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There has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.
We developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.
Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.
Staff were initially excited, reports submitted, feedback good, then a plateau and slump.
Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.
In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.
By July 2021 we saw 10 reports per week in the Specialist Directorate.
By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.
We recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.
After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.
A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.
Background: Carbapenem-resistant Enterobacterales (CRE) are an increasing threat to patient safety but only a small percentage of CRE identified are NDMs. Since 2018, clinical CRE isolates have been submitted to the Ohio Department of Health for sequencing and NDM cases have notably increased since that time. Candida auris is an emerging pathogen with similar risk factors for colonization as CRE. Methods: A point-prevalence study was initiated after an index patient was identified with NDM CRE infection or colonization during their inpatient admission. Two patient populations were included in the study: current patients on the same unit as the index patient and currently hospitalized patients who overlapped on any unit with the index patient for at least 72 hours. Patients had perirectal screening for CRE (via PCR) and axilla or groin screening for C. auris (via Xpert Carba-R Assay). Patients were excluded if they had been discharged, expired, or refused testing. Results: We completed 5 point-prevalence studies from March 21, 2021, to October 15, 2021. The index patients were admitted at different times and across 2 campuses including medical, cardiac, and surgical ICUs as well as medical-surgical and inpatient rehabilitation units. Moreover, 3 species of NDM were identified from urine and 2 species were identified from bronchoalveolar lavage: Enterobacter hormaechei, Citrobacter freundii, and Enterobacter cloacae complex. C. freundii and E. cloacae complex both had dual mechanisms of NDM and KPC. Although some of the index patients overlapped temporally within the health system, none overlapped in the same unit or building. None of the patients had recently received health care outside the United States, although 1 patient had emigrated from Togo >5 years prior and 4 had had prior local healthcare exposure within 12 months of admission. Also, 147 patients were identified for screening; 105 consented, 32 declined, and 10 were excluded due to being discharged, deceased, or unable to consent. Inpatient point-prevalence screening tests for all patients tested (n = 105) were negative for NDM CRE and C. auris. Conclusions: Despite an increase of inpatients with NDM CRE, evidence of patient-to-patient transmission was not identified, likely resulting from adherence to standard precautions. The diversity of species and lack of international travel suggests that these patients likely acquired NDM CRE from a local reservoir in the community or healthcare settings. Given the continued increase in NDM CRE without traditional risk factors, it is critical for hospitals and public health agencies to collaborate to identify these organisms and that they develop surveillance programs to clarify risk factors for colonization.
The foreword considers the ways in which the lives of the women in this book have impacted the field and invites the reader to become a part of their legacy. The women in this book enriched psychology across subdisciplines with the shared experience of accomplishing much in their scholarship, while also creating great change in the norms of their profession and society. The women in this book reflect the lived lives of women whose stories are not here but are echoed by those in this book. The women in this book are a testament to the lives of the women before them. The women in this book shaped a path forward for the future women in our field. Sharing the stories that follow here reinforces the challenges that others have experienced so that future generations have fewer of them and can find inspiration to take on new ones.
OBJECTIVES/GOALS: Rural teens have lower human papillomavirus (HPV) vaccination rates than urban teens, promoting geographical cervical cancer disparities. Giving HPV vaccination earlier than the recommended 11-12 years might increase vaccination rates. We describe a feasibility study for recruiting rural clinics to participate in early HPV vaccination studies. METHODS/STUDY POPULATION: Leveraging professional contacts, we identified two clinics in North Carolina that serve predominantly rural populations. To assess the feasibility of adapting clinic monitoring systems to promote early vaccination, we requested to review electronic medical records (EMR) to identify the size of the vaccine-eligible patient population, HPV vaccination coverage, and the accuracy of EMR queries to monitor HPV vaccination status. Next, we completed in-depth interviews with clinic staff to collect insights on perceived advantages and disadvantages of promoting early HPV vaccination at 9-10 years, and potential facilitators and barriers to doing so. RESULTS/ANTICIPATED RESULTS: We expect that existing clinic systems will easily accommodate early recommendation and administration of HPV vaccine by expanding EMR queries and vaccination status indicators to include 9- and 10-year-olds. Clinics that are interested in promoting early HPV vaccination can use these adapted tools to monitor vaccine coverage over time. From in-depth interviews we expect to encounter a mix of support and hesitation to promote early HPV vaccination, based on personal beliefs on safety and effectiveness of HPV vaccination, perceptions of adolescent HPV risk, perceptions of parental acceptability of HPV vaccination, and perceived burden of changing current clinic protocols. DISCUSSION/SIGNIFICANCE: This feasibility study’s findings will help determine clinic readiness to recommend early HPV vaccination, and intervention components that maximize staff acceptability of early HPV vaccination. A subsequent randomized effectiveness study will evaluate early HPV vaccination as a method to increase rural adolescent vaccination coverage.
Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment.
This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample (N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants.
Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL (Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status (Β = −3.79, 95% CI = −7.42, −0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability, and receiving social support.
Significance of results
Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.
A clinical decision tree was developed using point-of-care characteristics to identify patients with culture-proven sepsis due to extended-spectrum β-lactamase–producing Enterobacterales (ESBL-PE). We compared its performance with the clinical gestalt of emergency department (ED) clinicians and hospital-based clinicians. The developed tree outperformed ED-based clinicians but was comparable to inpatient-based clinicians.
The Canadian Nosocomial Infection Surveillance Program conducted point-prevalence surveys in acute-care hospitals in 2002, 2009, and 2017 to identify trends in antimicrobial use.
Eligible inpatients were identified from a 24-hour period in February of each survey year. Patients were eligible (1) if they were admitted for ≥48 hours or (2) if they had been admitted to the hospital within a month. Chart reviews were conducted. We calculated the prevalence of antimicrobial use as follows: patients receiving ≥1 antimicrobial during survey period per number of patients surveyed × 100%.
In each survey, 28−47 hospitals participated. In 2002, 2,460 (36.5%; 95% CI, 35.3%−37.6%) of 6,747 surveyed patients received ≥1 antimicrobial. In 2009, 3,566 (40.1%, 95% CI, 39.0%−41.1%) of 8,902 patients received ≥1 antimicrobial. In 2017, 3,936 (39.6%, 95% CI, 38.7%−40.6%) of 9,929 patients received ≥1 antimicrobial. Among patients who received ≥1 antimicrobial, penicillin use increased 36.8% between 2002 and 2017, and third-generation cephalosporin use increased from 13.9% to 18.1% (P < .0001). Between 2002 and 2017, fluoroquinolone use decreased from 25.7% to 16.3% (P < .0001) and clindamycin use decreased from 25.7% to 16.3% (P < .0001) among patients who received ≥1 antimicrobial. Aminoglycoside use decreased from 8.8% to 2.4% (P < .0001) and metronidazole use decreased from 18.1% to 9.4% (P < .0001). Carbapenem use increased from 3.9% in 2002 to 6.1% in 2009 (P < .0001) and increased by 4.8% between 2009 and 2017 (P = .60).
The prevalence of antimicrobial use increased between 2002 and 2009 and then stabilized between 2009 and 2017. These data provide important information for antimicrobial stewardship programs.
Sociolinguistic research demonstrates that speakers are ‘aware’ of some variables in their speech patterns, but not others, as evidenced by, for example, style shifting. In explaining this bifurcation, Labov (1993, 2008) suggests that speakers have a sociolinguistic monitor where ‘members of the speech community evaluate the surface forms of language but not more abstract structural features’. However, determining which linguistic variables are ‘surface’ and which are more ‘abstract’ is far from clear. In this chapter we test the sociolinguistic monitor by comparing the use of two variables which are considered to be abstract structural features - negative concord and use of never for didn't. We compare the use of these forms across two datasets: one where community members are in conversation with a community insider and another with a community outsider. We find that there is style shifting according to interlocutor with negative concord but not with never for didn’t, suggesting that only the former is ‘monitored’ in the speech of this community. These findings suggest that social pressures override similarities across linguistic structure in the operation of the sociolinguistic monitor.
The focus of this chapter is the role of the nurse in optimising child and youth mental health. An overview of mental disorders experienced during childhood and adolescence is followed by a discussion of mental health promotion for children and young people. Although the lifetime prevalence of eating disorders is very low, they are common, and nurses play an important role in the care of those affected children and young people admitted to hospital for treatment. The chapter looks specifically at how nurses can help support children and young people with eating disorders, and also considers the effects of digital technologies on the mental health of young people growing up in today's society. The importance of working closely with the parents and families of children and young people disabled by mental illness and the services available to them is emphasised throughout the chapter.
Dementia is a growing concern in Canada, affecting peoples’ health and raising the cost of care. Between June and October 2019, we conducted an environmental scan to identify primary care models, strategies, and resources for dementia care from 11 pre-selected countries and assess their impact on quality-of-life measures. Search strategies included a rapid scoping review, grey literature search, and discussions with stakeholders. Eighteen primary care-based models of dementia care were identified. Common factors include team-based care, centralized care/case coordination, individual treatment plans, a stepped-care approach, and support for care partners. Five provinces had released a dementia strategy. Evidence of positive outcomes supported primary care-based models for dementia care, although only one model demonstrated evidence of impact on quality of life. Although these findings are encouraging, further research is needed to identify primary care-based models of dementia care that demonstrably improve quality of life for people living with dementia and their care partners.
As the US faced its lowest levels of reported trust in government, the COVID-19 crisis revealed the essential service that various federal agencies provide as sources of information. This Element explores variations in trust across various levels of government and government agencies based on a nationally-representative survey conducted in March of 2020. First, it examines trust in agencies including the Department of Health and Human Services, state health departments, and local health care providers. This includes variation across key characteristics including party identification, age, and race. Second, the Element explores the evolution of trust in health-related organizations throughout 2020 as the pandemic continued. The Element concludes with a discussion of the implications for agency-specific assessments of trust and their importance as we address historically low levels of trust in government. This title is also available as Open Access on Cambridge Core.
Shakespeare games are emerging as legitimate objects of study and pedagogy, but a survey of such games reveals that the marriage between “Shakespeare” and “game” is conceptually problematic, offering relatively narrow understandings of what a play by Shakespeare might be. We briefly identify two broad trends in digital pedagogical Shakespeare games before discussing how their reliance on the act of “play” and their favoring of Shakespeare as a textual ontology ignores the complexity of theatrical performance. We identify three overlooked complexities, the first giving rise to the other two: the audience's contribution to theatre’s ontology, the different kinds of work that actors and spectators undertake in performance, and the primacy of collaborative ontogenesis in theatre over artifactual ontology.
Keywords: Shakespeare; game design; digital pedagogy; ontology; ontogenesis
The Game's Afoot
Gina Bloom has recently observed that since 2008, “the field of Shakespeare gaming has exploded.” Shakespeare games are emerging as legitimate objects of study in our field at a time when the broader field of game studies has firmly established game design as a legitimate form of pedagogy. Although popular Shakespeare games—even those with pedagogical goals—still largely aim merely to capitalize on the cultural currency of the Bard, Shakespeare scholars are increasingly thinking of games—in particular digital games—as opportunities to engage pedagogically with students and theatre audiences about Shakespeare's works for the theatre. To date, we are aware of two broad trends in digital pedagogical Shakespeare games designed by Shakespeare scholars, each taking a distinct approach to scaffolding deep engagements with Shakespeare's play-texts. The first—which we think of as gamified textual analyses—aims to develop students’ analytical skills by setting completion conditions that can only be achieved through detailed engagement with the language, plot, characters, and/or themes of Shakespeare's plays; E. B. Hunter's Something Wicked and Katherine Acheson et al.'s Who Killed Romeo and Juliet? take this approach. The second category—staging games, pioneered in digital form by Larry Friedlander in 1991 with TheatreGame—positions players as theatre-makers in variations on sandbox games that simulate the decision-making processes involved in staging a play; Staging Shakespeare, Places, Please!: Hamlet Edition, and Play the Knave are all examples.
Infants who require open heart surgery are at increased risk for developmental delays including gross motor impairments which may have implications for later adaptive skills and cognitive performance. We sought to evaluate the feasibility and efficacy of a tummy time intervention to improve motor skill development in infants after cardiac surgery.
Infants <4 months of age who underwent cardiac surgery were randomly assigned to tummy time with or without outpatient reinforcement or standard of care prior to hospital discharge. The Alberta Infant Motor Scale (AIMS) was administered to each infant prior to and 3 months after discharge. Groups were compared, and the association between parent-reported tummy time at home and change in motor scores at follow-up was examined.
Parents of infants (n = 64) who had cardiac surgery at a median age of 5 days were randomly assigned to tummy time instruction (n = 20), tummy time + outpatient reinforcement (n = 21) or standard of care (n = 23). Forty-nine (77%) returned for follow-up. At follow-up, reported daily tummy time was not significantly different between groups (p = 0.17). Fifteen infants had <15 minutes of tummy time daily. Infants who received >15 minutes of tummy time daily had a significantly greater improvement in motor scores than infants with <15 minutes of tummy time daily (p = 0.01).
In infants following cardiac surgery, <15 minutes of tummy time daily is associated with increased motor skill impairment. Further research is needed to elucidate the best strategies to optimise parental compliance with tummy time recommendations.
Background: The Ohio State University Wexner Medical Center identified a cluster of coronavirus disease 2019 (COVID-19) cases on an inpatient geriatric stroke care unit involving both patients and staff. The period of suspected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission and exposure on the unit was December 20, 2020, to January 1, 2021, with some patients and staff developing symptoms and testing positive within the 14 days thereafter. Methods: An epidemiologic investigation was conducted via chart review, staff interviews, and contact tracing to identify potential patient and staff linkages. All staff who worked on the unit were offered testing regardless of the presence of symptoms as well as all patients admitted during the outbreak period. Results: In total, 6 patients likely acquired COVID-19 in the hospital (HCA). An additional 6 patients admitted to the unit during the outbreak period subsequently tested positive but had other possible exposures outside the hospital (Fig. 1). One patient failed to undergo COVID-19 testing on admission but tested positive early in the cluster and is suspected to have contributed to patient to employee transmission. Moreover, 32 employees who worked on the unit in some capacity during this period tested positive, many of whom became symptomatic during their shifts. In addition, 18 employees elected for asymptomatic testing with 3 testing positive; these were included in the total. Some staff also identified potential community exposures. Additionally, staff reported an employee who was working while symptomatic with inconsistent mask use (index employee) early in the outbreak period. The index employee likely contributed to employee transmission but had no direct patient contact. Our epidemiologic investigation ultimately identified 12 employees felt to be linked to transmission based on significant, direct patient care provided to the patients within the outbreak period (Fig. 1). In addition, 3 employees had an exposure outside the hospital indicating likely community transmission. Conclusions: Transmission was felt to be multidirectional and included employee-to-employee, employee-to-patient, and patient-to-employee transmission in the setting of widespread community transmission. Interventions to stop transmission included widespread staff testing, staff auditing regarding temperature and symptom monitoring, and re-education on infection prevention practices. Particular focus was placed on appropriate PPE use including masking and eye protection, hand hygiene, and cleaning and disinfection practices throughout the unit. SARS-CoV-2 admission testing and limited visitation remain important strategies to minimize transmission in the hospital.
The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.
To understand how the different data collections methods of the Alberta Health Services Infection Prevention and Control Program (IPC) and the National Surgical Quality Improvement Program (NSQIP) are affecting reported rates of surgical site infections (SSIs) following total hip replacements (THRs) and total knee replacements (TKRs).
Retrospective cohort study.
Four hospitals in Alberta, Canada.
Those with THR or TKR surgeries between September 1, 2015, and March 31, 2018.
Demographic information, complex SSIs reported by IPC and NSQIP were compared and then IPC and NSQIP data were matched with percent agreement and Cohen’s κ calculated. Statistical analysis was performed for age, gender and complex SSIs. A P value <.05 was considered significant.
In total, 7,549 IPC and 2,037 NSQIP patients were compared. The complex SSI rate for NSQIP was higher compared to IPC (THR: 1.19 vs 0.68 [P = .147]; TKR: 0.92 vs 0.80 [P = .682]). After matching, 7 SSIs were identified by both IPC and NSQIP; 3 were identified only by IPC, and 12 were identified only by NSQIP (positive agreement, 0.48; negative agreement, 1.0; κ = 0.48).
Different approaches to monitor SSIs may lead to different results and trending patterns. NSQIP reports total SSI rates that are consistently higher than IPC. If systems are compared at any point in time, confidence on the data may be eroded. Stakeholders need to be aware of these variations and education provided to facilitate an understanding of differences and a consistent approach to SSI surveillance monitoring over time.
Increasingly globalized communication networks in the modern world may influence traditional patterns of linguistic change: in contrast to an orderly sequential pathway of change, more recently a number of “mega trends” have been identified, which accelerate simultaneously in time and space. The rise of obviously within the cohort of adverbs of evidentiality—naturally, evidently, clearly, and of course—may be one such trend. To examine this possibility, we conduct a large-scale sociolinguistic analysis of c12,000 adverbs of evidentiality across over thirty communities in the UK and Canada. The results reveal parallel development across time and space: obviously advances rapidly among individuals born in the 1960s in both countries. The rise of obviously illustrates key attributes that are beginning to emerge from other rapidly innovating features: “off the shelf” changes that (1) are easily borrowed, (2) receptive to global trends, but (3) exhibit parallel patterns as the change progresses.