Complex Health Systems Research Articles

Assessing Vaccination Delivery Strategies for Zero-Dose and Under-Immunized Children in the Fragile Context of Somalia.

Somalia is one of 20 countries in the world with the highest numbers of zero-dose children. This study aims to identify who and where zero-dose and under-vaccinated children are and what the existing vaccine delivery strategies to reach zero-dose children in Somalia are. This qualitative study was conducted in three geographically diverse regions of Somalia (rural/remote, nomadic/pastoralists, IDPs, and urban poor population), with government officials and NGO staff (n = 17), and with vaccinators and community members (n = 52). The data were analyzed using the GAVI Vaccine Alliance IRMMA framework. Nomadic populations, internally displaced persons, and populations living in remote and Al-shabaab-controlled areas are three vulnerable and neglected populations with a high proportion of zero-dose children. Despite the contextual heterogeneity of these population groups, the lack of targeted, population-specific strategies and meaningful engagement of local communities in the planning and implementation of immunization services is problematic in effectively reaching zero-dose children. This is, to our knowledge, the first study that examines vaccination strategies for zero-dose and under-vaccinated populations in the fragile context of Somalia. Evidence on populations at risk of vaccine-preventable diseases and barriers to vital vaccination services remain critical and urgent, especially in a country like Somalia with complex health system challenges.

The Potential and Challenges of A Unified Health System

The Covid-19 pandemic has claimed more than 700,000 victims in Brazil since 2020, putting the world’s largest public health system to the test. The Brazilian Unified Health System (SUS) has provided medicines, beds, rapid tests and laboratory surveillance free of charge, playing a significant role in tackling this health crisis. The current Brazilian Constitution, promulgated in 1988 and also known as the Citizen Constitution, for having extended essential rights to society, established a dynamic and complex health system, the Unified Health System (SUS).

The Application of Complexity Theory in Health and Social Care Research: A Scoping Review

Background: Complexity theory has been utilised by many researchers as an appropriate lens through which to examine health and care. Notwithstanding its potential value, many studies apply complexity theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.
 Objectives: This scoping review aimed to map and synthesise available research which has utilised complexity theory in health and social care settings. The research question was: “How has complexity theory been applied in health and social care research?”.
 Eligibility criteria: Qualitative and quantitative empirical research that utilised complexity theory informed approaches, published in English between 2012 and 2021.
 Sources of evidence: Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, The NHS Economic Evaluation Database (NHS EED), The Health Economic Evaluations Database (HEED). Additionally, a hand search of the reference lists of relevant articles was conducted.
 Charting methods: Data extraction was performed employing Covidence and a data extraction tool was created to produce a descriptive summary of the results, addressing the research question. The review employed the Arksey and O’Malley (2005) revised six-step framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).
 Results: A total of 2021 records were identified. 676 duplicate entries were removed before screening and a further 1108 did not meet the inclusion criteria. In total, 61 articles were subjected to data abstraction.
 Complexity theory was poorly defined and described and was frequently applied as a theoretical and analytical framework. Studies were predominantly hospital or health system focused and did not encompass the full continuum of care. Several studies used complexity theory within qualitative research to analyse and code data. The review also identified several case studies in which authors sought to understand a setting or service using a complexity-informed lens. Most publications originated in the United States and Canada. Complexity was applied in contexts where multi-disciplinary teams were involved, which has implications for managing the complexity of context. To perform research into complex systems in which power law distributions operate, there is a requirement to interpret the processes of dynamicity and that requires qualitative and longitudinal studies. There is also value in an abductive logic of inquiry, which allows for the interweaving and entanglement of previous evidence into a greater understanding of the whole complex adaptive system. It is recognised that engaging with complex systems requires theoretical and methodological pluralism so researchers should embrace a rich tapestry of approaches to develop a rich understanding of the complex health and care systems in which we work. As there is currently no definitive procedure for reporting such studies, the authors propose guidance to be interpreted and adapted to support the reporting of theoretically and methodologically divergent research.
 Conclusion: Heterogeneity was inherent in the empirical studies regarding the application of complexity theory. The authors provide guidance on conducting primary research which uses complexity theory as a conceptual, theoretical or analytical framework which seeks to promote rigor and transparency in the area.

Mapping Collaboration and Coordination of Health and Care Services for Older People with Dementia: A Scoping Review

Responsibility for health and care services for people with dementia is often divided between various professionals, agencies, and authorities, causing a fragmentation of care and an unclear division of responsibility between different stakeholders. In relation to this, collaboration and coordination of health and care services are often described as vital for catering to diverse needs and to provide adequate support. The aim of this scoping review was to map how different health and care agencies collaborate and coordinate services for older people with dementia. Joanna Briggs Institute’s proposed methodology for scoping reviews was used, and systematic searches were carried out in six databases. A total of 59 articles published within the last 10 years were included based on certain eligibility criteria. The Research Pyramid was used to critically appraise these articles, suggesting that available research is of moderate quality. The descriptive content analysis of the articles revealed eight categories describing the characteristics of collaboration and coordination for people with dementia, as presented in previous articles. These characteristics are described in terms of different barriers, the function of the care coordinator, assessment and planning to provide services, interprofessional collaboration, information sharing, knowledge needed to navigate a complex health and care system and understanding of dementia, and personalisation of care. Engaging care coordinators with diverse competencies to address both medical and social care needs is essential, especially since people with dementia experience multiple and complex needs. It is also important to explain and visualise available services and when these services are suitable for implementation. Knowledge about dementia is necessary to empower people with dementia in everyday life situations.

The impact of cognitive biases, mental models, and mindsets on leadership and change in the health system.

Understanding how cognitive biases, mental models, and mindsets impact leadership in health systems is essential. This article supports the notion of cognitive biases as flawed thinking or cognitive traps which negatively influence leadership. Mental models that do not fit with current evidence limit our ability to comprehend and respond to system issues. Resulting mindsets affect cognition, behaviour, and decision-making. Metacognition is critical. The wicked problems in today's complex health system require leaders and everyone involved to elevate their personal, organizational, and disciplinary perspectives to a systems level. Three examples of mental models/mindsets are reviewed. They do not change simply because we wish or will them to. The first step is being aware of what they are and how they impact our thinking and decision-making. Some tips for managing these traps are offered as examples of how to challenge our leadership approach in the health system.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BackgroundPrompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.MethodsWe searched the Pubmed database for concepts related to ‘resilience’ and ‘health systems’. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.ResultsThe intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, ‘resilience engineering’ is the most prominent one, followed by ‘community resilience’ and ‘organisational resilience’. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.ConclusionsOur review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

Emergency Department Overcrowding in Canada

What Is the Issue?
 
 Emergency departments (EDs) across Canada are under strain and experiencing overcrowding, a situation that arises when the demand for health services in the ED exceeds the capacity of the health system — which includes the ED, hospital, and community — to provide quality care in a reasonable amount of time.
 ED overcrowding is contributing to a deteriorating standard of care as health care providers and staff become overworked and burned out, is putting health and lives at risk, and is placing additional strain on an already overwhelmed health care system.
 
 What Did We Do?
 
 The CADTH Health Technology Expert Review Panel (HTERP) convened to develop objective, impartial, trusted pan-Canadian guidance to inform decisions about which evidence-informed solutions should be considered to help alleviate ED overcrowding in Canada.
 
 What Is HTERP’s Position on ED Overcrowding?
 
 ED overcrowding is a complex health system issue. EDs operate within hospitals and broader health and social systems, which means that accountability for causes, impacts, and solutions do not lie solely within the ED and its operations.
 Output factors (e.g., misalignment between acute care bed capacity within the hospital and population needs) and input factors (e.g., misalignment between care available in the community and population needs, including care outside of regular business hours) respectively, are the main contributors to ED overcrowding in Canada. Health system capacity is not aligned with, nor has kept pace with, the growing and changing health care needs of the population, which results in overcrowded EDs.
 Health systems will observe better results by implementing strategies that improve patient flow and focus on output and input factors relative to throughput factors.
 
 What Is HTERP’s Guidance to Help Alleviate ED Overcrowding?
 
 Interventions to alleviate overcrowding need to align with the main contributing factors to ED overcrowding in the particular context in which they will be implemented.
 Understanding the context in which ED overcrowding is occurring, with attention to bottlenecks to patient flow, should be the first step to identify evidence-informed solutions.
 Transparency and accountability should be key principles in ED, hospital, and health system operations. HTERP recommends identifying and ensuring clear roles, responsibilities, and reporting relationships embedded within an accountability framework for ED overcrowding across health system partners, including a commitment to act on data.
 Each province and territory should mandate consistent and comprehensive reporting by all hospitals to the Canadian Institute of Health Information’s National Ambulatory Care Reporting System (NACRS) database.
 HTERP’s guidance includes an Evidence Navigation Guide to support identification of evidence-informed interventions to help alleviate ED overcrowding.

Emergency Department Overcrowding: An Environmental Scan of Contributing Factors and a Summary of Systematic Review Evidence on Interventions


 Emergency department (ED) overcrowding occurs when the demand for health services in the ED exceeds the capacity of the ED, hospital, or community to deliver quality care in a reasonable amount of time. Overcrowding is worsening in jurisdictions across Canada and there is a need to address its many causes and identify potential solutions.
 This report uses a modified version of a conceptual model developed by Asplin et al. (2003) that organizes the emergency care system into 3 interdependent parts: input (arrival to the ED), throughput (flowing through the ED), and output (leaving the ED). We also examined an additional fourth part related to contextual factors and systems that affect overcrowding but lay outside of input, throughout, and output.
 
 Examples of factors include, but are not limited to, increased complexity of needs (input), diagnostic testing and procedures (throughput), boarding (output), and limited resources for mental health and substance use (outside the ED).
 Examples of interventions that were effective in some settings include, but are not limited to, prehospital decision-making by first responders, which reduced ED visits (input); short stay crisis units for people experiencing mental health challenges, which improved emergency department length of stay, wait times, boarding, and patient safety (throughput); ED-based discharge planning, which reduced ED return visits (output); and time-based policy reforms, which reduced ED length of stay (outside the ED).
 
 
 Most of the factors we identified in the published literature existed either outside of the ED or at the interface of the ED and other health care services (input and output), whereas most of the interventions we identified existed within the ED (throughput).
 We heard from participants (during multistakeholder dialogue sessions) and content experts that ED overcrowding is a complex health system issue for which the causes, impacts, and solutions extend beyond the ED. Specifically, the novel insights we heard included:
 
 ED overcrowding is better viewed as a problem of hospital overcrowding and strained resources in the broader social and health care systems. Contributing factors both within and outside the ED influence and interact with each other and are affected by economic, cultural, and institutional realities.
 Solving the issue requires addressing accountability and implementing multifaceted solutions in which several systems and voices work collaboratively.
 Existing technologies and data use and collection are not being used to their full potential; they can be better leveraged to alleviate this issue.
 
 
 In the identified literature, there was a lack of explicit reporting around equity and ethical considerations for factors contributing to, and interventions to alleviate, ED overcrowding. Future work should strive to deliberately and explicitly include ethical considerations inherent in research, planning, and policy-making; considerations of equity-deserving groups; and dedicate the time needed to consider the various facets of this issue.
 This CADTH report and our series of reports on ED overcrowding are a starting point to bridge the literature, stakeholder discussion, and expert opinion to help decision-makers understand the various parts of the issue and consult the relevant updated evidence to inform their work.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals.

Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

"We are not a typical family anymore": Exploring the experiences and support needs of fathers of children with Fragile X syndrome in Australia.

A diagnosis of the X-linked condition Fragile X syndrome (FXS) in a child commonly reveals the mother's carrier status. Previous research focused on the genetic counseling process for the child and maternal family, despite calls for more research on the support needs of fathers. This study explored experiences and support needs of fathers at least 1 year after their child's FXS diagnosis to understand barriers and enablers and optimize health outcomes for the family. In-depth interviews were conducted with 11 fathers recruited through the Australian Genetics of Learning Disability Service and the Fragile X Association. Deidentified transcripts were analyzed using thematic analysis guided by an inductive approach. Four themes emerged: (1) making life easier through understanding-yesterday and today, (2) the path to a new normal-today and tomorrow, (3) seeking information and support, and (4) what men want. Fathers reported diagnostic odysseys, postdiagnostic grief, and challenges adjusting. They highlighted difficulties in understanding their child's unique behaviors and needs, responding to their partner's psychological support needs, planning for their child's future, and navigating complex health and disability systems. Participants suggested health professionals facilitate father-to-father support and psychological counseling. These findings highlight the unmet needs of fathers and suggest that a strengths-based approach is critically important given the recognized mental health impact.

Innovation in cancer policy & health systems education during hematology-oncology (HO) fellowship training: Single center experience.

446 Background: Cancer care delivery and outcomes in the US are influenced by a complex health system and regulatory environment. To our knowledge, a structured approach to education on these topics during HO training is lacking. We sought to evaluate baseline knowledge and establish a longitudinal curriculum aimed at educating HO trainees on cancer policy. Methods: First year HO trainees at Johns Hopkins were surveyed on their prior education related to affordability, social determinants of health, and oncologic drug development. Based on these results, a longitudinal curriculum with 10 didactic sessions led by invited content experts was developed and implemented into the 2022-23 academic year schedule. Impact of curriculum was evaluated through anonymous surveys at the beginning and end of each teaching session. Results: Pre-curricular intervention survey was completed by 12 fellows (100% response rate; 58% female, 41.6% White; 16.6% IMGs). All had treated patients that were uninsured (100%, n = 12), unable to afford care (100%, n = 12), or lacked stable housing, transportation, food and employment (100%, n = 12). Smaller number had counseled patients on clinical trial enrollment (50%, n = 6) or discussed trial endpoints (33%, n = 4). Systems education prior to fellowship varied by topic: social determinants of health (33%, n = 4), critical appraisal of clinical trials (33%, n = 4), oncologic care in low-resource settings (41.6%, n = 5), high-value care (66%, n = 8), health insurance (91%, n = 11). Pre and post-surveys demonstrated each teaching session was associated with a significant improvement in fellows’ confidence in understanding pre-set lecture objectives (Table; cumulative mean improvement 1.14 from “neutral” pre-intervention, to “agree” or “strongly agree” post-intervention). Conclusions: We demonstrate lack of education on practice-relevant systems topics in HO trainees at time of subspecialty education initiation. Our longitudinal systems education curriculum improved trainee awareness and understanding of these complex topics. Future efforts will build on this scalable curriculum utilizing trainee feedback and departmental buy-in with the goal of training an oncologic workforce better equipped to counsel patients, navigate structural barriers, and appraise evidence.[Table: see text]

Communication in a Medical Emergency: The Influence of Intergroup Communication on Frontline Healthcare Workers’ Mental Health

Hospitals involve a complex socio-technical health system, where communication failures influence the quality of patient care. Research indicates the importance of social identity and intergroup relationships articulated through power, control, status and competition. In particular, Frontline healthcare workers (HCWs) is clinical workplaces in which doctors are involved in many social groups, including representatives of different professions, clinical specialities and workplace teams under crisis handling condition. A web-based cross-sectional survey was carried out between 1 and 12 December 2022 on a Jakarta area sample of 53 HCWs in Indonesia. The study questionnaire included 7 questions on the mental health of HCWs post-COVID-19 crisis and was analysed using Leximancer (text mining software) and interpretation of major themes. Findings indicated that intergroup conflict is a central influence on communication. Contested responsibilities emerged from a model of care driven by single-speciality professional identity and professionalism may be viewed in terms of self-categorisation rather than simply attainment. The salience of different identities may be considered as influences on teamwork and interprofessional learning, and issues in communication and assessment may be considered in terms of intergroup biases. These results contribute to the growing literature on communication organization and offer new practical insights on how to improve overall efficiency and work performance under crisis conditions.

3.L. Round table: Vaccine Literacy and vaccination uptake for newly arrived migrants and people living in prisons

Abstract Health systems are complex and health organisations are often structured and operate in ways that make access to vaccination services difficult and inequitable for some marginalized populations. In addition, professionals may not be equipped to identify and address the cultural and social needs of these groups of people. The concept of vaccine literacy (VL) emphasizes that VL is not simply knowledge of vaccines, but also development of a less complex health system for communicating and offering vaccines as a conditions of a functioning health system (Ratzan, 2011). Newly arrived migrants (NAM) and people living in prisons (PLP) are two populations with overall low vaccination rates compared to the general population. Efforts to change this situation must emphasize activities not only geared toward increasing individual vaccine literacy, but more importantly supporting the system to become more vaccine literate. The general aim of the “Access to Vaccination for Newly Arrived Migrants -AcToVax4NAM” project is to improve the responsiveness of health systems in terms of vaccination literacy, making the conditions for access to vaccinations more equitable and guaranteed. Similarly, the “Reaching the hard-to-reach: increasing access and vaccine uptake among the prison population in Europe -RISE-Vac” aims to improve the health of people living in prisons in Europe by promoting staff and prisoners’ VL, enhancing vaccine offer and increasing vaccine uptake. During the workshop, AcToVax4NAM and RISE-Vac will discuss strategies and tools developed within these two EU co-funded projects (3rd EU Health Programme) to address vaccine literacy at the organizational and individual level for the particular target groups. Key messages • Individual and organisational vaccine literacy are equally important to increase vaccine uptake and vaccination coverage among disadvantaged communities. • Intersectoral and multidisciplinary approaches are needed to tackle inequalities in access to prevention services including vaccination services.

Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis

BackgroundPatients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional...

Managing Local Health System Interdependencies: Referral and Outreach Systems for Maternal and Newborn Health in Three South African Districts

In complex health systems, referral and outreach systems (ROS) are formal strategies for connecting and managing interdependencies between facilities in service delivery pathways. Well-functioning maternal and newborn ROS are critical to successful outcomes, and therefore, a good lens through which to examine the management of local interdependencies. We conducted a qualitative study of maternal–newborn ROS, involving interviews with 52 senior, middle, and frontline managers, in three health districts of three different provinces in South Africa. We analyse the differences in functioning of ROS as an interplay of setting (urban, rural), individual facility strengths and weaknesses, the quality of emergency medical services (EMS), and the wider provincial strategic and organisational context. ROS are strengthened by sub-district governance arrangements that recognise and enable connectedness—in particular, between primary health care and district hospital services; by informal, day-to-day communication and collaboration across levels and professions; and by hybrid clinical–managerial players as system brokers and systems thinkers. We also identify leverage points, places where small shifts could have wider system effects, most notably in the design and functioning of EMS, and in addressing small, but significant bottlenecks in supply chains in lower level facilities that negatively impact the system as a whole.

Development of an individual index of social vulnerability that predicts negative healthcare events: a proposed tool to address healthcare equity in primary care research and practice

PurposeSocially disadvantaged patients may lack self-efficacy to navigate a complex health system making them vulnerable to healthcare inequity. We aimed to develop an Index of social vulnerability that predicts increased risk of negative healthcare events (e.g. emergency hospitalization), independent of chronic disease burden. The analysis illustrates the conceptual and practical steps leading to the development of a pragmatic Index of social vulnerability to limited healthcare self-efficacy.MethodsUsing data from a 3-year cohort of 2507 adult primary care patients in Québec (Canada), we applied two complementary structural equation modelling approaches—Partial Least Squares Path Modelling (PLS-PM) and Multiple indicators and Multiple Causes (MIMIC) modelling—to identify a minimal set of social characteristics that could be summed into an Index related to limited healthcare self-efficacy. We then used logistic regression to determine if the Index predicted: hospital emergency department use; hospital admissions; unmet need for care, and others. We privileged parsimony over explanatory capacity in our analytic decisions to make the Index pragmatic for epidemiologic and clinical use.ResultsThe Individual Social Vulnerability Index is the weighted sum of five indicators: two indicators of social support; educational achievement; financial status; limited language proficiency. The Index predicts increased likelihood of all negative healthcare outcomes except unmet need, with a clear threshold at Index ≥ 2. The effect is independent of chronic disease burden.ConclusionWhen social deficits outweigh social assets by two or more (Index ≥ 2), there is an increased risk of negative healthcare events beyond the risk attributable to poor health. The Index is a pragmatic tool to identify a minority of patients who will require additional support to receive equitable healthcare.

Shaping Social Justice Values Through Inclusive Assessment and Debriefing of eLearning Modules.

Nurses need to recognize how intersectionality shapes the experiences of individuals and families navigating complex health systems. Guided reflection on complex social justice issues serves as an approach to move beyond simply understanding social determinants of health toward shaping core professional values of developing nurses to promote lasting change. Third-year Canadian undergraduate prelicensure nursing students co-created assignment expectations, completed online modules, and submitted initial reflections before class in a mandatory social justice course. In-class debriefing was based on students' reflections and cofacilitated by subject matter experts. Students completed a final reflection that focused on advocating for social change. Student feedback, reflections, and grades as well as faculty observations support the success of this interactive student-centered approach. A flexible approach to debriefing modular content informed by universal design for learning and simulation theory enables nurse educators to promote in-depth, meaningful, and lasting student learning. [J Nurs Educ. 2024;63(1):48-52.].

Complexity around the Colombian Childhood Cancer Law: Requirements for its Evaluation

Introduction: The complexity of health problems such as childhood cancer poses challenges in health care and in the evaluation of interventions. This situation is aggravated if policy makers and decision makers assume that a healthcare system works in a delimited environment with defined rules. The approach to childhood cancer in Colombia required the promulgation of a law to contribute to the reduction of mortality from this cause with implications for nursing. This study characterized its complex nature, evidenced the potential implications in its evaluation and proposed an evaluation scheme. Methods: Documentary research with related information available between the years 2010 and 2020. Bowen's guidelines for the analysis of the information were followed, the categories included were relevant actors, context, components, organizational levels involved and results. Results: The analysis of the problem made visible the influence of the social determinants of health, the interaction of multiple actors in various scenarios and a high degree of uncertainty in a complex health system. The response is a complex intervention with multiple components and actors involved at different levels to achieve the proposed results. Conclusion: Evaluating this intervention implies context-sensitive approaches, a clear definition of the problem and identification of the underlying theory necessary to achieve the expected results; Establishing its evaluability provides important inputs to reorient its scope and its transferability.

Impact of primary language on health inequities in multiple myeloma.

e18640 Background: Limited English proficiency (LEP) has been shown to exacerbate health inequities in the US due to difficulties navigating a complex health system and assimilating complicated information regarding diagnosis, and treatment. Advances in multiple myeloma (MM) care have improved clinical outcomes but added complexity to diagnosis and treatment. However, there is limited data on whether LEP impacts health inequities in MM care. We sought to assess the impact of primary language on MM care and outcomes at our safety net hospital, serving a culturally and linguistically diverse population where patients have equal access to novel agents and autologous stem cell transplant (SCT). Methods: We retrospectively studied 213 patients with newly diagnosed MM between January 1st, 2000, and December 31st, 2021. Data were extracted from electronic medical records. Patients were classified as LEP or EP based on self-reported language at the time of diagnosis. Patients were subsequently propensity matched based on age, sex, type of insurance, Charlson comorbidity index, creatinine, LDH, year of MM diagnosis, ISS stage, presence of high-risk cytogenetics, and receipt of SCT. Type of insurance was used as a surrogate for socioeconomic status. Kaplan Meier estimate and log rank tests were used to assess overall (OS) and progression free survival (PFS). Results: Of 213 patients, 75 (35.2%) had LEP, 135 (63.4%) were black, 49 (23.0%) were white, 22 (10.3%) patients were of another race, and 7 (3.3%) did not self-identify. Mean age was 63.6 (SD ± 11.4), and 114 (53.5%) patients were male. Median follow-up of the entire cohort was 56.9 months. At baseline, there were no statistically significant differences in the covariates above between LEP and EP patients except for increased incidence of diabetes mellitus in EP patients (84.0% vs. 89.1%, p 0.02). More LEP patients were inpatients at the time of diagnosis compared to EP patients (36.0% [27/ 75] versus 23.9% [33/138]). Median number of hospitalizations and ED visits in the first 6 months of diagnosis were 4 and 3 versus 1 and 2 in LEP versus EP patients, respectively. There were no differences in adjusted PFS or OS between propensity matched LEP and EP patients. Conclusions: In our cohort, there were no significant differences in demographics, clinical parameters, socioeconomic status, or transplant utilization between LEP and EP patients, which allowed us to assess the association of primary language with any observed health inequities. In a setting where all patients have access to novel treatments, SCT, patient navigators, interpreters, and social workers, there were no differences in PFS or OS. However, language barriers may explain health inequities related to later diagnosis and increased healthcare utilization. LEP patients with MM may benefit from additional language-concordant resources to improve disparities.

723 Provincial Burn Mass Casualty Incident Planning: Preliminary Results

Abstract Introduction Burn mass casualty incident (BMCI) response planning includes involving relevant stakeholders, assessing regional burn care capacity, and addressing the specialized needs of burn patients. An essential component of these processes is an evaluation of existing resources and plans. In this study, a province with three important elements—a singular health authority to plan for, two burn centres, and updated health technology—was selected for evaluation. Aim What are the current policies, protocols, and practices that address a provincial response to a BMCI? Methods In this ethics approved case study, qualitative description methodology was used for data analysis. Data were gathered from documents outlining the health system response to a mass casualty incident from the health system internal emergency response plans. Health care professionals directly involved in the response were recruited for interviews. Participants were recruited from prehospital emergency management services, hospital emergency departments, inpatient burn units, and a provincial patient transport department. Interviews were conducted online, recorded, and transcribed. Qualitative description was used to code common themes across documents and transcripts. Results Thirteen documents and nine participant interviews were included. Only two documents included burn-specific considerations. Current policies and protocols were limited to all-hazards mass casualty incident planning and did not address specialized needs of burn care. Current plans were based on assumptions that all burn patients would be triaged and transported to burn centres and that surge capacity would be adequate to accommodate for increased demands. Prehospital participants (n=3) felt that existing plans would adequately manage a BMCI. Six participants stated the current plans were not sufficient to manage a BMCI. A comprehensive description of the complex health system response to a potential BMCI was obtained. Some major deficiencies identified included a lack of strategies to bolster burn care staffing capacity such as just-in-time training resources for non-burn trained staff or utilization of outpatient burn clinic staff. Considerations for increased operating room and wound care resources were absent. Conclusions Current provincial all hazards response plans are not sufficient to support adequate response to a BMCI and need to be amended to address the specialized needs of burn patients. Strategies for expanding capacity such as care of burn patients at non burn facilities and utilization of outpatient clinics must be integrated into future plans. Applicability of Research to Practice The provincial health authority needs to support BMCI response planning efforts to better address this unique hazard prior to an incident occurring for best patient outcomes.