Teaching Hospital In Toronto Research Articles

Preparing for Platelet Shortages: Which Surgeries Should be Cancelled?

Introduction: Due to their short shelf-life, platelet concentrates are particularly susceptible to the product shortages which may result from shortfalls in donor collections or disruptions to the manufacturing and supply chain. Mechanisms to address shortages are particularly important in light of the ongoing COVID-19 pandemic. Canadian Blood Services (CBS), the national blood center serving Canada except Quebec, called a national Green Advisory Phase from May to June 2020 on platelet products and O negative red blood cells, requesting daily hospital inventory reports. When such shortages occur, it may be challenging to identify which surgical procedures are likely to require platelet transfusion support and should therefore be rescheduled. Methods: Information systems maintained by the Blood Transfusion Service (Wellsky®) and the Department of Surgical Services (ORSOS®) were cross-referenced for the 2019 calendar year at a large adult teaching hospital in Toronto with active cardiovascular and transplant programs. Only procedures that were performed more than 25 times during this period were included in the analysis. Average platelet consumption on the day of surgery, 1 week post-operatively and 30 days post-operatively was calculated. Results: 50 procedures with a potential for requiring intra-operative platelet transfusion support were identified, with the greatest demand being those involving cardiopulmonary bypass (CBP) support (27% of cases transfused, median of 2.7 units per case) and heart, liver and lung transplantation (24% of cases transfused, median of 4.2 units per case). Although spinal surgery as a group was not a high platelet consumer (4% of cases transfused, median of 0.3 units per case), certain complex procedures such as thoracic-lumbar laminectomy and thoracic-lumbar decompression and fusion were more at risk of requiring platelet support during and in the post-operative period. Due to their frequency, procedures on CPB created the highest demand in platelets with close to 4500 units distributed during the year. Standard deviations for many procedures was large, up to 10 units in the intra-operative period. Other procedures with low-risk of intra-operative platelet transfusion support but a possibility of requiring platelet transfusion in the 30-day post-operative period included renal transplantation and neurosurgical procedures. Interestingly, renal transplant patients generally did not require transfusion support during surgery or in the immediate post-operative period but only when looking at 30-day requirements. For most patients, these procedures would therefore be at risk only in the setting of very prolonged shortages. Conclusion: Data-driven demand forecasting for intra-operative and post-operative platelet transfusion support may be of value in risk-benefit analysis of proceeding with specific surgical procedures in the setting of platelet shortages. However, some of the procedures with the highest platelet consumption serve the sickest patients and cannot be postponed. Disclosures No relevant conflicts of interest to declare.

Building Capacity in Health Professionals to Conduct Quality Improvement: Evaluation From a Collaborative Interorganizational Program.

The Toronto Academic Health Sciences Network Health Professions Innovation Fellowship Program began in 2014 as a pilot initiative among 4 academic teaching hospitals in Toronto, Ontario. The purpose of the Program was to cultivate applied leadership, interprofessional collaboration, and quality improvement capacity among health professionals. This article reports on the evaluation findings from the initial year as well as an update on current program status and sustainability. A formative evaluation was conducted focused on the impact on clinical practice, participant skill development, participant experience, and cross-organizational partnerships. Data were collected through a focus group, interviews, and pre- and postsurveys. Data from the initial pilot showed increases in leadership practices, project management, and quality improvement knowledge, with changes in leadership practices being significant. Positive changes in clinical practice at both the individual and unit/team levels and capacity for building relationships were also reported. Since the pilot, more than 160 participants from 15 health professions and 9 organizations have participated. Several graduates have taken on leadership roles since their participation in the Program. Health care organizations wishing to advance academic practice may benefit from implementing a similar collaborative program to reap benefits beyond organizational silos.

265-OR: Identifying Adults at Risk of Unintentional Severe Hypoglycemia in Hospital Using Artificial Intelligence (RUSHH-AI)

Background: Machine learning carries great promise to improve healthcare delivery. Clinical outcomes that are routinely and objectively measured, and have serious consequences that can be prevented, are ideal targets for prediction and intervention. Hypoglycemia, defined as a blood glucose less than 3.9 mmol/L (70 mg/dL), meets these criteria. The purpose of this study was to predict hypoglycemia using artificial intelligence models in patients hospitalized to general internal medicine (GIM) and cardiovascular surgery (CV) at a tertiary-care teaching hospital in Toronto, Ontario. Methods: Models were built using routinely-collected clinical data from the hospital’s electronic health record. Models were trained using data from Jan 2013-Apr 2017, tested using data from Apr 2017-Mar 2018, and validated using held-out test data from Apr 2018-Mar 2019. Three models were generated using supervised machine learning: LASSO regression, gradient boosted trees, and a recurrent neural network. Each model included baseline patient data and time-varying data. Natural language processing was used to incorporate text data from physician and nursing notes. Results: We included 8492 GIM admissions and 8044 CV admissions. The average age of patients was 68 years, 35% were women, the baseline creatinine was 90 μmol/L (1.0mg/dL) and the baseline A1C was 7%. Hypoglycemia occurred in 15% of GIM admissions and 13% of CV admissions. The area under the curve for the model in the held-out validation set was approximately 0.80 on the GIM ward and 0.82 on the CV ward. When the threshold for hypoglycemia was lowered to 2.9 mmol/L (52 mg/dL), similar results were observed. Among the patients at the highest decile of risk, the positive predictive value was approximately 50% and the sensitivity was 99%. Conclusion: Using natural language processing and machine learning we were able to accurately identify patients at high risk of hypoglycemia in hospital. Disclosure M. Fralick: None. D. Dai: None. C. Pou-Prom: None. A.A. Verma: None. M. Mamdani: None.

A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to community: A mixed-methods study

BackgroundPeople transitioning from hospital- to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation.MethodsPROMPT was implemented for 14 weeks (January–April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient’s community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists.ResultsThe intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists’ difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources.ConclusionImproving intraprofessional collaboration, through interventions such as PROMPT, positions pharmacists as leaders of medication management services across care settings and has the potential to improve patient care; however, more co-design work is needed to enhance the intervention and its fidelity.

Preference for Alternate-Day Versus Conventional In-Center Dialysis: A Health Utility Elicitation.

Background:Mortality rates for patients on hemodialysis (HD) continue to be high, in particular, following the long interdialytic period, yet thrice-weekly conventional HD (CHD) is still an almost universal regimen. Alternate-day dialysis (ADD) may have advantages over the current schedule because it would eliminate the long interdialytic break. A preliminary, as yet unpublished, patient simulation and cost-utility analysis compared CHD versus ADD and demonstrated that the economic attractiveness of ADD was sensitive, in particular, to patients’ preference for ADD versus CHD. To date, this preference has not been elicited.Objective:To elicit utilities for both CHD and ADD using 3 standard elicitation methods among a prevalent cohort of patients on CHD.Design:This study is a single-center survey of patient preferences (utilities).Setting:This study took place within the dialysis units of Sunnybrook Health Centre, a university-affiliated teaching hospital in Toronto, Ontario, Canada, which encompasses 174 patients on in-center HD.Patients:Those older than 18 years of age, on thrice-weekly HD, were included in this study.Measurements:Descriptive statistics were used to summarize patient characteristics and the utility values generated. A multiple linear regression was performed to determine an association between participant characteristics and the utility ratio.Methods:Via standardized face-to-face interviews by a single investigator, 3 utility elicitation methods, visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG), were administered to generate utilities for each patient for their current health state of CHD (thrice-weekly). After completing this task, we provided each patient with a concise summary regarding the current literature on how ADD may impact their health. Finally, patients were asked to envision their health while on an ADD regimen while repeating the VAS, TTO, and SG.Results:We recruited 65 participants. The mean utilities of CHD versus ADD were similar for all 3 methods. Visual analogue scale, TTO, and SG had utility values of 0.6 ± 0.2, 0.6 ± 0.3, and 0.7 ± 0.3, and 0.6 ± 0.2, 0.7 ± 0.3, and 0.7 ± 0.3 for CHD and ADD, respectively. The ratio for CHD to ADD was 1.1 ± 0.4, 1.1 ± 0.5, and 1.0 ± 0.2 for VAS, TTO, and SG, respectively.Limitations:Small sample size from a single center, where not all participants agreed to participate, wide variability in participant responses and requiring patients to conceptually imagine life on ADD may have affected our results.Conclusions:Compared with CHD, there was no difference in the preference toward ADD which demonstrates promise that adopting an alternate-day schedule may be acceptable to patients. Furthermore, with the generation of a utility for ADD, this will allow for more precise estimates in future simulation studies of the economic attractiveness of ADD.Trial registration:Not required as this article is not a systematic review nor does it report the results of a health care intervention.

Exploring accreditation from the front lines: A qualitative study of staff experiences & perceptions of hospital accreditation

Objective: Relative to the global investment in hospital accreditation programs overall, both the total amount and methodological quality of existing accreditation research is mediocre. To address this apparent gap in knowledge, we undertook a study of the experiences and perspectives of hospital staff, those most underrepresented in the accreditation research literature, including those working on the front lines and non-leaders who may or may not have been directly involved in the preparation for the accreditation survey visit.Methods: Design: Qualitative descriptive interview study. Setting: Tertiary care teaching hospital in Toronto, Ontario Canada. Study Participants: Program directors, unit managers, physicians, nurses, health discipline professionals (HDP), and non-clinical staff.Results: We have grouped what we heard from the data into three major groups of findings which we have titled: a) perceptions of the purpose of accreditation; b) the “work” of accreditation; and c) dissemination gaps regarding results. Informative finding from this study include the fact that participants put surprising value on the accreditation process, although mistaken feel it is mandatory; that the “work” of accreditation can be disappointing and feels disconnected from the bigger QI picture, and that the disconnect also exists in terms of their knowledge of and belief in the actual results of the process.Conclusions: These findings point to potential gaps in the accreditation culture which can be detrimental to the impact of the accreditation process. Such gaps likely exist in other health care organizations and could inform similar evaluations in other settings.

Satisfaction following surgery for hip, knee and spine osteoarthritis: the impact of physician-patient communication in the pre-surgical consultation

Purpose: Patient satisfaction is an important measure of patient-centered outcomes and physician performance. Given the continued growth of the population undergoing surgical intervention for osteoarthritis, and the concomitant growth in the associated direct costs, understanding what factors drive satisfaction in this population is critical. A potentially important driver not previously considered is satisfaction with pre-surgical consultation. We investigated the influence of pre-surgical consultation satisfaction on overall satisfaction following surgery for osteoarthritis. Methods: Study data are from 1263 patients who underwent surgery for hip (n=480), knee (n=597), and spine (n=186) osteoarthritis at a large teaching hospital in Toronto, Canada. Before surgery, patients reported their satisfaction with the information received and the degree of input in decision-making during the pre-surgical consultation, along with expectations of surgery (regarding pain, activity limitation, expected time to full recovery and likelihood of complete success). Pre- and post-surgery (6 weeks, and 3, 6, and 12 months) patients reported their average pain level in the past week (0-10; 10 is worst). At each follow-up time-point, two pain variables were defined, pain improvement (minimal clinically important difference from baseline ≥2 points) and ‘acceptable’ pain (pain score ≤ 3). Patients also completed a question on satisfaction with the results of the surgery (very dissatisfied/dissatisfied/somewhat satisfied/very satisfied) at each follow-up time point. We used multilevel ordinal logistic regression to examine the influence of pre-surgery satisfaction with consultation on the trajectory of satisfaction over the year of recovery controlling for expectations of surgery, pain improvement, acceptable pain, socio-demographic factors (age, sex, and education), body mass index, comorbidity, and depressive symptoms (Hospital Anxiety and Depression Scale). Results: The sample mean age was 65.5 years and over half (54.3%) were women. Overall, 74.0% and 78.9% of patients were satisfied with the information received and with the decision-making in the pre-surgical consultation, respectively; no significant differences were found by surgical joint (p=0.22). Post-surgery, levels of satisfaction varied very little over time (6 weeks: 92.5% were satisfied and 66.4% were very satisfied; 1 year: 91.1% were satisfied and 65.6% were very satisfied). Results from a model including time, surgical joint, satisfaction with consultation and control factors indicated that being satisfied with the information received in the pre-surgical consultation was associated with higher odds of being more satisfied after surgery (OR: 1.2, 95% CI: 1.0-1.4). Additionally, spine and knee patients were more likely to be dissatisfied than hip patients (OR: 3.2, 95% CI: 2.1-4.9 and OR: 2.5, 95% CI: 1.8-3.4 for spine and knee patients respectively). Achieving pain improvement (OR: 1.7, 95% CI: 1.3-2.4) and acceptable pain (OR: 2.5, 95% CI: 1.6-3.9) were both significantly associated with greater satisfaction. Pre-operative expectations were not significantly associated with post-surgery satisfaction. Conclusions: Our findings highlight the important role of pre-surgery physician-patient communication and information on post-surgery satisfaction. This points to the need to ensure organizational provisions that foster supportive and interactive relationships between surgeons and their patients to improve patients’ satisfaction. The findings also highlight that early post-recovery period (i.e. <=3 months) as a key driver of longer-term satisfaction.

Follow Up of Incidental High-Risk Pulmonary Nodules on Computed Tomography Pulmonary Angiography at Care Transitions.

Computed tomography pulmonary angiography (CTPA) detects incidental findings that require follow-up. In just over 50% of cases, those incidental findings are pulmonary nodules. Fleischner guidelines recommend that patients with nodules that have a high risk of malignancy should undergo CT follow-up within 3-12 months. We examined the proportion of patients with pulmonary nodules requiring follow up who received repeat imaging within six weeks of the time frame recommended by the radiologist. This retrospective cohort study included all patients who underwent CTPA in the emergency department and inpatient settings at three teaching hospitals in Toronto, Canada between September 1, 2014, and August 31, 2015. Natural language processing software was applied to a linked radiology information system to identify all CTPAs that contained pulmonary nodules. Using manual review and prespecified exclusion criteria, we generated a cohort with possible new lung malignancy eligible for follow-up imaging; then we reviewed available health records to determine whether follow-up had occurred. Of the 1,910 CTPAs performed over the study period, 674 (35.3%) contained pulmonary nodules. Of the 259 patients with new nodules eligible for follow-up imaging, 65 received an explicit suggestion for follow-up by radiology (25.1%). Of these 65 patients, 35 (53.8%) did not receive repeat imaging within the recommended time frame. Explicit mention that follow-up was required in the discharge summary (P = .03), attending an outpatient follow-up visit (P < .001), and younger age (P = .03) were associated with receiving timely follow-up imaging. Over 50% of patients with new high-risk pulmonary nodules detected incidentally on CTPA did not receive timely follow-up imaging.

Characteristics of short general internal medicine hospital stays: a multicentre cross-sectional study.

Short hospital stays may represent opportunities to avert unnecessary admissions or expedite inpatient care. To inform the design of interventions that target patients with potentially avoidable hospital admissions or brief stays, we examined the patient, physician and situational characteristics associated with short stays among patients admitted to general internal medicine wards and describe the use of hospital resources by these patients. This was a multicentre cross-sectional study conducted between Apr. 1, 2012, and Mar. 31, 2015, at 5 teaching hospitals in Toronto. We included all general internal medicine admissions through the emergency department. We examined patient, physician and situational predictors of a short hospital stay, which was defined as the patient's being discharged home alive in 2 possible time windows: less than 24 hours, or 72 hours or less. The final study sample included 56 055 admissions and 37 700 unique patients. Patients discharged in less than 24 hours and in 72 hours or less accounted for 4245 (7.6%) and 13 442 (31.6%) admissions, respectively. After we controlled for patient factors, patients of female physicians were less likely than those of male physicians to have stays lasting less than 24 hours (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86) or 72 hours or less (adjusted OR 0.82, 95% CI 0.79-0.86). Patients admitted at night or on a weekday were significantly more likely than those admitted at other times to have stays lasting less than 24 hours (night: adjusted OR 2.73, 95% CI 2.44-3.06; weekday: adjusted OR 1.26, 95% CI 1.17-1.36) or 72 hours or less (night: adjusted OR 1.29, 95% CI 1.22-1.37, weekday: adjusted OR 1.05, 95% CI 1.01-1.10). Among stays lasting less than 24 hours and 24-72 hours, intravenously administered medications were ordered for 2788 (65.7%) and 10 722 (79.8%) patients, respectively, and computed tomography scans were performed for 1561 (36.8%) and 5354 (39.1%) patients, respectively. Short general internal medicine hospital stays were common and were associated with patient, physician and situational factors. Interventions to avert hospital admission or reduce length of stay may be more effective if they are accessible outside typical working hours and provide access to intravenous therapy and radiological investigations.

Using artificial neural networks to identify patients with concussion and postconcussion syndrome based on antisaccades.

Artificial neural networks (ANNs) have shown considerable promise as decision support tools in medicine, including neurosurgery. However, their use in concussion and postconcussion syndrome (PCS) has been limited. The authors explore the value of using an ANN to identify patients with concussion/PCS based on their antisaccade performance. Study participants were prospectively recruited from the emergency department and head injury clinic of a large teaching hospital in Toronto. Acquaintances of study participants were used as controls. Saccades were measured using an automated, portable, head-mounted device preprogrammed with an antisaccade task. Each participant underwent 100 trials of the task and 11 saccade parameters were recorded for each trial. ANN analysis was performed using the MATLAB Neural Network Toolbox, and individual saccade parameters were further explored with receiver operating characteristic (ROC) curves and a logistic regression analysis. Control (n = 15), concussion (n = 32), and PCS (n = 25) groups were matched by age and level of education. The authors examined 11 saccade parameters and found that the prosaccade error rate (p = 0.04) and median antisaccade latency (p = 0.02) were significantly different between control and concussion/PCS groups. When used to distinguish concussion and PCS participants from controls, the neural networks achieved accuracies of 67% and 72%, respectively. This method was unable to distinguish study patients with concussion from those with PCS, suggesting persistence of eye movement abnormalities in patients with PCS. The authors' observations also suggest the potential for improved results with a larger training sample. This study explored the utility of ANNs in the diagnosis of concussion/PCS based on antisaccades. With the use of an ANN, modest accuracy was achieved in a small cohort. In addition, the authors explored the pearls and pitfalls of this novel approach and identified important future directions for this research.

Imaging Approach to the Diagnosis of Acute Appendicitis in a Group of Teaching Hospitals With 24/7 In-house Availability of Ultrasound Technologist: Effect of Timing of Request on Imaging Modality

PurposeThe study sought determine effect of requisition timing on the initial-choice imaging modality in appendicitis evaluation. MethodsThis was an institutional review board–approved retrospective study, encompassing 3 University of Toronto teaching hospitals, offering 24/7 radiology coverage. All surgically proven appendicitis cases, from 2012-2014, were included and presurgical ultrasound (US) or computed tomography (CT) reports were analysed. Examinations were all requested by the emergency department, performed by the same technologists and reviewed or finalized by the same radiology group (residents fellows or attending). Two coverage categories, namely regular hours (8 am-5 pm, Monday-Friday) or after hours (5 pm-8 am, Monday-Friday and weekends) were compared. The percentage of the starting modality (US or CT), the rate of CT following an indeterminate US, and the sensitivity of each modality was compared between the 2 categories, utilising Mann-Whitney U and chi-square tests. ResultsPresurgical US or CT studies of 494 patients, from February 2012-August 2014, were evaluated. Regular-hours and after-hours coverage demonstrated 174 (89:85 women:men) and 320 (141:179 women:men; P < .04) patients. The average age, 37.9 ± 17.1 women versus 35.2 ± 13.7 men was not statistically different (P = .8). Regular hours included 89 of 174 (51.1%) of US-only examinations, 50 of 174 (29%) of CT-only examinations, and 35 of 174 (20%) of US examinations followed by CT examinations. After hours included 147 of 320 (46%) of US-only examinations, 147 of 320 (46%) of CT-only examinations, and 26 of 320 (8%) of US examinations followed by CT examinations (P < .001). The total diagnostic sensitivities for US and CT were 86% (81% regular hours, 90% after hours; P = .041) and 99.2% (100% regular hours, 99% after hours; P > .05), respectively. ConclusionsUS was less utilised in acute appendicitis detection after hours, although its diagnostic sensitivity was better than regular-hours coverage.

Factors Affecting Surgical Decision-making-A Qualitative Study.

BackgroundGuidelines and Class 1 evidence are strong factors that help guide surgeons’ decision-making, but dilemmas exist in selecting the best surgical option, usually without the benefit of guidelines or Class 1 evidence. A few studies have discussed the variability of surgical treatment options that are currently available, but no study has examined surgeons’ views on the influential factors that encourage them to choose one surgical treatment over another. This study examines the influential factors and the thought process that encourage surgeons to make these decisions in such circumstances.MethodsSemi-structured face-to-face interviews were conducted with 32 senior consultant surgeons, surgical fellows, and senior surgical residents at the University of Toronto teaching hospitals. An e-mail was sent out for volunteers, and interviews were audio-recorded, transcribed verbatim, and subjected to thematic analysis using open and axial coding.ResultsBroadly speaking there are five groups of factors affecting surgeons’ decision-making: medical condition, information, institutional, patient, and surgeon factors. When information factors such as guidelines and Class 1 evidence are lacking, the other four groups of factors—medical condition, institutional, patient, and surgeon factors (the last-mentioned likely being the most powerful)—play a significant role in guiding surgical decision-making.ConclusionsThis study is the first qualitative study on surgeons’ perspectives on the influential factors that help them choose one surgical treatment option over another for their patients.

Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU.

New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery. This was a prospective observation trial of up to 14 days duration. A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada. We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours. We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines. Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption. Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.

Investigating the effect of sociodemographic factors on 30-day hospital readmission among medical patients in Toronto, Canada: a prospective cohort study

ObjectiveTo examine the influence of patient-level sociodemographic factors on the incidence of hospital readmission within 30 days among medical patients in a large Canadian metropolitan city.DesignProspective cohort study.Setting and participantsPatients...

“I Want to Help, but What Do You Do in a Situation Like That?” Health Care Providers' Qualitative Perspectives on Working with Disabled Women in Breast Cancer Screening

BackgroundDisabled women find that social and physical discomforts during encounters with health providers pose barriers to breast cancer screening. We studied providers' perspectives and learning needs related to this problem in order to develop a disability education initiative. DesignThis was a descriptive qualitative study with focus group methods. Participants were recruited from staff of a joint Department of Medical Imaging at three academic teaching hospitals in Toronto, Canada. Seven focus groups were held with 43 clerical staff, mammography technologists, and radiologists. ResultsParticipants reported that they aimed to provide positive breast screening experiences for disabled women but expressed uncertainty about respectful and appropriate communication with disabled women. Novel situations with disabled women were challenging and, without formal disability education, most relied on experiential learning. ConclusionsOur study elicited important information about the concerns and learning needs of health professionals who provide breast screening services to disabled women. This information supported development of a disability education curriculum for these providers.

Incidence and characteristics of needlestick injuries among medical trainees at a community teaching hospital: A cross-sectional study.

This field study aimed to determine the incidence and distribution of needlestick injuries among medical trainees at a community teaching hospital in Toronto, Canada. The study was performed during the 2013-2015 academic years at Toronto East General Hospital (TEGH), a University of Toronto-affiliated community-teaching hospital during the 2013-2015 academic years. Eight-hundred and forty trainees, including medical students, residents, and post-graduate fellows, were identified and invited via email to participate in an anonymous online fluidsurveys.com survey of 16 qualitative and quantitative questions. Three-hundred and fifty trainees responded (42% response rate). Eighty-eight (25%) respondents reported experiencing at least one injury at TEGH. In total, our survey identified 195 total injuries. Surgical trainees were significantly more likely to incur injuries than non-surgical trainees (IRR = 3.03, 95% CI 1.80-5.10). Orthopaedic surgery trainees had the highest risk of a needlestick injury, being over 12 times more likely to be injured than emergency medicine trainees (IRR = 12.4, 95% CI 2.11-72.32). Only 28 of the 88 most recent needlestick injuries were reported to occupational health. Trainees reported a perception of insignificant risk, lack of resources and support for reporting, and injury stigmatization as reasons for not reporting needlestick injuries. Needlestick injuries were a common underreported risk to medical trainees at TEGH. Future research should investigate strategies to reduce injury and improve reporting among the high-risk and reporting-averse trainees.

Overview of clinical work and research done on beta-lactam allergy at a community academic teaching hospital in Toronto, Canada

Overview of clinical work and research done on beta-lactam allergy at a community academic teaching hospital in Toronto, Canada

P044: HEADSTRONG: helmet education, advocacy, distribution &amp; social media trial to reduce obstacles &amp; nudge group behaviour

Introduction: Head injury is a major cause of bicycling-related disability and death, and more likely to occur in unhelmeted riders. Legislation regarding helmet use varies by province. In Ontario, helmet use is not mandatory for cyclists &gt;= age 18, and approximately 50 % of adult cyclists do not routinely wear helmets. Non-legislative approaches to increase helmet use have included education, public health campaigns, and helmet giveaways, but sustained effect is typically limited. The goal of the HEADSTRONG Behaviour Study is to identify injured adult cyclists who do not regularly wear helmets, and effect sustained helmet use. The strategy incorporates evidence-based elements of health behaviour change, including: reducing barriers, education and modelling, providing necessary materials, and social support. Methods: Prospective cohort study in downtown Toronto teaching hospital, launched Nov 2015. ED clinician (EP or NP) will recruit injured cyclists (consecutive, convenience sample) who report not regularly wearing a helmet nor owning a suitable one. Study endpoint: 100 enrolled (to estimate prevalence of usage of +/- 10%, alpha 0.05, power &gt;90%, assuming 80% study completion and 50 % helmet wearing at 12 months). Exclusion criteria: unable to consent, admitted to hospital, age &lt;18. Each element of the HEADSTRONG Behaviour Strategy is intended to facilitate patient adoption and maintenance of the desired behaviour, including: 1) enrolment/education by research associate while still in the ED; 2) provision and fitting of a free bicycle helmet; 3) social contract commitment and tailored reminders to document ongoing helmet use: participant agrees to respond to brief electronic survey follow-ups at two weeks, two months, six months, and twelve months; 4) social media engagement with participation in the HEADSTRONG Twitter group, which engages other enrolees and cycling advocacy groups; 5) peer nomination: the participant who is complying with the social contract is encouraged to nominate an uninjured non helmet-wearing colleague to enrol in the study. Results: Primary outcomes include: recruitment rate, enrolment, and sustained participation through follow-up period. Secondary outcomes include age, gender and social demographics of helmet recipients, and participation of peers. Conclusion: Discussion of strategy and interim results at six month interval will be presented at CAEP.

Conventional hemodialysis is associated with greater bone loss than nocturnal hemodialysis: a retrospective observational study of a convenience cohort.

BackgroundCompared with the general population, end-stage renal disease patients are at increased risk for bone loss and fractures. Nocturnal hemodialysis offers superior calcium-phosphate control and improved uremic clearance compared with conventional hemodialysis. Rates of bone loss by type of hemodialysis are unknown.ObjectivesThis study aims to determine whether there are differences in bone loss between frequent nocturnal hemodialysis and conventional hemodialysis.DesignThis is a retrospective observational study.SettingParticipants were selected from two teaching hospitals in downtown Toronto.ParticipantsThe study included 88 participants on dialysis for at least 6 months (52 patients on conventional hemodialysis and 36 patients converted from conventional hemodialysis to nocturnal hemodialysis). Patients on peritoneal dialysis and with previous renal transplants were excluded.MeasurementsWe obtained demographic variables and biochemical data by a chart review. We examined changes in bone mineral density at the hip (femoral neck, total hip) and spine (L1 to L4) measured at baseline and about 1 year in the two groups.MethodsWe used Student’s t test for evaluation of between-group mean differences in demographic and biochemical parameters. We used linear regression models adjusted for baseline age, weight, dialysis vintage, markers of mineral metabolism (serum phosphate, serum calcium, and parathyroid hormone), and baseline bone mineral density at the femoral neck, total hip, and lumbar spine to determine the annualized percent change by hemodialysis type.ResultsConventional hemodialysis subjects were older than nocturnal hemodialysis subjects (66 ± 9 vs 43 ± 10 years; p < 0.0001) with no significant differences in weight, dialysis vintage, serum phosphate, or parathyroid hormone between the two groups at baseline. In a period over 1 year, conventional hemodialysis compared to nocturnal hemodialysis subjects had significantly greater bone mineral density losses at all sites (1.6 % loss at the lumbar spine (95 % confidence interval (CI) 0.2–3.1), 1.3 % loss at the femoral neck (95 % CI 0.1–2.5), and 1.1 % loss at the total hip (95 % CI 0.1–2.6).LimitationsSome limitations to this study are the lack of medication administration history, short duration (~1 year), and small sample sizes.ConclusionsThis is the first study comparing bone density between hemodialysis modalities. Our study demonstrates that bone loss is less in nocturnal hemodialysis compared to that in conventional hemodialysis which may result in less fractures. Larger observational studies are ultimately needed to confirm preliminary findings from our study.

Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study.

BackgroundAntimicrobial decision making in intensive care units (ICUs) is challenging. Unnecessary antimicrobials contribute to the development of resistant pathogens, Clostridium difficile infection and drug related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve antimicrobial prescribing, but the optimal approach in the ICU setting is unknown. We assessed the impact of an audit and feedback antimicrobial stewardship intervention on antimicrobial use, antimicrobial costs, clinical outcomes and microbiologic outcomes in two ICUs with different patient populations.MethodsThe audit and feedback intervention was implemented in a trauma and neurosurgery ICU (TNICU) and a medical surgical ICU (MSICU) at a 465-bed teaching hospital in Toronto, Canada. ICU patients were reviewed Monday to Friday by a physician and pharmacist with infectious diseases training. Recommendations related to appropriate antimicrobial use were presented to ICU teams during a dedicated daily meeting. A controlled interrupted time series analysis was used to compare outcomes in the 12 months before and after the intervention. Cardiovascular and coronary care ICUs served as control units.ResultsMean total monthly antimicrobial use in defined daily doses (DDD) per 1000 patient days was reduced 28 % in the TNICU (1433 vs. 1037) but increased 14 % in the MSICU (1705 vs. 1936). In the time series analysis, total monthly antimicrobial use in the TNICU decreased by 375 DDD per 1000 patient days (p < 0.0009) immediately following the intervention, followed by a non-significant downward trend in use of −9 DDD per 1000 patient days (p = 0.56). No significant changes in antimicrobial use were identified in the MSICU. Antimicrobial use temporarily increased in one control unit and remained unchanged in the other. There were no changes in mortality, length of stay, readmission rate, incidence of C. difficile infection or resistance patterns of E. coli and P. aeruginosa in either intervention unit.ConclusionsAudit and feedback antimicrobial stewardship programs can lead to significant reductions in total antimicrobial use in the ICU setting. However, this effect may be context-dependent and further work is needed to determine the ingredients necessary for success.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-015-1223-2) contains supplementary material, which is available to authorized users.