Improving flow in the OR.

Purpose The purpose of this paper is to increase efficiency in ORs without affecting quality of care by improving the workflow processes. Administrative processes independent of the surgical act can be challenging and may lead to clinical impacts such as increasing delays. The authors hypothesized that a Lean project could improve efficiency of surgical processes by reducing the length of stays in the recovery ward. Design/methodology/approach Two similar Lean projects were performed in the surgery departments of two hospitals of the Centre Hospitalier Universitaire de Québec: Hôtel Dieu de Quebec (HDQ) and Hôpital de l'Enfant Jesus (HEJ). The HDQ project designed around a Define, Measure, Analyse, Improve and Control process revision and a Kaizen workshop focused on patients who were hospitalized in a specific care unit after surgery and the HEJ project targeted patients in a post-operative ambulatory context. The recovery ward output delay was measured retrospectively before and after project. Findings For the HDQ Lean project, wasted time in the recovery ward was reduced by 62 minutes (68 percent reduction) between the two groups. The authors also observed an increase of about 25 percent of all admissions made in the daytime after the project compared to the time period before the project. For the HEJ Lean project, time passed in the recovery ward was reduced by 6 min (29 percent reduction). Originality/value These projects produced an improvement in the flow of the OR without targeting clinical practices in the OR itself. They demonstrated that change in administrative processes can have a great impact on the flow of clinical pathways and highlight the need for comprehensive and precise monitoring of every step of the elective surgery patient trajectory.

EVALUATION OF THE SURGICAL TRAY OPENING PROCEDURE IN OPERATING SUITES: SYSTEMATIC REVIEW AND RECOMMENDATIONS.

INTRODUCTION: Optimizing the processes involved in managing operating suite activities is an essential element in obtaining gains in efficiency. The early opening of surgical trays could represent an innovative practice for reducing operating times and wait periods between surgeries as well as for increasing the number of daily surgeries. The purpose of this systematic review is to assess the risks and benefits of introducing this practice in the operating room. METHODOLOGY: A systematic literature review was conducted in various indexed databases as well as in the grey literature in order to identify synthesis studies, clinical guidelines and randomized and non-randomized studies on the impact of opening surgical trays early. The following indicators were sought: time lapse between the patient's entrance and the beginning of surgery, the frequency of surgical tray contamination, and the rate of surgical wound infection. RESULTS: An original study and four practice guides were included after a quality assessment. No studies on efficiency gains associated with the early opening of surgical trays were found. The results of the experimental study suggest that the contamination rate for uncovered surgical trays is low for the first 30 minutes (4%) and increases over time with exposure to the ambient air. Most clinical guidelines recommend preparing the surgical instruments as close to the beginning of surgery as possible without specifying the minimum time interval to be respected as well as whether or not the patient is in the operating room. DISCUSSION: The analysis- of all the available data does not make it possible to determine the optimal moment for opening the surgical trays. Given the uncertainty regarding the risks of infection, and the lack of data on the associated benefits, the decision to opt for a change in practice in the opening of surgical trays should be based on a range of factors. An assessment of the data therefore suggests caution and that a feasibility analysis, including a review of all processes and parameters for managing the risks associated with the early opening of surgical trays, be conducted before initiating any changes in the institutions where a change of practice is being sought.

Evaluation of patient involvement in a health technology assessment.

OBJECTIVES: We sought to evaluate patient involvement (consultation and direct participation) in the assessment of alternative measures to restraint and seclusion among adults in short-term hospital wards (in psychiatry) and long-term care facilities for the elderly. METHODS: We conducted individual semi-structured interviews with thirteen stakeholders: caregivers, healthcare managers, patient representatives, health technology assessment (HTA) unit members, researchers, and members of the local HTA scientific committee. Data were collected until saturation. We carried out content analysis of two HTA reports and four other documents that were produced in relation with this HTA. We also used field notes taken during formal meetings and informal discussions with stakeholders. We performed thematic analysis based on a framework for assessing patient involvement in HTA. We then triangulated data. RESULTS: For the majority of interviewees, patient consultation enriched the content of the HTA report and its recommendations. This also made it possible to suggest other alternatives that could reduce the use of restraint and seclusion and helped confirm some views and comments from healthcare professionals consulted in this HTA. The direct participation of patient representatives enabled rephrasing of some findings so as to bring the patient perspective to the HTA report. CONCLUSIONS: Patient consultation was seen as having directly influenced the content of the HTA report while direct participation made it possible to rephrase some findings. This is one of few studies to assess the impact of patient involvement in HTA and more such studies are needed to identify the best ways to improve the input of such involvement.

FRAMEWORK FOR USER INVOLVEMENT IN HEALTH TECHNOLOGY ASSESSMENT AT THE LOCAL LEVEL: VIEWS OF HEALTH MANAGERS, USER REPRESENTATIVES, AND CLINICIANS.

OBJECTIVES: The aim of this study was to explore stakeholders' points of views regarding the applicability and relevance of a framework for user involvement in health technology assessment (HTA) at the local level. We tested this framework in the context of the assessment of alternative measures to restraint and seclusion among hospitalized adults and those living in long-term-care facilities. METHODS: Twenty stakeholders (health managers, user representatives, and clinicians) from seven regions of Quebec participated in a semi-structured interview. A thematic analysis of the transcribed interviews was performed. RESULTS: The findings highlighted the relevance and applicability of the framework to this specific HTA. According to interviewees, direct participation of users in the HTA process allows them to be part of the decision-making process. User consultation makes it possible to consider the views of a wide variety of people, such as marginalized and vulnerable groups, who do not necessarily meet the requirements for participating in HTA committees. However, some user representatives emphasized that user consultation should be integrated into a more holistic and participatory perspective. The most frequent barrier associated with user involvement in HTA was the top-down health system, which takes little account of the user's perspective. CONCLUSIONS: The proposed framework was seen as a reference tool for making practitioners and health managers aware of the different mechanisms of user involvement in HTA and providing a structured way to classify and describe strategies. However, there is a need for more concrete instruments to guide practice and support decision making on specific strategies for user involvement in HTA at the local level.

[Patient participation in the assessment of alternatives to restraint and seclusion]. / La participation des patients à ;'évaluation des mesures alternatives à la contention et à l'isolement.

AIM: To explore the perceptions of members of a working group of caregivers, health technology assessment (HTA) units members, healthcare facilities managers and patients representatives regarding the participation of the latter in the assessment of alternatives to restraint and seclusion among adults in short-term psychiatric wards and in long-term care facilities for the elderly, in Quebec. METHODS: A descriptive design was used for this research based on fifteen semi-structured interviews with caregivers, healthcare managers, patient representatives and HTA unit members. The direct observation of two meetings of the working group and informal discussions with participants at these meetings was also performed. Data analysis was based on a framework developed to assess patients' involvement in HTA. RESULTS: Information resources and human resources were mobilized to support the participation of patients' representatives. Nevertheless, this participation was uneven between patients' representatives due to their personal characteristics, the understanding of their role in this working group and expectations of the committee. The presence of patient representatives led caregivers and managers to focus the assessment on patients' concerns and to adjust the language used during the meeting. Moreover, organizational and political context has been identified as a facilitator for this participation. CONCLUSION: Involving patients' representatives in HTA activities is thus possible. However, some resources must be mobilized to equip patients' representatives who participate in these activities and personal characteristics should be considered when selecting them to favour their involvement

Specimen plastic containers used to store expressed breast milk in neonatal care units: a case of precautionary principle.

Breast milk is the only milk that meets both the nutritional and immunitary needs of infants. Since breastfeeding is widely promoted, public health measures to preserve the nutritional qualities of expressed breast milk (EBM) should be applied in hospital care settings. The Health Technology Assessment Unit (HTAU) of the Centre hospitalier universitaire de Québec was requested by the Neonatal Care Unit to assess the acceptability of a plastic specimen container, designed to harvest tissues and body fluids, for storing collected EBM. An evidence-based public health perspective approach was taken to evaluate the safety of the specimen container. The HTAU recommended that plastic specimen containers no longer be used for storing EBM and that other options should be evaluated for neonatal care units. These recommendations are in accordance with the public health precaution principle and with legal considerations.

Involving patient in the early stages of health technology assessment (HTA): a study protocol.

BACKGROUND: Public and patient involvement in the different stages of the health technology assessment (HTA) process is increasingly encouraged. The selection of topics for assessment, which includes identifying and prioritizing HTA questions, is a constant challenge for HTA agencies because the number of technologies requiring an assessment exceeds the resources available. Public and patient involvement in these early stages of HTA could make assessments more relevant and acceptable to them. Involving them in the development of the assessment plan is also crucial to optimize their influence and impact on HTA research. The project objectives are: 1) setting up interventions to promote patient participation in three stages of the HTA process: identification of HTA topics, prioritization, and development of the assessment plan of the topic prioritized; and 2) assessing the impact of patient participation on the relevance of the topics suggested, the prioritization process, and the assessment plan from the point of view of patients and other groups involved in HTA. METHODS: Patients and their representatives living in the catchment area of the HTA Roundtable of Université Laval's Integrated University Health Network (covering six health regions of the Province of Quebec, Canada) will be involved in the following HTA activities: 1) identification of potential HTA topics in the field of cancer; 2) revision of vignettes developed to inform the prioritization of topics; 3) participation in deliberation sessions for prioritizing HTA topics; and 4) development of the assessment plan of the topic prioritized. The research team will coordinate the implementation of these activities and will evaluate the process and outcomes of patient involvement through semi-structured interviews with representatives of the different stakeholder groups, structured observations, and document analysis, mainly involving the comparison of votes and topics suggested by various stakeholder groups. DISCUSSION: This project is designed as an integrated approach to knowledge translation and will be conducted through a close collaboration between researchers and knowledge users at all stages of the project. In response to the needs expressed by HTA producers, the knowledge produced will be directly useful in guiding practices regarding patient involvement in the early phases of HTA.

Introducing the patient's perspective in hospital health technology assessment (HTA): the views of HTA producers, hospital managers and patients.

BACKGROUND: The recent establishment of health technology assessment (HTA) units in University hospitals in the Province of Quebec (Canada) provides a unique opportunity to foster increased participation of patients in decisions regarding health technologies and interventions at the local level. However, little is known about factors that influence whether the patient's perspective is taken into consideration when such decisions are made. OBJECTIVE: To explore the practices, perceptions and views of the various HTA stakeholders concerning patient involvement in HTA at the local level. METHOD: Data were collected using semi-structured interviews with 24 HTA producers and hospital managers and two focus groups with a total of 13 patient representatives. RESULTS: Patient representatives generally showed considerable interest in being involved in HTA. Our findings support the hypothesis that the patient perspective contributes to a more accurate and contextualized assessment of health technologies and produces HTA reports that are more useful for decision makers. They also suggest that participation throughout the assessment process could empower patients and improve their knowledge. Barriers to patient involvement in HTA at the local level are also discussed as well as potential strategies to overcome them. DISCUSSION AND CONCLUSION: This study contributes to knowledge that could guide interventions in favour of patient participation in HTA activities at the local level. Experimenting with different patient involvement strategies and assessing their impact is needed to provide evidence that will inform future interventions of this kind.

Involving patients in HTA activities at local level: a study protocol based on the collaboration between researchers and knowledge users.

BACKGROUND: The literature recognizes a need for greater patient involvement in health technology assessment (HTA), but few studies have been reported, especially at the local level. Following the decentralisation of HTA in Quebec, Canada, the last few years have seen the creation of HTA units in many Quebec university hospital centres. These units represent a unique opportunity for increased patient involvement in HTA at the local level. Our project will engage patients in an assessment being carried out by a local HTA team to assess alternatives to isolation and restraint for hospitalized or institutionalized adults. Our objectives are to: 1) validate a reference framework for exploring the relevance and applicability of various models of patient involvement in HTA, 2) implement strategies that involve patients (including close relatives and representatives) at different stages of the HTA process, 3) evaluate intervention processes, and 4) explore the impact of these interventions on a) the applicability and acceptability of recommendations arising from the assessment, b) patient satisfaction, and c) the sustainability of this approach in HTA. METHODS: For Objective 1, we will conduct individual interviews with various stakeholders affected by the use of alternatives to isolation and restraint for hospitalized or institutionalized adults. For Objective 2, we will implement three specific strategies for patient involvement in HTA: a) direct participation in the HTA process, b) consultation of patients or their close relatives through data collection, and c) patient involvement in the dissemination of HTA results. For Objectives 3 and 4, we will evaluate the intervention processes and the impact of patient involvement strategies on the recommendations arising from the HTA and the understanding of the ethical and social implications of the HTA. DISCUSSION: This project is likely to influence future HTA practices because it directly targets knowledge users' need for strategies that increase patient involvement in HTA. By documenting the processes and outcomes of these involvement strategies, the project will contribute to the knowledge base related to patient involvement in HTA.

Adaptation of clinical guidelines: literature review and proposition for a framework and procedure.

PURPOSE: The development and updating of high-quality clinical practice guidelines require substantial resources. Many guideline programmes throughout the world are using similar strategies to achieve similar goals, resulting in many guidelines on the same topic. One method of using resources more efficiently and avoiding unnecessary duplication of effort would be to adapt existing guidelines. The aim was to review the literature on adaptation of guidelines and to propose a systematic approach for adaptation of guidelines. DATA SOURCES: We selected and reviewed reports describing the methods and results of adaptation of guidelines from those found by searching Medline, Internet, and reference lists of relevant papers. On the basis of this review and our experience in guideline development, we proposed a conceptual framework and procedure for adaptation of guidelines. RESULTS: Adaptation of guidelines is performed either as an alternative to de novo guideline development or to improve guideline implementation through local tailoring of an international or national guideline. However, no validated process for the adaptation of guidelines produced in one cultural and organizational setting for use in another (i.e. trans-contextual adaptation) was found in the literature. The proposed procedure is a stepwise approach to trans-contextual adaptation, including searching for existing guidelines, quality appraisal, detailed analysis of the coherence between the evidence and the recommendations, and adaptation of the recommendations to the target context of use, taking into account the organization of the health care system and cultural context. CONCLUSIONS: Trans-contextual adaptation of guidelines is increasingly being considered as an alternative to de novo guideline development. The proposed approach should be validated and evaluated to determine if it can reduce duplication of effort and inefficient use of resources, although guaranteeing a high-quality product, compared with de novo development.

Endothelins regulate mediator production of rat tissue-cultured mucosal mast cells. Up-regulation of Th1 and inhibition of Th2 cytokines.

Mast cells have been shown to produce endothelin-1 (ET-1) and to express ET receptors. Thus, we postulated that ETs modulate mast cell mediator production in an autocrine manner. Rat tissue-cultured mast cells (RCMC-1) were incubated with exogenous ET-1 or ET-3, and beta-hexosaminidase release and TNF, IL-4, IL-10, IL-12, IL-13, macrophage inflammatory protein-1alpha (MIP-1alpha), and nitric oxide (NO) production were investigated. ET-1 and -3 induced the release of beta-hexosaminidase and TNF and of mRNA expression. An antagonist of the ET(B) receptor subtype abrogated ET-stimulated TNF release, although ET(A) and ET(B) receptors have been identified by immunocytochemistry. It is interesting that ET-1 and ET-3 inhibited (25-30%) mRNA expression of Th2-type cytokines (IL-4, IL-10, and IL-13) and increased IL-12 release (39% and 41%, respectively) without affecting MIP-1alpha and NO production. Thus, our data suggest that ETs may play an important role in modulating the cytokine network by regulating Th1/Th2 cytokine production by mast cells.