Is Liver Ultrasound Useful as Part of the Surveillance Strategy following Potentially Curative Colorectal Cancer Resection?

BACKGROUND: Optimal surveillance monitoring following curative resection of colorectal cancer remains unclear. Guidelines recommend computed tomography (CT)-based imaging for the initial 3 years following surgical intervention due to the high rates of local and distant recurrence. However, there is currently limited supporting evidence for this strategy. Our current follow-up practice is to offer annual interval abdominal ultrasound and abdominal/pelvis CT scans starting at 6 and 12 months with the sequence of radiological follow-up remaining at the discretion of each clinician. We aim to establish the additional diagnostic benefit of abdominal ultrasound to CT scans in colorectal cancer surveillance follow-up. METHODS: All patients who underwent colorectal resection with curative intent in our region during a single year were included. Patients were detected from a prospectively collected pathology database and supplemented retrospectively with patient demographics, imaging reports, and mortality data. RESULTS: A total of 243 patients (male n = 135, 55.6%) were included. There was a mortality rate of 31.3% over the study period. Patients who received abdominal ultrasound as their initial imaging modality (n = 64, 26.3%) were significantly older, had less severe disease, and a significantly lower mortality rate when compared to CT -patients (n = 148, 60.9%). All patients with new hepatic disease detected by ultrasound scans had their management discussed in multi-disciplinary team meetings before their next scheduled CT. CONCLUSION: In an era where cross-sectional imaging of colorectal cancer is commonplace, abdominal ultrasound offers additional benefit to CT as a postoperative imaging adjunct for the detection of hepatic disease recurrence.

Connecting patient experience, leadership, and the importance of involvement, information, and empathy in the care process.

To improve health outcomes, restore trust, and create a safe and healing environment for patients, the health system needs to shift from being disease, system, and provider focused to being patient centred. Drawing from a patient story, this article focuses on three aspects of the care process that have a significant impact on patient experience: involvement in care, information about treatment and care, and empathy and respect. It will also provide recommendations for leaders in how to become more patient centred and aligned to the LEADS competency framework.

No need to grow my resumé? Mentorship and the intersection of learning between emerging and established leaders.

Active ongoing learning is a foundational expectation of every healthcare leader whether at the beginning or end of their career. In order for leaders to be nimble and responsive to the ongoing changes in the healthcare environment, they must actively engage in a multiplicity of learning activities. One way of ensuring diversity of learning is for emerging and established leaders to learn together through formal or informal mentoring. This article will explore that intersection and the value add of a reciprocal mentoring relationship where mentor and mentee roles become blurred and joint learning becomes the goal. Capabilities from the LEADS in a Caring Environment framework will be drawn upon, and a challenge is suggested for experienced leaders to go beyond resumé building and invest in emerging leaders, as ultimately it is an investment in their own learning and the future.

Examining markers of safety in homecare using the international classification for patient safety.

BACKGROUND: Homecare is a growth enterprise. The nature of the care provided in the home is growing in complexity. This growth has necessitated both examination and generation of evidence around patient safety in homecare. The purpose of this paper is to examine the findings of a recent scoping review of the homecare literature 2004-2011 using the World Health Organization International Classification for Patient Safety (ICPS), which was developed for use across all care settings, and discuss the utility of the ICPS in the home setting. The scoping review focused on Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF); two chronic illnesses commonly managed at home and that represent frequent hospital readmissions. The scoping review identified seven safety markers for homecare: Medication mania; Home alone; A fixed agenda in a foreign language; Strangers in the home; The butcher, the baker, the candlestick maker; Out of pocket: the cost of caring at home; and My health for yours: declining caregiver health. METHODS: The safety markers from the scoping review were mapped to the 10 ICPS high-level classes that comprise 48 concepts and address the continuum of health care: Incident Type, Patient Outcomes, Patient Characteristics, Incident Characteristics, Contributing Factors/Hazards, Organizational Outcomes, Detection, Mitigating Factors, Ameliorating Actions, and Actions Taken to Reduce Risk. RESULTS: Safety markers identified in the scoping review of the homecare literature mapped to three of the ten ICPS classes: Incident Characteristics, Contributing Factors, and Patient Outcomes. CONCLUSION: The ICPS does have applicability to the homecare setting, however there were aspects of safety that were overlooked. A notable example is that the health of the caregiver is inextricably linked to the wellbeing of the patient within the homecare setting. The current concepts within the ICPS classes do not capture this, nor do they capture how care responsibilities are shared among patients, caregivers, and providers.

Home care safety markers: a scoping review.

Safety in home care is a new research frontier, and one in which demand for services continues to rise. A scoping review of the home care literature on chronic obstructive pulmonary disease and congestive heart failure was thus completed to identify safety markers that could serve to develop our understanding of safety in this sector. Results generated seven safety markers: (a) Home alone; (b) A fixed agenda in a foreign language; (c) Strangers in the home; (d) The butcher, the baker, the candlestick maker; (e) Medication mania; (f) Out of pocket: The cost of caring at home; and (g) My health for yours: Declining caregiver health.

Redesigning care delivery in British Columbia.

Phase 1 of this initiative was designed to examine the current state of practice in acute care and to provide administrators with research evidence for identifying areas for improvement. Data were collected through observational research using function analysis augmented by a staff survey and interviews. Data were collected from 17 acute care sites across Vancouver Island and the Mainland of British Columbia involving four health authorities.

Timing of urinary catheter removal after colorectal surgery with pelvic dissection: A systematic review and meta-analysis.

BACKGROUND: Urinary catheters are routinely placed before colorectal surgery. Enhanced recovery after surgery (ERAS) recommends their removal as soon as possible. However, premature removal risks urinary retention, and delayed removal increases risk of urinary tract infections (UTIs). This meta-analysis aims to synthesise the published literature on the optimal timing of urinary catheter removal following colorectal surgery with pelvic dissection. MATERIALS AND METHODS: The protocol for this meta-analysis is registered on PROSPERO (CRD42019150030).Pubmed, Ovid and Web of Science databases were searched (January 2020). Primary outcomes included urinary retention and catheter associated UTI. The intervention was removal of urinary catheter following colorectal surgery with pelvic dissection on postoperative days 1-2 (early); 3-4 (intermediate); or 5+ (late). Meta-analysis was performed using Comprehensive meta-analysis V2. RESULTS: Eight papers were analysed. 883 patients had early catheter removal, 236 intermediate and 204 late. Early catheter removal was associated with increased risk of urinary retention when compared to late removal RR = 2.352 95% CI = 1.370-4.038 (p = 0.002). No significant difference in urinary retention was found between early and intermediate or intermediate and late catheter removal groups. Early catheter removal was associated with reduced risk of UTIs compared to late removal RR = 0.498, 95% CI 0.306-0.811, (p = 0.005). No significant difference in UTIs was found between early and intermediate or intermediate and late catheter removal groups. CONCLUSIONS: Removal of urinary catheters on postoperative day 3-4 provides a balance between minimising the risks of urinary retention and UTIs. This analysis can be used to finesse future ERAS protocols concerning catheter removal in colorectal surgery involving pelvic dissection.

Hereditary sensory and autonomic neuropathy in a family of mixed breed dogs associated with a novel RETREG1 variant.

BACKGROUND: Hereditary sensory and autonomic neuropathies (HSANs) are a group of genetic disorders affecting the peripheral nervous system. Two different associated variants have been identified in dogs: 1 in Border Collies and 1 in Spaniels and Pointers. OBJECTIVES: Clinically and genetically characterize HSAN in a family of mixed breed dogs. ANIMALS: Five 7-month-old mixed breed dogs from 2 related litters were presented for evaluation of a 2-month history of acral mutilation and progressive pelvic limb gait abnormalities. METHODS: Complete physical, neurological, electrodiagnostic, and histopathological evaluations were performed. Whole genome sequencing of 2 affected dogs (1 from each litter) was used to identify variants that were homozygous or heterozygous in both cases, but wild type in 217 control genomes of 100 breeds. Immunohistochemistry was used to assess protein expression. RESULTS: Complete physical, neurological, electrodiagnostic, and histopathological evaluations confirmed a disorder affecting sensory and autonomic nerves. Whole genome sequencing identified a missense variant in the RETREG1 (reticulophagy regulator 1) gene (c.656C > T, p.P219L). All affected dogs were homozygous for the variant, which was not detected in 1193 dogs from different breeds. Immunohistochemistry showed no expression of RETREG1 in the cerebellum of affected dogs. One of the affected dogs lived for 5 years and showed gradual progression of the clinical signs. CONCLUSIONS AND CLINICAL IMPORTANCE: We confirmed the diagnosis of HSAN in a family of mixed breed dogs and identified a novel and possibly pathogenic RETREG1 variant. Affected dogs experienced gradual deterioration over several years.

Conditions underpinning success in joint service-education workforce planning.

Vancouver Island lies just off the southwest coast of Canada. Separated from the large urban area of Greater Vancouver (estimated population 2.17 million) by the Georgia Strait, this geographical location poses unique challenges in delivering health care to a mixed urban, rural and remote population of approximately 730,000 people living on the main island and the surrounding Gulf Islands. These challenges are offset by opportunities for the Vancouver Island Health Authority (VIHA) to collaborate with four publicly funded post-secondary institutions in planning and implementing responses to existing and emerging health care workforce needs. In this commentary, we outline strategies we have found successful in aligning health education and training with local health needs in ways that demonstrate socially accountable outcomes. Challenges encountered through this process (i.e. regulatory reform, post-secondary policy reform, impacts of an ageing population, impact of private, for-profit educational institutions) have placed demands on us to establish and build on open and collaborative working relationships. Some of our successes can be attributed to evidence-informed decision-making. Other successes result from less tangible but no less important factors. We argue that both rational and "accidental" factors are significant--and that strategic use of "accidental" features may prove most significant in our efforts to ensure the delivery of high-quality health care to our communities.

Enhancing ethical climates in nursing work environments.

In the current era of providing health care under pressure, considerable strain has been placed on nurses workplaces. Underneath the economic and organizational challenges prevalent in health-care delivery today are important values that shape the ethical climate in workplaces and affect the well-being of nurses, managers, patients and families. In this article, the authors report on the outcomes of Leadership for Ethical Policy and Practice, a three-year participatory action research study involving nurses, managers and other health-care team members in organizations throughout British Columbia. By using an ethics lens to look at problems, participants brought ethical concerns out into the open and were able to gain new insights and identify strategies for action to improve the ethical climate. Nurse leader support was essential for initiating and sustaining projects at six practice sites.

Home care safety perspectives from clients, family members, caregivers and paid providers.

There is a growing demand for home care services in Canada. Yet, overwhelmingly, research on patient safety has focused on institutional settings. The Canadian Patient Safety Institute convened a Core Safety in Home Care Team of researchers and decision-makers to identify priority research areas and to advance patient safety research in home care. As part of this initiative to investigate and extend our understanding of home care safety, key informant interviews were carried out with a wide range of respondents including researchers, decision-makers, service providers and regulators. In-depth audiotaped interviews were conducted in two Canadian provinces. Interpretive descriptive analyses revealed three main themes: the meaning of home care, safety concerns and the place of technology in the future of home care. Given the multidimensionality and complexity of home care as well as the challenges and strains involved, the risk to all the players is becoming increasingly evident.

Moving to a culture of safety in community home health care.

OBJECTIVE: Community home health care workers and their clients are faced with a mixture of occupational health and safety challenges that are not typically experienced by health care providers or patients in the acute care sector. The aim of this project was to explore the concept of safety in community home health in one health care authority in British Columbia. METHODS: A participatory action research approach was employed to explore staff and client safety risks in this environment. In the first phase, three focus groups were held with staff (n = 39) and the data analysed to identify themes. These were validated by additional focus groups. In the second phase, interviews were held with staff followed by chart reviews. Finally, in phase three, an interdisciplinary working group developed a risk identification tool for staff which was subsequently piloted. The exploration focused on answering the following questions: What constitutes safety in community home health care? What are the priority areas for action in relation to safety? What type of risk identification would be most helpful to community health workers to prepare them adequately to meet their clients' and their own safety needs? RESULTS: Risk themes identified included: poor communication, acute care staff not understanding the needs of community staff, working alone, mobility, medication concerns, lack of pre-screening of clients' homes, and community health workers accepting a high degree of risk. CONCLUSIONS: Findings suggest that typical notions of safety and risk in acute care are not easily translated into the community sector, that staff and clients' safety concerns are intertwined, and staff require better and more timely information from acute care staff when patients are discharged home.

Public Policy and Canadian Nursing: Lessons from the Field By Michael J. Villeneuve.

The recently released book Public Policy and Canadian Nursing: Lessons from the Field, by Michael J. Villeneuve, has been described as a "must read" by Gail Donner, professor emerita, Faculty of Nursing, University of Toronto, and by Kathleen Macmillan, professor and director of the School of Nursing at Dalhousie University. That is an excellent recommendation from two well-respected Canadian nurse leaders.

Disseminating Comparative Effectiveness Research Through Community-based Experiential Learning.

Objectives. To launch and evaluate a comparative effectiveness research education and dissemination program as part of an introductory pharmacy practice experience (IPPE). Methods. First- through third-year PharmD students received training on comparative effectiveness research and disseminated printed educational materials to patients in the community who they were monitoring longitudinally (n=314). Students completed an assessment and initial visit documentation form at the first visit, and a follow-up assessment and documentation form at a subsequent visit. Results. Twenty-three diabetes patients, 29 acid-reflux patients, 30 osteoarthritis patients, and 50 hypertension patients received materials. Aside from the patient asking questions, which was the most common outcome (n=44), the program resulted in 38 additional actions, which included stopping, starting, or changing treatments or health behaviors, or having additional follow-up or diagnostic testing. Small but positive improvements in patient understanding, confidence, and self-efficacy were observed. Conclusions. Dissemination of comparative effectiveness research materials in an IPPE program demonstrated a positive trend in markers of informed decision-making.

Scholar-in-Residence: An Organizational Capacity-Building Model to Move Evidence to Action.

Quality improvement healthcare leaders recognize that striving for excellence is dependent on a multitude of complex and interactive factors. Translating evidence into clinical practice guidelines, evidence-informed decision-making processes, and policy documents does not, however, guarantee that evidence will reach the point-of-care. This article describes an innovative engagement strategy called the Scholar-in-Residence program. The program represents a model of collaboration between a health region and a university, which is intended to build organizational research capacity while simultaneously facilitating quality in hospital care for seniors. We explain the program and provide implementation details with examples to illustrate how the program builds organizational research capacity at the point-of-care, where healthcare is delivered by professionals, and received by patients admitted to a hospital. By explaining the challenges we encountered, others interested in developing research engagement activities in their health region are assisted and pitfalls are avoided.

"Towering genius disdains a beaten path" Abraham Lincoln.

We see nursing leadership existing at all levels in nursing...all nurses leading. Nurse executives within academic health environments across Canada will be influencing health policy directions and dialogue within the profession nationally. They will be contributing to the development of a national agenda for nursing practice, education, research and leadership. These nurse executives will lead in a way that makes an invigorating impact on human service in health care environments and they will be dedicated to preparing the nursing leaders of tomorrow. The Academy of Canadian Executive Nurses will connect with the Office of Nursing Policy, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Association of Canadian Academic Health Care Organizations and others to develop position papers regarding key issues such as patient safety, health human resource planning and leadership in the Canadian health care system. Our definition of professional nursing practice, fully integrated with education and research, will be advanced through these endeavours. The end result of a strong individual and collective voice will be improved patient outcomes supported by professional nursing practice in positive practice environments. This paper is intended to stimulate dialogue among nursing leaders in Canada, dislodge us from a long and traditional path, and place us firmly in a new millennium of leadership for the profession and practice of nursing, a style of leadership that is needed, wanted and supported by nurses and the clients we serve. It is the responsibility of those of us who lead in academic health science centres to be courageous for the students we support, the puactitioners we lead and the renewal of the profession. We are the testing ground for nursing research, and need to be the source of innovation for nursing practice. It is incumbent on us to leap forward to engage a new vision of the professional practice of nursing with a reconfigured work design and work environment compatible with the new economy, workplace and workforce.

Ethics and safety in home care: perspectives on home support workers.

Home support workers (HSWs) encounter unique safety issues in their provision of home care. These issues raise ethical concerns, affecting the care workers provide to seniors and other recipients. This paper is derived from a subproject of a larger Canada-wide study, Safety at Home: A Pan-Canadian Home Care Safety Study, released in June 2013 by the Canadian Patient Safety Institute. Semi-structured, face-to-face, audiotaped interviews were conducted with providers, clients and informal caregivers in British Columbia, Manitoba and New Brunswick to better understand their perceptions of patient safety in home care. Using the BC data only, we then compared our findings to findings of other BC studies focusing on safety in home care that were conducted over the past decade. Through our interviews and comparative analyses it became clear that HSWs experienced significant inequities in providing home care. Utilizing a model depicting concerns of and for HSWs developed by Craven and colleagues (2012), we were able to illustrate the physical, spatial, interpersonal and temporal concerns set in the context of system design that emphasized the ethical dilemmas of HSWs in home care. Our data suggested the necessity of adding a fifth domain, organizational (system design). In this paper, we issue a call for stronger advocacy for home care and improved collaboration and resource equity between institutional care and community care.