Acute Care Hospitals In Ontario Research Articles

Multiple case study of processes used by hospitals to select performance indicators: do they align with best practices?

Several health policy institutes recommend reducing the number of indicators monitored by hospitals to better focus on indicators most relevant to local contexts. To determine which indicators are the most appropriate to eliminate, one must understand how indicator selection processes are undertaken. This study classifies hospital indicator selection processes and analyzes how they align with practices outlined in the 5-P Indicator Selection Process Framework. This qualitative, multiple case study examined indicator selection processes used by four large acute care hospitals in Ontario, Canada. Data were collected through 13 semistructured interviews and document analysis. A thematic analysis compared processes to the 5-P Indicator Selection Process Framework. Two types of hospital indicator selection processes were identified. Hospitals deployed most elements found within the 5-P Indicator Selection Process Framework including setting clear aims, having governance structures, considering indicators required by health agencies, and categorizing indicators into strategic themes. Framework elements largely absent included: adopting evidence-based selection criteria; incorporating finance and human resources indicators; considering if indicators measure structures, processes, or outcomes; and engaging a broader set of end users in the selection process. Hospitals have difficulty in balancing how to monitor government-mandated indicators with indicators more relevant to local operations. Hospitals often do not involve frontline managers in indicator selection processes. Not engaging frontline managers in selecting indicators may risk hospitals only choosing government-mandated indicators that are not reflective of frontline operations or valued by those managers accountable for improving unit-level performance.

Addressing Driving in Acute Care: Perceived Relevance and Competence.

Background. Recent legislation has expanded the responsibilities of occupational therapists regarding fitness to drive in the Canadian province of Ontario. To date, little is known about the practice of acute care occupational therapy with addressing driving, or how such responsibilities have affected clinical practice. Purpose. The objective of this study was to understand the relevance of driving-related knowledge areas to acute care occupational therapists and examine their self-reported competency for these areas. Method. Anonymous online surveys were administered to 41 occupational therapists working in acute care hospitals in Ontario. Findings. Therapists reported many driving-related knowledge areas are relevant to acute care practice yet consistently reported lower levels of competence for addressing such areas. Implications. Findings support the need for further competency development regarding driving-related practice in acute care. Occupational therapy curriculum and continuing education initiatives are avenues for capacity-building. Future research to identify effective competency development strategies is warranted.

Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals.

Patient experience when transitioning home from hospital is an important quality metric linked to improved patient outcomes. We evaluated the impact of a hospital-based care transition intervention, patient-oriented discharge summary (PODS), on patient experience across Ontario acute care hospitals. We used a repeated cross-sectional study design to compare yearly positive (top-box) responses to four questions centered on discharge communication from the Canadian Patient Experience Survey (2016-2020) among three hospital cohorts with various levels of PODS implementation. Generalized Estimating Equations using a binomial likelihood accounting for site level clustering was used to assess continuous linear time trends among cohorts and cohort differences during the post-implementation period. This research had oversight from a public advisory group of patient and caregiver partners from across the province. 512,288 individual responses were included. Compared to non-implementation hospitals, hospitals with full implementation (>50% discharges) reported higher odds for having discussed the help needed when leaving hospital (OR = 1.18, 95% CI = 1.02-1.37) and having received information in writing about what symptoms to look out for (OR = 1.44, 95% = 1.17-1.78) post-implementation. The linear time trend was also significant when comparing hospitals with full versus no implementation for having received information in writing about what symptoms to look out for (OR = 1.05, 95% CI = 1.01-1.09). PODS implementation was associated with higher odds of positive patient experience, particularly for questions focused on discharge planning. Further efforts should center on discharge management, specifically: understanding of medications and what to do if worried once home.

Abstract WMP54: Stroke Secondary Prevention Care In Persons With Schizophrenia

Introduction: Schizophrenia is associated with stroke incidence and case-fatality but the causes of this are not well-understood. We evaluated the association between comorbid schizophrenia and the quality of secondary prevention care after ischemic stroke. Methods: We used linked health administrative data to identify adults discharged alive from acute care hospitals in Ontario, Canada between 2004 and 2017 following an incident ischemic stroke and identified those with a history of schizophrenia using a validated algorithm. Outcomes were screening, treatment among those with the risk factor, control of vascular risk factors, and receipt of outpatient physician services. We used modified Poisson regression to model the relative risk of each indicator outcome among persons with and without schizophrenia who were alive one year after discharge, adjusting for age, sex, income, comorbidity and rural residence. Results: Among 85,046 persons with ischemic stroke, 886 (1.04%) had a diagnosis of schizophrenia. Those with schizophrenia were younger (median age 64 vs 72), more likely to be female (50.1% vs 44.6%), live in the lowest neighbourhood income quintile (41.1% vs 23.0%) and have diabetes (42.8% vs 32.3%). Of those alive 1 year after stroke, those with schizophrenia were less likely to be screened for hyperlipidemia (adjusted relative risk (aRR) 0.89; 95% confidence interval (CI) 0.84 to 0.94) or diabetes (aRR 0.93; 95% CI 0.89 to 0.97), be prescribed antihypertensive agents (aRR 0.96; 95% CI 0.93 to 0.99), or achieve target lipid levels (LDL < 2 mml/L) (aRR 0.87; 95% CI 0.78 to 0.96). There were no differences in prescription of antilipemic (aRR 0.96; 95% CI 0.91 to 1.01) or antiglycemic (aRR 0.95; 95% CI 0.87 to 1.03) agents or in achievement of target HbA1c ≤ 7% (aRR 0.89; 95% CI 0.78 to 1.02). Outpatient stroke specialist care in the 3 months after discharge was less likely among those with schizophrenia (aRR 0.72; 95% CI 0.65 to 0.78) as were visits to primary care physicians (aRR 0.93; 95% CI 0.91 to 0.96). Conclusions: People with schizophrenia and stroke are less likely to receive secondary preventive care across many indicators measured. This information may be useful for targeted interventions to improve post-stroke care in those with schizophrenia.

Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study.

Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.

422. Sustainability of Improvements to Hand Hygiene Performance Throughout the COVID-19 Pandemic

BackgroundHand hygiene (HH) is a standard infection prevention and control precaution to be applied in healthcare settings to prevent transmission of COVID-19. Many healthcare institutions observed significant improvements in HH performance during wave one of the COVID-19 pandemic but the sustainability of this change is unknown. Our aim was to evaluate long-term HH performance throughout subsequent waves of the pandemic across acute care hospitals in Ontario, Canada. MethodsHH adherence was measured using a previously validated group electronic monitoring system which was installed on all alcohol handrub and sink soap dispensers inside and outside each patient room across 56 inpatient units (35 wards and 21 critical care units) spanning 13 acute care hospitals (6 university and 7 community teaching hospitals) from 1 November 2019 to 31 May 2021. Daily HH adherence was compared with daily COVID-19 case count across Ontario. During this period, weekly performance continued to be reported to units but unit-based quality improvement discussions were inconsistent due to the COVID-19 response. ResultsFigure 1 depicts daily aggregate HH adherence plotted against the new daily COVID-19 case count across Ontario. An elevation in HH adherence was seen prior to the start of the first wave, rising almost to 80% and then remained above 70% for the peak of wave one. During waves two and three, peak COVID-19 case counts were associated with a maximum HH adherence of 51%, only marginally above the pre-pandemic baseline. After the end of wave one (from 1 July 2020 to 31 May 2021) the median HH performance was only 49% (interquartile range 47%-50%). Figure 1. Hand hygiene adherence across 13 acute care hospitals in comparison to overall new daily COVID-19 cases in Ontario ConclusionInitial improvements in HH adherence preceding the start of the COVID-19 pandemic were not sustained, possibly due to increasing comfort and reduced anxiety associated with providing care to COVID-19 patients leading to a perception of reduced COVID-19 transmission risk. These findings highlight the need for HH monitoring to be tied to longitudinal unit-led quality improvement in order to achieve durable changes in practice. Disclosures Susy S. Hota, MSc MD FRCPC, Finch Therapeutics (Research Grant or Support) Susy S. Hota, MSc MD FRCPC, Finch Therapeutics (Individual(s) Involved: Self): Grant/Research Support

\u201cShe knows me best\u201d: a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure

BackgroundPatients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge.MethodsA qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes.ResultsInterviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care.ConclusionsPatients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity.

The Comparison of Role Conflict Among Registered Nurses and Registered Practical Nurses Working in Acute Care Hospitals in Ontario Canada.

ObjectivesThe study aimed to describe and compare nurses’ perceptions of role conflict by professional designation [registered nurse (RN) vs registered practical nurse (RPN)] in three primary areas of practice (emergency department, medical unit, and surgical unit).MethodsThis analysis used data (n = 1,981) from a large cross-sectional survey of a random sample of RNs and RPNs working as staff nurses in acute care hospitals in Ontario, Canada. Role conflict was measured by the Role Conflict Scale.ResultsA total of 1,981 participants (RN = 1,427, RPN = 554) met this study’s eligibility criteria and provided complete data. In general, RN and RPN mean total scale scores on role conflict hovered around the scale’s mid-point (2.72 to 3.22); however, RNs reported a higher mean score than RPNs in the emergency department (3.22 vs. 2.81), medical unit (2.95 vs 2.81) and surgical unit (2.90 vs 2.72). Where statistically significant differences were found, the effect sizes were negligible to medium in magnitude with the largest differences noted between RNs and RPNs working in the emergency department.ConclusionsThe results suggest the need to implement strategies that diminish role conflict for both RNs and RPNs.

Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial

Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF. We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death. Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation. This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study

Background: The current approach to measuring hand hygiene (HH) relies on human auditors who capture &lt;1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Our goal was to assess the impact of group electronic monitoring coupled with unit-led quality improvement on HH performance and prevention of healthcare-associated transmission and infection. Methods: A stepped-wedge cluster randomized quality improvement study was undertaken across 5 acute-care hospitals in Ontario, Canada. Overall, 746 inpatient beds were electronically monitored across 26 inpatient medical and surgical units. Daily HH performance as measured by group electronic monitoring was reported to inpatient units who discussed results to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (%) between baseline and intervention. Secondary outcomes included transmission of antibiotic resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. Results: After adjusting for the correlation within inpatient units, there was a significant overall improvement in HH adherence associated with the intervention (IRR, 1.73; 95% CI, 1.47–1.99; P &lt; .0001). Monthly HH adherence relative to the intervention increased from 29% (1,395,450 of 4,544,144) to 37% (598,035 of 1,536,643) within 1 month, followed by consecutive incremental increases up to 53% (804,108 of 1,515,537) by 10 months (P &lt; .0001). We identified a trend toward reduced healthcare-associated transmission of MRSA (0.74; 95% CI, 0.53–1.04; P = .08). Conclusions: The introduction of a system for group electronic monitoring led to rapid, significant, and sustained improvements in HH performance within a 2-year period.Funding: NoneDisclosures: None

The occurrence and timing of delirium in acute care hospitalizations in the last year of life: A population-based retrospective cohort study

Background: Delirium is a distressing neurocognitive disorder that is common among terminally ill individuals, although few studies have described its occurrence in the acute care setting among this population. Aim: To describe the prevalence of delirium in patients admitted to acute care hospitals in Ontario, Canada, in their last year of life and identify factors associated with delirium. Design: Population-based retrospective cohort study using linked health administrative data. Delirium was identified through diagnosis codes on hospitalization records. Setting/participants: Ontario decedents (1 January 2014 to 31 December 2016) admitted to an acute care hospital in their last year of life, excluding individuals age of <18 years or >105 years at admission, those not eligible for the provincial health insurance plan between their hospitalization and death dates, and non-Ontario residents. Results: Delirium was recorded as a diagnosis in 8.2% of hospitalizations. The frequency of delirium-related hospitalizations increased as death approached. Delirium prevalence was higher in patients with dementia (prevalence ratio: 1.43; 95% confidence interval: 1.36–1.50), frailty (prevalence ratio: 1.67; 95% confidence interval: 1.56–1.80), or organ failure–related cause of death (prevalence ratio: 1.23; 95% confidence interval: 1.16–1.31) and an opioid prescription (prevalence ratio: 1.17; 95% confidence interval: 1.12–1.21). Prevalence also varied by age, sex, chronic conditions, antipsychotic use, receipt of long-term care or home care, and hospitalization characteristics. Conclusion: This study described the occurrence and timing of delirium in acute care hospitals in the last year of life and identified factors associated with delirium. These findings can be used to support delirium prevention and early detection in the hospital setting.

InterRAI Acute Care Instrument for Seniors in Canadian Hospitals: Findings of an Inter-Rater Reliability Pilot Study.

Older adults are the biggest users of emergency departments and hospitals. However, healthcare professionals are often ill equipped to conduct comprehensive geriatric assessments causing missed opportunities for preventing adverse outcomes. To evaluate the inter-rater reliability of the interRAI Acute Care (AC) instrument for hospitalized older adults in two acute care hospitals in Ontario, Canada. This descriptive study focused on evaluating the interRAI AC instrument, which was designed to facilitate a comprehensive nursing assessment for hospitalized seniors. Sample characteristics were described, and Cohen's Kappa was calculated to derive the inter-rater reliability. Assessment times to complete the instrument were collected as well. The Cohen's Kappa score for the instrument was 0.96. Many older adults who were interviewed had several challenges, including multimorbidity, polypharmacy, and lack of home support. The average time required for nurses to complete the interRAI AC instrument was 22 min. The interRAI AC instrument is reliable for use by trained nurses to conduct a comprehensive assessment. This instrument offers a standardized and efficient approach to assess for care and intervention priorities and could prevent adverse outcomes in hospitalized older adults.

Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study.

The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Group electronic monitoring is a validated method of measuring HH adherence, but data demonstrating the clinical impact of this technology are lacking. A stepped-wedge cluster randomized quality improvement study was performed on 26 inpatient medical and surgical units across 5 acute care hospitals in Ontario, Canada. The intervention involved daily HH reporting as measured by group electronic monitoring to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (percentage) between baseline and intervention. Secondary outcomes included transmission of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. After adjusting for the correlation within inpatient units and hospitals, there was a significant overall improvement in HH adherence associated with the intervention (incidence rate ratio [IRR], 1.73 [95% confidence interval {CI}, 1.47-1.99]; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1 395 450/4 544 144) to 37% (598 035/1 536 643) within 1 month, followed by consecutive incremental increases up to 53% (804 108/1 515 537) by 10 months (P < .0001). There was a trend toward reduced healthcare-associated transmission of MRSA (IRR, 0.74 [95% CI, .53-1.04]; P = .08). The introduction of a system for group electronic monitoring led to rapid, significant improvements in HH performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of HH.

Do hospital size, location, and teaching status matter? Role of context in the use of evidence-based discharge practices

ABSTRACT Background: In the manufacturing and service-sector industries, organizational characteristics associated with the use of innovation are well studied. This same study has not been applied to hospitals. The objective of this study was to find out whether size, location or teaching status have a relationship to the use of evidence-based hospital discharge practices. These practices were defined by Project RED (Re-Engineered Discharge), a set of practices which have been significantly associated with improved patient and hospital outcomes. Methods: A survey measuring the use of evidence-based discharge practices, based on Project RED, was administered to all 143 acute care hospitals in Ontario, Canada and 79 hospitals responded (55% participation rate). Multiple regression analysis was used to examine the relationship between survey score and the hospitals’ location, size, and teaching status. Results: This study found that smaller hospitals in rural locations had significantly greater use of evidence-based discharge practices. Teaching status was not found to be significantly related to the use of these practices. Conclusion: There is a need to investigate how the characteristics of size and location influence the uptake of evidence-based practices. Smaller hospitals may benefit from fewer levels of management, and more direct communication between staff, physicians, and managers.

Factors Associated With Intent to Leave in Registered Nurses Working in Acute Care Hospitals: A Cross-Sectional Study in Ontario, Canada.

Background: The work environment factors associated with nurses' intention to leave their jobs are not well understood because most studies have used non-probabilistic sampling methods, thus restricting the generalizability of the results. This study examined the relationship between work environment factors and intent to leave among nurses working in acute care hospitals in Ontario, Canada. Methods: This study included a random sample of 1,427 registered nurses who were part of a larger cross-sectional study and who responded to a mailed survey that included measures of resource availability, interprofessional collaboration, job satisfaction, and demographics. Results: Most of the respondents were female (94.8%), with an average age of 45.6 years, and 14.5 years of nursing experience at their current workplace, which included mostly urban (94.6%) and non-teaching hospitals (61.8%). In the multivariate model, we observed that the work environment variables explained 45.5% of the variance in nurses' intent to leave scores, F(9, 1362) =125.41, p < .01, with an R2 of .455 or 45.5%. Job satisfaction (p < .01), flexible interprofessional collaborative relationships (p = .030), and resource availability (p < .01) were significantly associated with nurses' intent to leave scores. Conclusion/Application to Practice: Nurses who reported greater job satisfaction, flexible interprofessional relationships, and resource availability were less likely to express an intent to leave their hospital workplaces. Employers and health policy makers may use these findings as part of a broader strategy to improve the work environment of nurses. Occupational health nurses are ideally positioned to demonstrate leadership in promoting retention efforts in the workplace by advocating for the importance of job satisfaction, flexible interprofessional relationships, and resources.

Infection prevention and control practices related to carbapenemase-producing Enterobacteriaceae (CPE) in acute-care hospitals in Ontario, Canada.

To determine infection prevention and control (IPAC) practices for carbapenemase-producing Enterobacteriaceae (CPE), an emerging threat, at acute-care hospitals in Ontario, Canada. A descriptive cross-sectional survey. We surveyed IPAC directors and managers at all acute-care hospitals in Ontario, Canada, to gather information on IPAC practices related to CPE, including admission screening, other patient screening, environmental testing, use of precautions to prevent transmission, and outbreak management. Of 116 acute-care hospitals, 105 (91%) responded. Admission screening included patients previously colonized or infected with CPE (n = 64, 61%), patients recently hospitalized outside of Canada (Indian subcontinent, n = 62, 59%; other countries, n = 56, 53%), and patients recently hospitalized in Canada (n = 22, 21%). Fifty-one hospitals (49%) screened patients for colonization during an outbreak. Almost all hospitals (n = 101, 96%) used precautions to prevent transmission from patients with CPE colonization or infection; most hospitals (n = 54, 53%) continued precautions indefinitely. Few hospitals (n = 19, 18%) performed environmental cultures. Eight hospitals (8%) reported at least 1 outbreak, and 6 hospitals (6%) reported transmission from sink or shower drains to patients. Variability in practices may result from lack of evidence and challenges in updating guidelines as evidence emerges. A coordinated approach to slow the emergence of CPE should be considered in our population.

The Relationships Between the Geriatric Practice Environment, Nursing Practice, and the Quality of Hospitalized Older Adults' Care.

To test the relationships between the geriatric practice environment, geriatric nursing practice, and overall quality of care for older adults and their families as reported by nurses working in hospitals, while controlling for nurse and hospital characteristics. A cross-sectional tailored survey design was employed. A questionnaire was mailed to a randomly selected sample of nurses whose primary practice area was medicine, surgery, geriatrics, emergency, or critical care in acute care hospitals in Ontario, Canada. Participants (N = 2,005) working in 148 hospitals responded to validated measures of the geriatric practice environment, geriatric nursing practice, overall quality of care for older adults and their families, and nurse and hospital characteristics. The relationships were tested using structural equation modeling. Controlling for nurse and hospital characteristics, the geriatric practice environment had a statistically significant positive relationship of large magnitude with both geriatric nursing practice (β = 0.52) and overall quality of care (β = 0.92); however, the indirect relationship between the geriatric practice environment and overall quality of care, mediated by geriatric nursing practice, was not significant (β = -0.02). Final model fit was acceptable, with the root mean square error of approximation = 0.07, comparative fit index = 0.93, and Tucker-Lewis Index = 0.87. A strong geriatric practice environment positively and directly influences geriatric nursing practice and overall quality of care for older adults and their families but does not appear to influence overall quality of care indirectly through geriatric nursing practice. The results can be used as the basis for promoting practice environments that support overall quality of care and geriatric nursing practice in acute care hospitals.

Assessing the impact of antibiotic stewardship program elements on antibiotic use across acute-care hospitals: an observational study.

Antibiotic use varies widely between hospitals, but the influence of antimicrobial stewardship programs (ASPs) on this variability is not known. We aimed to determine the key structural and strategic aspects of ASPs associated with differences in risk-adjusted antibiotic utilization across facilities. Observational study of acute-care hospitals in Ontario, Canada METHODS: A survey was sent to hospitals asking about both structural (8 elements) and strategic (32 elements) components of their ASP. Antibiotic use from hospital purchasing data was acquired for January 1 to December 31, 2014. Crude and adjusted defined daily doses per 1,000 patient days, accounting for hospital and aggregate patient characteristics, were calculated across facilities. Rate ratios (RR) of defined daily doses per 1,000 patient days were compared for hospitals with and without each antimicrobial stewardship element of interest. Of 127 eligible hospitals, 73 (57%) participated in the study. There was a 7-fold range in antibiotic use across these facilities (min, 253 defined daily doses per 1,000 patient days; max, 1,872 defined daily doses per 1,000 patient days). The presence of designated funding or resources for the ASP (RRadjusted, 0·87; 95% CI, 0·75-0·99), prospective audit and feedback (RRadjusted, 0·80; 95% CI, 0·67-0·96), and intravenous-to-oral conversion policies (RRadjusted, 0·79; 95% CI, 0·64-0·99) were associated with lower risk-adjusted antibiotic use. Wide variability in antibiotic use across hospitals may be partially explained by both structural and strategic ASP elements. The presence of funding and resources, prospective audit and feedback, and intravenous-to-oral conversion should be considered priority elements of a robust ASP.

The geographic distribution of tuberculosis and pyridoxine supply in Ontario.

Acute poisoning with isoniazid causes generalized convulsions which should be treated with intravenous pyridoxine and a rapidly-acting anticonvulsant. The purpose of this study was to determine the correlation between the distribution of tuberculosis (as a proxy for isoniazid use) and acute care hospital supplies of intravenous pyridoxine (the antidote for isoniazid overdose). The distribution of tuberculosis was based on Ontario public health regions. The study was descriptive using simple linear regression to assess the degree of correlation. Only 15.6% of Ontario acute care hospitals have enough intravenous pyridoxine to treat an average isoniazid overdose. The distribution of tuberculosis and the number of hospitals in the region correlated best with hospital supplies of pyridoxine, although these variables explained only 22% and 23.7%, respectively, of the variation in supply. It does not appear that the distribution of tuberculosis is a major determinant of the availability of the isoniazid antidote, pyridoxine. Acute care hospitals in Ontario should re-evaluate their need for pyridoxine in light of the incidence of tuberculosis in their regions. Each hospital should stock at least 5 Gm of intravenous pyridoxine; additional amounts may be appropriate if there is an increased incidence in the area.

"We are doing it together"; The integral role of caregivers in a patients' transition home from the medicine unit.

BackgroundAn admission to hospital for acute illness can be difficult for patients and lead to high levels of anxiety. Patients are given a lot of information throughout their hospital stay and instructions at discharge to follow when they get home. For complex medical patients, the ability to retain, understand, and adhere to these instructions is a critical marker of a successful transition. This study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions.MethodsA qualitative design of interviews with patients and caregivers was used. Participants were adult patients and caregivers with congestive heart failure, chronic obstructive pulmonary disease, or community-acquired pneumonia being discharged home from three academic acute care hospitals in Ontario, Canada. Semi structured interviews were conducted with participants within one week following their discharge from hospital. Interviews were audiotaped and transcribed. Five independent researchers participated in an iterative process of coding, reviewing, and analyzing the interviews using direct content analysis.ResultsIn total, 27 participants completed qualitative interviews. Analysis revealed the role of the caregiver to be critical in its relation to the ability of patients to understand and adhere to discharge instructions. Within the topic of caregiving, we draw on three areas of insight: The first clarified how caregivers support patients after they are discharged home from the hospital. The second highlighted how caregiver involvement impacts patient understanding and adherence to discharge instructions. The third revealed system factors that influence a caregiver’s involvement when receiving discharge instructions.ConclusionCaregivers play an important role in the transition of a complex medical patient by impacting a patient’s ability to understand and adhere to their discharge instructions. The themes identified in this paper highlight opportunities for healthcare providers and institutions to effectively involve caregivers during transitions from acute care hospitals to home.