the resource using the Patient Education Materials Assessment Tool (PEMAT). Resources rating ≥ 60% in both domains by either the research team or the patient partner were further considered for content review. During content review, resources were excluded if they contained product advertisements, inaccurate information, or use of noninclusive language. If content review criteria were met, resources were designated as "highly recommended" if both patient partners and researchers' PEMAT ratings were ≥ 60%. If PEMAT ratings were divergent and had a rating ≥ 60% from only 1 group of reviewers, the resource was designated "acceptable." RESULTS: We identified 44 resources; 12 were excluded as they did not pass the PEMAT assessment. Fourteen resources received ratings ≥ 60% on understandability and actionability from both researchers and patient partners; 10 of these were retained following content review as "highly recommended" flare resources. Of the 18 divergent PEMAT ratings, 8 resources were retained as "acceptable" following content review. CONCLUSION: There is high variability in the actionability and understandability of online RA flare materials; only 23% of resources were highly recommended by researchers and patient partners.

Content validity testing of the INTERMED Self-Assessment in a sample of adults with rheumatoid arthritis and rheumatology healthcare providers.

BACKGROUND: Care complexity can occur when patients experience health challenges simultaneously with social barriers including food and/or housing insecurity, lack of transportation or other factors that impact care and patient outcomes. People with rheumatoid arthritis (RA) may experience care complexity due to the chronicity of their condition and other biopsychosocial factors. There are few standardised instruments that measure care complexity and none that measure care complexity specifically in people with RA. OBJECTIVES: We assessed the content validity of the INTERMEDS Self-Assessment (IMSA) instrument that measures care complexity with a sample of adults with RA and rheumatology healthcare providers (HCPs). Cognitive debriefing interviews utilising a reparative framework were conducted. METHODS: Patient participants were recruited through two existing studies where participants agreed to be contacted about future studies. Study information was also shared through email blasts, posters and brochures at rheumatology clinic sites and trusted arthritis websites. Various rheumatology HCPs were recruited through email blasts, and divisional emails and announcements. Interviews were conducted with nine patients living with RA and five rheumatology HCPs. RESULTS: Three main reparative themes were identified: (1) Lack of item clarity and standardisation including problems with item phrasing, inconsistency of the items and/or answer sets and noninclusive language; (2) item barrelling, where items asked about more than one issue, but only allowed a single answer choice; and (3) timeframes presented in the item or answer choices were either too long or too short, and did not fit the lived experiences of patients. Items predicting future healthcare needs were difficult to answer due to the episodic and fluctuating nature of RA. CONCLUSIONS: Despite international use of the IMSA to measure care complexity, patients with RA and rheumatology HCPs in our setting perceived that it did not have content validity for use in RA and that revision for use in this population under a reparative framework was unfeasible. Future instrument development requires an iterative cognitive debriefing and repair process with the population of interest in the early stages to ensure content validity and comprehension. PATIENT OR PUBLIC CONTRIBUTION: Patient and public contributions included both patient partners on the study team and people with RA who participated in the study. Patient partners were involved in study design, analysis and interpretation of the findings and manuscript preparation. Data analysis was structured according to emergent themes of the data that were grounded in patient perspectives and experiences.

"How are you?" Perspectives From Patients and Health Care Providers of Text Messaging to Support Rheumatoid Arthritis Care: A Thematic Analysis.

OBJECTIVE: Patients with rheumatoid arthritis (RA) may need to access rheumatology care between scheduled visits. WelTel is a virtual care platform that supports secure two-way text-messaging between patients and their health care team. The objective of the present study was to explore perspectives and experiences of health care providers (HCPs) and patients related to the use of WelTel as an adjunct to routine care. METHODS: Seventy patients with RA were enrolled in a six-month WelTel pilot project launched in September 2021. Patients received monthly "How are you?" text message check-ins and could message their health care team during clinic hours to request health advice. The current project is a qualitative study of the WelTel pilot. A subgroup of pilot participants was purposively sampled and invited to participate in interviews. A thematic analysis of transcripts was conducted using a deductive approach leveraging quality of care domains. RESULTS: Thirteen patients (62% female, mean age 62 years, 10 White) completed interviews. Patients' views suggested that text messaging with the rheumatology team supported high-quality care across multiple quality domains including patient-centeredness, timeliness, efficiency, safety, effectiveness, equity, and appropriateness. Seven HCPs (57.1% female, one pharmacist and six rheumatologists) completed interviews. HCPs' perspectives varied based on their experience with the WelTel platform. Additional themes reported by HCPs included perceived increased workload and burnout. CONCLUSIONS: Patients with RA perceived text-based messaging as supporting high-quality care. The impact of increased communications on HCP burnout and workload requires consideration, and future studies should evaluate the effect of texting on patient outcomes.

Investigating the Influence of Patient Eligibility Characteristics on the Number of Deferrable Rheumatologist Visits: Planning for a Patient-Initiated Follow-Up Strategy.

OBJECTIVE: Patient-initiated follow-up (PIFU) for rheumatoid arthritis (RA) is a model of care delivery wherein patients contact the clinic when needed instead of having regularly scheduled follow-up. Our objective was to investigate the influence of different patient eligibility characteristics on the number of potentially deferred visits to inform future implementation of a PIFU strategy. METHODS: We conducted a retrospective chart review of 7 rheumatologists' practices at 2 university-based clinics between March 1, 2021, and February 28, 2022. Data extracted included the type and frequency of visits, disease management, comorbidities, and care complexities. Stable disease was defined as remission or low disease activity with no medication changes at all visits. The influence of patient characteristics on the number of deferrable visits in patients with stable disease was explored in 4 criteria sets that were based on early disease duration, medication prescribed, presence of care complexity elements, and comorbidity burden. RESULTS: Records from 770 visits were reviewed from 365 patients with RA (71.5% female, 70% seropositive). Among all criteria sets, the proportion of visits that could be redirected varied between 2.5% and 20.9%. The highest proportion of deferrable visits was achieved when eligibility criteria included only stable disease activity and patients with RA on conventional synthetic disease-modifying antirheumatic drugs or no medications (n = 161, 20.9%). CONCLUSION: PIFU may result in a more efficient use of specialist healthcare resources. However, the applicability of such models of care and the number of deferred visits is highly dependent on patient characteristics used to establish eligibility criteria for that model. These findings should be considered when planning implementation trials.

The Guyana Program to Advance Cardiac Care: A Model for Equitable Cardiovascular Care Delivery.

Guyana is one of the poorest countries in South America, with the highest rate of cardiovascular mortality on the continent. As is the case in many low- and middle-income countries, cardiovascular care is available through the private sector but is not accessible to much of the urban and rural poor. We present the 10-year experience of the Guyana Program to Advance Cardiac Care (GPACC), an academic partnership aiming to provide high-quality, equitable cardiovascular care in Georgetown's only public hospital. We discuss the implementation of a cardiac care program using the World Health Organization Framework for Action, outlining vital components for care delivery in resource-limited settings. GPACC was able to demonstrate that targeted investment, education of clinicians, and cohesive healthcare delivery strategies can contribute to sustainable service delivery for Guyana's largest burden of disease. This structured approach may provide lessons for implementation of similar programs in other resource-limited settings. Highlights: In many LMICs, specialized cardiovascular care is available in the private, but not public, sector.The WHO Framework for Action can guide development of sustainable programs in low-resource settings.GPACC can serve as a successful and innovative model for delivery of sustainable cardiovascular care.

A scoping review of shared care models for rheumatoid arthritis with patient-initiated follow-up.

OBJECTIVE: An emerging strategy to address access challenges to rheumatologists for patients with RA is shared care between primary and specialist care, with patient-initiated rheumatologist follow-up as needed. The objective of this scoping review was to explore studies implementing this model of care. METHODS: Four electronic databases were searched from 01/01/2000-31/03/2022 using three main concepts (RA, shared care, patient-initiated follow-up). English-language studies of any design were included if they described the implementation and/or outcomes of shared care model for RA with patient-initiated follow-up. Two authors reviewed and selected articles in duplicate and extracted data on study characteristics, care model implementation and outcomes according to a pre-specified protocol. RESULTS: Following duplicate removal, 1578 articles were screened for inclusion and 58 underwent full-text review. Sixteen articles were included, representing 10 unique studies. Five studies had qualitative outcomes and two were pre-implementation studies. Model implementation varied significantly between studies. Effectiveness data was available in 10 studies and demonstrated equivalent outcomes for the model of care (disease activity, radiographic damage, quality of life). Health system costs were equivalent or lower than usual care. While satisfaction with care was equivalent or improved in shared care models with patient-initiated follow-up, some concerns were expressed in qualitative evaluation around appropriate patient selection for such models, and information for health equity evaluation was not reported. CONCLUSIONS: While shared care models with patient-initiated follow-up may offer comparable outcomes for RA, further work is required to understand patient preferences, health equity considerations and longer-term outcomes for such models of care.

Intimate partner violence: A practice development issue for orthopaedic nurses.

Intimate Partner Violence (IPV) is an underrecognized healthcare phenomenon that causes significant harm to the health of those affected. The lifetime estimated global prevalence of IPV is one in three for women and one in twelve for men. Orthopaedic fracture clinics care for patients affected by IPV and, in fact, orthopaedic patients themselves believe they should be screened for IPV. Almost three percent of women seen for an acute musculoskeletal injury is a direct consequence of IPV. A major concern is that, in the absence of screening and no outward signs of IPV, healthcare providers do not screen patients. Current screening practices and policies are influenced by the nurses' practice or the organizational structure in which nurses work. The purpose of this article is to raise awareness of IPV in the orthopaedic patient population and to provide a review on IPV for orthopaedic nurses. It is important for organizational leaders to recognize the relationship between the barriers and facilitators in relation to IPV intervention. Facilitators and barriers to addressing IPV are discussed. In addition, the need to implement change in practice combined with empowering nurses to address IPV is described. Empowering orthopaedic nurses necessarily involves the provision of appropriate resources, information, and support to overcome barriers. The authors discuss unit policies, guidelines, and resources to address IPV.

Development and testing of the rheumatoid arthritis quality of care survey.

OBJECTIVES: The Rheumatoid Arthritis (RA) Quality of Care Survey (RAQCS) was developed to measure care quality according to a previously developed national RA quality improvement framework. METHODS: The development of the RAQCS occurred over 3 phases. First, the survey was developed by a team of healthcare providers, researchers, and two patient partners based on the existing national quality framework's 21 performance measures (PMs) and strategic objectives. Second, cognitive debriefing interviews were conducted with individuals living with RA to identify survey clarity, appropriateness of survey questions, and response options. Third, the survey was revised and distributed to participants recruited from Rheum4U (rheumatology longitudinal cohort). Results were tabulated and compared with a chart audit of participant medical records. RESULTS: Fifty-three participants completed the RAQCS. High performance (i.e., ≥70% meeting PM) was observed for 13 of 20 PMs. Lower performance was seen for the remaining PMs, which included documentation of body mass index (BMI) and smoking status, discussion of physical activity goals, comorbidity management including risk assessments for cardiovascular health and fragility fractures and disease activity assessment. There was high agreement (≥70%) between the RAQCS and chart review for 9 of 20 PMs. CONCLUSIONS: High agreement was observed between the RAQCS and chart review for selected PMs. The RAQCS may also be a valuable tool for quality improvement for measures where data are not usually available through other sources. Further testing of the RAQCS is needed to ascertain its reliability and validity as a patient self-reported tool to measure RA care quality.

Strategies for developing and implementing a rheumatoid arthritis healthcare quality framework: a thematic analysis of perspectives from arthritis stakeholders.

OBJECTIVES: To obtain stakeholder perspectives to inform the development and implementation of a rheumatoid arthritis (RA) healthcare quality measurement framework. DESIGN: Qualitative study using thematic analysis of focus groups and interviews. SETTING: Arthritis stakeholders from across Canada including healthcare providers, persons living with RA, clinic managers and policy leaders were recruited for the focus groups and interviews. PARTICIPANTS: Fifty-four stakeholders from nine provinces. INTERVENTIONS: Qualitative researchers led each focus group/interview using a semistructured guide; the digitally recorded data were transcribed verbatim. Two teams of two coders independently analysed the transcripts using thematic analysis. RESULTS: Perspectives on the use of different types of measurement frameworks in healthcare were obtained. In particular, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. Persons living with RA were less familiar with specific measurement frameworks, however, they had used existing online public forums for rating their experience and quality of healthcare provided. They viewed a standardised framework as potentially useful for assisting with monitoring the care provided to them individually. Nine guiding principles for framework development and 13 measurement themes were identified. Perceived barriers identified included access to data and concerns about how measures in the framework were developed and used. Effective approaches to framework implementation included having sound knowledge translation strategies and involving stakeholders throughout the measurement development and reporting process. Clinical models of care and health policies conducive to outcome measurement were highlighted as drivers of successful measurement initiatives. CONCLUSION: These important perspectives will be used to inform a healthcare quality measurement framework for RA.

Development of a Patient-centered Quality Measurement Framework for Measuring, Monitoring, and Optimizing Rheumatoid Arthritis Care in Canada.

OBJECTIVE: The aim of this study was to develop a patient-centered quality measurement framework to address a predefined vision statement and 7 strategic objectives for rheumatoid arthritis (RA) care that was developed in prior qualitative work with arthritis stakeholders. METHODS: One hundred forty-seven RA-related performance measures (PMs) were identified from a systematic review. A candidate list of 26 PMs meeting predefined criteria and addressing the strategic objectives previously defined was then assessed during a 3-round (R) modified Delphi. Seventeen panelists with expertise in RA, quality measurement, and/or lived experience with RA rated each PM on a 1-9 scale based on the items of importance, feasibility, and priority for inclusion in the framework during R1 and R3, with a moderated discussion in R2. PMs with median scores ≥ 7 on all 3 items without disagreement were included in the final set, which then underwent public comment. RESULTS: Twenty-one measures were included in the final framework (15 PMs from the Delphi and 6 published system-level measures on access to care and treatment). The measures included 4 addressing early access to care and timely diagnosis, 12 evidence-based care for RA and related comorbidities, 1 addressing patient participation as an informed partner in care, and 4 on patient outcomes. CONCLUSION: The proposed framework builds upon existing measures capturing early access to care and treatment in RA and adds important PMs to promote high-quality RA care and outcome measurement. In the next phase, the authors will test the framework in clinical practice in addition to addressing certain areas where no suitable PMs were identified.

Priorities for High-quality Care in Rheumatoid Arthritis: Results of Patient, Health Professional, and Policy Maker Perspectives.

OBJECTIVE: To elucidate the essential elements of high-quality rheumatoid arthritis (RA) care in order to develop a vision statement and a set of strategic objectives for a national RA quality framework. METHODS: Focus groups and interviews were conducted by experienced qualitative researchers using a semistructured interview or focus group guide with healthcare professionals, patients, clinic managers, healthcare leaders, and policy makers to obtain their perspectives on elements essential to RA care. Purposive sampling provided representation of stakeholder types and regions. Recorded data was transcribed verbatim. Two teams of 2 coders independently analyzed the deidentified transcripts using thematic analysis. Strategic objectives and the vision statement were drafted based on the overarching themes from the qualitative analysis and finalized by a working group. RESULTS: A total of 54 stakeholders from 9 Canadian provinces participated in the project (3 focus groups and 19 interviews). Seven strategic objectives were derived from the qualitative analysis representing the following themes: (1) early access and timeliness of care; (2) evidence-informed, high-quality care for the ongoing management of RA and comorbidities; (3) availability of patient self-management tools and educational materials for shared decision making; (4) multidisciplinary care; (5) patient outcomes; (6) patient experience and satisfaction with care; and (7) equity, the last of which emerged as an overarching theme. The ultimate vision obtained was "ensuring patient-centered, high-quality care for people living with rheumatoid arthritis." CONCLUSION: The 7 strategic objectives that were identified highlight priorities for RA quality of care to be used in developing the National RA Quality Measurement Framework.

Implementation and Evaluation of Audit and Feedback for Monitoring Treat-to-Target (T2T) Strategies in Rheumatoid Arthritis Using Performance Measures.

INTRODUCTION: In collaboration with the Alberta Medical Association's Physician Learning Program we developed individualized physician reports and held a group feedback session on rheumatoid arthritis (RA) performance measures (PM) to facilitate treat-to-target (T2T) strategies and evaluated physician experiences with this process. METHODS: 5 PMs addressing T2T concepts from an established Canadian quality framework were operationalized for physician practice reports at 2 university-affiliated rheumatology clinics. Rheum4U, a quality improvement and research platform, was the data source. The audit results were reviewed in a facilitated group feedback session. Rheumatologists provided experiential feedback on the process through survey and/or an interview. Transcripts from interviews were analyzed using a 6-step thematic analysis. RESULTS: 11 of 12 eligible rheumatologists consented to receive practice reports and provided feedback through surveys (n = 5) and interviews (n = 6). The practice reports from Rheum4U (n = 448 patients) revealed high rates of yearly follow-up (> 85%, PM1) and 100% performance on documentation of disease activity at ≥ 50% of visits (PM2). Only 34% of patients were seen within 3 months if not in remission (PM3) with 62% (2017) and 69% (2018) of those with active RA achieving a LDA state within 6 months (PM4). Approximately 70% of patients were in remission at any time point (PM5). All survey respondents agreed or strongly agreed comparison to peers was valuable and helped them reflect on their practice. Several strategies for improvement were identified, including but not limited to, leveraging of electronic records for future audit and feedback reports, providing additional granularity of results, additional stratification of results, and using high-performing peers as the comparator rather than the group mean. CONCLUSIONS: Audit and feedback was perceived by clinicians as a useful strategy for evaluating T2T efforts in RA. Future work will focus on longitudinal evaluation of the clinical impact of this quality improvement initiative.

Drug Overdose, Loss of Consciousness, and Compartment Syndrome: A Life-Threatening Combination.

Acute extremity compartment syndrome is considered an orthopedic emergency that has serious consequences if a correct diagnosis is not made rapidly. Patients who lose consciousness due to a drug overdose are known to collapse onto their extremities. The limbs are compressed for hours, placing them at an increased risk for acute extremity compartment syndrome and its sequelae. Compartment syndrome due to a compression of a limb from loss of consciousness secondary to drug overdose, presents unique issues to health care providers. In the setting of overdose compartment syndrome, it is similar to the more common traumatic type of compartment syndrome with respect to the pathophysiology, diagnosis and treatment. However, it differs in relation to the muscles affected, physical assessment strategy, and accurately determining the amount of the time from onset of injury to the presentation of symptoms. The purpose of this article is to facilitate emergency department nurses' understanding of the complexities of overdose compartment syndrome, combined with the importance of early recognition of the condition. In addition, the authors review the pathophysiology, the traditional and innovative diagnostic techniques, and the current treatment options available for overdose compartment syndrome.

Triage emergency nurse decision-making: Incidental findings from a focus group study.

INTRODUCTION: Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making. METHODS: Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis. RESULTS: Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'. DISCUSSION: The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Delirium in the Intensive Care Unit: Is Dexmedetomidine Effective?

Delirium in the intensive care unit affects approximately 30% of patients despite vigorous efforts to encourage the use of effective screening tools and preventive strategies. The success of pharmacological treatment of delirium remains equivocal; moreover, a paucity of research supports the use of atypical antipsychotic medications. However, dexmedetomidine appears to have a promising role in delirium management. This review includes an overview of the pathophysiology and types of delirium and describes 2 established tools used to screen for delirium. Published research related to the use of dexmedetomidine in the management of delirium is also discussed. The authors make recommendations for critical care nurses on dexmedetomidine use in the context of providing evidence-based nursing care to intensive care unit patients with delirium.

Rheum4U: Development and testing of a web-based tool for improving the quality of care for patients with rheumatoid arthritis.

OBJECTIVES: To develop a web-based tool (Rheum4U) to capture clinically meaningful data to direct treatment. Rheum4U integrates longitudinal clinical data capture of rheumatoid arthritis (RA) disease activity measures and patient-reported outcomes measures (PROMs). This study tests the feasibility, acceptability and efficiency of Rheum4U among patients and healthcare providers. METHODS: Rheum4U was developed in two phases: P1 design and development; and P2 pilot testing. P1: A working group of rheumatologists and researchers (n=13) performed a prioritisation exercise to determine data elements to be included in the platform. The specifications were finalised and supplied to the platform developer. Alpha testing was performed to correct initial software bugs. 18 testers (physicians, nurses and recruited non-patient lay-testers) beta tested Rheum4U for usability. P2: Rheum4U was piloted in 2 rheumatology clinics and evaluated for feasibility, efficiency and acceptability using interviews, observation and questionnaires with patients and healthcare providers. RESULTS: 110 RA patients, 9 rheumatologists and 9 allied health providers participated in the pilot. Mean patient age was 53 years and 74% were female. The majority (86%) were satisfied or very satisfied with online data entry and 79% preferred it to paper entry. Healthcare providers found Rheum4U easy and clear to use (90%), and they perceived that it improved their job performance (91%). Completeness and easy availability of the patient information improved clinic efficiency. CONCLUSIONS: Rheum4U highlights the benefits of a web-based tool for clinical care, quality improvement and research in the clinic and this study provides valuable information to inform full platform implementation.

Arthropathies in Inflammatory Bowel Disease: A Review for Clinicians.

Inflammatory bowel disease (IBD) is a systemic, chronic autoimmune disease of the digestive tract. The etiology and pathophysiology of IBD is not fully understood, though it is believed to be due to a complex interaction among the patient's genotype, immune system, and environmental factors. Inflammatory bowel disease is frequently accompanied by extraintestinal manifestations that occur in almost half of all patients. The most common extraintestinal manifestation that occurs is joint disease, collectively termed the arthropathies of IBD. While epidemiological studies have estimated that the arthropathies of IBD occur in over 46% of the IBD population, there is a paucity of nursing literature concerning the extraintestinal manifestations of IBD and the role of nurses in patient care. Thus, the purpose of this article is to facilitate a greater understanding for nurses and nurse clinicians regarding the arthropathies associated with IBD including classifications, pathophysiology, diagnosis, and management.

Nurse Practitioners in the Emergency Department: Barriers and Facilitators for Role Implementation.

Emergency department (ED) wait times, length of stay, and overcrowding are common issues in developed health care systems in many countries. These ED issues are multifactorial in nature and require further evaluation in an attempt to provide consistent, adequate health care to each patient. Authors in countries, such as Australia and the United Kingdom, have attempted to address the concerns of increasing wait times, length of stay, and overcrowding by establishing nurse practitioners (NPs) into the ED who practice in domains traditionally dominated by physicians. Unfortunately, Canadian health care system leaders lack experience in implementing the unique role of the NP in the ED. In addition, emergency department fast track (FT) models have been studied and operationalized in Australia and the United States to streamline care for less acute patients. However, it is evident from review of the literature that NPs, in the Canadian health care system, are underutilized within FT units. Despite the fact that NPs have been practicing since the 1960s, there remains confusion by the public and even health care professionals about their role, scope of practice, and capabilities. The purpose of this article is to provide a greater understanding of the NP role in Canada with the intent to elucidate current barriers and facilitators to having NPs practice in the ED setting through appraisal of national and international literature sources. The article also illustrates how FT units streamline patient care and are suitable areas for NP practice within the ED. In addition, the authors describe how assessment, implementation, and evaluation of the role of NPs in the ED might be facilitated through the use of a Participatory Evidence-informed Patient-focused Process for Advanced practice nursing role development, implementation, and evaluation (PEPPA framework).