Ottawa Hospital Research Articles

Distance to CAR-T Treatment Center Does Not Impede Delivery.

Chimeric antigen receptor T-cell (CAR-T) therapy has demonstrated remarkable efficacy in relapsed or refractory large B cell lymphoma, but real-world evidence is needed to confirm safety and efficacy when facing the unique challenges of a wide geographical catchment area. We reviewed patients treated with commercially available CAR-T at a medium-sized single center in Canada (The Ottawa Hospital) between December 2020 and July 2022 (Canadian implementation started in 2020). Fifty-one patients (59% male, median age 62) traveled a median distance of 655 km (range 3-3659) for treatment. Median time from apheresis to CAR-T infusion was 36 days (range 26-81). With a median follow-up of 383 days (95% CI: 333-480), median progression-free survival (PFS) and overall survival (OS) were 257 days (95% CI: 92-NE) and 422 days (95% CI: 106-NE), respectively. The median PFS for out-of-province patients was 115 days (95% CI: 91-NE) versus 280 days for in-province patients (95% CI: 142-NE), p = 0.12. Multivariate analysis demonstrated that distance from treatment center (p = 0.05) and refractory disease status (p = 0.003) were independently associated with shorter PFS. The time from the last disease progression to CAR-T referral was longer for out-of-province patients, but there was no difference in the time of referral to CAR-T consult, apheresis, or CAR-T infusion between in-province and out-of-province patients. Our results confirm that despite the complexity of CAR-T therapy administration, Ottawa can effectively provide commercial CAR-T therapy in a timely fashion for patients from across the country.

Predicting the critical administration threshold in bleeding trauma patients.

Delays in promptly recognizing and appropriately managing hemorrhagic injuries contribute to preventable trauma related deaths nationwide. We sought to identify patient variables available at the time of emergency department arrival associated with meeting the critical administration threshold. We conducted a trauma registry review from September 2016 to March 2020 of trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Our primary outcome was the frequency of meeting the critical administration threshold. Secondary outcomes included time to critical administration threshold, 24-h all-cause mortality, and 30-day all-cause mortality. Multivariate logistic regression identified factors independently associated with meeting the critical administration threshold. We assessed 762 patients, of which 78 (10.2%) met the critical administration threshold. The median time to critical administration threshold was 28.9min. Mortality at 24h occurred in 58 (7.6%) patients. Four variables available upon patient arrival predicted the critical administration threshold, including systolic blood pressure ≤ 90mmHg (OR 6.6; 95% CI 3.7-12.0), Glasgow Coma Scale ≤ 8 (OR 5.9; 95% CI 3.2-10.6), heart rate ≥ 100 beats/minute (OR 4.4; 95% CI 2.4-8.1), and respiratory rate ≥ 20 breaths/min (OR 2.2; 95% CI 1.2-4.0). We identified four clinical variables readily available to physicians upon patient arrival associated with meeting the critical administration threshold: systolic blood pressure ≤ 90mmHg, Glasgow Coma Scale ≤ 8, heart rate ≥ 100 beats/minute, and respiratory rate ≥ 20 breaths/min. Patients presenting with any of these clinical parameters should prompt physicians to consider ordering blood products immediately.

Professionalism in Residency Training: The Learning Environment for Professionalism Survey.

Role modelling is important in developing professionalism with a need for reliable, evidence-based tools to assess professionalism in the learning environment (LE). The Learning Environment for Professionalism (LEP) survey is brief, anonymous and balanced assessing medical trainees' and attendings' positive and negative professionalism behaviours that can be tracked longitudinally and identify problem areas in the LE. Seven training programs agreed to facilitate administration of the LEP survey at four hospitals in Ottawa, Canada. The survey was carried out iteratively between 2013 and 2020. A total of 3783 LE ratings of training programs and hospitals were assessed longitudinally using univariate linear regression. A Bonferroni corrected p-value of ≤.0045 was used to account for multiple comparisons. Positive professional behaviours were observed across time with some of the negative behaviors having improved. A negative signal was found, with attendings appearing to be treating patients unfairly because of their financial status, ethnic background, sexual or religious preferences. Applying LEP survey longitudinally across diverse training programs and institutions is feasible and may assist programs to identify areas requiring attention and acknowledging areas of exemplary professionalism. Continuous monitoring of LE to meet requirements of accrediting bodies can also be considered an important quality improvement metric.

The impact of various learner arrangements on emergency department staff productivity.

This study aimed to examine how different learner arrangements affect the number of patients seen per hour by staff emergency physicians in ambulatory and non-ambulatory zones of two tertiary teaching hospitals in Ottawa, Canada. This was a retrospective cohort study analyzing all emergency department (ED) shifts at the Civic and General Campus EDs of The Ottawa Hospital from April 2022 to March 2023. Data collected included shift type (ambulatory or non-ambulatory), learner arrangement, and number of patients seen per hour. Descriptive statistics and two-sample, two-tailed t tests to analyze the relationship between patients seen per hour and learner arrangements. We analyzed 8161 shifts over the study period, including 5233 in ambulatory care and 2928 in non-ambulatory care areas. Among ambulatory care shifts, the average number of patients seen per hour was 2.1 (95% CI 2.1-2.1) when working alone, 1.9 (1.9-2.0, p < 0.001) with a medical student, 2.1 (2.1-2.2, p = 0.20) with a junior resident, 2.6 (2.5-2.6, p < 0.001) with a senior resident, 2.1 (2.1-2.2, p = 0.33) with a junior resident and a medical student, and 2.6 (2.5-2.7, p < 0.001) with a senior resident and a medical student. In non-ambulatory care shifts, the average number of patients seen per hour was 1.4 (95% CI 1.3-1.5) when working alone (122 shifts, 4%), 1.4 (1.4-1.5, p = 0.63) with a medical student (85 shifts, 3%), 1.5 (1.5-1.5, p = 0.02) with a junior resident (1,013 shifts, 35%), 1.8 (1.7-1.8, p < 0.001) with a senior resident (682 shifts, 23%), 1.6 (1.5-1.6, p < 0.001) with a junior resident and a medical student (683 shifts, 23%), and 1.8 (1.7-1.8, p < 0.001) with a senior resident and a medical student (343 shifts, 12%). This study highlights the significant impact that learner arrangements have on staff physician productivity in the ED. These findings underscore the importance of strategic scheduling to optimize patient throughput.

Prevalence of diagnosed pulmonary embolism in patients with chronic obstructive pulmonary disease exacerbation presenting at the emergency department of a large North American academic hospital center

Background The real prevalence of pulmonary embolism (PE) in patients with chronic obstructive pulmonary disease exacerbation (COPDe) remains largely unknown, especially in North America. Our aim was to evaluate the prevalence of PE in patients with COPDe at a large academic Canadian hospital. Methods This is a retrospective cohort study of all adult patients with COPDe seen at the emergency department (ED) of The Ottawa Hospital, Ontario, Canada (June 2019-January 2022). The primary outcome was the prevalence of PE during the initial assessment and at 3 months. Secondary outcomes included prevalence of venous thromboembolism and mortality. Subgroup analyses based on the type of COPDe and the post-ED clinical setting were conducted. Results Of 1158 patients seen in the ED with COPDe, PE was diagnosed in 13 patients (1.1%; 95%CI 0.6%-1.9%). Five patients (5/1158; 0.4%) had a diagnosis of PE during initial assessment and 8/1141 (0.7%) patients were diagnosed with PE during the 3-month follow-up. The prevalence of PE did not differ based on the type of COPDe (p = 0.27) and was higher in patients admitted to the hospital compared to patients discharged from the ED (1.1% vs 0.0%; p = 0.01). Mortality was clinically but not statistically higher in patients with PE compared to patients without PE (15.4% vs 6.0%; p = 0.19). Conclusion Among patients with COPDe evaluated in the ED, the prevalence of diagnosed PE was low, but more than 60% of the PE were diagnosed during the 3-month follow-up. Further studies are needed to determine an appropriate diagnostic algorithm in this population.

Molecular Characterization and Xenotransplantation of Pancreatic Cancer Using Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA).

Pancreatic cancer has one of the worst prognoses among all malignancies and few available treatment options. Patient-derived xenografts can be used to develop personalized therapy for pancreatic cancer. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) may provide a powerful alternative to surgery for obtaining sufficient tissue for the establishment of patient-derived xenografts. In this study, EUS-FNA samples were obtained for 30 patients referred to the Ottawa Hospital, Ottawa, Ontario, Canada. These samples were used for xenotransplantation in NOD-SCID mice and for genetic analyses. The gene expression of pancreatic-cancer-relevant genes in xenograft tumors was examined by immunohistochemistry. Targeted sequencing of both the patient-derived tumors and xenograft tumors was performed. The xenografts' susceptibility to oncolytic virus infection was studied by infecting xenograft-derived cells with VSV∆51-GFP. The xenograft take rate was found to be 75.9% for passage 1 and 100% for passage 2. Eighty percent of patient tumor samples were successfully sequenced to a high depth for 42 cancer genes. Xenograft histological characteristics and marker expression were maintained between passages. All tested xenograft samples were susceptible to oncoviral infection. We found that EUS-FNA is an accessible, minimally invasive technique that can be used to acquire adequate pancreatic cancer tissue for the generation of patient-derived xenografts and for genetic sequencing.

Characterization of a colistin resistant, hypervirulent hospital isolate of Acinetobacter courvalinii from Canada.

Non-baumannii Acinetobacter spp. are becoming more prevalent in clinical settings including those that present resistance to last-resort antibiotics such as colistin. AB222-IK40 is an Acinetobacter courvalinii strain isolated from the Ottawa Hospital Research Institute located in Ottawa, Canada. To our knowledge, it is the first report of clinical A. courvalinii in Canada. Based on the susceptibility profile, AB222-IK40 is resistant to colistin and non-susceptible to ertapenem. Whole-genome sequencing allowed for genomic investigation into colistin resistance mechanisms. No previously identified mechanism(s) were observed, but a mobile colistin resistance (mcr)-like gene and a UDP-glucose dehydrogenase gene were identified. Based on phylogenomic analyses, the mcr-like gene is an intrinsic phosphoethanolamine transferase. This gene family is implicated in one of the many mechanisms responsible for colistin resistance in Acinetobacter baumannii as well as Acinetobacter modestus. UDP-glucose dehydrogenase is involved in colistin resistance in Enterobacterales and has been shown to be involved in capsule formation in A. baumannii. Global lipidomics revealed greater abundance of phosphatidyl-myo-inositol and lyso-phosphatidyl ethanolamine moieties in the membrane of A. courvalinii than in A. baumannii. Lipidomic profiles showed differences that were probably responsible for the colistin resistance phenotype in AB222-IK40. This isolate was also hypervirulent based on survival assays in Galleria mellonella. As this is the first report of A. courvalinii from a hospital in Canada, this species may be an emerging clinical pathogen, and therefore, it is important to understand this mechanism of its colistin resistance and hypervirulence.

Reliability and Sensitivity of a Virtual Assessment Developed for Workplace Concussions: Protocol for a Method-Comparison Study.

Workplace mild traumatic brain injuries are frequently associated with persistent symptoms, leading to a reduction in productivity at work or even disability. People who sustain workplace injuries frequently need rehabilitation and support, and the challenges of delivering these services was heightened during the COVID-19 pandemic as injured workers had to be cared for remotely. Currently, clinicians are conducting both in-person and virtual (remote) concussion assessments; however, the measures that are being used to complete these assessments have undocumented psychometric properties. This study will document the psychometric properties of the clinical measures that are being used remotely and their ability to produce similar results to in-person assessments. Specifically, through this method-comparison study, we aim to (1) evaluate the sensitivity of the measures included in a virtual assessment toolkit when compared to an in-person assessment and (2) determine the interrater and intrarater reliabilities of the measures included in a virtual assessment toolkit. Patient participants (people living with acquired brain injuries) will attend two assessments (in person and virtual) at the Ottawa Hospital. The two assessments will be identical, consisting of the measures included in our previously developed virtual concussion assessment toolkit, which includes finger-to-nose testing, the Vestibular/Ocular Motor Screening tool, balance testing, cervical spine range of motion, saccades testing, and evaluation of effort. All virtual assessments will occur using the Microsoft Teams platform and will be audio/video-recorded. The clinician assessor and patient participant will complete a feedback form following completion of the assessments. A different clinician will also document the findings on observed videos of the virtual assessment shortly after completion of both in-person and virtual assessments and approximately 1 month later. Interrater reliability will be assessed by comparing the second clinician's observation with the first clinician's initial virtual assessment. Intrarater reliability will be evaluated by comparing the second clinician's observation with their own assessment approximately 1 month later. Sensitivity will be documented by comparing the findings (identification of abnormality) of the in-person assessment completed by the initial clinician assessor with those of the second clinician assessor on the observation of the recording of the virtual assessment. As of May 2024, we have recruited 7 clinician assessors and completed study assessments with 39 patient participants. The study recruitment is expected to be completed by September 2024. Currently, it is unknown if completing concussion assessments virtually produces similar results to the in-person assessment. This work will serve as a first step to determining the similarity of the virtual assessment to the matching in-person assessment and will provide information on the reliability of the virtual assessment. DERR1-10.2196/57663.

Investigating factors influencing decision-making around use of breastmilk substitutes by health care professionals: a qualitative study

BackgroundBreastfeeding is recognized as the gold standard of infant feeding and nutrition. The World Health Organization recommends exclusive breastfeeding (EBF) of infants for the first 6 months of life. A variety of factors may impact breastfeeding practices in-hospital which may continue after hospital discharge, such as the use of breastmilk substitutes (BMS). The Baby-Friendly Initiative (BFI), which aims to promote and support breastfeeding practices, established a target rate of 75% for EBF from birth to hospital discharge. Currently, this target is not being met at The Ottawa Hospital (TOH), indicating there is room for improvement in EBF rates. The purpose of this study is to explore health care professionals (HCP) decision-making around use of BMS and identify factors that drive the use of BMS with and without medical indications.MethodsIn this qualitative study, semi-structured interviews were conducted with HCPs within TOH from January to June 2022. All participants had experience in maternity or postpartum care and were probed on factors influencing use of BMS at this institution. Interview transcripts were coded using an inductive approach.ResultsA total of 18 HCPs were interviewed including physicians, midwives, lactation consultants, and registered nurses. Multilevel barriers influencing the use of BMS were categorized into patient, HCP, and institution-level factors. Subthemes that emerged ranged from parental preferences, training differences amongst HCPs, to budget and staffing issues. Over half of HCPs were prepared to answer questions on EBF and were familiar with the BFI. Although most were supportive of this institution receiving BFI designation, a few providers raised concerns of its impact on parents who would like to supplement.ConclusionsSeveral modifiable factors influencing decision-making for use of BMS were identified. These findings will be used to inform unit leads, help identify effective strategies to address modifiable barriers, and develop tailored breastfeeding supports to improve EBF rates.

Outcomes with low dose anti-thymocyte globulin based graft versus host disease prophylaxis after mismatched unrelated donor allogeneic hematopoietic cell transplantation.

Anti-thymocyte globulin (ATG) based graft versus host disease (GVHD) prophylaxis is widely used for mismatched unrelated donor allogeneic hematopoietic cell transplantation (HCT) although optimal dose remains unclear. Although recent literature suggested improved outcomes with PTCy-based regimens when compared to ATG-based regimens these studies used doses of ATG ≥5 mg/kg. Thus, we analyzed outcomes of HLA 9/10 MMUD allogeneic HCTs using lower-dose ATG-based regimens at our center. We retrospectively analyzed outcomes of HLA 9/10 MMUD allogeneic HCTs using lower dose ATG-based regimens for all adults undergoing allogeneic HCT at The Ottawa Hospital from 2015 to 2022. Data regarding demographics, conditioning regimen, dose of ATG, rates of GVHD, duration of remission, and survival, were collected and analyzed. Seventy-seven (n = 77) patients (males 62.3%; median age 50 years) underwent allogeneic HCT from MMUD. Majority(81%; n = 63) received 2.5 mg/kg of rabbit ATG and remaining 18.2% (n = 14) received 4.5 mg/kg. Grade II-IV acute GVHD occurred in 24.7% (n = 19) while any chronic GVHD occurred in 32.5% (n = 25) patients. After a median follow-up of 21 months, relapse occurred in 28.6% of patients. Two-year OS, GRFS, CIR, and NRM were 60.6%, 45.3%, 16.9%, and 18.2% respectively. Dose of ATG (2.5 mg/kg vs. 4.5 mg/kg) was not associated with outcomes in either univariate or multivariate analyses. When compared to published studies using ATG doses ≥5 mg/kg, GVHD prophylaxis using lower dose ATG may potentially lead to improved outcomes in patients undergoing MMUD allogeneic HCT. Further studies are needed to directly compare lower dose ATG to PTCy-based regimens to determine ideal GVHD prophylaxis for these patients.

Prescription Patterns of Sodium-glucose Cotransporter-2 Inhibitors in Adults With Type 2 Diabetes and Heart Failure With Reduced Ejection Fracture Admitted to a Tertiary Care Centre in Ontario, Canada

ObjectivesOur aim in this study was to assess early adoption patterns of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in eligible patients with type 2 diabetes (T2DM) and heart failure with reduced ejection fracture (HFrEF), and to identify gaps in practice. MethodsA retrospective chart review was conducted of patients with T2DM and HFrEF admitted with decompensated heart failure to The Ottawa Hospital under cardiology or general internal medicine from June 2019 to May 2021. Patterns were assessed at 8-month intervals (1 period before release of the Diabetes Canada 2020 guidelines and 2 periods afterward). Baseline patient characteristics, comorbidities, and prescriber information were collected. ResultsOf the 98 patients who met the inclusion criteria, 36.7% had a prescription for an SGLT2i, either on admission, discharge, or follow-up. Trends showed a gradual increase over time. On admission, 9.8% of patients were on an SGLT2i in period 1, 19.2% in period 2, and 23.3% in period 3. Patients receiving a prescription for SGLT2i on discharge were 0.0% in period 1, 10.0% in period 2, and 9.5% in period 3, all of whom were admitted under cardiology. On follow-up, 13.9% of eligible patients were started on an SGLT2i in period 1, 21.1% in period 2, and 35.0% in period 3. Endocrinology was the main prescriber of SGLT2i in the outpatient setting, followed by cardiology. ConclusionsOverall, trends show a slow but steady increase in early prescriptions of SGLT2i. However, most eligible patients were not started on therapy during our study period with variability in practice between specialties, highlighting opportunities to boost uptake in the future.

Decreased patient discharges on weekends part 1: what do the data tell us?

We believe that hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. In part 1 of 3 concurrent studies, we documented the number of weekend discharges and the extent of hospital and ED crowding on the days following weekends. We conducted a data analysis study at The Ottawa Hospital, a major academic health sciences center with two EDs. We created reports of the 18-month period (January 1, 2022-June 30, 2023) regarding the status of in-patients at the two campuses. We compared the total admissions, discharges, and hospital occupancy on weekends (or long weekends), the Monday following weekends (or Tuesday following long weekends), or Tuesdays-Fridays. For these three time periods, we also compared the proportion of ED beds occupied by admitted patients to all ED beds, as well as the proportion of days with > 70% admitted patients housed in the ED at 8:00am. Our data for 55,692 patients demonstrated that on weekends compared to weekdays, there were almost 50% fewer discharges with the ratio of admissions to discharges averaging 1.16 (95% CI 1.10-1.22). This was accompanied by a 2.4% absolute increase (P < 0.001) in hospital occupancy on Mondays or Tuesdays, often exceeding 100%. Both EDs are particularly crowded on these Mondays and Tuesdays with the proportion of admitted patients to regular ED beds averaging 68%. We observed serious crowding with > 70% occupancy with admitted patients on almost 50% of Mondays. We have demonstrated that there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This blocks safe and timely access to beds for newly arriving patients in the ED. These results should spur Canadian hospitals to evaluate their own data and seek solutions to this important problem.

Development of a survey to support assessment of safety learning systems

BackgroundPatient safety learning systems play a critical role in supporting safety culture in healthcare organisations. A lack of explicit standards leads to inconsistent implementation across organisations, causing uncertainty about their...

Implementation of a hepatitis B screening program in patients receiving systemic anti-cancer therapy: A Canadian single center retrospective review.

e23242 Background: Cancer patients receiving non-endocrine anti-cancer therapies are at risk of hepatitis B virus (HBV) reactivation (HBVr). Medical society guidelines recommend HBV screening prior to treatment, but real-world uptake is slow and variable. The Ottawa Hospital Cancer Centre implemented a screening pilot program for all patients receiving FOLFOX based regimens or FOLFOXIRI between January and April 2023 which included incorporating HBV screening tests into treatment plan builds and specifying pharmacy and nursing pre-treatment checks. Methods: Charts were retrospectively reviewed, and patient and disease characteristics were collected. The primary endpoint was to identify the proportion of patients who underwent screening prior to treatment start. Univariate analyses assessed the association between baseline characteristics and failure to screen. We also reviewed quality metrics including time from consult to testing, time to result, number of duplicate screens, and treatment delays due to testing. Results: Baseline demographics of the 42 patients included can be found in Table 1. 32 patients (76.2%) completed screening and 5 (15.6%) had a positive screen. The majority of patients screened (78.1%) completed screening prior to first treatment as intended, however 38.1% were drawn on day of treatment. 9.52% of patients had duplicate screening inadvertently. All patients who tested positive were referred to Infectious Diseases. Of those, 1 received antivirals for chronic HBV, and 4 had resolved HBV and were recommended for monitoring. There were no treatment delays due to pending screening and no HBVr. Receipt of prior systemic therapy was significantly associated with failure to screen (55% vs 95%, OR 17.1 (95% CI 1.92-153), p = 0.011). Factors including age, sex, primary disease site, therapy intent, and regimen received were not significantly associated with screening completion or HBV positivity. Conclusions: The results of this pilot highlights the importance of building HBV screening into standardized treatment plans and engaging all team members to ensure high levels of screening. Prior systemic therapy receipt was associated with failure to screen, and thus programs should include education on the necessity of screening as recommended by medical guidelines. The prevalence of HBV in this population may also be higher than previously expected, which should be explored in future research. [Table: see text]

Cardio-Oncology Awareness: A multidisciplinary survey amongst health care trainees and practicing professionals at academic institutions.

e24023 Background: The awareness of cancer therapy-related adverse cardiac effects is incited by recent literature on cardiotoxicity incidence and detection strategies. Despite availability of guidelines, cardiotoxicity monitoring and treatment are not structurally performed across institutions. Aim: Assessing knowledge of health care professionals’ cardiac complications of cancer treatments, current perspectives on cardio-oncology ultimately to determine an agenda for improvements in practice. Methods: A web-based survey (Google Forms) was adapted from that of Ottawa Hospital Research Institute’s survey, consisting of 45 questions organized into 7 sections, modified according to our local needs and circulated to cardiologists, oncologists (radiation, medical) practicing or training in a multi-disciplinary setup and academic centers. Fortnightly reminders were sent for to receive a maximum response. The survey enquired about implementing respondent’s perception of cardio-oncology, availability of cardio-oncology services at the respondent’s institution, opinions towards current practice. A descriptive statistical analysis was carried out. Results: Fifty-five professionals completed the survey, of which 12 were cardiologists, 31 radiation oncologists, and 12 medical oncologists. Majority, 31 (54.5%) were trainees and only 1.8% had some formal training in cardio-oncology while 20% respondents reported to have a formal cardio-oncology training programme. Nearly 90% understood cardio-oncology as a stream to be able to identify side-effects and refer for treatment to the cardiologists while 84% felt that timely referral would improve outcomes.72% recognized follow-up and 67.3% felt patient education to be important component. Awareness of cardio-oncology guidelines was reported by 38.2% respondents. In the setting of metastatic cancer, there was a difference in risk tolerance for cardiotoxicity with the majority accepting 1-5% risk in curative setting and 56% accepting &gt; 5% risk of cardiotoxicity in the metastatic setting. None of the institutions reported on having a formal training programme. Limited infrastructure (54.5%) and limited interest (47.3%) were cited the most common reasons. Conclusions: This survey identified that professionals recognize cardio-oncology services to be an important component of cancer treatment. Lack of formal training and awareness about guidelines was reported. There is a felt need for collaboration between cardiologists and oncologists to improve cardiovascular outcomes of cancer patients.

Successes and challenges of best practice alerts to identify and engage individuals living with hepatitis C virus.

Many individuals living with hepatitis C virus (HCV) are unaware of their diagnosis and/or have not been linked to programs providing HCV care. The use of electronic medical record (EMR) systems may assist with HCV infection identification and linkage to care. In October 2021, we implemented HCV serology-focused best practice alerts (BPAs) at The Ottawa Hospital (TOH) via our EMR (EPIC). Our BPAs were programmed to identify previously tested HCV seropositive individuals. Physicians were prompted to conduct HCV RNA testing and submit consultation requests to the TOH Viral Hepatitis Program. We evaluated data post-BPA implementation to assess the design and related outcomes. From 1 September 2022 to 15 December 2022, a total of 2,029 BPAs were triggered for 139 individuals. As a consequence of the BPA prompts, nine HCV seropositive and nine HCV RNA-positive individuals were linked to care. The proportion of total consultations coming from TOH physicians increased post-BPA implementation. The BPA alerts were frequently declined, and physician engagement with our BPAs varied across specialty groups. Programming issues led to unnecessary BPA prompts (e.g., no hard stop to the prompts even though the individual was treated and cured and individuals linked to care without first undergoing HCV RNA testing). A fixed 6-month lookback period for test results limited our ability to identify many individuals. An EMR-based BPA can assist with the identification and engagement of HCV-infected individuals in care. However, challenges including issues with programming, time commitment toward BPA configuration, productive communication between healthcare providers and the programming team, and physician responsiveness to the BPAs require attention to optimize the impact of BPAs.

Decreased patient discharges on weekends part 3: what do the leaders tell us?

Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays. In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions. We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week. We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.

Evaluation of Unsolicited Feedback from Patients with Cancer and Their Families as a Strategy to Improve Cancer Care Delivery.

Unsolicited patient feedback (compliments and complaints) should allow the healthcare system to address and improve individual and overall patient, family, and staff experiences. We evaluated feedback at a tertiary cancer centre to identify potential areas for optimizing care delivery. unsolicited feedback submitted to the Patient Relations Department, relating to the Divisions of Medical and Radiation Oncology, at the Ottawa Hospital, was analyzed. Of 580 individual reports submitted from 2016 to 2022, patient demographics were available for 97% (563/580). Median patient age was 65 years (range 17-101), and 53% (301/563) were female. The most common cancer types were breast (127/545, 23%) and gastrointestinal (119/545, 22%) malignancies, and most (64%, 311/486) patients had metastatic disease. Feedback was submitted mainly by patients (291/579, 50%), and predominantly negative (489/569, 86%). The main reasons for complaints included: communication (29%, 162/566) and attitude/conduct of care (28%, 159/566). While feedback rates were initially stable, an increase occurred from 2019 to 2021. Unsolicited feedback remains mostly negative, and relates to physician communication. If we are to drive meaningful changes in care delivery, more standardized means of assessing feedback and implementation strategies are needed. In addition, in an era of increased healthcare provider burnout, strategies to enhance formal positive feedback are also warranted.

Perspectives on shorter durations of anti-HER2 therapy in early-stage HER2-positive breast cancer: a patient survey.

Despite previous studies proposing shorter durations of anti-HER2 therapy for selected patients with HER2-positive early breast cancer (EBC), 12-months remains standard of care. A survey was performed to assess patient perspectives and willingness to participate in studies evaluating shorter durations of anti-HER2 therapy. Patients with HER2-positive EBC completing or having previously completed anti-HER2 therapy, were recruited by healthcare professionals at The Ottawa Hospital Cancer Centre to participate in an anonymous online survey. The primary objective was to learn about patients' perspectives on shorter durations (less than 12-months) of anti-HER2 therapy. Secondary objectives were to explore patients' interest in clinical trials of shorter durations of anti-HER2 therapy and the degree of increased breast cancer risk they would accept with a shorter treatment duration. Responses were received from 94 eligible patients. Most patients received Trastuzumab alone (78%, 73/94), while 13% (12/94) received trastuzumab and pertuzumab. Side effects were experienced by 52% (46/89), the most common being; fatigue (61%, 28/46), myalgia (37%, 17/46), and diarrhea (24%, 11/46). Most patients (88%, 78/89) did not find treatment bothersome. Regarding perspectives on shorter durations of anti-HER2 therapy, most (79%, 74/94) respondents stated they would agree to less treatment if it were possible to receive fewer treatments with the same cancer benefits. 56% of patients were interested in clinical trials, however, about half stated they would not be accepting of any increase in breast cancer recurrence risk. Trials to investigate who can safely and effectively be treated with shorter durations of anti-HER2 therapy are needed. This study provides important insights to patients' perspectives on shorter durations of anti-HER2 treatment, and their concerns regarding potential increased cancer risk with less treatment.

Environmentally sustainable opportunities for health systems: metered-dose inhaler prescribing, dispensing, usage, and waste at The Ottawa Hospital

BackgroundThe carbon footprint of Canada's health sector is among the worst in the world, responsible for 4·6% of Canada's total greenhouse gas emissions. A quarter of emissions from Canada's health sector are linked to pharmaceuticals, including metered dose inhalers (MDIs). MDIs use propellants, such as hydrofluorocarbons, which act as greenhouse gas emissions and contribute to the health-care sector's overall carbon footprint. The objective of this study was to describe MDI prescribing, dispensing, usage, and waste patterns at The Ottawa Hospital (Ottawa, ON, Canada). Secondary objectives included estimating the monetary and carbon cost of current practice and the potential benefits and costs of switching to the more environmentally friendly dry powder inhalers. MethodsIn this retrospective point-prevalence cohort study, we identified 100 consecutive patients from medical and surgical services at both campuses of The Ottawa Hospital from health records discharged from medical and surgical services and who were prescribed at least one MDI during their admission. Medical records were reviewed and data related to demographics, MDI prescribing, dispensing, usage, and wastage were collected using a pre-piloted electronic case report form. Financial cost was calculated using local costing estimates and carbon cost was calculated using published estimates. FindingsBetween Jan 1, 2023, and June 1, 2023, we collected data for 100 eligible patients, of whom 60 (60%) were female and 90 (90%) were admitted to hospital medicine wards (10% from surgical wards). The median length of stay was 7 (range 1–47) days. The most common inpatient diagnoses were respiratory tract infections in 43 (43%) of 100 patients and chronic obstructive pulmonary disease exacerbations in 28 (28%) of 100 patients. The median number of MDIs prescribed during a patients stay was two (range one to 15) and the median number dispensed was one (range one to seven). For formulary options of MDIs, of the 200 (range 30–1400) actuations dispensed per patient, 8% were used, representing 92% wastage. During the audit, 315 MDIs were dispensed in total, of which 97 were not used at all. InterpretationMDIs are significant contributors to the carbon footprint attributed to pharmaceutical use in hospitals. This study suggests that 90% of MDI doses are wasted, showing that there is substantial room for improvement. FundingNone.