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The Canadian Stroke Best Practice Recommendations suggests that patients suspected of transient ischemic attack (TIA)/minor stroke receive urgent brain imaging, preferably computed tomography angiography (CTA). Yet, high requisition rates for non-cerebrovascular patients overburden limited radiological resources, putting patients at risk. We hypothesize that our clinical decision support tool (CDST) developed for risk stratification of TIA in the emergency department (ED), and which incorporates Canadian guidelines, could improve CTA utilization.
Retrospective study design with clinical information gathered from ED patient referrals to an outpatient TIA unit in Victoria, BC, from 2015-2016. Actual CTA orders by ED and TIA unit staff were compared to hypothetical CTA ordering if our CDST had been used in the ED upon patient arrival.
For 1,679 referrals, clinicians ordered 954 CTAs. Our CDST would have ordered a total of 977 CTAs for these patients. Overall, this would have increased the number of imaged-TIA patients by 89 (10.1%) while imaging 98 (16.1%) fewer non-cerebrovascular patients over the 2-year period. Our CDST would have ordered CTA for 18 (78.3%) of the recurrent stroke patients in the sample.
Our CDST could enhance CTA utilization in the ED for suspected TIA patients, and facilitate guideline-based stroke care. Use of our CDST would increase the number of TIA patients receiving CTA before ED discharge (rather than later at TIA units) and reduce the burden of imaging stroke mimics in radiological departments.
Extracorporeal membrane oxygenation within CPR (ECPR) may improve survival for refractory out-of-hospital cardiac arrest (OHCA). We developed a prehospital, emergency department (ED), and hospital-based clinical and educational protocol to improve the key variable of time-to-ECPR (TTE).
In a single urban health region we involved key prehospital, clinical, and administrative stakeholders over a 2-year period, to develop a regional ECPR program with destination to a single urban tertiary care hospital. We developed clear and reproducible inclusion criteria and processes, including measures of program efficiency. We conducted seminars and teaching modules to paramedics and hospital-based clinicians including monthly simulator sessions, and performed detailed reviews of each treated case in the form of report cards. In this before-and-after study we compared patients with ECPR attempted prior to, and after, protocol implementation. The primary outcome was TTE, defined as the time of initial professional CPR to establishment of extracorporeal circulation. We compared the median TTE for patients in the two groups using the Wilcoxon signed rank test.
Four patients were identified prior to the protocol and managed in an ad hoc basis; for nine patients the protocol was utilized. Overall favourable neurological outcomes among ECPR-treated patients were 27%. The median TTE was 136 minutes (IQR 98 - 196) in the pre-protocol group, and 60 minutes (IQR 49 - 81) minutes in the protocol group (p=0.0165).
An organized clinical and educational protocol to initiate ECPR for patients with OHCA is feasible and significantly reduces the key benchmark of time-to-ECPR flows.
To define the scope of an outbreak of Legionnaires’ disease (LD), to identify the source, and to stop transmission.
DESIGN AND SETTING
Epidemiologic investigation of an LD outbreak among patients and a visitor exposed to a newly constructed hematology-oncology unit.
An LD case was defined as radiographically confirmed pneumonia in a person with positive urinary antigen testing and/or respiratory culture for Legionella and exposure to the hematology-oncology unit after February 20, 2014. Cases were classified as definitely or probably healthcare-associated based on whether they were exposed to the unit for all or part of the incubation period (2–10 days). We conducted an environmental assessment and collected water samples for culture. Clinical and environmental isolates were compared by monoclonal antibody (MAb) and sequence-based typing.
Over a 12-week period, 10 cases were identified, including 6 definite and 4 probable cases. Environmental sampling revealed Legionella pneumophila serogroup 1 (Lp1) in the potable water at 9 of 10 unit sites (90%), including all patient rooms tested. The 3 clinical isolates were identical to environmental isolates from the unit (MAb2-positive, sequence type ST36). No cases occurred with exposure after the implementation of water restrictions followed by point-of-use filters.
Contamination of the unit’s potable water system with Lp1 strain ST36 was the likely source of this outbreak. Healthcare providers should routinely test patients who develop pneumonia at least 2 days after hospital admission for LD. A single case of LD that is definitely healthcare associated should prompt a full investigation.
Stroke and transient ischemic attack (TIA) are common disorders treated by Canadian emergency physicians. The diagnosis and management of these conditions is time-sensitive and complex, requiring that emergency physicians have adequate training. This study sought to determine the extent of stroke and TIA training in Canadian emergency medicine residency programs.
A two-page survey was emailed to directors of all English-speaking emergency medicine residency programs in Canada. This included both the Fellow of the Royal College of Physicians of Canada (FRCPC) and the College of Family Physicians Enhanced Training [CCFP(EM)] residency programs. The number of mandatory and elective rotations, lectures, and examinations relevant to stroke and TIA were assessed.
Nine FRCPC programs responded (of 11; RR=82%) and 11 CCFP(EM) programs responded (of 18; RR=61%), representing 20 of 29 programs in Canada (RR: 20/29=69%). Mandatory general neurology (3/9) and stroke neurology (2/9) rotations were offered in a minority of FRCPC programs and not at all in CCFP(EM) programs (0/11). Neuroradiology rotations were mandatory in 1/9 FRCPC programs and no CCFP(EM) programs (0/11). Acute ischemic stroke was allocated 3 hours of lecture time per year in all residency programs, regardless of route of training. Despite the fact that 100% of respondents train residents in facilities that administer thrombolysis for stroke, only 1/11 (9%) CCFP(EM) programs and 0/9 FRCPC programs have residents act as stroke team leaders.
Formal training in stroke and TIA is limited in Canadian emergency medicine residency programs. Enhanced training opportunities should be developed as this disease is sudden, life-threatening, and can have disabling or fatal consequences, and therapeutic options are time sensitive.
Central-line–associated bloodstream infection (CLABSI) rate is an important quality measure, but it suffers from subjectivity and interrater variability, and decreasing national CLABSI rates may compromise its power to discriminate between hospitals. This study evaluates hospital-onset bacteremia (HOB, ie, any positive blood culture obtained 48 hours post admission) as a healthcare-associated infection–related outcome measure by assessing the association between HOB and CLABSI rates and comparing the power of each to discriminate quality among intensive care units (ICUs).
In this multicenter study, ICUs provided monthly CLABSI and HOB rates for 2012 and 2013. A Poisson regression model was used to assess the association between these 2 rates. We compared the power of each measure to discriminate between ICUs using standardized infection ratios (SIRs) with 95% confidence intervals (CIs). A measure was defined as having greater power to discriminate if more of the SIRs (with surrounding CIs) were different from 1.
In 80 ICUs from 16 hospitals in the United States and Canada, a total of 663 CLABSIs, 475,420 central line days, 11,280 HOBs, and 966,757 patient days were reported. An absolute change in HOB of 1 per 1,000 patient days was associated with a 2.5% change in CLABSI rate (P<.001). Among the 80 ICUs, 20 (25%) had a CLABSI SIR and 60 (75%) had an HOB SIR that was different from 1 (P<.001).
Change in HOB rate is strongly associated with change in CLABSI rate and has greater power to discriminate between ICU performances. Consideration should be given to using HOB to replace CLABSI as an outcome measure in infection prevention quality assessments.
Infect. Control Hosp. Epidemiol. 2016;37(2):143–148
The current study examines the impact of a nutrition rating system on consumers’ food purchases in supermarkets.
Aggregate sales data for 102 categories of food (over 60 000 brands) on a weekly basis for 2005–2007 from a supermarket chain of over 150 stores are analysed. Change in weekly sales of nutritious and less nutritious foods, after the introduction of a nutrition rating system on store shelves, is calculated, controlling for seasonality and time trends in sales.
One hundred and sixty-eight supermarket stores in the north-east USA, from January 2005 to December 2007.
Consumers purchasing goods at the supermarket chain during the study period.
After the introduction of the nutrition ratings, overall weekly food sales declined by an average of 3637 units per category (95 % CI –5961, –1313; P<0·01). Sales of less nutritious foods fell by 8·31 % (95 % CI –13·50, –2·80 %; P=0·004), while sales of nutritious foods did not change significantly (P=0·21); as a result, the percentage of food purchases rated as nutritious rose by 1·39 % (95 % CI 0·58, 2·20 %; P<0·01). The decrease in sales of less nutritious foods was greatest in the categories of canned meat and fish, soda pop, bakery and canned vegetables.
The introduction of the nutrition ratings led shoppers to buy a more nutritious mix of products. Interestingly, it did so by reducing purchases of less nutritious foods rather than by increasing purchases of nutritious foods. In evaluating nutrition information systems, researchers should focus on the entire market basket, not just sales of nutritious foods.
Survey data indicates that low public trust in business is an enduring phenomenon, but does not illuminate the underlying causes of this reality. While significant academic research has been done in the areas of interpersonal and interorganizational trust, little has been done in the area of public trust in business. This makes it difficult for business leaders to truly understand the problems posed by a lack of public trust and creates hurdles for their efforts to build and maintain public trust.
What do business leaders know about building public trust in their companies? What don’t they know and how might that be important for their particular business? What factors play a role in low levels of public trust in business? Why does trust matter to companies? What are the core dynamics of trust in business?
Public trust in business is a highly complex phenomenon that is impacted by social and technological change. Low trust in business is not the result of a single factor, but rather emerges from the interaction of multiple causes. Some aspects of what shapes public trust in business seem fairly constant and stable over time (e.g., suspicion of large institutions) other dimensions seem more contextual and fluid (e.g., the rise of the internet, information sharing, and the decrease in direct human interaction as a part of business).
Public trust in business is one of the most important but least understood issues for business leaders, public officials, employees, NGOs and other key stakeholders. This book provides much-needed thinking on the topic. Drawing on the expertise of an international array of experts from academic disciplines including business, sociology, political science and philosophy, it explores long-term strategies for building and maintaining public trust in business. The authors look to new ways of moving forward, by carefully blending the latest academic research with conclusions for future research and practice. They address core drivers of public trust, how to manage it effectively, the consequences of low public trust, and how best to address trust challenges and repair trust when it has been lost. This is a must-read for business practitioners, policy makers and students taking courses in corporate social responsibility or business ethics.