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Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration.
An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback.
Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program.
A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.
The difference in the defect structures produced by different ion masses in a tungsten lattice is investigated using 80 MeV Au7+ ions and 10 MeV B3+ ions. The details of the defects produced by ions in recrystallized tungsten foil samples are studied using transmission electron microscopy. Dislocations of type b = 1/2 and  were observed in the analysis. While highly energetic gold ion produced small clusters of defects with very few dislocation lines, boron has produced large and sparse clusters with numerous dislocation lines. The difference in the defect structures could be due to the difference in separation between primary knock-on atoms produced by gold and boron ions.
Introduction: When presenting to the Emergency Department (ED), the care of elderly patients residing in Long Term Care (LTC) can be complicated by threats to patient safety created by ineffective transitions of care. Though standardized inpatient handover tools exist, there has yet to be a universal tool adopted for transfers to the ED. In this study, we surveyed relevant stakeholders and identified what information is essential in the transitions of care for this vulnerable population. Methods: We performed a descriptive, cross sectional electronic survey that was distributed to physicians and nurses in ED and LTC settings, paramedics, and patient advocates in two Canadian cities. The survey was kept open for a one month period with weekly formal reminders sent. Questions were generated after performing a literature review which sought to assess the current landscape of transitional care in this population. These were either multiple choice or free text entry questions aimed at identifying what information is essential in transitional periods. Results: A total of 191 health care providers (HCP) and 22 patient advocates (PA) responded to the survey. Within the HCPs, 38% were paramedics, 38% worked in the ED, and 24% were in LTC. In this group, only 41% of respondents were aware of existing handover protocols. Of the proposed informational items in transitional care, 100% of the respondents within both groups indicated that items including reason for transfer and advanced care directives were essential. Other areas identified as necessary were past medical history and baseline functional status. Furthermore, the majority of PAs identified that items such as primary language, bowel and bladder incontinence and spiritual beliefs should be included. Conclusion: This survey demonstrated that there is a need for an improved handover culture to be established when caring for LTC patients in the ED. Education needs to be provided surrounding existing protocols to ensure that health care providers are aware of their existence. Furthermore, we identified what information is essential to transitional care of these patients according to HCPs and PAs. These findings will be used to generate a simple, one page handover form. The next iteration of this project will pilot this handover form in an attempt to create safer transitions to the ED in this at-risk population.
To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications.
Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit.
Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases.
In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive.
We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.
Practical Implementation of an Antibiotic Stewardship Program provides an essential resource for healthcare providers in acute care, long-term care, and ambulatory care settings looking either to begin or to strengthen existing antibiotic stewardship programs. Each chapter is written by both physician and pharmacist leaders in the stewardship field and incorporates both practical knowledge as well as evidence-based guidance. This book will also serve as a useful resource for medical students, pharmacy students, residents, and infectious diseases fellows looking to learn more about the field of antibiotic stewardship.
Agriculture in the Central Himalayan Region depends on the availability of suitable germplasm as well as natural conditions. Due to extreme weather conditions, food and nutrition security is a major issue for communities inhabiting these remote and inaccessible areas. Millets are common crops grown in these areas. Foxtail millet (Setaria italica (L.) P. Beauv) is an important crop and forms a considerable part of the diet in this region. The aim of the present study was to explore, collect, conserve and evaluate the untapped genetic diversity of foxtail millet at the molecular level and discover variability in their nutritional traits. A total of 30 accessions having unique traits of agronomic importance were collected and molecular profiling was performed. A total of 63 alleles were generated with an average of 2.52 alleles per locus and average expected heterozygosity of 0.37 ± 0.231. Significant genetic variability was revealed through the genetic differentiation (Fst) and gene flow (Nm) values. Structure-based analysis divided whole germplasm into three sub-groups. Rich variability was found in nutritional traits such as dietary fibre in husked grains, carbohydrate, protein, lysine and thiamine content. The collected germplasm may be useful for developing nutritionally rich and agronomically beneficial varieties of foxtail millet and also designing strategies for utilization of unexploited genetic diversity for food and nutrition security in this and other similar agro-ecological regions.
We compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children <5 years in four communities, made 11 subsequent weekly home visits to assess acceptability and use of water treatment methods, measured Escherichia coli concentration in stored water, and determined diarrhoea prevalence among children <5 years. Of 281 households surveyed, boiling (83%) and Air RahMat (7%) were the principal water treatment methods. Multivariable log-binomial regression analyses showed lower risk of E. coli in stored water treated with Air RahMat than boiling (risk ratio (RR) 0·75, 95% confidence interval (CI) 0·56–1·00). The risk of diarrhoea in children <5 years was lower among households using Air RahMat (RR 0·43, 95% CI 0·19–0·97) than boiling, and higher in households with E. coli concentrations of 1–1000 MPN/100 ml (RR 1·54, 95% CI 1·04–2·28) or >1000 MPN/100 ml (RR 1·86, 95% CI 1·09–3·19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children <5 years than water treatment by boiling, Air RahMat use remained low.
The mountain ecosystem of the Central Himalayan Region is known for its diversity of crops and their wild relatives. In spite of adverse climatic conditions, this region is endowed with a rich diversity of millets. Hence, the aim of the present study was to explore, collect, conserve and evaluate the diversity of barnyard millet (Echinochloa frumentacea) to find out the extent of diversity available in different traits and the traits responsible for abiotic stress tolerance, and to identify trait-specific accessions for crop improvement and also for the cultivation of millets in the region as well as in other similar agro-ecological regions. A total of 178 accessions were collected and evaluated for a range of morpho-physiological and biochemical traits. Significant variability was noted in days to 50% flowering, days to 80% maturity, 1000 seed weight and yield potential of the germplasm. These traits are considered to be crucial for tailoring new varieties for different agro-climatic conditions. Variations in biochemical traits such as lipid peroxidation (0·552–7·421 nmol malondialdehyde formed/mg protein/h), total glutathione (105·270–423·630 mmol/g fresh weight) and total ascorbate (4·980–9·880 mmol/g fresh weight) content indicate the potential of collected germplasm for abiotic stress tolerance. Principal component analysis also indicated that yield, superoxide dismutase activity, plant height, days to 50% flowering, catalase activity and glutathione content are suitable traits for screening large populations of millet and selection of suitable germplasm for crop improvement and cultivation. Trait-specific accessions identified in the present study could be useful in crop improvement programmes, climate-resilient agriculture and improving food security in areas with limited resources.
Purpose: We measured anterior cerebral artery (ACA)-middle cerebral artery (MCA) and posterior cerebral artery (PCA)-MCA pial filling on single-phase computed tomography angiograms (sCTAs) in acute ischemic stroke and correlate with the CTA-based Massachusetts General Hospital (MGH) and digital subtraction angiography (DSA)-based American Society of Interventional and Therapeutic Neuroradiology (ASITN) score. Methods: Patients with acute stroke and M1 MCA±intracranial internal carotid artery occlusion on baseline CTA were included. Baseline sCTA was assessed for phase of image acquisition. An evaluator assessed collaterals using the Calgary Collateral (CC) Score (measures pial arterial filling in ACA-MCA and PCA-MCA regions separately), the CTA-based MGH score, and on DSA using the ASITN score. Infarct volumes were measured on 24- to 48-hour magnetic resonance imaging/ computed tomography. Results: Of 106 patients, baseline sCTA was acquired in early arterial phase in 9.9%, peak arterial in 50.7%, equilibrium in 32.4%, early venous in 5.6%, and late venous in 1.4%. Variance in ACA-MCA collaterals explained only 32% of variance in PCA-MCA collaterals on the CC score (Spearman’s correlation coefficient rho [rho]=0.56). Correlation between ACA-MCA collaterals and the MGH score was strong (rho=0.8); correlation between PCA-MCA collaterals and this score was modest (rho=0.54). Correlation between ACA-MCA collaterals and the ASITN score was modest (n=53, rho=0.43); and correlation between PCA-MCA collaterals and ASITN score was poor (rho=0.33). Of the CTA-based scores, the CC Score (Akaike [AIC] 1022) was better at predicting follow-up infarct volumes than was the MGH score (AIC 1029). Conclusion: Collateral assessments in acute ischemic stroke are best done using CTA with temporal resolution and by assessing regional variability. ACA-MCA and MCA-PCA collaterals should be evaluated separately.
Introduction: In light of recent local initiatives aimed at improving emergency department (ED) patient flow, we sought to characterize how patients aged 65 and older who reside in long term care (LTC) facilities utilize the services of the EDs in Regina, Saskatchewan as compared to an age-matched comparison of community dwelling individuals. Methods: A retrospective chart review was performed with a convenience sample of the first 50 patients who presented to each ED at both hospitals in Regina starting January 1, 2012 for each population. Two separate patient populations were included: those who reside in the health region run LTC facilities and those who live in the community. We abstracted data from a variety of different clinical, demographic and administrative parameters. Results: The charts of 100 patients were reviewed for the LTC population (54 females, mean age 82.6) and 99 patients for the community dwelling population (55 females, mean age 77.3). The CTAS distribution for the LTC patients was found to be CTAS 1: 5%, CTAS 2: 9%, CTAS 3: 43%, CTAS 4: 33% and CTAS 5: 10%. For the community dwelling individuals, the distribution was CTAS 1: 1%, CTAS 2: 21%, CTAS 3: 44%, CTAS 4: 22%, CTAS 5: 10%. This is a significantly different distribution (p = 0.047). From the LTC population, we found that 50% of patients were admitted, with 46% being discharged and 4% leaving without being seen. Furthermore, we also noted that 75% of patients were brought to the ED by EMS. From the community dwelling population, we noted that 43% of patients were admitted, with 55% being discharged and 1% leaving without being seen. This population used EMS services 41% of the time. With respect to length of stay, LTC patients had a mean duration of 5.7 (±4.3 hours) compared to 4.8 (±4.0) hours for the non-LTC population (p=0.111). Conclusion: Our findings suggest that the highest volume of acuity for the LTC patients falls within the CTAS 3 or 4 categories whereas there is a higher proportion of CTAS 2 acuity patients in the community dwelling population. Exactly half of our LTC sample was admitted as compared to 43% of the community population. The LTC population also required EMS services for a considerably higher proportion of their presentations to the ED (75% compared to 41%). It is our intent that the findings of this study will help guide future quality improvement initiatives.
Depression is characterized by poor executive function, but – counterintuitively – in some studies, it has been associated with highly accurate performance on certain cognitively demanding tasks. The psychological mechanisms responsible for this paradoxical finding are unclear. To address this issue, we applied a drift diffusion model (DDM) to flanker task data from depressed and healthy adults participating in the multi-site Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care for Depression (EMBARC) study.
One hundred unmedicated, depressed adults and 40 healthy controls completed a flanker task. We investigated the effect of flanker interference on accuracy and response time, and used the DDM to examine group differences in three cognitive processes: prepotent response bias (tendency to respond to the distracting flankers), response inhibition (necessary to resist prepotency), and executive control (required for execution of correct response on incongruent trials).
Consistent with prior reports, depressed participants responded more slowly and accurately than controls on incongruent trials. The DDM indicated that although executive control was sluggish in depressed participants, this was more than offset by decreased prepotent response bias. Among the depressed participants, anhedonia was negatively correlated with a parameter indexing the speed of executive control (r = −0.28, p = 0.007).
Executive control was delayed in depression but this was counterbalanced by reduced prepotent response bias, demonstrating how participants with executive function deficits can nevertheless perform accurately in a cognitive control task. Drawing on data from neural network simulations, we speculate that these results may reflect tonically reduced striatal dopamine in depression.
To investigate Acinetobacter baumannii infection, colonization, and transmission related to a long-term care facility (LTCF) providing subacute care (facility A).
We reviewed facility A and affiliated local hospital records for facility A residents with A. baumannii isolated during the period January 2009 through February 2010 and compared A. baumannii antimicrobial resistance patterns of residents with those of hospital patients. During March 2010, we implemented a colonization survey of facility A residents who received respiratory support or who could provide sputum samples and looked for A. baumannii colonization risks. Available clinical and survey isolates underwent pulsed-field gel electrophoresis (PFGE); PFGE strains were linked with overlapping stays to identify possible transmission.
During the period January 2009 through February 2010, 33 facility A residents had A. baumannii isolates; all strains were multidrug resistant (MDR), which was a significantly higher prevalence of MDR strains than that found among isolates from hospital patients (81 [66%] of 122 hospital patient isolates were MDR; P < .001). The sputum survey found that 14 (20%) of 70 residents had A. baumannii colonization, which was associated with ventilator use (adjusted odds ratio, 4.24 [95% confidence interval, 1.06–16.93]); 12 (86%) of 14 isolates were MDR. Four facility A resident groups clustered with 3 PFGE strains and overlapping stays. One of these facility A residents also clustered with 3 patients at an affiliated hospital.
We documented substantial MDR A. baumannii infections and colonization with probable intra- and interfacility spread associated with a single LTCF providing subacute care. Given the limited infection prevention and antimicrobial stewardship resources in such settings, regional collaborations among facilities across the spectrum of health care are needed to address this MDR threat.