Choosing Wisely: An idea worth sustaining.

OBJECTIVES: To evaluate the sustainability potential of Choosing Wisely (CW) to address unnecessary medical care at Ontario community hospitals. DATA SOURCES/STUDY SETTING: Ontario community hospitals and their affiliated family health teams (FHTs). STUDY DESIGN: A mixed-methods study involving the administration of a validated sustainability survey to CW implementation teams followed by their participation in focus groups. DATA COLLECTION/EXTRACTION METHODS: Survey data were collected using an Excel file with an embedded, automated scoring system. We collated individual survey scores and generated aggregate team scores. We also performed descriptive statistics for quantitative data (frequencies, means). Qualitative data were triangulated with quantitative assessments to support data interpretations using the meta-matrix method. PRINCIPAL FINDINGS: Fifteen CW implementation teams across four Ontario community hospitals and six affiliated primary care FHTs participated. CW priority areas investigated were de-prescribing of proton pump inhibitors (PPIs) and reducing Pre-Op testing and BUN/Urea lab testing. Survey results showed steady improvements in sustainability scores from baseline to final follow-up among most implementation teams: 10% increase for PPI de-prescribing (six FHTs) and 2% increase (three hospital teams); 18% increase in BUN/Urea lab testing (three hospital teams). Regardless of site or CW priority area, common facilitators were fit with existing processes and workflows, leadership support, and optimized team communication; common challenges were lack of awareness and buy-in, leadership engagement or a champion, and lack of fit with existing workflow and culture. All teams identified at least one challenge for which they co-designed and implemented a plan to maximize the sustainability potential of their CW initiative. CONCLUSIONS: Evaluating the sustainability potential of an innovation such as Choosing Wisely is critical to ensuring that they have the best potential for impact. Our work highlights that implementation teams can be empowered to influence implementation efforts and to realize positive outcomes for their health care services and patients.

Hip and Knee Replacement Patients' Experiences With an Orthopaedic Patient Navigator: A Qualitative Study.

Hip and knee replacement surgery is common, yet more than 10% of patients who undergo total hip replacement (THR) and total knee replacement (TKR) report postsurgery dissatisfaction. Recommendations for improving patient experience after total joint replacement surgery include increasing support to patients, including having a patient navigator available to patients before and after surgery. This article reports on THR and TKR patients' experiences of using an orthopaedic patient navigator. We employed qualitative description to understand THR and TKR patients' experiences of interacting with an orthopaedic patient navigator in a community teaching hospital. Telephone interviews were conducted with 15 purposefully selected total joint replacement patients (TKR: n = 11; THR: n = 4) who had at least one contact with the navigator. Interview transcripts were analyzed using thematic analysis. Patients described receiving physical support services, emotional support services, informational support services, and care coordination services from the patient navigator. All interactions with the patient navigator were positive. Knowing the patient navigator was available for any future concerns also provided indirect benefits of reassurance, comfort, and security. Patients described these direct and indirect benefits as potentially having long-lasting and resilient positive effects. An orthopaedic patient navigator can have a positive impact on patients' THR and TKR experience and fill gaps in support identified in earlier studies. Addressing patients' complex and varied care needs is well suited to a clinical nurse specialist in the role. Investing in an orthopaedic patient navigator provides reassurance to patients that their needs are a priority and will be addressed in a timely manner.

The impact of patient navigation on length of hospital stay and satisfaction in patients undergoing primary hip or knee arthroplasty.

BACKGROUND: Healthcare organizations are implementing innovative ways to deliver patient centered care, which includes the addition of the orthopedic nurse navigator role. PURPOSE: The purpose of this study was to examine length of hospital stay and patient satisfaction following the implementation of an orthopedic surgery CNS-patient navigator. METHODS: This prospective descriptive study (n = 226) examined length of stay, location of discharge, and readmission to hospital by reviewing the participants' electronic hospital record. Patient satisfaction was examined by telephone using the Patient Satisfaction with Interpersonal Relationship with Navigator scale, and generic health related quality of life and patient experience were measured by the howRu/howRwe scale. RESULTS: The mean length of hospital stay was 2.8 (±1.0), which was less than the provincial mean length of stay for the same time period. The majority of participants were discharged to home, and only 1.3% of participants were readmitted to the same hospital within 30 days following discharge. All participants were satisfied with the care they received from the navigator, and reported a positive patient experience and health related quality of life. CONCLUSION: The mean length of stay in our hospital was lower than the provincial mean. Participants were satisfied with the care provided by the navigator.

Using Simulation to Enhance Education Regarding Epidural Analgesia for Registered Nurses.

BACKGROUND: Registered nurses (RNs) receive didactic training regarding caring for patients receiving epidural analgesia. Although RNs are tested on their knowledge after this training, their ability to critically think through adverse events has not been assessed at our institution. AIM: The aim of this study was to examine the feasibility and effectiveness of simulation education for RNs regarding the assessment and management of patients receiving epidural analgesia. METHOD: The study included an education intervention, which consisted of a 4-hour workshop. After obtaining informed consent, RNs completed a preworkshop evaluation of skill performance where they completed an Objective Structured Clinical Examination (OSCE) in which they demonstrated an epidural assessment of a standardized patient. RNs then completed a demographic and knowledge questionnaire followed by a lecture regarding care, management, and assessment of patients who are receiving epidural analgesia. After the lecture, RNs practiced epidural assessments within small groups. A postworkshop OSCE, questionnaire, and debriefing were completed before the end of the workshop. RESULTS: Thirty-seven RNs completed the workshop. The mean age of participants was 43 years. For the pre- and postworkshop knowledge questionnaire, there was significant improvement in answers related to epidural pharmacology and assessment of blockade questions. For the pre- and postworkshop OSCE, there was a significant increase in the number of correct procedures performed in all categories, with the exception of assessment of equipment. There was also a significant change in the proportion of RNs who stated that they felt confident in their assessment of a patient receiving epidural analgesia.