Provincial Guidelines Research Articles

Impact of implementing a fast-track protocol and standardized guideline for the management of pediatric appendicitis.

Background:In 2017, a provincial guideline was created to fast track and standardize care for pediatric appendicitis in Alberta. We conducted a study to determine the impact of implementation of the guideline at our institution on length of stay (LOS), antibiotic stewardship efforts and costs.Methods:We performed a retrospective review of the charts of all patients younger than 18 years of age who underwent appendectomy at our institution in 2 periods: before guideline implementation (Dec. 1, 2016, to May 31, 2017) and after implementation (Dec. 1, 2017, to May 31, 2018). We compared LOS, duration of antibiotic therapy, 30-day postdischarge complication rates and variable cost between the 2 cohorts.Results:Of the 276 total appendectomy procedures performed, 185 were for simple appendicitis (81 before guideline implementation and 104 after implementation), and 91 were for complicated appendicitis (44 and 47, respectively). The median LOS was shorter in the postimplementation cohort for both simple and complicated appendicitis (15.5 h [interquartile range (IQR) 12–19 h] v. 17.0 h [IQR 13–22 h], p = 0.03; and 3.0 d [IQR 2–4 d] v. 3.0 d [IQR 3–5 d], p = 0.05, respectively). Patients with complicated appendicitis had fewer antibiotic days after guideline implementation; the difference was statistically significant for patients without diffuse peritoneal contamination or abscess formation (p = 0.02). There were no differences between the cohorts with respect to 30-day rates of complications, including emergency department visits, readmission and surgical site infections. After guideline implementation, the average variable cost per patient was reduced by $230, equating to a total average annual cost savings of $75 842 for our institution.Conclusion:The implementation of a provincial guideline aimed at standardizing care in pediatric appendicitis at our institution was associated with shortened LOS, improved antibiotic stewardship efforts and reduced cost of care. Other institutions may replicate our model of a standardized pathway in the management of pediatric appendicitis in an effort to improve the quality of patient care and reduce health care costs.

Global development of human papillomavirus vaccination guidelines: a systematic review

Objective: To systematically summarize the development of global human papillomavirus (HPV) vaccination guidelines. Methods: The retrieval for all the Chinese and English literature published before August 2020 was conducted in PubMed, Embase and China Biomedical Literature Database, with "papillomavirus vaccines" "wart virus vaccine" "guideline" "practice guideline" "health planning guidelines" "guidelines as topic" "practice guidelines as topic" "immunization programs" in English as well as "papillomavirus vaccines" "HPV vaccine" "guideline" "recommendation" "consensus" in Chinese as search keywords. A total of 18 guidelines were included for data extraction and analysis. Results: The 18 pieces of guidelines included 1 pieces of World Health Organization (WHO) position paper, 6 pieces of guidelines at national or provincial level and other 11 pieces of by academic institutions. In national or provincial guidelines, the recommendation for routine vaccination mainly focused on 11-13 year-old adolescents and the recommendation for catch-up vaccination extends to 17-26 years old. Recommendation of guidelines by academic institutions were similar to the WHO position paper: girls aged 9-14 as the primary target for the routine vaccination; females aged 15-26 years old as the secondary target populations when it's feasible, affordable and cost-effective; women aged over 26 could be vaccinated at an individual level. There were only three guidelines simultaneously updated with the national immunization programme and covered four aspects: the vaccinated population (girls-only to gender-neutral vaccination), the periodic catch-up immunization, the dose schedule updates and the change of vaccine types. Conclusions: It's recommended that the development of Chinese HPV vaccination guidelines refer to global guidelines and updates and take full consideration of the epidemiological evidence, resources and current status of the immunization system in China.

Ecological change associated with historic industrial activity in the St. Lawrence River at Cornwall, ON: A paleo-ecotoxicological assessment using subfossil chironomid assemblages

Twentieth-century historic industrial activity in Cornwall, ON loaded high amounts of metals and metalloids to the St. Lawrence River. Despite industrial improvements and the eventual closure of point-source polluters, sedimentary contamination in the Cornwall waterfront remains above provincial guidelines, causing concern for ecosystem management. We analysed chironomid (Order: Diptera) subfossils from modern-day surface-sediment samples and a sediment core from the Cornwall waterfront in order to better understand historic pollution impacts and potential recovery. Modern-day chironomid assemblages were diverse (48 genera, >70 species) and overall assemblage structure was weakly related to sedimentary zinc concentrations, with Procladius, Paratanytarsus, and Ablabesmyia identified as zinc-tolerant and Rheotanytarsus, Polypedilum and Paratendipes identified as zinc-sensitive. The sediment core showed peak total mercury (THg) concentrations were an order of magnitude higher than in modern-day surface sediments. In sections of the core below 10 cm in depth, THg concentrations were high (~30–50 µg/g) and chironomids were nearly absent from the record. Above 10 cm (c. 1980) THg concentrations decreased and chironomid taxa returned in low abundances. Subsequent intervals displayed an increase in diversity, abundance, and the relative abundance of metal-sensitive taxa. This study provides evidence of ecological change which co-occurs with Cornwall’s historic industrial activity and indicates progress toward related ecological goals identified in the current management strategy.

Ineffectiveness of high-dose methotrexate for prevention of CNS relapse in diffuse large B-cell lymphoma.

Central nervous system (CNS) relapse affects 5% of diffuse large B-cell lymphoma (DLBCL) patients and portends a poor prognosis. Prophylactic intravenous high-dose methotrexate (HD-MTX) is frequently employed to reduce this risk, but there is limited evidence supporting this practice. We conducted a multicenter retrospective study to determine the CNS relapse risk with HD-MTX in DLBCL patients aged 18-70 years treated in Alberta, Canada between 2012 and 2019. Provincial guidelines recommended HD-MTX for patients at high-risk of CNS relapse based upon CNS-IPI score, double-hit lymphoma, or testicular involvement. Among 906 patients with median follow-up 35.3 months (range 0.29-105.7), CNS relapse occurred in 1.9% with CNS-IPI 0-1, 4.9% with CNS-IPI 2-3, and 12.2% with CNS-IPI 4-6 (p < .001). HD-MTX was administered to 115/326 (35.3%) high-risk patients, of whom 96 (83.5%) had CNS-IPI score 4-6, 45 (39.1%) had double-hit lymphoma, and four (3.5%) had testicular lymphoma. The median number of HD-MTX doses was two (range 1-3). Central nervous system relapse risk was similar with versus without HD-MTX (11.2% vs. 12.2%, p = .82) and comparable to previous reports of high-risk patients who did not receive CNS prophylaxis (10-12%). In multivariate and propensity score analyses, HD-MTX demonstrated no association with CNS relapse, progression-free survival, or overall survival. This study did not demonstrate a benefit of prophylactic HD-MTX in this high-risk patient population. Further study is required to determine the optimal strategy to prevent CNS relapse in DLBCL.

Consensus Recommendations for MRD Testing in Adult B-Cell Acute Lymphoblastic Leukemia in Ontario.

Measurable (minimal) residual disease (MRD) is an established, key prognostic factor in adult B-cell acute lymphoblastic leukemia (B-ALL), and testing for MRD is known to be an important tool to help guide treatment decisions. The clinical value of MRD testing depends on the accuracy and reliability of results. Currently, there are no Canadian provincial or national guidelines for MRD testing in adult B-ALL, and consistent with the absence of such guidelines, there is no uniform Ontario MRD testing consensus. Moreover, there is great variability in Ontario in MRD testing with respect to where, when, and by which technique, MRD testing is performed, as well as in how the results are interpreted. To address these deficiencies, an expert multidisciplinary working group was convened to define consensus recommendations for improving the provision of such testing. The expert panel recommends that MRD testing should be implemented in a centralized manner to ensure expertise and accuracy in testing for this low volume indication, thereby to provide accurate, reliable results to clinicians and patients. All adult patients with B-ALL should receive MRD testing after induction chemotherapy. Philadelphia chromosome (Ph)-positive patients should have ongoing monitoring of MRD during treatment and thereafter, while samples from Ph-negative B-ALL patients should be tested at least once later during treatment, ideally at 12 to 16 weeks after treatment initiation. In Ph-negative adult B-ALL patients, standardized, ideally centralized, protocols must be used for MRD testing, including both flow cytometry and immunoglobulin (Ig) heavy chain and T-cell receptor (TCR) gene rearrangement analysis. For Ph-positive B-ALL patients, MRD testing using a standardized protocol for reverse transcription real-time quantitative PCR (RT-qPCR) for the BCR-ABL1 gene fusion transcript is recommended, with Ig/TCR gene rearrangement analysis done in parallel likely providing additional clinical information.

A Review of Canadian Cancer-Related Clinical Practice Guidelines and Resources during the COVID-19 Pandemic.

(1) Background: Preventive measures taken in response to the coronavirus disease 2019 (COVID-19) pandemic have adversely affected an entire range of cancer-related medical activities. The reallocation of medical resources, staff, and ambulatory services, as well as critical shortages in pharmaceutical and medical supplies have compelled healthcare professionals to prioritize patients with cancer to treatment and screening services based on a set of classification criteria in cancer-related guidelines. Cancer patients themselves have been affected on multiple levels, and addressing their concerns poses another challenge to the oncology community. (2) Methods: We conducted a Canada-wide search of cancer-related clinical practice guidelines on the management and prioritization of individuals into treatment and screening services. We also outlined the resources provided by Canadian cancer charities and patient advocacy groups to provide cancer patients, or potential cancer patients, with useful information and valuable support resources. (3) Results: The identified provincial guidelines emphasized cancer care (i.e., treatment) more than cancer control (i.e., screening). For cancer-related resources, a clear significance was placed on knowledge & awareness and supportive resources, mainly relating to mental health. (4) Conclusion: We provided a guidance document outlining cancer-related guidelines and resources that are available to healthcare providers and patients across Canada during the COVID-19 pandemic.

Appetite for change? Facilitators and barriers to nutrition guideline implementation in Canadian recreational facilities.

As providers of community-based physical activity programs, recreation and sports facilities serve as an important resource for health promotion. Unfortunately, the food environments within these settings often do not reflect healthy eating guidelines. This study sought to describe facilitators and barriers to implementing provincial nutrition guidelines in recreation and sports facilities in three Canadian provinces with nutrition guidelines. Semi-structured interviews were analysed thematically to identify facilitators and barriers to implementing provincial nutrition guidelines. Facilitators and barriers were then categorised using a modified "inside out" socio-ecological model that places health-related and other social environments at the centre. A total of 32 semi-structured interviews were conducted at two time-points across the three guideline provinces. Interview participants included recreation staff managers, facility committee or board members and recreation volunteers. Eight facilitators and barriers were identified across five levels of the inside out socio-ecological model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Findings reinforce the importance of top down (clear expectations regarding guideline implementation at the time of approval) and bottom up (need for buy-in from multiple stakeholders) approaches to ensure successful implementation of nutrition guidelines. The application of a modified socio-ecological model allowed for a more nuanced understanding of leverage points to support successful guideline implementation. Lay summary Healthy eating is an important behaviour for preventing chronic diseases. Supporting people to access healthy foods in places where they live, learn, work or play is a public health priority. Recreation and sports facilities are a setting where people can be physically active. Unfortunately, the food environment in these settings may not reflect nutrition guidelines. In this study, we interviewed key stakeholders from recreation and sports facilities in three Canadian provinces who had put guidelines for healthy eating in place. We used a specific framework to do this called the inside out socio-ecological model. Eight facilitators and barriers were identified using this model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Our findings can help people working in recreation and sports facilities to identify issues that may help or hinder healthy food provision in these settings.

Strategies to maintain a family-centered care approach in the era of COVID-19: Experiences of a Canadian pediatric cardiology program

The COVID-19 pandemic has resulted in strict provincial guidelines to prevent its spread. Physical distancing requirements, the postponement of elective pediatric cardiac surgeries and non-invasive cardiac interventions, and hospital visitor restrictions have significantly impacted services provided by our pediatric cardiac program. Rapid modifications to current inpatient and outpatient practices were required to maintain a family-centered care approach. Strategies our team used to maintain a family-centered care approach focused on six key areas including inpatient care, outpatient pediatric cardiology clinics, family meetings, discharge planning and teaching, the connection of inpatient pediatric patients to the outside world, and social support. The majority of our strategies are adaptable to other pediatric cardiology programs and some may prove useful after the pandemic and as restrictions lift. These strategies each have their own limitations and challenges that must be considered when adapting them to other pediatric cardiology programs and continuing their use after the pandemic has resolved.

What is stopping us? An implementation science study of kangaroo care in British Columbia\u2019s neonatal intensive care units

BackgroundThe goal of the Neonatal Intensive Care Unit (NICU) is to provide optimal care for preterm and sick infants while supporting their growth and development. The NICU environment can be stressful for preterm infants and often cannot adequately support their neurodevelopmental needs. Kangaroo Care (KC) is an evidence-based developmental care strategy that has been shown to be associated with improved short and long term neurodevelopmental outcomes for preterm infants. Despite evidence for best practice, uptake of the practice of KC in resource supported settings remains low. The aim of this study was to identify and describe healthcare providers’ perspectives on the barriers and enablers of implementing KC.MethodsThis qualitative study was set in 11 NICUs in British Columbia, Canada, ranging in size from 6 to 70 beds, with mixed levels of care from the less acute up to the most complex acute neonatal care. A total of 35 semi-structured healthcare provider interviews were conducted to understand their experiences providing KC in the NICU. Data were coded and emerging themes were identified. The Consolidated Framework for Implementation Research (CFIR) guided our research methods.ResultsFour overarching themes were identified as barriers and enablers to KC by healthcare providers in their particular setting: 1) the NICU physical environment; 2) healthcare provider beliefs about KC; 3) clinical practice variation; and 4) parent presence. Depending on the specific features of a given site these factors functioned as an enabler or barrier to practicing KC.ConclusionsA ‘one size fits all’ approach cannot be identified to guide Kangaroo Care implementation as it is a complex intervention and each NICU presents unique barriers and enablers to its uptake. Support for improving parental presence, shifting healthcare provider beliefs, identifying creative solutions to NICU design and space constraints, and the development of a provincial guideline for KC in NICUs may together provide the impetus to change practice and reduce barriers to KC for healthcare providers, families, and administrators at local and system levels.

Contaminant characterization in wetland media surrounding a pulp mill industrial effluent treatment facility

Three media (sediment, surface water, and dragonfly larvae tissue) were collected from wetlands surrounding an industrial effluent treatment facility prior to closure. Samples were analyzed for metals, total mercury, and polychlorinated dibenzo-p-dioxins/polychlorinated dibenzofurans (PCDD/PCDF) concentrations. Sediment and surface water concentrations were compared to provincial and federal guidelines, as well as reference wetland concentrations. Exceedances of arsenic, cadmium, chromium, copper, zinc, and PCDD/PCDF guidelines were found in deeper areas of wetlands historically contaminated from effluent, as well as wetlands exposed to current effluent inputs. Composite Libellulidae samples were collected from wetlands, and comparisons were made to reference tissue concentrations + 20%. Elevated As, Cu and Pb tissue concentrations were measured at two site wetlands, but total mercury (THg) and PCDD/PCDF reference tissue concentrations were higher than wetlands near the effluent treatment facility. Spearman rho tests identified a significant correlation between sediment and tissue Pb concentrations and between surface water and sediment THg concentrations. Results suggest relatively low ecological risk to macroinvertebrates within wetlands near the effluent treatment facility from current effluent inputs, and highlight strengths and weaknesses of federal and provincial guidelines.

Emergency medicine airway leads: a rapid response distributed educational model for emergency department COVID-19 airway management.

With the first case of COVID-19 confirmed in Canada in early 2020, our country joined in the fight against a novel pathogen in a global pandemic. The stress of uncertainty and practice change was most apparent in the emergency department when it came to managing known or suspected COVID-19 patients requiring airway management. Recognizing the need for a coordinated approach, a province wide rapid response distributed model of continuing professional development for airway management was developed utilizing Airway Leads to help prepare front-line medical personnel providing airway management for these patients. Airway Leads worked with local physicians to deliver consistent, high quality airway education across the province during the initial surge of cases. Education included both in person and virtual sessions along with real time ongoing support through provincial guidelines, videos, and other documents. Physician reported “stress level” pre- and post-Airway Lead support declined from a median score of 9 to 7 (on a 10-point Likert Scale).

Leading a Long-Term Care Facility through the COVID-19 Crisis: Successes, Barriers and Lessons Learned.

The long-term care (LTC) sector has been the epicentre of COVID-19 in Canada. This paper describes the leadership strategies that helped manage the pandemic in one COVID-19-free LTC facility in British Columbia. Qualitative interviews with four executive leaders were collected and analyzed. The facility implemented most provincial guidelines to prevent or mitigate virus spread. Crisis leadership competencies and safety prioritization helped this site's successful management of the pandemic. There was room for improvement in communication and staffing practices and policies in the facility.

Variability in instructions for performance of nasopharyngeal swabs across Canada in the era of COVID-19 \u2013 what type of swab is actually being performed?

BackgroundThe primary method of surveillance for the presence of SARS-CoV-2 is with nasopharyngeal swabs. Given the significant demand for nasopharyngeal swabs, a large number of previously untrained and unfamiliar staff are now performing this test. It was noted that there was significant heterogeneity in instructions for performing nasopharyngeal swabs in Canada, in contrast to the guidance provided by the Centers for Disease Control and Prevention (CDC), and the Pan American Health Organization (PAHO). The objective of this study was to review the instructions provided across Canada and contrast them to those of the CDC and PAHO.MethodsA standard series of steps for nasopharyngeal swab performance was outlined based on the CDC, PAHO, and New England Journal of Medicine instructions. A comprehensive search was performed in August 2020 to identify nasopharyngeal swab guidelines provided by public health in the provinces and territories of Canada. Regional health authority guidance was also collected. Instructions provided were contrasted against the standardized steps.ResultsInstructions were identified for all provinces and territories, and for 81 regional health authorities. From the provincial and territorial guidelines, 10/13 (77%) cleared the nasal passages before swab insertion, 11/13 (85%) tilted the patient’s head back slightly, 12/13 (92%) inserted the swab parallel to the palate, but only 3/13 (23%) inserted the swab to at least a depth of two-thirds the distance between the patient’s nose and ear. A clear majority (81%) of regional health authority guidelines followed their respective provincial guidelines.For depth of insertion, Quebec provided a pictogram but no distance or technique for estimation. Six provinces and territories - Northwest Territories, Nunavut, Ontario, Saskatchewan, Prince Edward Island and Alberta - recommended 4 cm or one-half the distance from nostrils to ear. British Columbia and Manitoba recommended a 7 cm depth of insertion. Nova Scotia recommended one-half to two-thirds the distance from nose to ear. Lastly, Newfoundland, New Brunswick and the Yukon recommended an insertion from nose to the external ear canal.ConclusionThere is significant heterogeneity in guidance for nasopharyngeal swab performance across Canada. The instructions provided by the majority of provinces and territories in Canada would not be effective in reaching the nasopharynx.Graphical abstract

Optimizing Practices, Use, Care and Services‐Antipsychotics (OPUS‐AP): A phase 2 scale‐up to 129 long‐term care (LTC) centers in Quebec, Canada

AbstractBackgroundAntipsychotics are often used for the first‐line management of behavioral and psychological symptoms of dementia (BPSD) despite risks and side effects, and with disregard for guidelines recommendations to prioritize non‐pharmacological interventions. OPUS‐AP builds on Canadian Foundation for Healthcare Improvement, Appropriate Use of Antipsychotic initiatives and previous work by the 4 university‐affiliated research centers on an aging population in Quebec. The OPUS‐AP strategy is supported by an evidence‐based approach, involving provincial clinical guidelines developed by Québec’s health‐technology assessment agency, the Institut national d’excellence en santé et en services sociaux (INESSS). In phase 1 of OPUS‐AP, conducted in 24 long‐term care (LTC) centers in Quebec, Canada, antipsychotic deprescribing (cessation or dose decrease) was achieved in 85,5% of residents in whom it was attempted (Cossette et al. JAMDA, 2019).MethodPhase 2 of OPUS‐AP was conducted in 129 LTC centres in Quebec, Canada, from April to December 2019. OPUS‐AP aims at improving resident care through increased staff’s knowledge and competency, resident‐centered approaches, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. OPUS‐AP is implemented through integrated knowledge translation and mobilization activities. Antipsychotic, benzodiazepine, antidepressant prescriptions and BPSD were evaluated every 3 months for 6 months.ResultAt baseline, 10,601 residents were admitted on OPUS‐AP participating wards from which 74% had a diagnosis of major neurocognitive disorder (MNCD) and 47% an antipsychotic prescription. The follow‐up cohort included 4,087 residents with both MNCD and antipsychotic prescription. Among the 1216 residents in whom antipsychotic deprescribing was attempted between baseline and 6 months and still included at 6 months, successful deprescribing was achieved in 85.6% (cessation 50.0% or dose decrease 35.6%). No increase in benzodiazepine or antidepressant prescriptions nor worsening of BPSD were observed.ConclusionPhase 2 of OPUS‐AP confirmed phase 1 results of successful antipsychotic deprescribing with scale‐up to 129 LTC centers. Phase 3 of OPUS‐AP is underway in 2020 in all of Quebec’s 341 public LTC centers.

Unhealthy food options in the school environment are associated with diet quality and body weights of elementary school children in Canada.

Increasing evidence links unhealthy food environments with diet quality and overweight/obesity. Recent evidence has demonstrated that relative food environment measures outperform absolute measures. Few studies have examined the interplay between these two measures. We examined the separate and combined effects of the absolute and relative densities of unhealthy food outlets within 1600 m buffers around elementary schools on children's diet- and weight-related outcomes. This is a cross-sectional study of 812 children from thirty-nine schools. The Youth Healthy Eating Index (Y-HEI) and daily vegetables and fruit servings were derived from the Harvard Food Frequency Questionnaire for Children and Youth. Measured heights and weights determined BMI Z-scores. Food outlets were ranked as healthy, somewhat healthy and unhealthy according to provincial paediatric nutrition guidelines. Multilevel mixed-effects regression models were used to assess the effect of absolute (number) and relative (proportion) densities of unhealthy food outlets within 1600 m around schools on diet quality and weight status. Two urban centres in the province of Alberta, Canada. Grade 5 students (10-11 years). For children attending schools with a higher absolute number (36+) of unhealthy food outlets within 1600 m, every 10 % increase in the proportion of unhealthy food outlets was associated with 4·1 lower Y-HEI score and 0·9 fewer daily vegetables and fruit. Children exposed to a higher relative density of unhealthy food outlets around a school had lower diet quality, specifically in areas where the absolute density of unhealthy food outlets was also high.

Mental health of healthcare workers during the COVID-19 outbreak: A rapid scoping review to inform provincial guidelines in South Africa

COVID-19 is prevalent in sub-Saharan Africa. The healthcare response to the pandemic depends upon a mentally and physically healthy workforce. Infectious disease outbreaks cause high psychosocial stress among healthcare workers, which may impact negatively on workplace functioning. To understand which mental health conditions may occur and which interventions could be considered, we conducted a rapid scoping review. Using a 2018 systematic review as the starting point, PubMed, Cochrane, Web of Science and MEDLINE databases were searched for any type of evidence published in English between 2014 and 2020 on mental health of healthcare workers exposed to infectious disease outbreaks; 19 primary studies and 13 opinion pieces were included. Depression, anxiety, post-traumatic stress, and other mental health conditions were noted among healthcare workers exposed to COVID-19 and other outbreaks. Although no effectiveness studies were identified, certain proposed interventions may be implemented by healthcare leaders. Further research is recommended.

Abstract PO-026: Minimize impact of pandemic on radiation oncology department: Experience from a moderate-sized regional cancer program in the battle against COVID-19 virus

Abstract Introduction: The World Health Organization (WHO) declared COVID-19 virus as pandemic on March 12, 2020. Now it has infected more than 5 million people in 188 countries and caused more than 340,000 deaths. The purpose of this paper is to share the experience of our radiation oncology department in a moderate-sized regional cancer center (1,600 new consults for radiation per year) in the battle against COVID-19, including the safety measures taken and the lessons learned. Methods: Our institution is located in the neighbor city of one of the largest COVID-19 epicenters in the USA. We have taken precautionary measures gradually to continue our practice in radiation oncology in order to reduce impact on vulnerable cancer patients. These include reducing the number of entrance doors for both staff and patients; restricted visitor policy; mandatory screening questionnaires; social distancing in waiting rooms; self-quarantine of staff with travel history or symptoms similar to COVID-19; most responsible physicians reviewing every case to prioritize or defer consultation, investigation, or treatment; telemedicine for most consultation and follow-up visits; universal COVID-19 swabbing test for all symptomatic and asymptomatic cancer patients before starting treatment planning or radiotherapy; full personal protective equipment (PPE) for staff doing CT simulation or delivering treatment; mandatory face mask for everyone in the building; keeping 2/3 of all radiation oncologists (RO) and dosimetrists working from home on a roster schedule; and discouraging handling physical paper charts and documents in a completely paperless working environment. Results: We saw 267 new consults in the 10 weeks between March 16 and May 24, 2020, vs. 274 in the same period last year. There is no significant difference in average consults per RO, 44.5 (30-60) vs. 45.7 (24-67), p=0.799 (Student’s t-test), or wait time within provincial target of 2 weeks, 93.5% vs 97%, p=0.074. We performed 193 swabbing tests for 183 patients, with 10 patients bein.g swabbed twice. Most were asymptomatic (144), with 49 symptomatic. Only 0.52% tested positive (1 asymptomatic case), lower than many other cancer institutions reported in the literature, and there were no cases among staff. During the same 10 weeks, confirmed cases in our community and the province increased from 0 to 912 (6.05% positive tests) and from 142 to 25,904 (4.18% positive tests), with 63 and 2,102 deaths, respectively. Conclusions: Due to restrictions to test asymptomatic patients and to use PPE, the COVID-19 testing rate is far from reaching the provincial target and the new cases and deaths are more than originally predicted. However, our department was not heavily affected due to the diligent team effort ahead of policy changes in the province. It is possible for frontline health care teams to minimize the risk of cancer patients getting COVID-19 and avoid treatment interruptions by planning safety measures early, even before the first case in the community and before formal provincial guidelines become available. Citation Format: Ming Pan, Khalid Hirmiz, Junaid Yousuf, Kitty Huang, Colvin Springer, Ken Schneider, Laura D’Alimonte. Minimize impact of pandemic on radiation oncology department: Experience from a moderate-sized regional cancer program in the battle against COVID-19 virus [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-026.

110 Improving Asthma Education in the Emergency Department: A Quality Improvement Initiative

Abstract Introduction/Background Asthma education and action plans have been shown to improve compliance and symptom control. Provincial guidelines, created in 2015, included asthma action plans, but use of these resources across our site was not consistent. Objectives The objectives of this study were to develop and implement an asthma education package, standardize discharge instructions and improve appropriate referrals to Asthma Clinics. Design/Methods Using process mapping, staff surveys and patient interviews, we undertook a current state analysis. The resulting change ideas were implemented between October 2018 and January 2020 in 5 PDSA (Plan Do Study Act) cycles, utilizing chart reviews and a standardized data tool to measure outcomes. Rates of repeat Emergency Department (ED) attendances, 2 weeks following the initial encounter and overall rates of ED asthma visits were assessed, using patient medical record data. Results Two-hundred-and-twenty-five ED presentations were reviewed, 65.2% (146/224) had a previous diagnosis of asthma. 48.9% (110/225) reported using an inhaled corticosteroid (ICS) at presentation. 89.7% (201/224) had not seen a healthcare provider during this acute illness. Asthma action plan utilization increased from 0% at baseline to an average of 60%, sustained over 2 years. 74.2% (167/225) had an ICS prescribed or advised at discharge. Only 3.8% (8/209) of patients re-presented to an ED within 2 weeks of this asthma visit. 57.3% (129/225) children were referred for ongoing pediatric care: either by a community pediatrician (72.9%; 94/129) or our hospital Asthma Clinic (34.8%; 32/129). Between 2017 and 2019, there was no significant change in total asthma presentations to our ED/per year (1300, 1395 and 1307, respectively) (Figure 1). Conclusion A standardized asthma education package including pre-printed discharge resources, asthma action plans, and a provincially adopted, multi-language education video was successfully implemented into our ED. This demonstrates a multi-disciplinary approach to asthma education that can be utilized across the province. Our data highlights the need for a strong community-based approach for asthma care, and further work is ongoing to assess the efficacy of this education package on medication compliance and recurrent ED visits.

Compliance with Fetal Fibronectin Testing at a Canadian Tertiary Care Perinatal Centre.

The purpose of this study was to assess compliance with fetal fibronectin (fFN) testing recommendations at a single tertiary care perinatal centre. The secondary objective was to identify factors associated with compliance with these recommendations. A retrospective cohort study was conducted from January 1, 2016 to December 31, 2016 of all patients who presented to the IWK Health Centre with suspected preterm labour. Inclusion criteria included symptoms of preterm labour prior to 370 weeks gestation, singleton or multiple pregnancy, and established fetal wellbeing. Exclusion criteria included severe fetal anomaly, contraindications to tocolysis, transfer from community hospital, or inadequate documentation. Provider compliance was evaluated to determine: 1) whether the test was performed for appropriate indications according to provincial fFN guidelines; 2) whether fFN results were appropriately being used to inform patient care. Logistic regression was used to determine factors associated with compliance. A total of 528 patients presented with symptoms of preterm labour. The overall compliance with testing recommendations was 76.1%. Compliance for patients who met criteria for fFN testing was 73%, and compliance for those not meeting criteria was 76.4%. Of patients with a negative fFN result, 85.3% were appropriately discharged home without intervention. Gestational age, time of day, and non-obstetrician provider type were found to be associated with compliance. Despite regional and national guidelines, this study demonstrates a compliance rate of 76% in our centre, indicating a gap in provider knowledge regarding proper use and interpretation of fFN. Non-obstetrician provider type was associated with decreased compliance.

Women's views about breast cancer prevention at mammography screening units and well women's clinics.

Women attending mammography screening units (msus) and well women's clinics (wwcs) represent a motivated cohort likely to engage in interventions aimed at primary breast cancer (bca) prevention. We used a feasibility questionnaire distributed to women (40-49 or 50-74 years of age) attending msus and wwcs in Halifax, Nova Scotia, to examine■ women's views about bca primary prevention and sources of health care information,■ prevalence of lifestyle-related bca risk factors, and■ predictors of prior mammography encounters within provincial screening guidelines.Variables examined included personal profiling, comorbidities, prior mammography uptake, lifestyle behaviours, socioeconomic status, health information sources, and willingness to discuss or implement lifestyle modifications, or endocrine therapy, or both. A logistic regression analysis examined associations with prior mammography encounters. Of the 244 responses obtained during 1.5 months from women aged 40-49 years (n = 75) and 50-74 years (n = 169), 56% and 75% respectively sought or would prefer to receive health information from within, as opposed to outside, health care. Lifestyle-related bca risk factors were prevalent, and most women were willing to discuss or implement lifestyle modifications (93%) or endocrine therapy (67%). Of the two age groups, 49% and 93% respectively had previously undergone mammography within guidelines. Increasing age and marital status (single, separated, or divorced vs. married or partnered) were independent predictors of prior mammography encounters within guidelines for women 40-49 years of age; no independent predictors were observed in the older age group. Women attending msus and wwcs seem to largely adhere to mammography guidelines and appear motivated to engage in bca primary prevention strategies, including lifestyle modifications and endocrine therapy. Women's views as observed in this study provide a rationale for the potential incorporation of bca risk assessment within the "mammogram point of care" to engage motivated women in bca primary prevention strategies.