Energizing scholarly activity in a regional medical campus.

Medical education is increasingly delivered at distributed sites away from Academic Health Sciences Centres. The Council of Ontario Faculties of Medicine recommends schools develop resources and metrics to foster regional campus scholarly activity. Opportunities for distributed program trainees must support learning core skills in research and critical appraisal to comply with medical school accreditation standards and to develop their interests and skills in scholarly work for their future medical careers. We describe a scholarly activity program that is a template for distributed campuses or regional teaching sites seeking to increase learner and faculty engagement and research productivity.

La formation médicale décentralisée se déroule de plus en plus souvent loin des centres universitaires de sciences de la santé. Le Conseil des facultés de médecine de l'Ontario recommande aux facultés de se doter de ressources et de indicateurs pour encourager les activités d'érudition sur les campus régionaux. Les possibilités offertes aux stagiaires des programmes décentralisés doivent favoriser l'apprentissage des habiletés de base en recherche et en lecture critique pour se conformer aux normes d'agrément des facultés de médecine et développer des intérêts et des habiletés en érudition qui leur seront utiles dans leur carrière médicale. Nous décrivons un programme d'activités d'érudition qui peut servir de modèle pour les milieux de formation décentralisés ou les sites d'enseignement régionaux souhaitant stimuler la productivité scientifique et l'implication des apprenants et du corps professoral dans la recherche.

Exploring Changes in Patient Safety Incidents During the COVID-19 Pandemic in a Canadian Regional Hospital System: A Retrospective Time Series Analysis.

OBJECTIVES: The COVID-19 pandemic has placed unprecedented strain on healthcare systems and may have consequential impacts on patient safety incidents (PSIs). The primary objective of this study was to examine the impact of the COVID-19 pandemic on PSIs reported in Niagara Health. METHODS: Flexible Farrington models were used to retrospectively detect weeks from January to September 2020 where PSI counts were significantly above expected counts. Incident counts were adjusted to weekly inpatient-days. Outcomes included overall incident numbers, incidents by category, and incidents by ward type. RESULTS: The overall number of PSIs across Niagara Health did not increase during the first wave of the COVID-19 pandemic. However, significant increases in falls were observed, suggesting that other types of incidents decreased. Falls increased by 75% from February to March 2020, coinciding with the onset of the first wave of the pandemic. Further investigation by unit type revealed that the number of falls increased specifically on internal medicine and complex continuing care wards. CONCLUSIONS: Despite no observed changes in overall number, significant composition shifts in PSIs occurred during the first wave of the COVID-19 pandemic, with increased falls on internal medicine and complex continuing care wards. Possible explanations include restrictions on patient visitation, reduced patient contact/supervision, and/or personal protective equipment requirements. Providers should maintain a particularly high vigilance for patient falls during pandemic outbreaks, and hospitals should consider targeting resources to higher-risk locations. The results of this study reinforce the need for ongoing pandemic PSI monitoring and rapidly adaptive responses to new patient safety concerns.

Improving patient flow in a regional anaesthesia block room.

University Hospital is a tertiary academic centre in London, Ontario, Canada. A designated space known as the block room (BR) supports a model of care to perform regional anaesthesia prior to entering the resource intense operating room (OR). Stress due to time pressure was reported by BR staff. It was presumed that upstream delays in patient admission, preparation, transportation and in the BR resulted in late OR starts. There was limited data for a patient's preoperative transit at our institution. A prospective quality improvement project was conceived to understand and address concerns surrounding patient flow. Using Plan-Do-Study-Act (PDSA) methodology, we collected baseline data of patients perioperative transit and performed three PDSA cycles for improvement. We established targets for OR entry time and patient arrival to the BR. We examined communication between the surgical preparation unit, BRandORs, involved stakeholders in decision making and continuously sourced feedback for improvement. Over three incremental rapid PDSA cycles and reaudit of our baseline, we found a statistically significant improvement in patients arriving to the BR 60 min prior to the scheduled OR time from a baseline of 31%-53% (p=0.04) and patient operations commencing on time improved from 52% to 65% (p=0.03). The availability of patients in the BR within 15 min of a decision to have them available reached 98% from a baseline of 69% (p<0.001). As a result of the quality improvement process, we were able to significantly improve the flow of the preoperative patient journey at our institution. With a better understanding of complex preoperative processes, we can strategically intervene and potentially improve efficiency, morale and safety.

A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative.

Hospital-acquired pressure injuries (HAPI) are a significant cause of morbidity and mortality, and represent a major health concern worldwide. Patients suffering from HAPI report a poor quality of life on several dimensions of health. Moreover, HAPI is reported to lengthen in-hospital stay in the acute setting, posing significant healthcare resource utilisations and costs. Given the clinical and economic burden of HAPI, recent best practice guidelines provide recommendations to reduce the prevalence of pressure injuries. Humber River Hospital (HRH), a large community hospital in Toronto, Canada, has a daily census of approximately 500 patients. The aim of this project was to reduce the prevalence of HAPI within the intensive care unit (ICU) and non-ICU setting at HRH within a 1-year period. Using the International Pressure Injury/Ulcer Prevalence (IPUP) Survey we established a baseline prevalence of HAPI of 27.6% (n=315) for non-ICU and 30% for ICU (n=33) patients at our institution in 2015. Using the Plan-Do-Study-Act (PDSA) method for quality improvement, we implemented a multifaceted approach aimed at improving equipment, digital documentation and education on risk assessment, prevention and treatment strategies. Over multiple PDSA cycles, our prevalence of HAPI reduced to 16% for non-ICU patients with no changes to the HAPI prevalence in ICU patients in 2016. Sustainability continues with HAPI prevalence currently at 10% in 2017 for non-ICU patients, which outperforms the Canadian prevalence (13.7%) by census size for 2017. However, the prevalence of HAPI in the ICU increased to 45% in 2017 despite multiple quality improvement initiatives, suggesting critically ill patients represent a unique challenge for reducing HAPI for these patients at our institution.

Reducing inappropriate ESR testing with computerized clinical decision support.

Laboratory test overutilization increases health care costs, leads to unwarranted investigations, and may have a negative impact on health outcomes. The American Society of Clinical Pathology, in its Choosing Wisely Campaign, advocates that inflammation be investigated with C-reactive protein (CRP) instead of Erythrocyte Sedimentation Rate (ESR). London Health Sciences Centre (LHSC), a tertiary care hospital organization in Ontario, Canada, set a goal to reduce inappropriate ESR orders by 50%. After developing appropriateness criteria for ESR, we used a series of PDSA cycles to reduce inappropriate ESR ordering and analyzed our results with an interrupted time series design. Our intervention began with an educational bulletin and moved to city-wide implementation of computerized Clinical Decision Support (CDS). After implementation, ESR orders decreased by 40% from 386 orders per week to 241 orders per week. Our results are supported by previous literature on the effectiveness of CDS in reducing overutilization and suggest that provider habit is a significant contributor to inappropriate ordering.

Pulmonary artery hypertension in formerly premature infants with bronchopulmonary dysplasia: clinical features and outcomes in the surfactant era.

BACKGROUND: Although abnormal pulmonary vascular structure and function in preterm infants with bronchopulmonary dysplasia may predispose infants to pulmonary artery hypertension, little is known about the characteristics and outcomes of bronchopulmonary dysplasia-associated pulmonary artery hypertension in the surfactant era. METHODS: We studied 42 premature infants (< 32 weeks of gestation) with bronchopulmonary dysplasia who were diagnosed as having pulmonary artery hypertension > or = 2 months after birth, between 1998 and 2006, at a median age of 4.8 months. Pulmonary artery hypertension was graded through echocardiography for all patients; 13 patients also underwent cardiac catheterization. RESULTS: Eighteen (43%) of 42 patients had severe pulmonary artery hypertension (systemic or suprasystemic right ventricular pressure). Among 13 patients who underwent catheterization, the mean pulmonary artery pressure was 43 +/- 8 mmHg and the pulmonary vascular resistance index was 9.9 +/- 2.8 Wood units. In 12 patients, pulmonary artery pressure and pulmonary vascular resistance improved with 100% oxygen and 80 ppm inhaled nitric oxide but remained elevated. The pulmonary vascular resistance index decreased to 7.9 +/- 3.8 Wood units in 100% oxygen and to 6.4 +/- 3.1 Wood units with the addition of nitric oxide. Sixteen patients (38%) died during the follow-up period. Estimated survival rates were 64% +/- 8% at 6 months and 53% +/- 11% at 2 years after diagnosis of pulmonary artery hypertension. In multivariate analyses, severe pulmonary artery hypertension and small birth weight for gestational age were associated with worse survival rates. Among 26 survivors (median follow-up period: 9.8 months), pulmonary artery hypertension was improved, relative to its most severe level, in 24 patients (89%). CONCLUSION: Premature infants with bronchopulmonary dysplasia and severe pulmonary artery hypertension are at high risk of death, particularly during the first 6 months after diagnosis of pulmonary artery hypertension.

Arithmetic processing in children with spina bifida: Calculation accuracy, strategy use, and fact retrieval fluency.

Three studies compared 98 children with spina bifida myelomeningocele (SBM)-a disorder associated with high rates of math disability and spatial deficits-to 94 typically developing children on multidigit subtraction and cognitive addition tasks. Children with SBM were classified into those with reading decoding and math disability, only math disability, and no reading or math disability. Study 1 showed that visual-spatial errors in multidigit arithmetic were not elevated in children with SBM. In Study 2, deficits in accuracy, speed, and strategy-use in single-digit addition characterized groups with math disability regardless of reading status. Accuracy and speed on single-digit addition was strongly related to performance on multidigit subtraction. A math-level matching design in Study 3 revealed less mastery of math facts by the group with SBM. The results are discussed with reference to cognitive and neuropsychological models of math disability.