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Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in >80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, >80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.
Patients’ rights can be seen as a precondition to empowering people and moving to health systems that are more person-centred. They provide a foundation for citizens to be considered as actors in control of their own health care delivery process.
Increasingly, the challenges and potential solutions that health systems are facing are explored through a patients’ rights lens. Changes, such as the rapid ageing of the population and the rising burden of chronic conditions (including mental health problems), along with scientific and technological developments as well as cultural preferences, are creating new questions that are often debated within the context of fundamental rights, including self-determination, dignity and equality. The growing complexity of health care together with innovations in the fields of medicine (e.g. precision medicine) and of information and communication technology (ICT) (e.g. e-health), along with an increased focus on quality and safety, are likely to impact patients’ rights, especially with regard to privacy and equity.
Currently, there is limited knowledge on the impact of father-only sessions or parenting programs supporting impending fatherhood. This research explored an antenatal dads program aimed at fathers to assess the benefits of such interventions.
Literature regarding parenting programs and early childhood education initiatives, especially those aimed at children and families in disadvantaged circumstance, have been demonstrated to act as a buffer to poorer health and lifestyle outcomes in later life.
A qualitative research approach was used to explore the experiences of 16 fathers and 6 staff of a community-based parenting program with sessions focusing on fatherhood.
Four main themes were identified from the data regarding the experiences of groups engaged with the Antenatal Dads and First Year Families program. The first theme ‘Knowledge and Capacity Building’ stated that the information provided in the program helped fathers to be better informed and prepared for their impending fatherhood. The second theme was ‘Mental Health Awareness’ and identified the importance of raising awareness of depression and suicide in fathers, including where and how to get help. The third theme was ‘Soft-Entry’ and highlighted how the attendance at one service helped participants to learn about additional services through word of mouth and targeted promotion. The final theme was ‘Feeling Connected’, which helped fathers to feel more connected with the process of childbirth and development including playing and engaging with their children. Overall, the fathers found that the male-only sessions assisted them by supporting frank discussions on fatherhood. Additionally, the study helped identify the advantages of fathers meeting other fathers through attendance in the program, or even other couples in similar situations that helped fathers to feel less lonely regarding their situation.
CompStat emerged in the mid 1990s and quickly came to be seen as a major innovation in American policing. By the turn of the century it had received national awards from Harvard University and former Vice President Gore, and was featured prominently along with William Bratton (the police administrator who created the program) in the national news media. Its originators and proponents gave CompStat credit for impressive reductions in crime and improvements in neighborhood quality of life in a number of cities that had adopted the program (Silverman, 1996; Remnick, 1997; Gurwitt, 1998; Bratton, 1999). And while CompStat was first introduced only in 1994 in New York City, police departments around the country had begun to adopt it or variations of it by the first decade of the new century (Law Enforcement News, 1997; Maas, 1998; McDonald, 1998; Weisburd et al., 2003; Willis, Mastrofski & Kochel, 2010a). Indeed, in a Police Foundation survey conducted only six years after CompStat emerged on the scene in New York City, more than a third of American police agencies with 100 or more sworn officers claimed to have implemented a CompStat-like program (Weisburd et al., 2001). By 2006, Willis, Mastrofski, and Kochel (2010b) reported that about 60 percent of large police agencies had adopted CompStat, and a Police Executive Research Forum membership survey in 2011 reported that 85 percent of 166 responding member agencies reported having adopted or plans to adopt CompStat (Bureau of Justice Assistance & Police Executive Research Forum, 2013). Drawing on this survey and the comments of police leaders, researchers, and others attending a conference on CompStat in 2013, a report on the meeting offered a uniformly positive assessment of CompStat’s performance to date, as well as its future potential: “Regardless of how it develops in the future, it is clear that Compstat has become an integral part of policing in the United States by helping agencies become more productive, agile, and effective” (BJA & PERF, 2013: 30).
Surface debris covers much of the western portion of the McMurdo Ice Shelf and has a strong influence on the local surface albedo and energy balance. Differential ablation between debris-covered and debris-free areas creates an unusual heterogeneous surface of topographically low, high-ablation, and topographically raised (‘pedestalled’), low-ablation areas. Analysis of Landsat and MODIS satellite imagery from 1999 to 2018, alongside field observations from the 2016/2017 austral summer, shows that pedestalled relict lakes (‘pedestals’) form when an active surface meltwater lake that develops in the summer, freezes-over in winter, resulting in the lake-bottom debris being masked by a high-albedo, superimposed, ice surface. If this ice surface fails to melt during a subsequent melt season, it experiences reduced surface ablation relative to the surrounding debris-covered areas of the ice shelf. We propose that this differential ablation, and resultant hydrostatic and flexural readjustments of the ice shelf, causes the former supraglacial lake surface to become increasingly pedestalled above the lower topography of the surrounding ice shelf. Consequently, meltwater streams cannot flow onto these pedestalled features, and instead divert around them. We suggest that the development of pedestals has a significant influence on the surface-energy balance, hydrology and flexure of the ice shelf.
Bowel cancer risk is strongly influenced by lifestyle factors including diet and physical activity. Several studies have investigated the effects of adherence to the World Cancer Research Fund (WCRF)/American Institute for Cancer Research (AICR) cancer prevention recommendations on outcomes such as all-cause and cancer-specific mortality, but the relationships with molecular mechanisms that underlie the effects on bowel cancer risk are unknown. This study aimed to investigate the relationships between adherence to the WCRF/AICR cancer prevention recommendations and wingless/integrated (WNT)-pathway-related markers of bowel cancer risk, including the expression of WNT pathway genes and regulatory microRNA (miRNA), secreted frizzled-related protein 1 (SFRP1) methylation and colonic crypt proliferative state in colorectal mucosal biopsies. Dietary and lifestyle data from seventy-five healthy participants recruited as part of the DISC Study were used. A scoring system was devised including seven of the cancer prevention recommendations and smoking status. The effects of total adherence score and scores for individual recommendations on the measured outcomes were assessed using Spearman’s rank correlation analysis and unpaired t tests, respectively. Total adherence score correlated negatively with expression of Myc proto-oncogene (c-MYC) (P=0·039) and WNT11 (P=0·025), and high adherers had significantly reduced expression of cyclin D1 (CCND1) (P=0·042), WNT11 (P=0·012) and c-MYC (P=0·048). Expression of axis inhibition protein 2 (AXIN2), glycogen synthase kinase (GSK3β), catenin β1 (CTNNB1) and WNT11 and of the oncogenic miRNA miR-17 and colonic crypt kinetics correlated significantly with scores for individual recommendations, including body fatness, red meat intake, plant food intake and smoking status. The findings from this study provide evidence for positive effects of adherence to the WCRF/AICR cancer prevention recommendations on WNT-pathway-related markers of bowel cancer risk.
On 2 March 2016, several small en échelon tabular icebergs calved from the seaward front of the McMurdo Ice Shelf, and a previously inactive rift widened and propagated by ~3 km, ~25% of its previous length, setting the stage for the future calving of a ~14 km2 iceberg. Within 24 h of these events, all remaining land-fast sea ice that had been stabilizing the ice shelf broke-up. The events were witnessed by time-lapse cameras at nearby Scott Base, and put into context using nearby seismic and automatic weather station data, satellite imagery and subsequent ground observation. Although the exact trigger of calving and rifting cannot be identified definitively, seismic records reveal superimposed sets of both long-period (>10 s) sea swell propagating into McMurdo Sound from storm sources beyond Antarctica, and high-energy, locally-sourced, short-period (<10 s) sea swell, in the 4 days before the fast ice break-up and associated ice-shelf calving and rifting. This suggests that sea swell should be studied further as a proximal cause of ice-shelf calving and rifting; if proven, it suggests that ice-shelf stability is tele-connected with far-field storm conditions at lower latitudes, adding a global dimension to the physics of ice-shelf break-up.
Morphosyntactic dialect variation, once a neglected area of dialect research, has recently witnessed a large growth in interest. Various methods from geospatial data analysis have been applied to morphosyntactic data. To date, the focus has largely been on analyzing the distribution of stable patterns of variation. This article extends this work to examine patterns of ongoing change. It uses a body of data from the Syntactic Atlas of Welsh Dialects and the Siarad Corpus of spoken Welsh to examine the innovation and diffusion of a new second-person singular pronoun, chdi, testing the usefulness of Geographically Weighted Regression (GWR) as a method for identifying and modeling patterns of ongoing syntactic change. It is shown that GWR provides plausible models of the diachronic development of changes that are still in progress. Furthermore, it allows us to test whether rates of change are constant across geographical space, allowing us to test whether the Constant Rate Hypothesis (that diffusion of change proceeds at the same rate in different environments) holds between dialects.
This study investigates consumer preferences for a marketing system that improves integration of farmers into a local food system. Attribute-based methods are used to estimate consumer willingness to pay for a locally grown product that is bundled with a local food bank (LFB) donation. Estimates reveal that, on average, households are willing to pay 11% more for locally grown relative to nonlocal agricultural products. When the locally grown product attribute is combined with a donation to support a LFB, the premium nearly doubles. Results suggest that the proposed system could provide resources to strengthen local food distribution networks.
Clinical databases in congenital and paediatric cardiac care provide a foundation for quality improvement, research, policy evaluations and public reporting. Structured audits verifying data integrity allow database users to be confident in these endeavours. We report on the initial audit of the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry.
Materials and methods
Participants reviewed the entire registry to determine key fields for audit, and defined major and minor discrepancies for the audited variables. In-person audits at the eight initial participating centres were conducted during a 12-month period. The data coordinating centre randomly selected intensive care encounters for review at each site. The audit consisted of source data verification and blinded chart abstraction, comparing findings by the auditors with those entered in the database. We also assessed completeness and timeliness of case submission. Quantitative evaluation of completeness, accuracy, and timeliness of case submission is reported.
We audited 434 encounters and 29,476 data fields. The aggregate overall accuracy was 99.1%, and the major discrepancy rate was 0.62%. Across hospitals, the overall accuracy ranged from 96.3 to 99.5%, and the major discrepancy rate ranged from 0.3 to 0.9%; seven of the eight hospitals submitted >90% of cases within 1 month of hospital discharge. There was no evidence for selective case omission.
Based on a rigorous audit process, data submitted to the PC4 clinical registry appear complete, accurate, and timely. The collaborative will maintain ongoing efforts to verify the integrity of the data to promote science that advances quality improvement efforts.
Despite many advances in recent years for patients with critical paediatric and congenital cardiac disease, significant variation in outcomes remains across hospitals. Collaborative quality improvement has enhanced the quality and value of health care across specialties, partly by determining the reasons for variation and targeting strategies to reduce it. Developing an infrastructure for collaborative quality improvement in paediatric cardiac critical care holds promise for developing benchmarks of quality, to reduce preventable mortality and morbidity, optimise the long-term health of patients with critical congenital cardiovascular disease, and reduce unnecessary resource utilisation in the cardiac intensive care unit environment. The Pediatric Cardiac Critical Care Consortium (PC4) has been modelled after successful collaborative quality improvement initiatives, and is positioned to provide the data platform necessary to realise these objectives. We describe the development of PC4 including the philosophical, organisational, and infrastructural components that will facilitate collaborative quality improvement in paediatric cardiac critical care.
Malaria is a disease that still affects a significant proportion of the global human population. Whilst advances have been made in lowering the numbers of cases and deaths, it is clear that a strategy based solely on disease control year on year, without reducing transmission and ultimately eradicating the parasite, is unsustainable. This article highlights the current mainstay treatments alongside a selection of emerging new clinical molecules from the portfolio of Medicines for Malaria Venture (MMV) and our partners. In each case, the key highlights from each research phase are described to demonstrate how these new potential medicines were discovered. Given the increased focus of the community on eradicating the disease, the strategy for next generation combination medicines that will provide such potential is explained.