2018 National Meeting LEADING AND IMPLEMENTING CHANGEDoes Emergency Physician (EP) Diagnostic...
Transcript of 2018 National Meeting LEADING AND IMPLEMENTING CHANGEDoes Emergency Physician (EP) Diagnostic...
Abstract Book
LEADING AND IMPLEMENTING CHANGE
2018 National Meeting
LEAD SPONSOR SPONSORS
In partnership with the Canadian Medical Association
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OverallProgramGoals
• EngagewiththeChoosingWiselycommunityinanenergizedexchangeofideasonoveruse
• Hearaboutpracticalandimplementablestrategiesforreducingoveruse,andunderstandtheirimpact
• Networkwithcolleagueswhoshareyourpassion
OverallLearningObjectives
Attheendofthismeeting,participantswillbeableto:
• Exchangeknowledgeandbestpracticesforreducinglow-valuecarewithintheclinicalsetting
• Learnaboutstrategiestomeasureandevaluateinterventions
• Acquiretoolsandskillsofimplementationscienceastheyrelatetoreducinglow-valuecare
STUDY CREDITSCollege of Family Physicians of Canada – Mainpro+:ThisGroupLearningprogrammeetsthecertificationcriteriaoftheCollegeofFamilyPhysiciansofCanadaandhasbeencertifiedbyContinuingProfessionalDevelopment,FacultyofMedicine,UniversityofTorontoforupto6.0Mainpro+credits.
Royal College of Physicians and Surgeons of Canada – Section 1:ThiseventisanAccreditedGroupLearningActivity(Section1)asdefinedbytheMaintenanceofCertificationProgramoftheRoyalCollegeofPhysiciansandSurgeonsofCanada,approvedbyContinuingProfessionalDevelopment,FacultyofMedicine,UniversityofToronto.Youmayclaimamaximumof6hours(creditsareautomaticallycalculated).
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ContentsProgramGoalsandObjectives 2Chair’sForeword 6Agenda 7
DEPRESCRIBINGPromotingAppropriatePrescribing:AntipsychoticStewardshipforOlderPatientsinAcuteCare 10ExploringDeprescribingOpportunitiesforCommunityPharmacists 11UseofaStandardizedProcessforProtonPumpInhibitor(PPI)DeprescribingatMarkhamStouffvilleHospital 12DevelopingaSustainableCultureforaDeprescribingProgramatMichaelGarronHospital(MGH) 13PAACT(PartnersforAppropriateAnti-infectiveCommunityTherapy):25YearsofAntimicrobialStewardship 14ImplementationofaFamilyMedicineGuideforPainManagement 15
QUALITY IMPROVEMENT PositivelyChangingRedBloodCellTransfusionPracticeUsingEducationalStrategies 17ChoosingWiselyintheEmergencyDepartmenttoReduceUnnecessaryTests 18BetterTogether:WorkingAcrossPrimaryCareOrganizationstoImplementChoosingWisely 19ReducingBenzodiazepines&Sedative-HypnoticsAmongHospitalizedPatients:LessonsLearnedfromaMulti-SiteImplementationJourney 20ARTICChoosingWisely:AnIdeaWorthSpreadingAcrossFiveOntarioHospitalsandAffiliatedFamilyHealthTeams 21ReducingUnnecessaryBUNTestingatNorthYorkGeneralHospital 22AnIdeaWorthSustaining:EvaluatingtheSustainabilityPotentialoftheChoosingWiselyInitiativeAcrossFiveOntarioCommunityHospitals&AffiliatedFamilyHealthTeams 23GainingMomentumThroughtheUseofChoosingWiselyCanada:OntarioTransfusionQualityImprovementPlan(OTQIP) 24DoubleEdgedSword:OrderSetModificationtoReduceTwoUnitRedCellTransfusionsonanOncologyWard 25AnInnovativeDigitalStrategyforDisseminationofChoosingWiselyCanadaGuidelinesInTransfusionMedicine 26De-ImplementingWisely:PlanningyourImplementationStrategy 27ReducingtheRateofPostoperativeUrinaryTractInfectionAmongstOrthopaedicPatientsinaCommunityTeachingHospital 28LosetheTubeatHumberRiverHospital 29CollabwiththeLab:ImplementingChoosingWiselywithLaboratory 30ComparingPhysicianandNurseOrderinginEmergencyDepartments:AQualitativeStudy 31APharmacistLedStrategytoReduceUnnecessaryLabTestsforNewAdmissionsintoLongTermCare 32EvaluatingHealthcareProviders’UnderstandingofCBT-IinanInterdisciplinaryFamilyHealthTeam 33EngageatEveryStage,LearnatEveryTurn:HowSaskatchewanisBuildingContinuousClinicalQualityImprovementLearningPathwaysforPhysicians 34ExaminingtheImplementationofPreoperativeDiagnosticTestingGuidelinesinManitoba 35LeveragingAudit&FeedbacktoSupportPracticeChange 36TheChecklistforHeadInjuryManagementEvaluationStudy(CHIMES):AQIInitiativeintheEmergencyDepartment 37ImplementingChoosingWiselyRecommendationsAcross5AlbertaEmergencyDepartmentsThroughElectronicDecisionSupport 38ReducingUnnecessaryBloodTestsinaDowntownEmergencyDepartment 39
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Pilotinga“chestx-rayforacuteasthma”knowledgedisseminationtoolinAlbertaemergencydepartments 40DoIReallyNeedAntibiotics?AskYourDoctororNursePractitioner 41RandomizedControlledTrialofAuditandFeedbackInterventiontoImproveAdherencetotheChoosingWiselyRecommendationsinPrimaryCare 42Implementationofchangesincervicalscreeningrecommendations. 43PrimedforSuccess:UsingImplementationSciencetoImplementChange 44AssessingtheCompletionandAppropriatenessofHeadacheandLowBackMRIandCTRequisitions:ACanadianPerspectiveonPatient-CentredReferrals 45TheJoysandSorrowsofImplementing 46ElectiveLumbarLaminectomy:RoutinePerioperativePracticesandPostoperativeOutcomes 47UnnecessaryUltrasoundintheManagementofSubcutaneousLipomas 48ByeByeBedrest:ShiftingICUCulturefrom‘TooSicktoGetOutofBed’to‘TooSicktoStayinBed’ 49UnnecessaryUltrasoundintheManagementofUmbilicalandInguinalHernias 50ACollaborative,DiagnosticStewardshipInitiativetoImproveUrineCultureUtilizationInAlberta 51DoesEmergencyPhysician(EP)DiagnosticImaging(DI)useAffectClinicalProductivity? 52InfluenceofLabTests(LT)OrderingonEmergencyPhysician(EP)Productivity(PP) 53ImprovingAppropriatenessofMgTestinginICU 54TheRoadTraveled-NPAC’sJourneyinDevelopmentofthe“NineThingsNursePractitionersandPatientsShouldQuestion” 55ExploringPhysician-ReportedBarriersandFacilitatorstoUsingEvidence-BasedRecommendationsRegardingImagingforLowBackPain:AMeta-SynthesisUsingtheTheoreticalDomainsFramework 56FundamentalsofHealthEvidence:PracticalApproachestoCriticalAppraisal 57ReducingRadiationandCostAssociatedwithFollow-UpImagingforPneumothorax 58BladderMatters:ACorporateStrategytoReduceUrinaryTractInfectionsandUrinaryRetentionRates 59ElectronicReferralFormsandDecisionSupportToolsIntegratedintoElectronicMedicalRecordSystemsForVascularTestOrderingbyPhysiciansinPrimaryCareSettingsinNewfoundlandandLabrador(NL) 60InfluencingEmergencyDepartmentManagementandImagingPracticesforTwoCommonPresentations:DevelopingandImplementingaTheoryandData-InformedIntervention 61ImplementationofaNewDiagnosticAlgorithmforAnti-NeutrophilCytoplasmicAntibody(ANCA)Testing 62Conceptualizing‘UnnecessaryCare’inEmergencyDepartments(ED):QualitativeInterviewswithEdPhysiciansandSiteChiefs 63TheUseofClinicalDecisionSupportToolsintheEmergencyDepartmenttoOptimizeClinicalPractice:ASystematicReviewandMeta-Analysis 64ReducedCD4MeasurementsinStableHIVPatientsisAssociatedwithSignificantCostSavings 65LHINCollaboration&StandardizationImprovingImagingPractices 66EndometrialBiopsyinanOutpatientGynaecologicalSetting:OverInvestigation 67OptimizingtheuseofEndoscopyforYoung,OtherwiseHealthyPatientswithDyspepsia 68ImprovingAppropriatenessofOxygenSaturationMonitoringinPaediatricPatientsWithAcuteRespiratoryIllness:aQIInitiative 69MergingInitiatives:ChoosingWiselyandAntimicrobialStewardship–AnUnderutilizedConnection 70DermatologyGuidelinesforChoosingWiselyCanada:FiveThingsPatientsandProvidersShouldQuestion 71BronchiolitisManagementinCalgaryEmergencyDepartments 72Howtoreduceinappropriatepreventivecare. 73ChoosingWisely–EngagingourPatients-AUniqueOpportunityforNursePractitioners 74ImplementingCriticalAppraisalintheChoosingWiselyRecommendationWritingProcess 75
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MEASUREMENT & EVALUATION TheRoleofAuditandFeedbackInChoosingWisely:ArePhysiciansAbletoAccuratelyPredictTheirOwnPractice? 77DrivingChangeUsingAuditandFeedback:PrimaryHealthcarePanelReports 78PhysicianUtilizationScorecardsinPrimaryCare:ACross-SectorPartnershiptoImproveTestUtilization 79ScreeningforNewPrimaryCancersinPatientswithMetastaticBreastCancer:AProvincialAnalysisoftheChoosingWiselyCanadaRecommendations 80FrequencyandUtilityofPre-ConsultationMRIUseinPatientsReferredforPossibleTotalKneeArthroplasty 81AData-DrivenApproachtoIdentifyingLaboratoryOverutilization–ResultsfromtheGeneralMedicineInpatientInitiative(GEMINI) 82UsingFacilitatedAuditandFeedbacktoSupportChoosingWiselyInitiativesforPrimaryCarePhysicians 83TreatmentofAsymptomaticBacteriuriainElderlyPatientsWithDelirium:ASystematicReview 84ADatabasePlatformtoMonitorIn-HospitalGlucometerUse 85TheUseofTheoriesandFrameworkstoUnderstandandAddresstheReductionofLow-ValueHealthcarePractices:AScopingReview 86AScopingReviewExploringInterventionsChangingImageOrderinginPediatricEmergencyMedicine 87PilotingaTooltoReduceCTforBenignHeadacheinAlbertaEmergencyDepartments 88ChoosingWiselyinRadiationOncology:DrivingPracticeChangethroughMeasurementandQualityImprovement 89WhatBehaviourChangeTechniquesHaveBeenUsedtoReducePhysician’sImage-OrderingforLowBackPain 90MeasuringBenzodiazepineuseAmongSeniorswithIn-HospitalDelirium 91AssessingtheRiskofIntracranialBleedinginEmergencyDepartmentSeniorswhohaveFallen 92ThePrevalenceofIntracranialBleedinginElderlywhohaveFallen 93SerumProteinElectrophoresisTestinginNorthernAlberta:AnAuditandInterventiontoCurtailOveruse 94AllergyTestinginNorthernAlberta:AnAuditandInterventiontoCurtailOveruse 95CurtailingtheInappropriateUrineHcgQualitativeTestinginaCommunityLabSetting 96StewardshipwithaHandshake:ImpactofCollaborative,ProspectiveAuditandFeedbackAntimicrobialStewardshipRoundsinanAdult,Medical-SurgicalIntensiveCareUnitinSaskatoon,Saskatchewan 97AppropriatenessofCTandX-rayOrderingbyPhysiciansforLowBackPain:ASystematicReview 98
MEDICAL EDUCATION IncorporatingResourceStewardshipintoUndergraduateMedicalEducationatMcMasterUniversity 100ChoosingWiselyCanadaSTARS:TrainingtheNextGenerationofMedicalProfessionalsatUBC 101IncorporatingResourceStewardshipintotheUniversityofManitobaUndergraduateMedicalEducationProgram102TimetoForgetAboutDRE? 103ResourceStewardshipinUndergraduateMedicalEducation(UME) 104EvaluatingCanadianMedicalStudents’InterestinandReadinessforLearningandPracticingHigh-ValueCare:PreparingforChange 105
PATIENT ENGAGEMENTEngagingPatientsasPartnersinCWNL:LowBackImagingCaseStudy 107RegionalMediaStrategies:ChoosingWiselyinFormerCypressHealthRegion 108ChangingtheWayweUnderstandandLabelBehaviourwillReducetheuseofAntipsychoticsinDementiaCare 109DeepeningPatientEngagement:Sharingthepatientvoiceatalllevelsofanorganizationandbeyond110
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Chair’s ForewordDearChoosingWiselyCanada2018NationalMeetingAttendees,
Welcome to the third annual Choosing Wisely Canada National Meeting!
Weareexcitedtobehostingthisyear’sNationalMeetinginTorontoattheGlobeandMailCentre.TheNationalMeetingisacelebrationofwhatwehaveaccomplishedtogetherinpartnershipwithyou,ourcollaboratorsfromacrossthecountry,andanopportunitytolookforwardanddiscusshowwecansustainthemomentumforourcampaign.
Thisyear’stheme,LeadingandImplementingChange,wasinspiredbythefantasticeffortsofourChoosingWiselycommunity.WehopethismeetingwillprovideanopportunitytoshowcasepracticalandimplementableexamplesofChoosingWiselyprojectsfromacrossCanada.
Thecontentsofthisabstractbookareatestamenttothebreadthofclinicianleadership,engagement,anddedicationofourstakeholdersthatareleadingchangeandimprovingthequalityofhealthcareintheirownorganizationsorpracticesettings.Browsethecontentsofthisabstractbookbytopic,whichinclude:deprescribing,medicaleducation,patientengagement,qualityimprovementandmeasurement.
Wehopethisbookwillserveasacontinuedsourceofinspiration,innovationandideasthatengagethegrowingcommunityofclinicians,individualsandorganizationscommittedtotheChoosingWiselyCanadacampaignbeyondtheNationalMeeting.Thiswillbeathought-provokingmeetingthatwillinspireandcontinuetobuilduponourcollectiveeffortsintheareasofqualityandappropriateness.
IsincerelythankallofyourforthecommitmentyouhavemadetoChoosingWiselyandyourcontinuedeffortsinimprovingourhealthcaresystem.
Yours,
WendyLevinson,MDOCChair,ChoosingWiselyCanada&InternationalProfessorofMedicine,UniversityofToronto
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Itinerary
8:00AM-8:30AM
8:30AM-9:00AM
9:00AM-9:50AM
9:50AM-10:10AM
10:10AM-11:10AM
11:10AM-11:25AM
11:25AM-12:25PM
12:25PM-1:25PM
Registration and Breakfast
Welcome and Opening RemarksTheHonourableGinettePetitpasTaylor,FederalMinisterofHealthDr.LaurentMarcoux,President,CanadianMedicalAssociationDr.JoshuaTepper,PresidentandChiefExecutiveOfficer,HealthQualityOntario
Morning Keynote: Common Pitfalls in Quality Improvement: Lessons for Choosing Wisely ProjectsDr.KavehShojania,Director,CentreforQualityImprovement&PatientSafety,UniversityofTorontoandEditor-in-chief,BMJQuality&Safety
SessionLearningObjectives:• Appreciatethesharedgoalsofqualityimprovementactivities;• Understandcommonwaysqualityimprovementprojectsgowrong;• Identifyeffectivestrategiesfortranslatingevidenceintopractice.
Networking Break
Successful Tales of Choosing Wisely From Coast-to-Coast TheplenarywillhighlightChoosingWiselyimplementationprojectsfromourabstractsubmissions.Panelistswillbeaskedtopresentontheirtopicandtakequestionsfromtheaudience.
1. Positively changing red blood cell transfusion practice using educational strategies• Dr.SusanWitt,AlbertaHealthServices
2. Choosing Wisely in the emergency department to reduce unnecessary tests• Dr.SamCampbell,QEIIHealthSciencesCentre
3. Better Together: Working across primary care organizations to implement Choosing Wisely• Dr.KimberlyWintemute,ChoosingWiselyCanada,NorthYorkFamilyHealth
Team
4. Reducing benzodiazepines and sedative-hypnotics among hospitalized patients: Lessons Learnedfrom a multi-site implementation journey• Dr.ChristineSoong,SinaiHealthSystem
Networking Break
Concurrent Sessions 1ConcurrentsessionsfeaturebreakoutandworkshopsessionsthatwillhighlightChoosingWiselyimplementationprojectsandinteractivediscussionswithpresenters.
Lunch and Networking
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1:25PM-2:25PM
2:25PM-2:45PM
2:45PM-3:45PM
3:45PM-3:55PM
3:55PM-4:05PM
4:05PM-4:55PM
4:55PM-5:00PM
Concurrent Sessions 2ConcurrentsessionsfeaturebreakoutandworkshopsessionsthatwillhighlightChoosingWiselyimplementationprojectsandinteractivediscussionswithpresenters.
Networking Break
Concurrent Sessions 3ConcurrentsessionsfeaturebreakoutandworkshopsessionsthatwillhighlightChoosingWiselyimplementationprojectsandinteractivediscussionswithpresenters.
Networking Break
Remarks from the Canadian Medical Protective Association (CMPA) Dr.HartleyStern,CanadianMedicalProtectiveAssociation
Afternoon Keynote: Choosing Wisely and Medicine’s Third EraDr.DeeMangin,Professor,DavidBraley&NancyGordonChairinFamilyMedicine,McMasterUniversity
SessionLearningObjectives:• Appreciatethepastandcurrentinfluencesshapingthechangingframeworkof
medicine;• Understandtheimplicationsforthethirderaofmedicine;• ConsidertheopportunitiesforChoosingWisely.
Closing Remarks
DEPRESCRIBING - PAGE 9
DEPRESCRIBING
DEPRESCRIBING - PAGE 10
Promoting Appropriate Prescribing: Antipsychotic Stewardship for Older Patients in Acute CareDeborahBrown,SunnybrookHeathSciencesCentreJesikaContreras,RegionalGeriatricProgramofTorontoMireilleNorris,SunnybrookHealthSciencesCentreDovGandell,SunnybrookHealthSciencesCentreRobertJaunkalns,SunnybrookHealthSciencesCentreJoyMakari,SunnybrookHealthSciencesCentreRominaMarchesano,SunnybrookHealthSciencesCentreBarbaraLiu,SunnybrookHealthSciencesCentre,UniversityofToronto
BackgroundInhospital,olderpatientswithdementiaordeliriummayexhibitbehaviourssuchasagitationorhallucinations,thatmayleadtopharmacologicalintervention.Evidencetoguideappropriateuseofantipsychoticsinolderpatientsislackingandasaclass,antipsychoticshavesignificantadverseeffects.
ObjectiveToimplementandevaluateanantipsychoticstewardshipprogramwiththeaimofoptimized,appropriateuseofneurolepticsforresponsivebehavioursinolderpatientsinacutecare.
InterventionWereviewedpatients(>70years)whohadantipsychoticsorderedon3acutecareunits.Thestewardshipprocessincluded:• Reviewofthechartandassessmentofthepatient• Determiningiftheantipsychoticwasnecessary;theappropriatedruganddoseordered;determinationof
theantipsychoticeffectonthetargetbehaviour• Ensuringappropriatemedicalassessmentandinvestigations• Reinforcingtheuseofnon-pharmacologicalinterventions• Ensuringthatthepatient’sresponsewasmonitored
Results120patientswerereviewed,meanage82years,55%aremale;86%fromcommunity.Wediscontinuedordecreasedantipsychoticsin64%oforders.Inpatientsonantipsychoticsathome,wereducedordiscontinuedthedrugsin53%oforders.Weincreasedawarenessofappropriatedosinginolderpatientsandcreatedapositiveimpactondeliriumawareness.Wehavedevelopedaweb-basedappforantipsychoticdosingandeducationalmaterialstosupportnon-pharmacologicalstrategiesforresponsivebehaviours.
Lessons LearnedAvaluableopportunitytoreinforcenon-pharmacologicalapproachestobehaviourmanagement;prescriberengagementiscrucialandthereisneedforsystematiccareplanningwithresponsivebehaviours.Asfollowup,adeliriumordersethasbeencreated.
DEPRESCRIBING - PAGE 11
Exploring Deprescribing Opportunities for Community Pharmacists ClaraKorenvain,Women’sCollegeHospitalLindaMacKeigan,UniversityofTorontoKatieDainty,NorthYorkGeneralHospitalSaraGuilcher,UniversityofTorontoLisaMcCarthy,Women’sCollegeHospital
BackgroundDeprescribingcanreducetheuseofharmfulorunnecessarymedicationsbutisachallengingprocessforpatientsandprescribers.Communitypharmacistshavepotentialopportunitiestobeinvolvedwithdeprescribingbutfewstudieshaveexploredtheirroleinthedeprescribingprocess.WesoughttodescribeOntariocommunitypharmacists’involvementwithdeprescribingandpotentialopportunitiesforenhancingdeprescribing.
MethodsWeconductedqualitativetelephoneinterviewswithaconveniencesampleofOntariocommunitypharmacistsselectedtoachievevariabilityinexperience,pharmacyposition,andurban/rurallocation.Threeinterviewtranscriptswerecodedindependentlybyfourinvestigatorstodevelopacodebook,andtheremainderwerecodedandanalyzedthematicallybyoneinvestigator.
ResultsAll17participantswereinvolvedwithdeprescribingintheirpracticesbuttovariableextents.Threethemeswereidentified:(1)pharmacists’conceptualizationofdeprescribingaffectshowtheyidentifyandactondeprescribingopportunities;(2)communitypharmacists’professionalandbusinessroleschallengetheirabilitytoprioritizedeprescribingindailypractice;and(3)suboptimalaccesstoinformationfromprescribersinfluencespharmacists’willingnesstoassumeresponsibilityfordeprescribing.
ConclusionRecommendationsforenhancingcommunitypharmacists’involvementindeprescribingincludefocusingpharmacists’timeonstepsintheprocessthattheycancontributetoefficientlyandeffectively(suchasmonitoring),andincreasingpatientengagementinthedeprescribingprocesstohelppharmacistsgainaccesstoinformationtheyareotherwisechallengedtoobtain.Futureresearchiswarrantedexaminingbroaderstrategiessuchasintegratingeducationaboutdeprescribingwithexistingeducationaboutbestprescribingpractices.
DEPRESCRIBING - PAGE 12
Use of a Standardized Process for Proton Pump Inhibitor (PPI) Deprescribing at Markham Stouffville HospitalAliceHogg,MarkhamStouffvilleHospital
GoalThegoaloftheprojectwastoreducethenumberofpatientsdischargedfromhospitaloninappropriatePPIprescriptions.
ImplementationAprocesswasdevelopedtoteachpharmacystudentstouseastandardizedassessmenttoidentifypatientsadmittedtotherehab/medicineunitsatMarkhamStouffvilleHospitalthatarecandidatesfordeprescribing.OnceidentifiedthepharmacystudentdiscussespotentialPPIdeprescribingwiththepatientandprovideswritteninformation.Ifthepatientisdeterminedtobeeligible,thestudentcompletesaPPIDeprescribingPreprintedOrderSet(PPO)providingtherationalefordeprescribingandtherecommendeddeprescribingregimen.ThecompletedPPOisleftonthepatientchartforphysicianreviewandsignoffifagreeable.ThestudentfollowsthepatientwhileinhospitalandassessestoleranceofPPIdeprescribing.
MeasuresAtbaseline,11%ofassessedpatientsthatwerecandidatesforPPIdeprescribingwereinitiatedonadeprescribingregimenpriortodischarge.Aftertheinterventionthisincreasedto45%representinga62%decreaseininappropriatePPIprescriptionsatdischarge.
ChallengesThemainchallengesofthisprojectwere1)missedopportunitiestocompletetheintervention2)completedPPO’snotbeingsignedbythephysicianand3)PPIprescriptionsbeingwrittenincorrectlyatdischarge.LessonsLearned:Toaddresstheabovechallengessomeadjustmentsweremadetotheprocess.TheseincludedaddingacommentssectiononthePPOforphysiciantoindicateareasonfordisagreeingwiththerecommendationanddevelopmentofalettertosendtothefamilyproviderdetailingtheinterventionandrequestingfollow-upwiththepatient.
DEPRESCRIBING - PAGE 13
Developing a Sustainable Culture for a Deprescribing Program at Michael Garron Hospital (MGH)JohnAbrahamson,MichaelGarronHospitalHeatherSampson,MichaelGarronHospitalPatrickDarragh,MichaelGarronHospitalAndrewLiu,MichaelGarronHospitalCaraTannenbaum,UniversityofMontrealStephanieVoong,UniversityofTorontoNazigGabriel,UniversityofTorontoAjanthiyThayalan,UniversityofTorontoMayuriMahenth,UniversityofToronto
ObjectivesDevelopasustainabledecision-makingframeworkfordeprescribingprojectsguidingreproducibleprogramdevelopmentsapplicabletootheracutecaresettings
BackgroundUpto50%ofpatientsprescribedinhaledcorticosteroids(ICS)areunlikelytobenefitfromtheiruse.ICSarenotbenignmedicationswithsubstantialevidenceforadverseeffects.Thesecostlymedications,whenprescribedinappropriatelyresultinsignificantpatientandhealthcaresystemburden.Lastyear,MGHspent$120,000onICS.
MethodsDeprescribingprincipleswereintroducedatMGHin2016.ExtrapolatingthesesuccessfulcomponentsencouragedMGHtoruna“real-life”prospectiveQIprojectdeprescribingICS.ElectronicstopondispensingICSwasutilizeduntiltheappropriatenessofICSwasdeterminedforMedicinepatientsadmittedwithanon-respirologydiagnosis.Patients/familieswereengagedintheshareddecision-makingprocesswiththepharmacist/physicianteam.WheretheappropriatenessofICSwasnotclear,respirologyconsultandpulmonaryfunctiontestswererequested.Primarycarephysicianandcommunitypharmacistswereelectronicallynotifiedonrecommendations
ResultsPatientpopulationwascharacterizedi.e.demographics,comorbidities,smokinghistory,respiratoryexacerbationsandadmissions.TheproportionoftotaladmittedpatientsusingICSandtheproportionofthosethatcanhaveICSdeprescribedweredetermined.ImpactonsevendayreadmissionsandpatientadherencetodeprescribingrecommendationscontinuestobeevaluatedusingMinistryrecordsandphonecallfollowup.
ConclusionICSdeprescribingreducescostanddiseaseburdentothehealthcaresystem.PrototypingICSstewardshipinacollaborativemulti-professionalmodeldevelopedsystems-basedchangesrequiredforasustainablehospitalbaseddeprescribingprogram.AbusinessplanbasedonsavingsaccruedthroughdeprescribingisunderwayatMGH.
DEPRESCRIBING - PAGE 14
PAACT (Partners for Appropriate Anti-infective Community Therapy): 25 Years of Antimicrobial StewardshipLaurieDunn,PArtnersforAppropriateCommunityTherapy(PAACT)AlexandraBarany,MUMSHealthJohnStewart,PortPerryMedicalAssociatesJohnPilla,PArtnersforAppropriateCommunityTherapy(PAACT)
Goal: PAACTisanationaleducationnetworkoffamilyphysiciansthatfocusesonappropriatetreatmentofcommunity-acquiredinfectiousdiseasewhosemainreferenceistheAnti-infectiveGuidelinesforCommunity-acquiredInfections(“OrangeBook”).Thegoalsaretheimplementationofacommunity-basedantimicrobialstewardshipprogramandthereductionofunecessaryantibioticprescriptions.Thishascurtailedantimicrobialresistanceratesandpreserveantibioticsforfutureuse.
Implementation: Twophases:1)Developmentofevidence-based,user-friendlyclinicalguidelines.2)Disseminationofguidelinerecommendationsthroughsmallgroupcasebasedworkshops.
Measures: Datawasobtainedfromon-siteprograms(e.g.,accreditedCFPCsessions)evaluationsandpost-reflectiveexercises.Quantitativeandcontentanalyseswereperformed.
Challenges: Variouschallegesweredescribedbypractitionersincludingpatientpressuretoprescribeantibiotics,lackofsuccint,user-friendlytools(e.g.,guidelines,patienteducationalmaterials),andenvironmental(e.g.,walk-inclinics).
Lessons Learned: Anumberofbroadthemesemergedfromthedata.Post-program,participantsfelttheywereprescribingfewerantibioticsandthattheyhadshiftedawayfromuseofsecondlineantibiotics.Thischangeinantibioticusewasconfirmedinapublishedquantitativestudies.Changesinpatienteducationtechniquesandincreasedconfidencewithrespecttodialoguearoundantibioticresistancewasreported.Properlydesignedguidelinesforoptimalknowledgetranslationwereessentialandtoolstoassist(e.g.,viralprescribingpad)withthepatient-physicianencounterprovedtobevaluable.
DEPRESCRIBING - PAGE 15
Implementation of a Family Medicine Guide for Pain ManagementLaurieDunn,PartnersforAppropriateCommunityTherapy(PAACT)AlexandraBarany,MUMSHealthJohnPilla,PartnersforAppropriateCommunityTherapy(PAACT)
BackgroundChronicandacutepainisacommonpresentationintheprimarycaresetting.OneoutcomeofaCanadianexpertreviewpanelonopioids,convenedbyISMPCanada,wasthatdevelopmentofaknowledgetranslationversionofpreviouslypublishedCanadianandinternationalpainmanagementguidelineswouldbeuseful.AModified-Delphiprocess,includingapeer-reviewedcomponent,wasusedtoproduceanevidence-basedresourceforfront-lineclinicians.
GoalsToimplementthePainManagementGuideforFamilyPractice.
Development/ImplementationThedocumentwasinitiallyimplementedusingamulti-faceteddistributionandeducationalapproachwhichincludedprovisionatnationalmedicalconferences;aCFPCaccredited,case-basedCPDprogramandaccessibilitythroughawebsite.
ChallengesItisachallengetoimplementaknowledgetranslationdocumentforfamilypractitionersunlessithasundergonearobust,peer-reviewedprocessandismadeaccessibleviamultipleplatforms.
Lessons LearnedAnydocumentthataimstosetoutclinicalpracticeobjectivesshouldbefieldtestedextensivelywithfront-lineclinicians.Amulti-prongedapproachisthemostsuccessfulinimplementingtheguidelines,themosteffectivebeingaccesstoaprintversionofthedocumentandsmall-group,case-based,accreditedlearning.Itisalsoessentialthattheguidewillbecontinuallyrevisedbasedonuserfeedbackandtheemergingevidence.
QUALITY IMPROVEMENT - PAGE 16
QUALITY IMPROVEMENT
QUALITY IMPROVEMENT - PAGE 17
Positively Changing Red Blood Cell Transfusion Practice Using Educational StrategiesSusanWittandKenWouAlbertaHealthServices
BackgroundRedbloodcells(RBCs)arealimitedresourceandtransfusionposespotentialpatientharms.ChangesinRBCtransfusionbestpracticepromoteaconservativeapproachinstablenon-bleedingpatients.Anecdotalevidencesuggestedtheserecommendationshadnotbeenincorporatedintolocalphysicianpractices.Wesoughttoimproveclinicians’understandingofthesenewguidelinesanddemonstrateameasurablereductioninunnecessaryandtotalRBCtransfusionrates.
MethodsInpartnershipwithlab/transfusionphysiciansandChoosingWiselyCanada’s“WhyGiveTwoWhenOneWillDo?”campaign,wecollectedmonthlydatafromApril2015toOctober2017.PercentageofRBCtransfusionswhenhemoglobinMultifacetededucationalinterventionstargetedphysicians,nursesandlabstaff.Theseincluded:multi-siteTelehealthworkshop;succinctposterhighlightingnewguidelines(prominentlydisplayedinkeylocations);repeateddataandinformationfeedbackusingexistingcommunicationstreams(newsletters,bulletins,meetings).
ResultsAftertheinterventions,thefollowingimprovementswerenoted:104%increaseofpercentagesingleunitRBCtransfusionorders,41%increaseinRBCtransfusionswhenpre-transfusionhemoglobin
ConclusionsWerealizedsignificantimprovementinphysicianRBCtransfusionpracticesutilizingsimplelowcosttechniquesandsurrogatemeasuresfortransfusionappropriateness.
QUALITY IMPROVEMENT - PAGE 18QUALITY IMPROVEMENT - PAGE 18
Choosing Wisely in the Emergency Department to Reduce Unnecessary Tests SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversityManalElnenaei,DalhousieUniversityBassamNassar,DalhousieUniversityAmyLou,NovaScotiaHealthAuthority,DalhousieUniversityBryanCrocker,NovaScotiaHealthAuthorityNancyConnor,NovaScotiaHealthAuthority
BackgroundInaresponsetoEDover-crowding,guidelinescommonlyexisttoguidebloodtestorderingusing‘ordersets’forpatientswaitingforcare.Inmanycases,thisincreasestheuseoftestswithoutbenefittingpatients.Wedescribeaqualityimprovementprojectdesignedtoreducethenumberoflaboratorytestsconsidered‘routine’forwaitingpatients.
MethodsAmultidisciplinarygroupreviewedexistingsymptom-promptednursingbloodtestguidelinesforserumelectrolytesandglucose,renalfunctiontests,livertests,lipase,toxicologicaltestsandbetaHumanChorionicgonadotrophinlevels.Ordersetswererevisedwithtestseliminatedfromthe‘routine’panelsthatwerenotfeltto‘routinely’contributetopatientcare.Thenewguidelineswerecommunicatedtonursingstaffinaseriesofeducationalsessions,andtherevisedguidelineswerepostedatnursingstations.Physicianorderingpracticewasnotaddressed.Apre-postevaluationcomparedtheperiod1December2014,-30November2015with1December2015-30November2016.Clinicaloutcomesandpatientwaittimeswerenotevaluated.
ResultsTheuseoftestsinthesecategoriesdecreased32%betweenthetwoperiods,atanetsavingof$210,246.Thelargestsavingscamefromtotalprotein(73%decrease),Creatinekinase(68%),chloride(64%),glucose(49%),andalbumin(47%).Sodium/Potassiumtestingdecreasedbyonly13%.TheonlyincreaseintestorderingrecordedwasAST(3%increase).
ConclusionSimplychangingordersetsresultedinsignificantsavingstothesystem.Furtherstudyisneededtoassesstheeffectofthesechangesonpatientflowandonclinicaloutcome.
QUALITY IMPROVEMENT - PAGE 19QUALITY IMPROVEMENT - PAGE 19
Better Together: Working Across Primary Care Organizations to Implement Choosing Wisely KarunaGupta,HealthforAllFamilyHealthTeamBettyHum,SouthEastTorontoFamilyHealthTeamTracyLindsay,NorthYorkGeneralHospital
GoalAspartoftheAdoptingResearchtoImproveCare(ARTIC)-ChoosingWiselyproject,sixFamilyHealthTeams(FHTs)workedcollaborativelytoimplementfourcommonChoosingWiselyrecommendations:reducingunnecessarythyroidfunctiontesting,andde-prescribingProtonPumpInhibitors,Glyburide,andSedativeHypnotics.
ImplementationOvertwoyears,theFHTschosetwocommonrecommendationstoaddresseachyear.LeadPhysiciansfromeachFHTbrainstormedinterventionstotestandimplement,sharinglearningsandtoolsfromtheirrespectiveorganizationsthroughouttheprocess.
MeasuresTheFHTsmeasuredasetofcommonindicators,includingthebaselinenumberofpatientstargetedforeachrecommendation,thenumberofpatientssuccessfullyde-prescribedorthenumberoftestsreduced,andthenumberofphysiciansinvolvedinimplementingchange.Positivereductionsintestorderingandde-prescribingwereobservedacrossallfourselectedrecommendations.
ChallengesFHTsexperiencedchallengestovaryingdegreesdependingontheircontextandtherecommendationbeingimplemented.Challengesincludedstaffturnover,competingprioritieswithinFHTsanddatarelatedissues.TheFHTssharedideasandresourcestotacklethesechallenges,includingconductingsharedstafftraining,andfocusingtheirQualityImprovementPlans(QIPs)onChoosingWiselywork.
Lessons LearnedTheFHTsdidthingscollectivelythatwouldnothaveoccurredhadtheyworkedalone.Sharedcoordinationofworkandsharedtimelines/deadlineshelpedkeepChoosingWiselyworkmovingforward.Inhindsight,theFHTswouldhavebroadenedsharingandlearningopportunitiestootherteammembers,changedthetimingofonerecommendationtoenablegreaterplanningandimplementationtimeandadjustedthereportusedtoimplementanotherrecommendation.
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Reducing Benzodiazepines & Sedative-Hypnotics Among Hospitalized Patients: Lessons Learned from a Multi-Site Implementation JourneyChristineSoong,SinaiHealthSystemCherylEthier,SinaiHealthSystemDeborahBrown,SunnybrookHealthSciencesCentreLisaBurry,SinaiHealthSystemJesikaContreras,RegionalGeriatricProgramofTorontoYunaLee,StMichael’sHospitalKarenNg,SinaiHealthSystemZahraSyavashVahabi,SinaiHealthSystemPeterWu,St.Michael’sHospitalBarbaraLiu,SunnybrookHealthSciencesCentre,UniversityofToronto
BackgroundInappropriateuseofbenzodiazepinesandsedative-hypnotics(BSH)forsleepisprevalent.WedescribetheimplementationandLessonsLearnedfromamulti-siteChoosingWiselyproject.
Goal ToreducetheproportionofnewprescriptionsofBSHmedicationsusedforsleepinselecthospitalizedpatientsby20%acrossfivehospitalsinoneyear.
Methods ImplementtheSedativeReductionBundlethroughiterativePDSAcyclesStep-wedgeevaluationdesign
InterventionSedativeReductionBundle:Sleephygieneandpromotion,patientandcaregivereducation,ordersetamendments,pharmacyreviewsofneworders,auditfeedbacktofrontlinestaffandincorporatingsleepandsedativeconversationsintodailynursinghuddles.
Metrics Outcomemeasure:ProportionofBSH-naïvepatientsprescribedanynewBSHinhospitalfortheprimaryindicationofsleep.PROM:PatientreportedsleepqualityBalancingmeasure:aggregateprescribingpatternsofothersedatives.
Lessons LearnedSuccessenablers:alignmentwithorganizationalstrategytoreducehigh-riskmedicationuseandfalls,empoweringnurses
Challenges1. Synchronizingimplementationacross5sites:amendmentofelectronicordersetswaschallenging.
achievingconsensustochangelong-standingprocess,complexapprovalsandclinicianresistance.2. Context:Variabilityinleadershipandcultureacrosshospitalsshapedtheeffectivenessofthe
implementation.AmbiguousrolesandprocesseswereclarifiedthroughknowledgegainedfromPDSAcycles.
3. Staffchanges:personnelchangeswhenateammemberlefttheproject,constantreminderstonewtrainees
4. Sustainability:labour-intensiveaudit-feedbackdatacollection5. “ResearchvsQI”:frontlinestaffattimesviewedtheworkas“research”ratherthanqualityimprovement.
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ARTIC Choosing Wisely: An Idea Worth Spreading Across Five Ontario Hospitals and Affiliated Family Health TeamsDeepakSharmaandDonnaMcRitchieNorthYorkGeneralHospital
GoalThisprojectaimedtoreduceunnecessarytesting,treatmentandproceduresin5hospitalsand6FamilyHealthTeams(FHT)servingtheGreaterTorontoArea,Markham,andNewmarket.CollectivelyreferredtoastheJointCentresforTransformativeHealthcaretheselike-mindedorganizationsstrivetodevelop,evaluateandimplementinnovativeimprovementsinhealthcaredelivery.
ImplementationImplementationfocusedoncreatingawarenessbyformalizingclinicianinvolvement,sparkinginspirationbysharingstoriesandinvolvingpatients,buildingasustainableinfrastructurethroughlocalleadership,andcontinuingspreadbysharingandpublishinglearnings.
MeasuresPurposeorientedmeasuresweredevelopedtomeettheneedsoflocalimprovementteams(e.g.,labtestsreducedandpatientsde-prescribedcomparedtobaseline),externalprojectreporting(i.e.,patientslesslikelytohaveanunnecessarytestandprovidersawareofChoosingWisely),andfuturefocusedsustainability(e.g.,throughaSustainabilitySub-Studyconductedwithinthisproject).
ChallengesChallengesexperiencedvarieddependingonthesite,thesector,andtherecommendationimplemented.CommonchallengesexperiencedacrosssitesincludedtimeandcapacitytodoChoosingWiselywork,competingwithotherorganizationalpriorities,humanresourcesavailabilityandexpertiseanddataavailability/qualitychallenges.
Lessons Learned1. Contextmatters.HospitalsandFHTsapproachedChoosingWiselyrecommendationimplementation
differentlytoreflecttheirorganizationalneedsandareasoffocus:FHTsconcurrentlyimplementedcommonrecommendations;hospitalseachimplementeddifferentrecommendations,withonlysomeoverlappingacrosssites.
2. Dataisimportantbutshouldservetheultimategoalofculturechange.BecauseChoosingWiselyworkoftenrequiresnon-traditionaldatasets,dataworkcanconsumetimeandattention.
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Reducing Unnecessary BUN Testing at North York General HospitalManuelGiraldo,NorthYorkGeneralHospital
GoalToreduceunnecessarytestingofBloodUreaNitrogen(BUN)byatleast50%atNorthYorkGeneralHospital(NYGH).
ImplementationAmongthepillarsofCWCisimprovingtheappropriatenessofLaboratorytesting.In2016,weproposedrevisionstoourordersetscontainingBUNinordertoimprovetheappropriateutilizationofthistest.ThiswasbasedontheknowledgethatCreatinineisabettermeasureofrenalfunctioneventhoughmosthealthcareprovidersstillusebothmarkerstoevaluaterenalfunction.FundsfromtheAdoptingResearchtoImproveCare(ARTIC)projectfacilitateditsadoptionandimplementation.
MeasuresAbaselinereportconductedinsummer2016showedthatBUNwasorderedonaverage6,000permonthandCreatinine5,400.AfterMACapproval,amulti-specialtyNYGHphysiciangroupwithlaboratoryrepresentationwasorganizedtoreviewourOrderEntryalgorithms.ItwasagreedtoremoveBUNfrom90%oftheOrderSets,100%ofCareSetsandfromfouroftheeightEmergencyDepartment’sMedicalDirectives.Thesechangeshavenotaffectedpatientcareandhavenotchangedthetriageprocessorlengthofstay.OverallBUNtestingdecreasedhospital-wideby50%.
ChallengesAlthoughsomephysiciangroupsrequestedre-institutionofBUNandthenumbersofAdd-onsincreasedslightly,wehavesustainedthereductionsmade.
Lessons LearnedEngagingphysicians,otherleadersandkeystakeholderswascriticaltothesuccessofthisinitiative.Westronglyrecommendaphysicianchampiontoleadtheconversationswithotherclinicians.Usingelectronictoolsfororderentry(i.e.CPOE)facilitatesthereviewandimplementationofthisintervention.
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An Idea Worth Sustaining: Evaluating the Sustainability Potential of the Choosing Wisely Initiative Across Five Ontario Community Hospitals & Affiliated Family Health TeamsMonikaKastner,JulieMakarski,KateMossman,KeganHarrisandDeepakSharmaNorthYorkGeneralHospital
BackgroundEvaluatingthesustainabilitypotentialofinnovationsiscriticaltomaximizingtheirpotentialforimpact.WeevaluatedthesustainabilitypotentialofCWatfiveOntariocommunityhospitalsandaffiliatedfamilyhealthteams(FHTs)aspartofaCWspreadproject.
MethodsWeconductedamixed-methodsstudy:1)avalidatedsustainabilitysurveywithCWimplementationteamsatT0(baseline),T1(6months),andT2(12months)toidentifysustainabilitydeterminants;2)focusgroupswithteamsfollowingsurveycompletionatT0(todiscussidentifiedchallengesfromthesurvey,andtoco-createanactionplantoaddressthem)andatT1(todiscussactionplanimplementation,andanynewchallenges).Sessionswereaudio-recordedandtranscriptswereanalyzedusingcontentanalysis.
Results78participantsrepresenting15teams(5hospitals;6FHTs)completedsurveysandparticipatedin30focusgroups.ThreeCWde-adoptionpriorityareaswereinvestigated:protonpumpinhibitor(PPI)de-prescribing;reducingpre-optesting,BUN/Urealabtests.Themeanteamsustainabilityscoresranged61-73%(PPI),87-89%(BUN/Urea),and82-92%(Pre-Op),whichwereabovethethresholdofwhatisconsideredasustainableinnovation(55%).Topsustainabilityfacilitatorswereclinicalleadershipengagementandfitwithorganization’sstrategicaims/culture;topchallengeswereadaptabilityofimprovedprocessesandinfrastructureforsustainability.Allteamsidentifiedatleastonechallengeforwhichtheyco-designedandimplementedanactionplan.
ConclusionsOurworkcontributestoadvancingsustainabilitymethodsandhighlightsthatimplementationteamscanbeempoweredtoinfluencetheirimplementationefforts,andtorealizepositiveoutcomesfortheirservicesandpatients.
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Gaining Momentum Through the Use of Choosing Wisely Canada: Ontario Transfusion Quality Improvement Plan (OTQIP)DeniseEvanovitch,OntarioRegionalBloodCoordinatingNetworkYuliaLin,SunnybrookHealthSciencesCentreAllisonCollins,OntarioRegionalBloodCoordinatingNetworkSheenaScheuermann,OntarioRegionalBloodCoordinatingNetwork
BackgroundTheOntarioRegionalBloodCoordinatingNetwork(ORBCoN)inconjunctionwiththeOntarioTransfusionQualityImprovementPlan(OTQIP)CommitteedevelopedaqualityimprovementtoolkitthatwaslaunchedinApril2016.Theplan’sgoalistoreducepatientharmbyimprovingtransfusionpracticeinhospitals.
Design/MethodologyTheOTQIPCommitteehasbroadrepresentationfromthetransfusioncommunityinallregionsofOntario.TheCommitteealsocollaboratedwithHealthQualityOntario(HQO),ChoosingWiselyCanada,theLocalHealthIntegrationNetworks(LHIN),CanadianSocietyforTransfusionMedicineandtheHealthcareInsuranceReciprocalofCanada.SeveralhospitalsurveysrevealedastronginterestanddesiretoimplementallorportionsoftheOTQIP.
ResultsThetoolkitcontains:• AnarrativetemplatebasedonHQO’smodel• Clinicalpracticerecommendations• Transfusionordersettemplate• ChoosingWiselyCanadascreensaver• SOP,algorithm,andtrainingaidfortechnologistprospectivebloodorderscreening
Post-launch,othertoolswereaddedtofurtherassisthospitalsinadvancingtheirQIPs:atechnologistprospectivescreeningeducationalmoduleandanelectronictrackingtool.Bothhospitalandprovincialreportscanbegeneratedfromthetrackingtool.Twelvehospitalsareusingthetoolandhaveconducted72audits.
ConclusionHelpinghospitalsthroughthedevelopmentofstandardizedtemplates,instructions,educationandothertoolsfortransfusionqualityimprovementincreasestheabilityofhospitalstouptakequalityimprovementinitiatives.Takingastandardizedapproachacrosstheprovinceallowsforbothaggregateandhospitaldatacomparisonanalyses.
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Double Edged Sword: Order Set Modification to Reduce Two Unit Red Cell Transfusions on an Oncology WardAlanGob,AnuragBhallaandIanChin-YeeWesternUniversity
IntroductionChoosingWiselyCanadawasintroducedin2014tohelpguideconscioushealthcarepracticestoreduceunnecessarytests,proceduresandtreatments.Aspartofthecampaign,CanadianSocietyforTransfusionMedicinerecommendsoneovertwopackedredbloodcellunit(pRBCs)transfusions.
ObjectiveAimofthestudywastodevisestrategiestolimitunnecessary2pRBCstransfusions.
MethodsWeconductedreal-timeandretrospectiveaudits,andsurveyoffrontlinestaffononcologyinpatientwardatLondonHealthSciencesCentretoidentifyfactorsassociatedwith2pRBCstransfusions.Basedonthesurveys,weimplementedtwomaintargetedinterventionsincludingeducatinghealthcareprovidersthroughpostersandbulletins,andremovalofautomatic2pRBCscomputerizedtransfusionsorders.WemonitorednumberofpRBCsorderedonamonthlybasisfromOctober2015toNovember2016.
ResultsAfterimplementationofproposedstrategiesinApril2016,therewasa50%reductioninproportionof2pRBCsorderedinMay2015.Inaddition,thereductionin2pRBCsorderedwassustainedforremainedofthemonitoringperiod.Thenumberof2pRBCstransfusiondecreasedby89%from71unitspermonth(51.1%oftotaltransfusionsordered)inOctober2015to6unitspermonth(5.6%oftotaltransfusionsordered)inNovember2016.
ConclusionThereductioninproportionof2pRBCsorderedwassecondarytotheproposedintervention,andwassustainedoveraperiodofsixmonths.Theseinitiativeshighlightanovelwayoflimitingoverutilizationattheleveloffrontlineprovidersandhealthcaresystem.
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An Innovative Digital Strategy for Dissemination of Choosing Wisely Canada Guidelines In Transfusion MedicineClintonCampbell,QEIIHealthSciencesCentre
ChoosingWiselyCanada(CWC)hashighrelevancetothetransfusionofhumanbloodproducts,whichcarriessignificantrisksandisbasedonahighlylimitedsupply.OneconcernraisedaboutCWCisthatitmayrequiremoreeffectivedisseminationstrategiestoimplementsystemicpracticechange.Manyhealthcareprofessionalsnowusevideo-basedplatformssuchasYouTubeforcontinuedprofessionaleducation.Specifically,YouTubeallowsvideoproducerstolearnfromviewers’watchinghabitsthroughdatametrics,leadingtoimprovedvideoefficacy.WesummarizedCWCbloodtransfusionguidelinesasaseriesofshort,entertainingandinformativeanimatedvideosonYouTube,withtheaimthatthiswillenhanceguidelinedisseminationtowardthesafestandmostresponsibletransfusionpractice.
ImplementationWeproducedfivedigitallyanimatedvideosencompassingkeyCWCtransfusionmedicineguidelines.VideoswereproducedbetweenMayandDecember2017,anduploadedontoYouTubeinJanuary2018.
MeasuresYouTubedatametricsincludingviewmetrics,watchtimemetrics,engagementmetrics,playlistmetricsandaudienceretentionmetricsarebeingcollected.Datametricswillbemeasuredafter6months.
ChallengesChallengesincludedtranslatingcomplexmedicalknowledgeintoasimplifiedformatacrossdisciplines(transfusionmedicinetodigitalanimation).ThemostsignificantongoingchallengeisknowledgetranslationtoaugmentphysicianawarenessofthevideosonYouTube.
Lessons LearnedTranslationofCWCtransfusionmedicineguidelinesintoavideoformatwasahighlychallengingyetrewardingprocess.Initialfeedbackhasbeenhighlypositive;however,theefficacyofdisseminationwillbeevaluatedafterseveralmonthsofYouTubewatchdatametricsarecollated.
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De-Implementing Wisely: Planning your Implementation Strategy JeremyGrimshaw,OttawaHospitalResearchInstituteAndreaPatey,OttawaHospitalResearchInstituteStefanieLinklater,OttawaHospitalResearchInstituteFrançoiseKo,ChoosingWiselyCanadaSachaBhatia,ChoosingWiselyCanadaWendyLevinson,ChoosingWiselyCanada
BackgroundLowvaluecareiscommoninhealthcaresystemsinCanadaandgloballyresultingindirectharmtopatientsandthreateninghealthcaresystemsustainability.Thereisconsiderableuncertaintyabouthowbesttoreducelow-valuecare,suggestingtheurgentneedforimplementationresearchinthisarea.ToaddressthisissueCWChasestablishedtheCWCImplementationResearchNetwork(CWC-IRN)involving12provincialandterritorialCWcampaignstoestablishaCanadianlearninghealthcaresystemonde-implementation.ThisNetworkbringstogetherCWC,CWprovincialcampaigns,patientandhealthsystempartnersandinternationallyleadingimplementationresearchers.
AimTheoverallgoaloftheCWC-IRNistodevelopthescientificbasistosupportimplementationofCWCrecommendationsinCanadianhealthcaresettings.WewillbuildcapacityininnovativeCRTsandimplementationresearchwithpatientpartners,early-andmid-careerscientistsandtrainees.Patientpartnerswillbegiventheopportunitytoparticipateinawiderangeofresearchtrainingandpatientengagementactivities.IndividualswithintheCWC-IRNwillreceivetailoredadvancedtrainingactivitiesandengagewiththescientistsontheteam(e.g.,webinarsandtrainingonimplementationscience,patientengagementstrategies).WewillengageinawiderangeofdisseminationactivitiestargetingCWC-IRN,provincialhealthcaresystemsandinternationalCWgroups.
ConclusionImplementationscienceaimstounderstandtheunderlyingreasonsforhealthcareprocessesandtodevelopandtestpotentialsolutionstoimprovethem.TheCWC-IRNlinksCWC,provincialandterritorialpatientandhealthsystempartnerswithleadingCanadianimplementationscientiststodevelopandtestsolutionsforde-implementationoflow-valuecare.
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Reducing the Rate of Postoperative Urinary Tract Infection Amongst Orthopaedic Patients in a Community Teaching HospitalHannahBrooks,DavidSmith,LindaJussaume,KomalPatel,PaulinaFerreira,HosseinMehdian,ShawnGarbedian,SanjhoSrikandarajah,LindsayTaam,MaryKapetanos,NicoleGolda,JenniferPage,ValeriaThompson,DavidHajek,JanetMoffat,MichellRichardsonandMariaSalangaNorthYorkGeneralHospital
BackgroundPostoperativeurinarytractinfections(UTI)areacommonlyavoidablecomplication,withassociatednegativepatientandadministrativeimplications.During2016,NorthYorkGeneralHospital(NYGH)inTorontoCanadaidentifiedUTIasaqualityimprovementopportunitywithinthesurgicalorthopedicpatientpopulation.Atbaseline,NYGHidentifiedanoddsratioof1.50,placingitin9thdecilein2016asreportedbytheHealthQualityOntario-NationalSurgicalQualityImprovementProgram(NSQIP).
ObjectiveToreduceUTIinsurgicalorthopedicpatientstoanoddsratio
MethodsAninter-professionalteamdevelopedandimplementeda“bladderbundle”changeprotocolreflectiveofbestevidenced-basedpractices,ChoosingWiselyCanadarecommendationsandlocalstakeholderinput.Theprimaryfocusofthebundleincluded1)Proceduralinsertioncriteria2)Earlyremovalofcatheter3)Thedevelopmentofaurinaryretentionalgorithmand4)multi-professionaleducationonappropriatesteriletechniqueandcathetercare.TheprimarymetricwasidentifiedastheUTIrateasdefinedbyNSQIP.ThesecondarymetricwasthetotalcatheterizationrateamongstNSQIPabstractedpatientsandthebalancingmetricwasretentionrates.
ResultsFromMay2017-October2017,thesurgicalorthopedicpopulationhadanUTIoddsratioof0.91.Inconclusion,theorthopedicbladderbundlehasshownearlyindicationsofbeingeffectiveinreducingurinarytractinfectionsinsurgicalorthopedicpatients.
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Lose the Tube at Humber River HospitalNarendraSingh,EktaKhemani,RosemaryMulock,SarahBranton,ChristinaMoldovan,MichaelGardam,BarbCollins,VanessaBurkoski,JenniferYoon,TrevorHall,NicoletteCaccia,LauraCopeland,KenLee,AndreaLo,RajiniSinghal,JohnHagen,SonuGaind,QuocHuynh,AtoosaRezvanpour,TinaKerelska,AlbertKaras,PaulineGiancroce,MaryOseiandAmritaTyagiHumberRiverHospital
BackgroundHumberRiverHospital(HRH),NorthAmerica’sfirstfullydigitalhospital,recognizestheimportanceofreducingunnecessarytreatmentsaspartoftheChoosingWiselyCanada(CWC)campaign.Aspartofthisinitiative,HRHembarkedonahospital-widestrategytoreduceunnecessaryurinarycatheterizationusingtheCWC“LosetheTube”toolkit.Bymonitoringurinarycatheterizationusingelectronicordersoneighttargetedinpatientunits,weestablishedatbaselineaveragecatherizationrateof22%atourinstitution.Assuch,HRHembarkedonamulti-disciplinaryqualityimprovement(QI)projecttoreduceunnecessaryurinarycatheterinsertion.
MethodsUsingthemodelforimprovement,anumberofinterventionsweretakentoreducetherateofunnecessaryurinarycatheterizationatHRHincluding:1)establishingaCWCsteeringcommitteewithrepresentativesfrommedicalandsurgicalspecialties,2)modifyingdigitalordersetstoincludereassessmentofcatheterneedforhospitalizedpatients,3)implementingmulti-disciplinaryeducationalactivitiessuchasaCWCnewsletterandmulti-disciplinarygrandrounds,and4)introducingstandardizedequipmentforFoleycatheterizationwithteachingonpropercatheterinsertionandindicationsdiscussedwithnursingstaff.
ResultsFromAugust2016toOctober2017,HRHwasabletoreducetheurinarycatheterizationglobalaveragerateto10%ontargetedinpatientunits.
ConclusionsTherateofurinarycatheterizationatHRHhassignificantlyreducedinjustoverayearthroughmultipleQIstrategiesaimedateducation,promotion,standardizedequipment,andforcedfunctionsthroughtheuseofcomputerizeddecisionsupport.FuturerecommendationsincludeexploringthecostofqualitytodemonstrateannualsavingsasaresultofCWCimplementation.
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Collab with the Lab: Implementing Choosing Wisely with LaboratoryKun-YoungSohn,TrilliumHealthPartners
BackgroundEvenaftertheintroductionofTroponinasthemostspecificmarkerofmyocardialinjury,CreatinineKinase(CK)hadstillbeenincludedinlaboratorytestprofilesandclinicalordersets.InadditiontoorderingCKandTroponintogetherintentionally,bundledCK-Troponinalsohindersorderingtheappropriatetest.Testutilizationauditwasperformedtoestimatetheimpactofeducationalmemoandinterventionatthetestprofileandorderset.
MethodFortheimprovementofutilization,thetwohospitalsites(A&B)ofTrilliumHealthPartnersapproachedintwostages:1)sendingoutofaneducationalmemo;2)removalofCKfromtestprofilesandordersets.Toassesstheirimpacts,CKandTroponinresultsweredownloadedfromtheLISfortheyears2011-2017.TheCK/TroponinIndex,numberofCKtestsper100Troponintests,wasusedastheutilizationindicator.
ResultTheCK/Troponinindexbeforesendingoutofamemowas103atsiteAand93atsiteB.Evenaftersendingoutthememo,theindexremainedsameat105atthesiteA,whiledecreasedto55atthesiteB.AfterremovalofCKfromthetestprofilesandordersets,theindexdroppedsignificantlyto6atthesiteAand12atthesiteB.
ConclusionTheresultsimpliedthattheeducationalmemohelpedphysiciansinchoosinglaboratorytestwiselyandtheconcertedeffortsattheoperationallevel,suchaslaboratorytestprofilesandclinicalordersets,producedagreaterimpact.
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Comparing Physician and Nurse Ordering in Emergency Departments: A Qualitative StudyLeanneDelaney,DalhousieUniversityAllysonGallant,DalhousieUniversityJanetCurran,DalhousieUniversitySamCampbell,NovaScotiaHealthAuthority,DalhousieUniversity
BackgroundAlthoughLTorderinginEDsisavaluablediagnostictool,italsohasimplicationssuchasincreasedsystemcostsandpatientlengthofstay.WeaimedtoidentifyandcomparepatternsandperceptionsassociatedwithLTorderingbyemergencyphysicians(EP)andemergencynurses(ERN)attwoEDs.
MethodsUsingtheTheoreticalDomainsFrameworktodevelopaquestionnaireaimedtosortcontentinto14broaddomains,weconductedinterviewswith25EpsandERNstoexploreinfluencesindecisionstoorderLTs.Qualitativedatawasanalyzedbytwoindividualsusingaconsensusmethodologytohighlightkeythemesthatwereassociatedwithdifficultorinconsistentclinicaldecisionmaking.
ResultsWhileEPsandERNsagreedthatLTorderingcouldimprovepatientflow,theydifferedinperceptionsaboutflowdisruption,busyEDs,andpatientanxietyasmotivatingfactorsfororderingLTs.Additionally,ERNsreportedtobemostinfluencedbythestaffEPs,whileEPsreportedmostinfluencebyconsultingservices.Finally,moreEPsorderedLTsbasedontestresultinterpretation,whileERNsweremorelikelytoorderbasedonpatientsymptoms.
ConclusionERNsandEPsdifferinfactorsinfluencingLTordering,especiallyinthebroaddomainsofbeliefsaboutconsequences,environmentalcontextandresources,socialinfluence,emotions,andknowledge.FurtherresearchwilldeterminehowthisinformationcanbeusedtosupportdecisionmakingaroundLTuse.
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A Pharmacist Led Strategy to Reduce Unnecessary Lab Tests for New Admissions into Long Term Care ParnianGhafari,MedicalPharmacies
Growingevidenceshowsinappropriatelaboratorytestingisacontributortowasteinhealthcareandit’sacommonproblem.Longtermcaresettingisnotimmunetosuchwastefulpractice.Inalongtermcaresetting,routinelaboratorytestingonnewadmissionshasbecomethenorm.Infact,therearefacilitiesthathaveablanketmedicaldirectiveforroutinenewadmissionbloodwork.
TheBetterCoordinatedCrossSectoralMedicationReconciliation(BOOMR)project,whichisaqualityimprovementinitiativethatinvolvesaclinicalpharmacistremotelyleadinganovelinterdisciplinarymedicationreconciliation(MedRec)processhascreatedanewopportunitytointerveneandinterceptunnecessarylaboratorytestorders.Priortotheadmission,thepharmacistretrievesrecentpertinentbloodworkfromtheOntariolaboratoriesinformationsystem(OLIS)andotherorganizationsthatmaynotbecontributingdataintoOLIS.ThisinformationalongwithotherclinicalconcernsaresharedwiththepractitionersatthetimeofMedRectoguideclinicaldecisionmakinginatimelymannerandminimizere-orderingofunnecessarybloodwork.
Thisuniqueinformationsharingatthetimeofadmissionhaschallengedthestatusquooforderingroutinebloodtestsfornewadmissionsinlongtermcarewithpotentialtoimproveclinicaloutcomesandreducecosts.
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Evaluating Healthcare Providers’ Understanding of CBT-I in an Interdisciplinary Family Health TeamNicolaYang,MarkhamStouffvilleHospital
BackgroundInsomniaisthemostcommonlydiagnosedsleepdisorderandonethatcanhavesignificantpersonalandeconomicconsequences.Moreover,itisbothasymptomandindependentriskfactorformultiplephysicalandmentalhealthconditions.CognitiveBehaviouralTherapyforInsomnia(CBT-I)isaneffectivetreatmentforchronicinsomnia,andduetoitslow-riskprofile,isrecommendedasthefirst-linetreatmentofchoice.HealthforAll(HFA)isacommunity-basedacademicteachingunitandoneofsixfamilyhealthteamsthatimplementedtheChoosingWiselyrecommendationofdeprescribingsedativehypnoticsaspartoftheARTIC-ChoosingWiselyProject.Althoughreferralstothedeprescribeprogramcommencedin2017,aneedsassessmenthadyettobedonetoassessperceivedneedorinterestintheprogram,healthcareproviders’approachtochronicinsomniamanagement,understandingofCBT-Iandperceptionofitseffectiveness.ThisstudywillprovidebaselinedatatosupportsuccessfulimplementationoftheCBT-IProgramatHFA.
MethodsAformalneedsassessmentsurveywasdistributedelectronicallytoallhealthcareprovidersatHFA(i.e.staffphysicians,familymedicineresidents,nursepractitioner,andphysicianassistant).Thesurveyevaluatesproviders’demographics,currentapproachtoinsomniamanagement,knowledgeandperceptionofCBT-IandinterestinfurtherCBT-Ieducation.
ResultsResultsarepending(currentresponserate:87%).
ConclusionsThecollectedresponseswillhopefullyimprovethedesignandexecutionoftheCBT-I/hypnoticdeprescribeprogramatHFA.Analysisofdatawillhelpidentifyknowledgegapsininsomniamanagementandguidefurtherdevelopmentofeducationaltoolsandcurriculumonthesubject.
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Engage at Every Stage, Learn at Every Turn: How Saskatchewan is Building Continuous Clinical Quality Improvement Learning Pathways for PhysiciansGaryGroot,UniversityofSaskatchewanTanyaVerrall,HealthQualityCouncil
GoalHowdoyouchangetheconversationaroundimprovingAppropriatenessofCare(AC)?Howdoyouengagephysiciansinleadingculturalchange?Saskatchewanisusingaunified,comprehensiveapproachtophysiciandevelopmentinleadershipandqualityimprovement.
ImplementationWorkingfromacollaboratively-designedACframework,theprovincehasmobilizedtobuildcapacitythroughbothinformalandformallearningopportunities,suchas:• Informallearning–provincialACprogram(withtopicssuchaspre-operativetesting),SaskatchewanMedicalAssociationAppropriatenessofCareInitiative(SACI)physiciancoachingsupport.
• Formallearning–ResidentQualityImprovementProgram,ClinicalQualityImprovementProgram,undergraduatequalityimprovementcourses.
MeasuresInadditiontotheACprogramevaluationmatrix,presentationwillshareearlyresultsfromthepilotCQIPcohort– includingwhyoneparticipantdescribeditas“oneofthebestlearningexperiencesinmyworkinglife”.Theevaluationframeworkincludesresultsfromparticipantexperience,coach/facultyexperience,andprojectprogress.
Challenges• Accessto/supportwithdata.• Findingtimeforbusyclinicianstolearn.• Long-termfinancialinvestmentfromfunders–buildingforthenextdecade,notthenextday.
Lesson Learned• Managingexpectationsregardingpaceofchange,returnoninvestment.• Powerofcollaboration–uniquepartnershipoftheSMAandMinistryofHealth.• Systembuy-inandalignment–startwiththewilling,engagemorestrategically.• Benefitsofinvestinginphysiciansaspeercoaches.• Potentialforspread–severalprojectsshowstrongpotentialforgreaterprovincialimpact.
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Examining the Implementation of Preoperative Diagnostic Testing Guidelines in ManitobaSarahKirby,GeorgeandFayYeeCentreforHealthcareInnovationEricBohm,UniversityofManitobaAshleyStruthers,George&FayYeeCentreforHealthcareInnovationThomasMutter,UniversityofManitoba
GoalInManitobaauditshaveshownthatmanypatientscontinuetoreceiveunnecessarypreoperativetestsdespiteprovincewideguidelines.ThisprojectaimedtoidentifythebarriersandfacilitatorstoeffectiveguidelineadoptionandimplementationinManitobainordertodevelopimplementationstrategiestoreduceinappropriatepreoperativetestinginlowrisksurgeries.
ImplementationImplementationstrategiesincludedphysicianengagement,guidelinerevision,standardizingandremovingcuesfrompreoperativedocuments(i.e.patientcoverletters,preoperativehistoryandphysicalforms)andauditandfeedback.
MeasuresTheprojectisbeingevaluatedusingqualitative,quantitativeandsurveymethods.Datacollectioninvolvedaccessingexistingadministrativeandchartdataandcollectingnewdataintheformofinterviewsandsurveyswithpatients,healthcareprovidersandstakeholders.
ChallengesThequantitativeevaluationisongoing.Preliminaryauditresultsrevealthatoutofasampleof1769surgeries,inappropriatetestswereorderedin722cases(41%).Theseinitialresultsunderscorethechallengeofchangingindividualphysicianbehaviourdespiteextensivestakeholderengagementandmultiplesystemlevelinterventions.Qualitativeandsurveydatademonstratethatmanyofthechallengeslayinuptakeandcommunicationthatwasnotalignedwithguidelines.
Lessons LearnedImplementationmethodsmustbemultifaceted,involveestablishedleadersandengagealldisciplinesinvolvedinpreoperativecare.Preliminaryresultsofsurgicalauditsforauditandfeedbackrevealthatthereislargevariationinthenumberofinappropriatetestsbeingorderedbetweensurgeonsandsurgicalspecialties(22%-72%),indicatinganeedfortargetedfeedback.
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Leveraging Audit & Feedback to Support Practice ChangeDavidZago,HealthQualityOntario
Background ChoosingWiselyCanadahasdevelopedrecommendationstoavoidunnecessarytestsortreatments.HealthQualityOntariohasproducedarangeofcomparativeauditandfeedbackproductsandsupportsalignedwiththeserecommendationstoenableimprovementacrossOntario.
Areas of FocusAvoidroutinepre-operativetestingforasymptomaticpatientsundergoinglow-risksurgery.Avoidinappropriateuseofantipsychoticsinlongtermcare.Manageappropriateuseofopioidsinprimarycare.Reduceurinarytractinfectionperioperatively.
MethodsComparativeutilizationrateindicatorsaredefinedforeachareaoffocus.Usingavailableadministrativedatasources,organizationorpractice-levelratesaregeneratedandtrendedovertimeinaquarterlyorbiennialreporttotheorganizationorclinician.Ifappropriate,abetterperformingrateortargetisincludedforcomparisonpurposes.Actionsorchangeideas(includingCWCToolkits)accompanytheindicatorstopromptorganizationsorcliniciansonapproachestoimprovement.Collaboratives/communitiesofpracticeengageorganizations/clinicianstoshareideasandsuccesswithchangingpracticeleadingtoimprovement.
ResultsFourauditandfeedbackapproachesregularlyprovidecomparativedata,evidence-basedchangeideasandopportunitiestoconnectwithpeerstoinitiatechange.
HospitalPerformanceSeriesReport–127hospitalorganizationsreceivethisreport
MyPracticeLong-TermCarereport-over300primarycarephysiciansworkinginlong-termcaresubscribetothisreport
MyPracticePrimaryCarereport-over2200primarycarephysicianssubscribetothisreport
OntarioSurgicalQualityImprovementNetwork-31hospitalsparticipate
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The Checklist for Head Injury Management Evaluation Study (CHIMES): A QI Initiative in the Emergency DepartmentSameerMasood,UniversityHealthNetworkLucasChartier,UniversityHealthNetworkJooYoon,UniversityofToronto
BackgroundOver90%ofpatientswithheadinjuries(HIs)seenatemergencydepartments(EDs)areminorHIs.Over-utilizationofcomputedtomography(CT)scansresultsinunnecessaryexposuretoradiationandincreaseshealth-careutilization.UsingrecommendationsfromtheChoosingWiselyCampaign(CWC)andqualityimprovement(QI)methodology,ouraimwastoreducetheCT-scanrateforpatientspresentingwithHIsby10%overa6-monthperiodattwoacademicEDs.
MethodsBaselineCT-scanratesweredeterminedthrougha10-monthretrospectivecohortreview.OurPDSAcyclesincluded:1)ImprovingproviderknowledgeabouttheCWCrecommendations;2)Testing,refiningandimplementingamodifiedCanadianCTHeadRulechecklist;3)DevelopingandgivingpatientsCWC-themedHIhandouts;4)BimonthlyreportingofCT-scanratestoproviders.OurprimaryoutcomemeasurewasthenumberofCT-scansperformedforpatientswithHIs.ProcessmeasuresincludedthenumberofchecklistscompletedandEDlength-of-stay(LOS).OurbalancemeasurewasreturnEDvisitswithin72hours.
ResultsWeobserveda16%relativedecreaseinCT-scansat3months(47.9%to40.5%,P=0.005)and10.4%at8months(47.9%to43.1%,P=0.02.Overallbefore-and-aftermediantimeswerenotsignificantlydifferent(237minto225min,P=0.18).33%oftotalchecklistswerecompleted.72-hrreturnvisitsdidnotchangeduringthe8-monthstudyperiod(4.0%to4.16%,P=0.85).
ConclusionsOurlocalQIinitiativewassuccessfulindecreasingCTratesforpatientspresentingwithaHI.Thedecreaseineffectat8monthssuggeststheneedforcontinuedfeedbackandreminderstoensurelong-termsustainability.
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Implementing Choosing Wisely Recommendations Across 5 Alberta Emergency Departments Through Electronic Decision SupportDanielGrigat,JamesAndruchow,AndrewMcRae,GrantInnesandEddyLangAlbertaHealthServices
GoalToimplementChoosingWiselyCanadarecommendationsforappropriateCTuseforpatientswithmildtraumaticbraininjury(MTBI)andsuspectedpulmonaryembolism(PE).
ImplementationEmergencyphysicians(EPs)at5Calgarysiteswererandomizedtoreceiveelectronicclinicaldecisionsupport(CDS)forCTimagingofpatientswithMTBIorsuspectedPE.CDSwaslaunchedinanexternalwindowwheneveraCTwasorderedfromcomputerizedorderentry.Physicianinteractionwasvoluntary.
MeasuresDuringthefirst8monthsoftheintervention102EPsrandomizedtoMTBICDSsaw2,189eligiblepatients,usingCDS36.2%ofthetime,andorderingheadCTfor38.5%.Among100controlEPswhosaw1,707eligiblepatients,CTheadwasorderedfor45.1%.Therewasnodifferencein30-dayEDreturnvisits,hospitalizations,ortraumaticheadinjurydiagnosesbetweengroups.4EPsrandomizedtoPECDSsaw9,609eligiblepatientsandusedCDS43.2%ofthetime.CTPulmonaryAngiogram(CTPA)utilizationwas9.7%amongEPsreceivingCDS,comparedto8.2%among91controlphysicianswhosaw9,498eligiblepatients.Therewasnodifferencein90-dayEDreturnvisitsorvenousthromboembolismdiagnosesbetweengroups.
ChallengesCDSusewasvariable,rangingfrom0-100%amongphysicians,likelyowingtothevoluntarynatureoftheintervention.
Lessons LearnedCDSimplementationwasassociatedwithreducedheadCTuseforpatientswithMTBI,butincreaseduseforpatientswithsuspectedPE.ThevoluntarynatureoftheinterventionaswellastriggeringonlyonCTorderinglikelycontributedtoitsmodestimpact.
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Reducing Unnecessary Blood Tests in a Downtown Emergency DepartmentPatrickO’Brien,HinaChaudhry,SholzbergMichelle,MikeFralick,AlunAckryandLisaHicksSt.Michael’sHospital
LaboratorytestingisacorecomponentofpatientassessmentintheEmergencyDepartment(ED).However,sometestingmaybeunnecessary.WeaimedtoidentifyunnecessarylabtestingintheEDandtoreduceitby30%.
Ourchangestrategyincludedengagementofkeystakeholders,education(aroundappropriateuseofPT/aPTT)andchangestoEDlabpanels.ThemajorityoflabtestingintheEDistriggeredbymedicaldirectiveswhereinEDnursesorderfromlabspanelsforcommonpresentations.IncollaborationwithED,LabMedicineandwithreferencetobestpractices,wereviewedalloftheSMHlabpanels.Fourtestswereidentifiedthatwereuninformativeincertainsettings(PT,aPTT,urea,albumin),andtwotestswereidentifiedthatwereredundantwithnewertests(CK,amylase).Thesetestswereremovedfromfivelabpanels.Measurementfocusedonthemeantestingratepermonthoftargetedtestsandthereagentcosts.
Immediatelysubsequenttoourinitiative,dramaticchangesinthetestingratesoftargetedtestswereobserved.Asillustratedbelow,monthlytestvolumesdecreasedby47%to93%dependingonthetest.Thechangesresultedinaprojectedannualsavingsof$77,000inreagentcosts.BalancemetricsincludingEDlengthofstayandtransfusionratesshowednochange.Add-ontestrateswereassessedpreandpostpanelchangesforasubsetoftests(PT/aPTT)andwerestable.
PT aPTT Urea AlbuminCK AmylasePre-MeanTestVol./Mth 2341 2308 2948 1504 1204 1080Post-MeanTestVol./Mth 918 872 198 800 634 380%Decrease -61% -62% -93% -47% -47% -65%
RevisionofEDlabpanelsisarelativelysimplechangestrategythatcanresultindramaticreductionsintestvolumeswithoutadverselyimpactingpatientcare.
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Piloting a “chest x-ray for acute asthma” knowledge dissemination tool in Alberta emergency departmentsLynetteD.Krebs,CristinaVilla-Roel,MariaOspina,BrianR.HolroydandBrianH.RoweUniversityofAlberta
BackgroundTofacilitateclinician-patientdialogue,apatientknowledgedisseminationtoolwasdesignedtoportraywhenchestx-rays(CXR)areneededforacuteasthma(AA)care.ThistoolwaspilotedwithpatientsandemergencyphysicianspracticinginAlbertapriortouseinanimplementationtrial.
MethodsAnonlinesurveywasdistributedtoemergencyphysiciansviaemail.Patients(17-55years)withAAwereenrolledinanemergencydepartment(ED)studyattwourbancentres.Bothpopulationsprovidedfeedbackonthetool.
ResultsAtotalof55physicians(29%)and38patientsresponded.Approximately55%ofphysiciansfeltcompletelyormostlycomfortableusingthetool.SuggestedchangesweretoincludeinformationonCXRradiationriskandrefrainfromdiscussingimagingvariation.Mostpatients(92%)agreedtheyunderstoodtheinformationand68%felttheinformationappliedtothem.Nearlyhalfofthepatients(45%)agreedthatbecauseofthetooltheyknewmoreaboutwhenapatientwithAAshouldhaveaCXRand71%agreedthattheywoulddiscusstheirCXRneedwiththeiremergencyphysician.Tenpatients(26%)suggestedtoolmodifications,including:additionaldetailsabouttheCXRs(i.e.,risks,indications),removingthestatementthatCXRsareoverused,andincludinganinstructionforpatientsnottoshyawayfromaskingtheirphysicianquestions.
ConclusionTheseresultsindicatetheneedtoensurepatientsunderstandhowtheinformationindecisionaides/toolsappliestothem.FurtherresearchisneededtouncoverwhetherpatientswouldactontheinformationandwhetherthoseactionswouldinfluenceEDmanagement.
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Do I Really Need Antibiotics? Ask Your Doctor or Nurse PractitionerRobertWilson,PatrickParfreyandBrendanBarrettTranslationalandPersonalizedMedicineInitiative
GoalToreduceunnecessaryprescribingofantibioticsbyFamilyPhysicians&NursePractitionersinNewfoundland&Labrador(NL).
ImplementationNLusesmoreantibioticsthananyotherprovinceinCanada.In2016,NLprovided955prescriptionsper1,000inhabitants,19%morethanthesecondhighestprovince.CWNL,incollaborationwiththeNLMedicalAssociation(NLMA)andtheAssociationofRegisteredNursesofNL(ARNNL)createdapeercomparisonprogramforGP’sandNPsantibioticprescribingratesusingdatafromtheNLPrescriptionDrugProgram(NLPDP).
MeasuresAtotalof502GPsand84NP’sinNLweresentbyemail,individualizedde-indentifiedreportsontheirantibioticprescribingvolumeandratesplustypeofantibioticprescribedduringthe2015/6fiscalyearcomparedtotheirpeers.TheChoosingWiselyCanadarecommendationsforantibioticusewereprovided,andalinktoresourcescreatedbyQualityofCareNLtoreduceantibioticoveruse.Datawillbeanalyzed6monthsafterthereleaseofthereporttoseetheeffectoftheintervention
Challenges(1)AccesstoprovincialpharmacynetworkforallresidentsofNLonlyavailablefrom2017,(2)ethicalandbureaucraticbarriersfordatasharing,(3)constructingclearandconcisemessagingwiththereportforeasyunderstanding.
Lessons LearnedThePharmacyNetworkdatabaseisactivethereforefutureanalysiswillincludeprescriptionsforalldemographics.AdatasharingagreementhasbeenconstructedandacceptedbytheNLMA,ARNNLandMemorialUniversitytoallowethicalandconfidentialdatasharingamongstCHIAandtheGPsandNPs
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Randomized Controlled Trial of Audit and Feedback Intervention to Improve Adherence to the Choosing Wisely Recommendations in Primary CareAlexanderSinger,UniversityofManitobaLeanneKosowan,UniversityofManitobaKheiraJolin-Dahel,UniversityofManitobaAlbertMota,CentreforHealthcareInnovationLisaLix,CentreforHealthcareInnovationAlanKatz,ManitobaCentreforHealthCareInnovation(MCHP),UniversityofManitoba
BackgroundTheeffectivenessofauditandfeedbackinterventionsinprimarycareisunclear.TheManitobaPrimaryCareResearchNetwork(MaPCReN)providesquarterlypracticefeedbackreportstoprimarycareproviders.UsingMaPCReN,thisstudyassessedtheimpactofanauditandfeedbackprogramregarding4ChoosingWiselyrecommendations:antimicrobialprescriptionsforviralinfection,antipsychoticprescriptionsforpatientswithdementia,screeningserumvitaminDandannualbloodscreening(i.e.PSA).
Methods243cliniciansfrom46clinicswererandomizedintooneofthreegroups:(1)currentpracticefeedbackreports(controlgroup),(2)currentfeedbackreportswithnon-personalizedinformationonCWrecommendations,or(3)modifiedfeedbackreportswithpractice-basedinformationrelatedtoCWrecommendations.Followingimplementation,descriptivestatisticsandmultivariatemodelsexploreddifferencesinprescribingandscreeningbetweengroups.
ResultsPriortoimplementationoftheauditandfeedbackprogram,15.6%(N=25,629)oftheprimarycareencountershadanoutcomecontrarytotheCWrecommendationsevaluated.Ofthese,65.4%wereprescribedanantibioticforaviralinfection,28.7%receivedaPSAscreenand9.0%hadaVitaminDtest.Amongpatientsdiagnosedwithdementia,17.0%wereprescribedanantipsychoticmedication.Statisticalanalysisofthestudydataiscurrentlybeingconducted.Thispresentationwillexploredifferencesinprescribingandscreeningfollowingimplementationoftheauditandfeedbackprogram.
ConclusionOurstudyaimstoevaluatetheeffectivenessofalowcostandaccessibleauditandfeedbackmechanismforprimarycareproviders.Byreducingunnecessarycare,wecanimprovepopulationhealthandreducehealthcarecosts.
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Implementation of changes in cervical screening recommendations.JamesDickinson,UniversityofCalgary
GoalTochangeCanadiancervicalscreeningpracticestoevidencebase.
ImplementationTheCanadianTaskForcereportoncervicalscreeningmadestrongrecommendationsagainstscreeningwomenunderage20,weakrecommendationsagainstfor20-25,weakrecommendationsforscreeningwomen25-29years,strongrecommendationstoscreenfrom30to69,Weakrecommendationagainstscreeningafterage70.
MeasuresTheTaskForcereportwaspublishedin2013,butprovincialguidelinesseemtodominate,anddidnotchangefromtheirexistingstartageof21.BCandAlbertaguidelineschangedin2016,andsincethenbehaviourchangeshavebeenobservedinthoseprovinces.
ChallengesMostFamilyPhysiciansfocusontheirprovincialguidelines,andtheTaskForceisnotyetabletoencouragethemtochangeagainsttheirlocalguidelines.Currentguidelinecommitteesinmostprovincesareentrenchedintheirideas,andunwillingtoconsiderchange.SomehavemisquotedtheTaskForceguidelinesandinterpretedtheirapproachasbeingcongruent.
Lessons LearnedWemustunderstandhowtochangelocalguidelines,notsimplyprovideevidence-basedrecommendations.
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Primed for Success: Using Implementation Science to Implement ChangeShusmitaRashid,SobiaKhan,JuliaMoore,MelissaCourvoisier,andSharonStrausSt.Michael’sHospital
Knowledgetranslation(KT)involvestheimplementationofresearchevidenceintoreal-worldpractice.ThescienceandpracticeofKThasbecomerecognizedasincreasinglyimportantwithinhealthcaresystemsthatcontinuouslystrivetointegrateevidence-basedpractices,recommendations,andpoliciesintoroutinehealthcare.Inanefforttofacilitatetheseobjectives,wedevelopedacourse,entitledPracticingKT(PKT)https://knowledgetranslation.net/education-training/pkt/,toprovideindividualsandorganizationswiththeknowledgeandsupporttoapplyimplementationsciencetodevelop,implement,andevaluateevidence-basedprograms.
Drawingfromourexperienceofdeliveringmorethan15implementationtrainingcourses,weproposedeliveringaworkshoptoprovideanoverviewonhowtouseimplementationsciencetonavigateimplementationchallengesandplanforenhancedoutcomesforChoosingWiselyrecommendations.Participantswillthinkthroughidentifyingandengagingstakeholdersinvolvedinimplementation;challengesattheindividual,organizationalandsystemlevel;andhowtooperationalizestrategiestofosterchange.Thisworkshop,informedbybestpracticesinorganizationallearningandadulteducation,willfacilitateopportunitiesforparticipantstolearnandapplyconceptsthroughaninteractivepresentation,smallgroupactivity,andasummaryofimplementationtipsandresources.Participantswillhaveexamplesofhowtouserelevanttheories,models,andframeworkstohelpunderstandimplementationissues,stakeholders,resources,andregulationsatorganizationandsystemlevels.Ourgoalistomakeimplementationscienceaccessibletopractitionersinavarietyofhealth-relateddisciplinesandthisworkshopwillbebeneficialforindividualsandorganizationsworkingtoimplementevidenceandde-implementunnecessarycareacrossclinical,publichealthandpolicysettings.
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Assessing the Completion and Appropriateness of Headache and Low Back MRI and CT Requisitions: A Canadian Perspective on Patient-Centred ReferralsMarkKhoury,BrockUniversity/I-EQUIPMichaelTolentino,BrockUniversity
InappropriatediagnosticimagingisaburgeoningproblemwithintheCanadianhealthcaresystemandimposesconsiderableburdenstoefficiency,timeliness,andcost-effectivenessofcare.Apreliminaryreviewof267patientchartsindicatesthat55%ofMRIreferralsforheadache(HA)andlowbackpain(LBP)fromtheDiagnosticImagingDepartmentatNiagaraHealth(NH)weredeemedinappropriateorincompletebasedonChoosingWiselyCanada(CWC)guidelines.TheubiquityofLBPandHA,concomitantwithinefficientuseofresources,hascontributedtorisesinMRIandCTscansinCanada.Therein,improvingtheappropriatecompletionofMRIandCTrequisitionswouldallowNHtoreducewaittimesandimprovepatientsatisfaction.ThequalityimprovementobjectiveistodecreaseinappropriateorincompletereferralsforheadandlumbarMRIandCTscansintheNiagaraRegionfrom55%to20%,asdefinedbytheCWCguidelines,byApril2018.WeintendtoaccomplishthisobjectivethroughmodificationoftheMRIandCTrequisitionforms.
ChangestotherequisitionformreflectCWCguidelinesandareexpectedtoimprovecompletionrates;changesincludechecklistsforredflagindications,completionof6weeksofconservativemanagement,andsupplementaryinformationincaseswheretestsarenotindicated.NewrequisitionformshavebeendistributedtoasamplegroupofprimarycarephysiciansintheNiagaraRegionandpost-interventiondataiscurrentlybeingcollected.Ultimately,thisinterventionaimstofacilitateapatient-centredapproachtodiagnosticreferralsthroughaffirmationthatthepatient’ssymptomsappropriatelyindicateascanaccordingtoCWCguidelines.
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The Joys and Sorrows of Implementing CatherineKohm,FraserHealth
FraserHealthisthelargestRegionalHealthAuthorityinBritishColumbiaservingapopulationof1.7millionpeople.Careareasincludehospital,residential,homehealth,mentalhealthandaddictions,andpublichealthservices.OurservicesareasareorganizedintotencommunitieswithanExecutiveDirectorleadingtheoperationsofthecommunity.TheExecutiveDirectorforBurnabyCommunityrequestedaChoosingWiselyCampaigndesignedtosupportelevenresidentialcarehomes,housing1428residents.BurnabyCommunityhasthehighestunscheduledtransferrateinFraserHealthtotheEmergencyDepartment,andthiswasidentifiedasaspecificobjectivetomeetFraser’stargetof7.5transferspermonthper100residents.WiseuseoftheEmergencydepartmentforthevulnerablelongtermcareresidentensurestherighttreatmentfortherightpersonattherightplace.
AninterdisciplinarytaskforcewhichincludedfamilymemberscollaboratedtodevelopaBurnabyfocusedcampaignaimingtoimprovethecareofresidentsthroughappropriatetransferstotheED.Theteamdevelopeddocumentswiththreespecificgoalsinmind:enhancecommunicationswithresidents&families,supportourcommunityphysicianstoprovideservicesatlongtermcaresites,andarticulatetoouracutecarepartnersthetypesofservicesthataresafelyavailableinlongtermcarehomes.
ThenextstepsforthiscampaignaretosharewithFraser’snineothercommunitiesthelessonslearned,thechallengesandsuccesses.Aplanhasbeendevelopedtomeasuretheresultsofthisinitiativeinmeetingthethreedefinedgoals.
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Elective Lumbar Laminectomy: Routine Perioperative Practices and Postoperative OutcomesMinaTohidi,TiffanyLungandDavidYenQueen’sUniversity
BackgroundRoutineinvestigationsforasymptomaticpatientsundergoinglow-risk,non-cardiacsurgerycontributelittlevaluetoperioperativecare,butthesetestsarestillorderedinmanycentres,includingours.Theprimarypurposeofthisstudywastodeterminetheprevalenceofpreoperativebloodworkforelectivelumbarlaminectomy.Secondaryobjectivesweretodeterminetheprevalenceofintraoperativetranexamicacidadministration,intraoperativecomplications,lengthofstay,and30-dayreadmission.
MethodsThestudysampleincludedallpatients18yearsofageandolderwhounderwentelectivelumbarlaminectomybyoneOrthopaedicspinesurgeonbetweenJuly1,2013andJune30,2017.AllprocedureswereperformedattheUniversityHealthSciencesCentre.
Results256patientsunderwentelectivelumbarlaminectomyofoneormorelevelsduringthestudyperiod.Amongthesepatients,89.5%underwentatleastonepreoperativebloodtest.Theintraoperativecomplicationratewas2.34%.Inthe30daysfollowingsurgery,therewerenohospitalre-admissionsrelatedtocomplications.Lengthofstaywaslowerforpatientstreatedwithbilateraldecompressionusingalessinvasive,unilateralapproachcomparedtothetraditionalbilateralapproach(p=0.0063).Estimatedbloodlossanddurationofsurgerydidnotdiffersignificantlybetweenthesetwogroups(p=0.86,p=0.30,respectively).
ConclusionHospitalpoliciesshouldbere-evaluatedtoaddresstheoveruseofpreoperativeinvestigationsforelectivelumbarlaminectomies,whichhavelowperioperativetransfusionandcomplicationrates.Theuseofalessinvasivesurgicalapproach,whichisassociatedwithshorterhospitallengthofstaywithoutincreasedriskofcomplications,offerscost-savingopportunitiesandwarrantsfurtherinvestigation.
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Unnecessary Ultrasound in the Management of Subcutaneous LipomasHarisImsirovic,EmilyZehnderandTrevorBardellQueen’sUniversity
BackgroundLipomasarecommonbenigntumourswhichsometimesrequireremovalbecauseofsymptomsorrapidgrowth.Oftenpatientsarereferredforsurgicalexcisionhavingundergoneadiagnosticultrasound;however,itisusuallypossibletodiagnoselipomasbyhistoryandphysicalexaminationalone.Theaimofthecurrentstudyistoexaminetheprevalenceofunnecessaryultrasounduseinthediagnosisoflipomas.
MethodsAretrospectivereviewusingelectronicmedicalrecorddatawasconductedforallpatientsassessedbyasinglecommunitygeneralsurgeonwiththediagnosticcodeforlipomafromJanuary2015toDecember2017.Demographicinformation,diagnosis,ultrasounduse,andwhetherthediagnosiswasclinicallyapparentwithoutanultrasoundwerecollected,aswellasreferringpractitionerinformation.Referringpractitionerswereclassifiedintothreegroups:nursepractitioners,recentlygraduatedphysicians(10orlessyearsofexperience),andexperiencedphysicians(morethan10yearsofexperience).
ResultsInformationpertainingto115patientswasanalyzed.Ofthepatientsreferred,48.7%hadanultrasoundattached.Ofthosewhohadreceivedanultrasoundfordiagnosticpurposes,98.2%weredeemedunnecessary.Fifty-ninepercentofnursepractitioners,46.8%ofrecentlygraduatedphysicians,and45.1%ofexperiencedphysiciansorderedanunnecessaryultrasound.Thesedifferenceswerenotstatisticallysignificant(p=0.61).
ConclusionAlmosthalfofallpatientsreferredforassessmentofalipomacamewithanultrasound,whichwasalmostalwaysunnecessary.Reducingunnecessaryimagingofbenignlesionscouldhelpreducehealthcareexpenses,inconvenienceandlossofproductivityforpatients.
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Bye Bye Bedrest: Shifting ICU Culture from ‘Too Sick to Get Out of Bed’ to ‘Too Sick to Stay in Bed’KarenWebb-Anderson,MarleneAsh,PatriciaDaley,DouglasVincent,CynthiaIsenor,GiselleDavis,ElinorKelly,TaraMercier,RobertGreenandSarahMcMullenNovaScotiaHealthAuthority
Numerousadvancementsincriticalcarehaveresultedinimprovedmortalitydespitesicker,morecomplexpatients.However,thishasalsoexposedICU-associatedmorbidityinsurvivors,includinglong-termcomplicationssuchasneurocognitivedeclineandprofoundphysicaldeconditioning.Alongwiththeseadverseevents,evidencehasdemonstratedthat“lessismore”inseveralkeyareas:sedation,ventilationdays,polypharmacy,andbedrest.OrganizationsincludingtheSocietyofCriticalCareMedicinesupportanevidence-basedapproachtocare.Inaddition,ChoosingWiselyCanada(CriticalCare)identifiestheoveruseofbedrestasapriorityforaction.
WehaveusedourEarlyMobilityProgramtoshiftourparadigmofcarefrom“toosicktogetoutofbed“to“toosicktoNOTgetoutofbed”.Indoingso,manyinsightshavebeenappreciated.Earlymobilitymitigatesseveraldeleteriouseffectsofsurvivingcriticalillness,andsupportspatientsandfamiliesingettingbacktothelifetheywantwithimprovedqualityoflife.Adoptingateam-basedapproachtomovingpeopleearlyandoften,hascontributedtoanoverallreductioninICUdeliriumby25%.Withinourtraumasubpopulationwehaveseena33%dropinintubationdays,10%fewercomplications,andadecreaseinmortalityfrom26.5%to16.5%.Ourexperienceisanexcellentexampleofmakingsmartchoicestolimitunnecessarytreatmentsandtheiruntowardimpacts.
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Unnecessary Ultrasound in the Management of Umbilical and Inguinal HerniasEmilyZehnder,HarisImsirovicandTrevorBardellQueen’sUniversity
AbstractBackground:Althoughclinicallysignificantherniascanusuallybediagnosedbyphysicalexaminationalone,medicalpractitionersoftenorderanultrasoundpriortoreferraltoasurgeon.Unnecessaryultrasoundsresultinneedlessinconveniencetopatients,inadditiontothecosttothesystem.Theobjectiveofthisstudywastoassessfactorsassociatedwithunnecessaryultrasoundsinpatientsreferredtogeneralsurgeryforherniaassessment.
MethodAretrospectivereviewofelectronicmedicalrecorddatawasperformedforallpatientsreferredwithanumbilicaloringuinalherniabetweenJanuary1,2014andDecember31,2015.Onehundredandeightpatients(22withumbilicalhernia,84withinguinalherniaand2withbothumbilicalandinguinalhernias)wereidentified.Patientswithherniasnotidentifiableonphysicalexaminationwereconsideredtorequireanultrasound,otherwiseitwasconsideredunnecessary.Referringpractitionerswereclassifiedasnursepractitioners,recentlygraduatedphysicians(10orlessyearsofexperience)orexperiencedphysicians(greaterthan10yearsinpractice).Thenumberofunnecessaryultrasoundswascomparedbetweenthesegroups.
ResultsFifty-onepercentofherniapatientsarrivedhavinghadanultrasound,ofwhich83.9%weredeemedunnecessary.Therewasnosignificantdifferencefoundinthenumberofunnecessaryultrasoundrequestsbetweenthethreegroups(p=0.196).Additionally,nosignificantdifferencewasfoundinthenumberofunnecessaryultrasoundsbetweenumbilicalandinguinalhernias(p=0.840).
ConclusionNearlyhalfofpatientsreferredhadanunnecessaryultrasound.Reducingunnecessaryimaginginthemanagementofinguinalandumbilicalherniashaspotentialtoreducecostsubstantially.
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A Collaborative, Diagnostic Stewardship Initiative to Improve Urine Culture Utilization In AlbertaShobhanaKulkarni,DynalifeDiagnosticLaboratoriesMichaelGroeschel,CalgaryLaboratoryServices
GoalTomandatetheprovisionofrelevantclinicalinformationforurineculturerequeststothelaboratoryanddeveloplaboratorymechanismsthatwillrestrictrequestsintheabsenceofaclinicalindication.
ImplementationTheCollegeofPhysiciansandSurgeonsofAlbertaReferralConsultationStandardstipulatesthattestrequestsareaformofclinicalconsultationandthataccompanyingrelevantclinicalhistoryshouldbeprovidedsincethisisvitalforinterpretationofresultsbylaboratoryphysicians.Currently,themajorityofrequisitionslackthisimportantinformation.Aprovincialurineculturestewardshipworkinggroupisdevelopingaframeworktosupportcompliancewiththisstandard,whichincludes:
• Establishingclearindicationsforurineculturerequests• Communicationtostakeholdersthatprovisionofclinicalinformationonrequisitionswillbemandatory• Developingprocessesforlaboratoriestobestcapturesubmitterprovidedclinicalinformation• Developingprocessesallowinglaboratoriestorestrictrequestsintheabsenceofaclinicalindication• Developingpost-implementationstrategiestomonitortheimpactofthisinitiativeonpatientcare,testutilization,andstakeholderresponse
ChallengesAsignificantchangeinmindsetandcurrentpracticeswillbeneededforbothcareprovidersandlaboratories.LaboratorysystemsarealsotechnicallyandoperationallyheterogeneousinAlberta,whichposeschallengestotheimplementationofthisinitiativeonaprovincialscale.Effortstoovercomethesechallengeswillbemadeworthwhilebybetterensuringtheclinicalrelevanceofurinecultureresultswithconsequentimprovementsinpatientcareandsafety,antimicrobialstewardshipandtestutilization.
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Does Emergency Physician (EP) Diagnostic Imaging (DI) use Affect Clinical Productivity?SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversitySwarnaWeerasinghe,DalhousieUniversityDavidUrquhart,DalhousieUniversity
IntroductionConsiderablevariationexistsintestusebyEPs.Weexaminedtheassociationbetweenphysicianproductivity(PP)anddiagnosticimaging(DI)use.
MethodsUsingprincipalcomponentanalyses,weanalysedPPusingpatientsperhour(pt/hr),percentageofreturnvisitsandadjustedworkloadmeasurement(AWM),assigninghigherscorestoCTAS1-3patients,of85EPsatanacademicED,June1,2013-May31,2017.DIutilizationincludedultrasound(US),CTscan(CT)andx-ray(XR).
ResultsMeanpt/hr(1.8;range1.2-2.5)andAWM(6.9;4.4-9.7)variedsignificantly.AnincreaseofDIwasassociatedwithlowerpt/hrandAWM.Forpt/hr:40%CTreduction,doubledthemean(p=0.001);50%x-rayreduction,increasedthemeanto2.3(27%)ForAWM:40%CTreduction,doubledthemean(p=0.001),50%Xrayreductionincreasedthemeanby30%(p=0.0001)and10%reductionofUS,increaseditby20%(p=0.02).Pt/hrwasbettercorrelatedwithDI(R2=38%)thanAWM(R2=30%).ThebenchmarkofPPwithcombinationsofpositivept/hr,positiveAWMandnegative%ofreturnvisitswasbetterpredictedbyDIuse(R2=42%).LessDI(p=0.0001),CCFP(EM)training(p=0.01),Malegender(p=0.02),youngerage(p=0.04),lessCTAS4decisiontime(p=0.01)andlesspatientsbyalearner(p=0.07)wereallassociatedwithhigherPP.
ConclusionIncreaseduseofDIwereassociatedwithlowerpt/hrandAWMandlikelycontributestoEDovercrowding.FurtherresearchisneededtoassesstheassociationbetweenDIuseandclinicaloutcome.
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Influence of Lab Tests (LT) Ordering on Emergency Physician (EP) Productivity (PP)SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversitySwarnaWeerasinghe,DalhousieUniversityDavidUrquhart,DalhousieUniversity
IntroductionEmergencyDepartment(ED)overcrowdingincreasestheimportanceoftheabilityofEmergencyPhysicians(EPs)toseepatientsasrapidlyasissafelypossible.Weexaminedtheassociationbetweenphysicianproductivity(PP)andlabtest(LT)use.
MethodsWeanalyzedthepracticevariablesof42EPsworkingatanacademicED,fromJune1,2015-May31,2017.PPwasmeasuredbypatientsperhour(pt/hr)andadjustedworkloadmeasurement(AWM),assigninghigherscorestohigheracuitypatients.LTwasmeasuredbytheorderrateofcommontests.
ResultsPPvariedsignificantly:meanpt/hr(1.8;range1.2-2.5)andmeanAWM(6.9,4.4-9.7).LTwassignificantlyassociatedwithPt/hr,butnotwithAWM.50%reductioninLTforCTAS2and3patientsincreasedpt/hrby32%whilethesamereductionforCTAS4testsorderedincreasedby5%.Decisiontimeissignificantlycorrelated(R2=50%)withthecombinationofCTAS2-4labtestsorderedand50%increasecoulddoublethedecisiontime.NostaticallysignificantdifferencesofLTorderingacrossdemographicfactors(training,ageandgender).DiagnosticimagingandlabtestsorderingarebothcorrelatedwithPP,howeverdiagnosticimagingwasmorestronglyassociatedwithPP(R2=41%)thanLT(R2=7%).
ConclusionWefoundasignificantassociationbetweenLTuseonPP.IncreaseduseoflabtestsforCTAS2-4wereassociatedwithlowerpt/hrandincreaseddecisiontimeandlikelycontributestoEDovercrowding.Furtherresearchisneededtoassesstheassociationbetweenlabuseandclinicaloutcome.
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Improving Appropriateness of Mg Testing in ICUAdaLo,UniversityofBritishColumbiaPeterDodek,St.PaulsHospitalTonyZhao,UniversityofBritishColumbiaFacultyofMedicine
BackgroundMgis99%intracellularandserumtotalMgconcentrationdoesnotcorrelatewithintracellularMgconcentration.However,serumtotalMgismeasuredroutinely.
MethodsWeaimedtodecreasethenumberofroutineserumtotalMgtestsina15-bedmedical-surgicalICU.First,wesummarizedcurrentevidenceandworkedwithICUphysicianstoagreeonindicationsforMgtesting:1.suspectedhypomagnesemiainthesettingofrenalfailure,2.optionalinsuspectedhypermagnesemia.Thenweimplemented:educationforclinicalstaffaboutthelackofevidencesupportingroutineMgtests,promptsintheelectronicordersystemtoencourageourindications,andpostersremindingstaffofthisimprovementinitiative.PatientdatawereacquiredfromanICUdatabase.NumberofserumtotalMgtests12monthsbeforeimplementation(Dec19th,2016)and5monthsafterwardwerecollectedfromtheorderentrysystem.
Results1yearbeforeintervention,ameanof69(SD16)tests(55(SD13)routineand14(SD5)non-routine(stat))wereorderedweekly.Afterinterventions,56(SD16)tests(42(SD15)routineand14(SD5)non-routine)wereorderedweekly.Thiswasa24%reductioninroutinetestswithoutanychangeinnon-routinetests.SeverityofillnessandlengthofICUstaywerenotdifferentbetweenbaselineandpost-interventionperiods.
ConclusionRepeatededucationsessionsandapromptintheorderentrysystemwereassociatedwithasignificantdecreaseinthenumberofroutineserumtotalMgtestsorderedinanICUwithoutcompromisingpatientoutcomes.
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The Road Traveled-NPAC’s Journey in Development of the “Nine Things Nurse Practitioners and Patients Should Question” CathyScofield-SInghandJenniferFournierNursePractitionerAssociationofCanada
TheNursePractitionerAssociationofCanada(NPAC)isanationalorganizationwithamembershipofnursepractionersfromacrossCanada.TheNPACpresentationwilllookatthejourneyfromthefirstcontactofNPACwithChoosingWiselyCanada(CWC),andcollaboratingwithCWCtoexplorethepotentialdevelopmentofaNPACCWClistandtherationalefordoingso.ThepresentationwillfollowthepathofthedevelopmentoftheNPACCWCworkinggroup,tothepublicationofthe“NineThingsNursePractitionersandPatientsShouldQuestion”.ThispresentationwillalsoexploretheopportunitiesformovingforwardtoencouragedialoguearoundtheNPACCWClist,encouragediscussionaboutnecessaryandunnecessarycareamongnursepractitionersandpatientsandincreaseawarenessofChoosingWiselyCanada’scampaigntopromoteawarenessofbestpracticesandcurrentevidence.
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Exploring Physician-Reported Barriers and Facilitators to Using Evidence-Based Recommendations Regarding Imaging for Low Back Pain: A Meta-Synthesis Using the Theoretical Domains FrameworkSamanthaScurrey,MemorialUniversityofNewfoundlandCharlotteAlbury,NuffieldDepartmentofPrimaryCareHealthSciences,UniversityofOxfordHelenRichmond,RehabilitationResearchinOxford(RRIO),OxfordClinicalTrialsResearchUnit,UniversityofOxfordHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLPatrickParfrey,TranslationalandPersonalizedMedicineInitiativeMemorialUniversityJamesMatthews,SchoolofPublicHealth,Physio&PopScience,CenterforSportsStudies,UniversityCollegeDublinJillHayden,DepartmentofCommunityHealth&Epidemiology,DalhousieUniversityAmandaHall,MemorialUniversity
BackgroundSeveralqualitativestudieshaveexploredphysicians’reasonsforusingimagingforlowbackpain(LBP).Weconductedameta-synthesisaboutbarriersandfacilitatorsofappropriateimagingforLBPusingtheTheoreticalDomainsFramework(TDF).
MethodsWesearched3electronicdatabasestoJuly2017forEnglish-languagequalitativestudiesofPhysicianswhotreatLBPandassessedtheirbarriers/facilitatorstousingimaging.Tworeviewersselectedstudies,extracteddataintoNVivoandindependentlycodedthemesusingtheTDF.
ResultsWeincluded9studies;eachusedfocusgroups/interviewsanalysedusingthematicanalysis.Weidentified4overarchingdomains:Socialinfluence–includingsocialpressurefromthepatientseitherrequestinganimageorwantingadiagnosisandtheGPfeltthatanimagewouldprovidethisinformation.Beliefsaboutconsequence–includingoutcomeexpectancywhereGPsbelievedthatthescanwouldreassurethepatientandotherconsequencesincludingfearofblameorlegalactioniftheydonotrequesttheimage.Skills–whereGPsreportedtheylackedsufficientcommunicationskillstoexplainwhyatestisnotnecessaryforpatientsrequestinganimage.Environmentalcontextandresources–includedlackoftimetohaveafullconversationwithpatientsaboutdiagnosis,andorganisationalcultureinwhichscansareorderedasarequirementforsickcertificates,treatmentreferrals,orlegalcases.Knowledgeaboutwhentouseimagingwasnotidentifiedasabarrier.
ConclusionsInterventionsmustincludestrategiesthattargetpatientexpectations,communicationaboutdiagnosiswithoutimaging,andappropriatetreatmentstrategies.
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Fundamentals of Health Evidence: Practical Approaches to Critical Appraisal LisaPyke,JenniferHartellCADTH
HealthcareProfessionalsworkingonChoosingWiselyRecommendationsdemonstrateleadershipinevidence-basedmedicinewhentheyseekoutcrediblesourcesofinformationandapplyrigorousmethodologiestodevelopstrongevidencebasestosupportrecommendationdevelopment,toolsandapproaches.Yet,dowereallyknowhowtofindandevaluatetheevidence?Weareincreasinglytaskedtoreviewbestavailableevidenceandtobeskepticaloftheinformationprovided.Yet,howdoweevaluateevidence:Isitreliable?Isthesourceunbiased?Isitbasedonhigh-qualityevidence?Evidenceisaccessedinmanyforms,throughjournalsandonwebsitesforconsiderationaspartofevidence-informedpractice.Someformsofevidence,however,maycontainbias,inaccurateinformation,orbebasedonopinionandconjecture.Notallcontent,definitions,orsummarizedresearchinterpretationsmaybenecessarilyaccurateortrulyrelevanttoourclinicalneeds.Wherewefindresearchisanotherfactor—somewebsiteshavegreatercredibility,structure,andpre-screeningforvaliditythanothers.Withincreasedaccessanduseofweb-basedinformation,professionalsneedasimplifiedapproachtocriticalappraisalofevidencethatcanbeusedquicklyandefficientlytodeterminequalityandvalueinresearchtheylocateontheinternetorreceiveinotherforms.Thisinteractiveoralsessionwillprovideasimplified,straight-forwardstep-by-stepapproachtocriticalappraisalandwebsitequalityassessmentthatanyonecanusetodetectpotentialbiasinwhattheyread.Severalexampleswillbeusedthroughoutthepresentationtoillustratecommonbiasissuesthatareunfortunatelymorecommonthanwerealize!
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Reducing Radiation and Cost Associated with Follow-Up Imaging for PneumothoraxUsamaMalik,UniversityofCalgary,CummingSchoolofMedicinePeterDickhoff,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgarySimonChi,DiagnosticImaging,CalgaryZone,AlbertaHealthServices(AHS)SandraHovey,DiagnosticImaging,CalgaryZone,AlbertaHealthServices(AHS)GeoffSchneider,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgaryMarkMacMillan,DiagnosticImaging,AlbertaHealthServicesRichardWalker,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgary
IntroductionManagementofpneumothorax(PTX)typicallyincludesserialfollow-upchestx-ray(CXR)exams.Multipleguidelinesrecommendanerectpostero-anterior(PA)CXRforfollow-upofprimaryspontaneouspneumothorax(PSP),withalateralviewrecommendedonlywhenadditionaldiagnosticinformationisrequired.Thisstudyaimstodeterminewhethertheseguidelinesarebeingfollowedattwotertiaryacademiccentresinourregion.
MethodsDepartmentanalystsretrospectivelyidentified260patientsdiagnosedwithPTXandatleastonefollow-upCXRbetweenJanuary1andMarch31,2017.Inclusioncriteriaincludedage?18-yearsandspontaneouspneumothoraxorpneumothoraxassociatedwithminortrauma.Consensusreviewofimageswasperformedbyastaffradiologistandmedicalstudent.Datacollectedincludedpatientage,gender,CXRorder(2-view,1-view,1-viewportable),orderingphysician,patientlocation(inpatientoremergencydepartment),andPTXetiology.
Results35patientsmeetingtheinclusioncriteriaunderwent226follow-upCXRs.2-viewswereperformed71.7%(162/226)anda1-viewor1-viewportable28.3%(64/226).Therewasnodifferencewhethertheorderingphysicianwasaresidentorattending(p=0.161).Inpatientsweremorelikelytoreceivea2-viewfollow-upexam(p=0.00012).Theincrementalcostassociatedwithorderinga2-viewfollow-upwas$1,989.36andresultedin2.0mSvofadditionalradiationexposuretotheaveragePTXpatient.
ConclusionOurstudydemonstratesanopportunitytodecreasecostandradiationexposureforinpatientandemergencydepartmentpatientsbeingfollowedforPTX.Aneducationactionplandirectedtowardsdepartmentsmanagingpatientswithpneumothoraxisplannedwithcompliancere-evaluatedbetweenFebruary1andApril30,2018.
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Bladder Matters: A Corporate Strategy to Reduce Urinary Tract Infections and Urinary Retention RatesMaryKapetanos,DonnaRuffo,PrateekKhatriandLindaJussaumeNorthYorkGeneralHospital
GoalTodevelopandimplementacorporateapproachforreducingcatheter-associatedurinarytractinfections(CAUTI)andurinaryretentionratesatNorthYorkGeneralHospital(NYGH).
ImplementationAworkinggroupwithrepresentationthatcrossedmedicalservices,clinicalprograms,andprofessionswasestablished.LearningsfromtheChoosingWiselyLosetheTubeToolkit(2017)wereleveraged,inadditiontoNYGH’sCAUTIworkaspartoftheNationalSurgicalQualityImprovementProgram(NSQIP).Theteambeganwithareviewofcurrentpracticesrelatedtourinarycatheterizations,themanagementofurinaryretention,anditsimpactonpatientcare.Strategiesimplementedincluded:1)developmentofastandardizedurinaryretentionmanagementprotocol,2)revisionofelectronicordersrelatedtourinarycatheterization,3)revisionofmedicaldirectivesthatauthorizedinsertionandremovalofurinarycatheters,and4)broadeducationandcommunicationtoprovidersandnursingstaff.
MeasuresKeymetricsinclude:1)urinarycatheterdays,2)indwellingurinarycatheterrates,3)urinarytractinfectionrates,and4)urinaryretentionrates.
ChallengesDiscussionpointsinclude:1)engagingabroadgroupofstakeholderstostandardizeacorporateurinaryretentionprotocol,2)operationalizingthechangesacrossclinicalprograms,includingchangestoordersetsandmedicaldirectives,3)sustainabilityofthestrategy,and4)ensuringdataqualitytoallowformeasurementofkeyoutcomes.
Lessons LearnedEarlyandongoingengagementofstakeholdersfrominceptionofprogramdevelopmentiskeytothesuccessofanycorporateinitiative.
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Electronic Referral Forms and Decision Support Tools Integrated into Electronic Medical Record Systems For Vascular Test Ordering by Physicians in Primary Care Settings in Newfoundland and Labrador (NL)KristaMahoney,ChoosingWiselyNLandQualityofCareNLBrendanBarrett,TPMI/MemorialUniversityGregBrowne,EasternHealthAmandaHall,MemorialUniversityOwenParfrey,MemorialUniversityofNewfoundlandPatrickParfrey,TPMI/MemorialUniversity
BackgroundOveruseofdiagnostictestinghasbeendemonstratedtobeasignificantprobleminCanada.AnalysisoftestutilizationpatternsattheprovincialvascularreferralcentreindicatesthatthisissueisprevalentinNL;Of17,600carotidarterytestsand15,858peripheralarterytestsundertakenfrom2007to2015,60%(10,560)and56%(8,901)werenotindicated,respectively.
AimToreduceunnecessaryvasculartestingattheonlytertiaryvascularreferralcentreinNL.
MethodTheintroductionofelectronicorderingindiagnosticvasculartests,withbuilt-indecisionsupportstoguideappropriatereferringbehaviourscanhelpmitigatethispatternofoveruse.Usingclinicalguidelinesandalgorithms,wewillembeddecisiontreeswithine-referralforms.Physicianresponsestoasetofcheckboxesincludingpatienthistory,symptomsandprevioustestingwilldeterminewhethertestingisneededurgently,recommended,ornotrecommended.Inadditiontodecidingonpriorityfortesting,thetoolwillconnecttoane-schedulertoautomaticallyprovideatestdate.Allorderingforvascularlabtestingwillbeelectronic,elinimatingallpaperforms.Accessfore-orderingwillbethroughtheprovincialelectronichealthrecord,Health-eNL.Ananalyticscomponentwillreportappropriateorderingbydoctorandindividualizedfeedbackwillbeaccessibleonline.Theelectronicreferralwillnotprohibitorderingbutwillensurespecificrationalefororderingisprovidedifnotrecommendedbythetool.Appropriatenesswillbeevaluatedtodeterminetheeffectivenessofthesee-referralformsinreal-worldsettings.Wewillbuilduponexistingtechnologyinfrastructureintheprovincetodesignanddeliverthisreferralsystem.
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Influencing Emergency Department Management and Imaging Practices for Two Common Presentations: Developing and Implementing a Theory and Data-Informed Intervention LynetteD.Krebs,UniversityofAlbertaCristinaVilla-Roel,UniversityofAlbertaNicoleHill,UniversityofAlbertaScottW.Kirkland,UniversityofAlbertaChrisAlexiu,AlbertaHealthServicesPatrickMcLane,AlbertaHealthServicesBrianR.Holroyd,UniversityofAlbertaMariaOspina,UniversityofAlbertaBrianH.Rowe,UniversityofAlberta
GoalThegoalofthisstudywastodevelopatheoreticallygroundedanddata-informedinterventiontoimproveemergencydepartment(ED)managementofpatientswithacuteasthma(AA)andbenignheadache(BHA),specificallyasitrelatestoimagingandvariationinimageordering.
ImplementationPrecedingtheinterventiondevelopment,studieswereundertaken,asfollows:1)systematicreviews,2)administrativedataanalyses,3)surveyswithpatientsintheEDaswellasemergencyphysicianswithqualitativefollow-up,4)sitechiefinterviews,and5)nurseinterviews.UsingtheBehaviourChangeWheel,preliminarydatafromthesestudiesidentifiedtheinterventionfunctions:education,incentivizationandenvironmentalrestructuring.Contentofinterventionmaterialswasinformedbyparticipatingsitedata.ImplementationatAlberta’slargesturbanandregionalEDsisongoingusingasteppedwedgedesign.
MeasuresSeveralinterventionfidelitymeasureswereimplemented.Theprimaryoutcomesforthestudy(e.g.,imaging,lengthofstay,dispositionstatus)arebeingtrackedthroughadministrativedata.
ChallengesSiteclinicianengagementcontinuestobeasubstantialchallengeathigh-volumeurbanandregionalEDs,includingacademicEDs.Newertechnologies,suchasQRcodesforclinicalorpatientengagementhavebeenrelativelyunsuccessful.
Lessons LearnedThisinterventiondevelopmentapproachrevealedtheneedforasystematicunderstandingofthesourcesofcurrentimageorderingbehaviour.LocalEDswillingnesstoengageinthestudyhasvariedconsiderablyandcanlimitsuccessfulimplementation.CollectingdataoninterventionfidelitymaybekeytounderstandingwhyandhowinterventionsintheEDfailtoachievetheintendedordesiredresults.
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Implementation of a New Diagnostic Algorithm for Anti-Neutrophil Cytoplasmic Antibody (ANCA) Testing MariaPasic,St.Joseph’sHealthCentreandSt.Michael’sHospitalAdrianaKrizova,St.Michael’sHospitalJeffCompanion,St.Joseph’sHealthCentreCathyStreutker,St.Michael’sHospitalDrakeYip,St.Michael’sHospitalJeffZaltzman,St.Michael’sHospitalDanielBeriault,St.Michael’sHospitalMalgorzataKisiel,St.Michael’sHospitalBeverleyYoung,St.Michael’sHospitalDawn-MarieKing,St.Joseph’sHealthCentreandSt.Michael’sHospitalVictorTron,St.Joseph’sHealthCentreandSt.Michael’sHospital
Anti-neutrophilcytoplasmicantibodies(ANCAs)areanimportantdiagnostictoolforANCA-associatedvasculitides.Thedominantautoantigensintheseconditionsareproteinase3(PR3)andmyeloperoxidase(MPO).ANCAtestingalsohasaroleindiagnosisofinflammatoryboweldiseases(IBD)andautoimmuneliverdiseases.Historically,thegold-standardtestforANCAvasculitisscreeninghasbeenindirectimmunofluorescence(IIF),withsubsequentantigen-specificimmunoassay/ELISAforMPOandPR3.RecentevidencesuggeststhatELISAisaseffectiveasthetwo-stepalgorithmpreviouslyproposed.Forlabsthatdonotperformthesespecializedtestson-site,turnaroundtimesmaybeprolongedduetosend-outandbatchtestingrestraints.Furthermore,performingmultiplemanualtestscanbecostlyandpotentiallyunnecessary.Inordertoensurethattheappropriatepatientsarebeingtestedandresultsarereceivedinatimelymanner,weaimedto:1)restrictorderingtosubspecialtiesthattreatANCAvasculitis/IBD/hepatitis;and2)optimizethediagnosticalgorithmfororderingANCAs.Basedonnewdevelopmentsinmethodologiesanddiscussionswithclinicalcolleagues,wecreatedtwotypesoforders:ANCAvasculitis(tobetestedbyELISA),andANCAIBD/hepatitis(tobetestedbyIIF,withnoreflextoMPO/PR3).As99%ofANCAordersatourinstitutionsareforANCAvasculitis,wedecidedtorestrictorderingofANCAIBD/hepatitistogastroenterologistsandhepatologists.
TheexpectedoutcomesareareductionininappropriateANCAordering,fasterturnaroundtimes,andimprovedusageoflabresources.Thesechangeshavebeenimplemented(January2018)andwillbefollowed-upprospectivelytoobserveiftheexpectedoutcomesaremet.
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Conceptualizing ‘Unnecessary Care’ in Emergency Departments (ED): Qualitative Interviews with Ed Physicians and Site ChiefsLynetteD.Krebs,UniversityofAlbertaNicoleHill,UniversityofAlbertaCristinaVilla-Roel,UniversityofAlbertaBrianH.Rowe,AlbertaHealthServices
Background“Unnecessarycare”(UC)isanincreasinglycommonterminmedicineandfrequentlyassociatedwithChoosingWisely®literatureandinterventions.PrevioussurveyresearchindicatesdefinitionsofUCvaryamongemergencydepartment(ED)stakeholders.Thisresearchexploreshowemergencyphysicians(EPs)andsitechiefs(SCs)understandUC.
MethodsSCsandEPsinAlbertawererecruitedthroughemailandonlinesurveysforonehourone-on-onein-depthinterviewsexploringUCconceptualizationswithintheED.Transcriptsunderwentthematicanalysis.
ResultsFiveEPsandsevenSCscompletedinterviews.Twokeythemesemerged.First,intervieweesconceptualizedUCasinappropriate/non-urgentpresentations.Thispatient-centricviewraisednon-urgentpresentationsasasystemproblemresultingfrom:alackofpublicknowledgeand/orwillingnesstouseotherresourcesandshrinkingcomfort/scopeofcommunityproviders.Despitenon-urgentvisitconcerns,intervieweesexpressedthatthesepatientsrequiredassessment/management.Thesecondconceptualizationfocusedonover-investigation(andtolesserextent,treatment).Thisphysician-centricconceptualizationidentifiedissuesaround:variationinphysicianrisktolerance,establisheddecisionruleswithallowable“missrates”,patientexpectationfortestingorphysicianfeelingthatthepatientwas“owed”something.IntervieweeswereconcernedbyconnectionsbetweenUCandwastedresources.IntervieweesemphasizedthatpatientconversationsareoutsidethescopeofUCdespitetheirpossibleimplicationsforlimitedtimeresources.
ConclusionArangeofconceptssurroundingUCintheEDwereidentified.Exploringnuancesoftheseconceptualizationsmayenhancetheeffectivenessofcampaignsseekingtoimproveefficiencyandreduceinappropriatecare.ThisworkprovidesanimpetusfordevelopingclearerconceptsofcarewithintheED.
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The Use of Clinical Decision Support Tools in the Emergency Department to Optimize Clinical Practice: A Systematic Review and Meta-AnalysisKatherineMemedovich,UniversityofCalgaryLauraDowsett,HTAUnit,UniversityofCalgaryDanielGrigat,AlbertaHealthServicesDianeLorenzetti,HTAUnit,UniversityofCalgaryJamesAndruchow,AlbertaHealthServicesAndrewMcRae,AlbertaHealthServicesGrantInnes,AlbertaHealthServicesEddyLang,AlbertaHealthServicesFionaClement,HTAUnit,UniversityofCalgary
BackgroundChoosingWiselyCanadahasidentifiedthat30%oftestsandproceduresperformedinCanadaarepotentiallyunnecessary.ClinicalDecisionSupport(CDS)toolsofferevidence-based,actionablerecommendationstoimprovedecisionmaking.WeundertookasystematicreviewofCDSimplementationsintheemergencydepartmenttoevaluateeffectivenessinchangingphysicianbehavior.
MethodsMEDLINE,EMBASE,PsychINFO,theCochraneCentralRegisterofControlledTrials,andCochraneDatabaseofSystematicReviewsweresearched.IncludedstudiesexaminedCDSintheED,reportedonphysicianadherencetooruseofCDS,utilizedacomparativestudydesign,andreportedprimarydata.Meta-regressionassessedtheeffectofcharacteristicsofthetool.
ResultsSeventy-twoarticlesmetinclusioncriteria;forty-sixreportedoutcomesappropriateformeta-regression.AtrendofincreasedCDSusewasfound(RCTOR:1.36[95%CI:0.97-1.89];observationalOR:2.12[95%CI:1.75-2.56]).Overall,physicianinteractionwithCDSrangedfrom0.37%to100%;adherencetorecommendationsrangedfrom16.2%to93.5%.Clinicalpracticeguidelinesweresuperiorcomparedtootherinterventions(p=.150).Multi-modaltoolswerenotmoresuccessfulthatsingleinterventions(p=.810).Lastly,voluntarytoolsmaybesuperiortomandatorytools(p=.148).Noneoftheresultswerestatisticallysignificant.
ConclusionOurreviewsuggeststhatCDSmayhavesmallbutmeaningfulimpactsonphysicianpractice.CDSmaybemostacceptableandimpactfulwithimplementationsintegratedintoworkflowafterconsultationwithphysicians.Futureresearchshouldexaminephysician’sperspectivesduringCDStoolstooldevelopmentandimplementationandwhattheyperceivetobemostuseful.
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Reduced CD4 Measurements in Stable HIV Patients is Associated with Significant Cost SavingsAhmedGhaly,LiseDupuis,GordonDowandDanielSmythHorizonHealthNetwork
MonitoringofCD4countshasbeenpartofHIVmanagementforyears.In2015,ChoosingWiselyCanadastated“Don’troutinelyrepeatCD4measurementsinpatientswithHIVinfectionwithHIV-1RNAsuppressionfor>2yearsandCD4counts>500/µL,unlessvirologicfailureoccursorintercurrentopportunisticinfectiondevelops.”ThepurposeofthisstudywastoidentifyhowmuchCD4testingcouldbereducedandtoidentifythecostsavingsassociatedwiththisovera12monthperiod.ThisstudywasconductedinasmallhospitalbasedHIVclinicwherepatientswerehavingCD4countsperformedevery3to4months.CD4testingwasdoneonlywhenrecommendedbuttheremainderofourfollowup(viralloadtesting,hematologyandbiochemistrymonitoring,andclinicalassessments)didnotchange.WekepttrackofallHIVpatientvisitsandwhenCD4testingwasorderedandthereason.Therewereatotalof381recordedpatientvisits.Ofthese,250(65.6%)hadCD4countsmeasured.131patientvisits,whereroutineCD4testingwouldhavepreviouslybeendone,didnothaveCD4measurementsdone.Ofthe250patientvisitswhereCD4testingwascompleted,themostcommonreason(130;52%)wasaCD4count<500.OurlocalcostforCD4testingwas$133.TheactualcostsavingsfromreducedCD4monitoringwas$17,290(131x$133)overa12monthperiod..Insummary,reducedCD4testinginstableHIVpatientswasassociatedwithasignificantcostsavingsandnoharmtothepatient.
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LHIN Collaboration & Standardization Improving Imaging PracticesWaltRomano,St.ThomasElginGeneralHospitalChristianBaldauf,GreyBruceHealthServicesMichellePierce,LondonHealthSciencesCentre/SouthWestLHINBrendonPilgrim,LondonHealthSciencesCentre/SouthWestLHIN
TheSouthWestLHINMedicalImagingIntegratedCareProjectwaslaunchedin2016toaddressthedemandissuesandstrainonthesystemsothatpatientexperienceandpatientcarecanbesustainablyimprovedwithregardstoMedicalImagingservices.Oneofthekeybarrierstoefficiencyoccurswhenthereisalackofconsistencyintoolsanprocesses.AsofNov2017,theSWLHINisthefirstLHINtoimplementastandardMRIrequisitionthatisusedbyallhospitalsitesintheregion.SupportingtheMRIrequisitionformsaretwoappropriatenesschecklistsforkneeandspine,whichhelpphysicianstodetermineifanMRIisnecessaryandwhichconditionsmaynotbenefitfromascan.AnadvisorycommitteeofLHINRadiologistsalsocollaboratedonastandardMRIprotocolsetforthemostcommonscans,tocreatefurtherefficienciesandeliminaterepeatscansforpatientsthatmovebetweensites.Therearechallengesachievingengagementandagreementofallstakeholderteamsacrosssuchabroadgeographicregion.Creatingandsustainingproductivecollaborationtakestimeandawillingnesstocollaborate.StrongleadershipandengagementoftheLHINteam,comprisedoftechniciansandphysicianleadersinradiology,familymedicineandmedicalandsurgicalspecialtieshasproducedwellthoughtout,highqualityworkwithChoosingWiselyatitscentre.Ensuringpatientsreceivethesamequalityservicesandexperiencenomatterwhatsitetheyvisitistheprimarygoal.Byintroducingonerequisitionformandensuringeachhospitaldeliversthesamequalityofimaging,theregionwillbeabletoreduceandeliminateunnecessaryduplicationoforderingandtesting.CTisnext.
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Endometrial Biopsy in an Outpatient Gynaecological Setting: Over InvestigationLaurenceSimard-Émond,CHUM
ObjectiveWereviewedtheindicationsforendometrialbiopsyatthegeneralgynecologyoutpatientclinicoftheUniversitédeMontréalHospitalCenterandmeasuredtheircompliancewiththeSocietyofObstetriciansandGynaecologistsofCanadaandotherinternationalguidelines.
Methods371filesofpatientswhohadanendometrialbiopsybetweenJanuaryandOctober2015werereviewed.Indicationforendometrialbiopsyandpathologyresultswerenoted.Fileswereseparatedintofourcategories.
ResultsInthepostmenopausalbleedingcategory,allfilescompliedwiththeSOGC.Wefoundhyperplasiaorneoplasiain13%ofpatients.Intheasymptomaticendometrialthickeningcategory,9%ofthefilesdidnotshowsufficientindicationforbiopsy.Noneofthepatientspresentedhyperplasiaorneoplasia.Intheabnormaluterinebleeding(AUB)–under41yearsoldcategory,therewasnoindicationforbiopsyin23%ofthefiles.Wefoundhyperplasiaorneoplasiain13%ofpatients,butonlyinpatientswithanindicationforbiopsy.InpatientswithAUB–over40,noncompliancewithSOGCwas3%.Butaccordingtointernationalguidelines,42%ofpatientswithAUBbetween41and45yearsolddidnothaveanindicationforbiopsyandnoneshowedhyperplasiaorneoplasia.
ConclusionWedemonstratedclinicallysignificantoverinvestigationinpatientswithAUB.Indicationsshouldbereviewedcarefullybeforeperforminganendometrialbiopsyinwomenunder41.Inaddition,thevalueofendometrialbiopsiesinpatientsbetween41and45yearsoldwithmenorrhagiaandnoadditionalriskfactorshouldbereevaluated.
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Optimizing the use of Endoscopy for Young, Otherwise Healthy Patients with DyspepsiaJenniferHalasz,BrennaMurray,SampsonLaw,ShawnDowling,KellyBurak,MarkSwain,GilaadKaplan,TarunMisra,JenniferWilliams,LindaSlocombeandKerriNovakUniversityofCalgary
BackgroundDyspepsiaisacommonreferraltoGastroenterology(GI).CollaborationbetweenprimarycareandGIinCalgaryhelpeddevelopadyspepsiapathwayandatelephoneadviceservice“SpecialistLink”.ChoosingWiselyCanada(CWC)recommendsagainsttheuseofesophagogastroduodenoscopy(EGD)inpatients<55yearswithoutalarmsymptoms,asclinicallysignificantfindingarerareinthesepatients.TheaimofthisstudywastomeasureandimproveadherencetotheCWCguidelinesfordyspepsiainCalgary.
MethodsEthicsapprovalwasobtained.EGDreportsandpathologyforproceduresperformedfordyspepsiainCalgarywereevaluated(April1-June31in2015,2016,2017).Onlyproceduresafterclinicconsultationwereincluded.ReferralsdeclinedthroughCentralTriagesinceJanuary1st2015werealsoreviewed.Laboratorydatafurtherrefinedthecohort.Physiciansconsentedtoreceiveindividualreportswithpeercomparators.Afacilitatedaudit&feedbacksessionwasheldtodevelopchangeplans.
ResultsTherewere12,184EGDsevaluatedwith1358performedtoinvestigatedyspepsiainpatients.
ConclusionThenumberoflowyieldEGDstoinvestigatedyspepsiaissignificant.Opportunitiesexisttobetterinvestigatedyspepsia.Partnershipswithprimarycareareimportanttoenhanceappropriateresourceutilization.
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Improving Appropriateness of Oxygen Saturation Monitoring in Paediatric Patients With Acute Respiratory Illness: a QI InitiativeBrigitteParisien,DarylCheng,MariaMarano,JulieJohnstone,NicoleCarmichael,AliAl-MaawaliandBethGamulkaHospitalforSickChildren
BackgroundOxygensaturationmonitoring(OSM)isakeyaspectintheassessmentofpaediatricpatientswithacuterespiratoryillnessessuchasbronchiolitis,asthmaandpneumonia.Itoftenservesasaproxyforillnessseverity.However,thereisapaucityofguidelinesaroundappropriateOSM.Existingevidenceshowsintermittentpulseoximetryisassafeascontinuousoximetrymonitoringinchildrenwithbronchiolitis.Furthermore,inappropriateOSMmayleadtooverdiagnosisandovertreatmentofmildhypoxiaandcontributetoprolongedlengthofstay.
MethodsAspartofthelocalChoosingWiselyCampaign,ouraimistoincreasetheappropriateuseofOSMinpaediatricinpatientswithasthma,bronchiolitisorpneumoniato90%byApril2018.AppropriatemonitoringwasdefinedasintermittentOSMwhenapatientisoffoxygenfor>2hoursandcontinuousOSMwhilstthepatientisreceivingsupplementaloxygen.A4-weekpre-interventionchartreviewshowed62%(23/37)hadappropriateOSM.Aseriesofinterventionswerethenchosentoimprovethemainoutcomemeasure:• Educationalsessionsorientedatmedicalandnursingstaff• Visualcuesdisplayedinpatientrooms• WeeklyelectronicremindersandperformanceupdatesPost-interventiondatacollectionbyprojectleadersoccurredfromJanuarytoApril2018.
ResultsOSMappropriatenessincreasedto77%(56/72)inthefirstmonthpost-intervention.TherewerenorecordedsafetyeventsassociatedwithappropriateOSM.
ConclusionThisQIinitiativewillimprovetheappropriateuseofOSMinpatientsadmittedforbronchiolitis,pneumoniaorasthmaatourpaediatrictertiaryhospitalwithoutincreasingthenumberofsafetyevents.Furtherinterventionsareplannedtoensuregreatersustaineduptake.
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Merging Initiatives: Choosing Wisely and Antimicrobial Stewardship – An Underutilized Connection.OliviaOstrow,KathrynTimberlake,LaurenWhitney,JeremyFriedmanandMichelleScienceTheHospitalforSickChildren
BackgroundRationaluseofantibioticsisaglobalpriority.Inappropriateorunnecessaryuseofantibioticsdrivesselectionofantibioticresistantorganismsandmayleadtopatientharm.TheChoosingWisely(CW)campaignatourhospital,withitsrecordofsignificantimprovementinmetricsforpastrecommendations,providedanovelopportunitytopromoteantimicrobialstewardship(AS).
GoalTodescribetheexpansionofahospital-wideCWcampaigntoincludeafocusonASatalargeCanadianchildren’shospital.
ImplementationTheASandCWprogramscombinedeffortstoidentifytargetsforimprovement.AntimicrobialusagedatawasreviewedandkeystakeholdersandsubspecialtysocietyCWlistswereconsulted.Asurveywasdevelopedandbroadlyadministered.Prioritywasgiventoinitiativesthatalignedwithorganizationalpriorities.
MeasuresThreeASinitiativeswereselected:1)improvingpost-operativeprophylacticantibioticuse,2)limitingbroadspectrumantibioticuseand3)improvingoutpatientantibioticuseforsuspectedurinarytractinfections(UTI).Baselinedrugutilizationevaluations(DUE)identifiedopportunitiesintheseareas.Anauditofpostoperativeantibioticuseshowed70%adherencetotheguidelines(ranging0%to100%).DUEsofvancomycinandmeropenemidentifieddurationoftreatmentasakeycontributortoinappropriateuse.Finally,areviewofpatientsdischargedfromtheEmergencyDepartmentwithasuspectedUTIshowedthatalmost50%receivedantibioticsdespitesubsequentnegativecultures,leadingto530unnecessaryantibioticdays.
Lessons LearnedDevelopingaCWlistwithanASfocuswasfeasibleandincreasedawarenessandpublicityfortheprogram.Similarinitiativescouldeasilybeadoptedbyotherinstitutions.
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Dermatology Guidelines for Choosing Wisely Canada: Five Things Patients and Providers Should QuestionSabrinaNurmohamed,UniversityofCalgaryLindaZhou,UniversityofOttawaRégineMydlarski,UniversityofCalgary
Dermatologistsdiagnoseandtreatdiseaseofthehair,nailsandskin.Thesepresentationscommonlypresenttobothprimarycareandspecialistphysicians.Thespecialistreferralsystemandrelativeshortageofdermatologistscontributetoapracticegapforappropriatemanagementofcommondermatologicconditions.TodatenoChoosingWiselyCanada(CWC)guidelinesexistforthespecialtyofDermatology.TheUSAandAustralianChoosingDermatologyguidelineswerereviewedindepthtoidentifymanagementprincipleswithsubstantialevidencebasis.Afocusedliteraturereviewwasperformedtogenerateanexhaustivelistofcommontests,proceduresandtreatmentsfordermatologicconditionssuchas:cellulitis,urticaria,fungalnailinfections,stasisdermatitisandsurgicalwounds.Across-Canadianpanelofdermatologistsinacademicandcommunitypracticeweretheninvitedtocontributetheirinputtodevelopafinallistoffiverecommendations.Thisprojectdevelopedrecommendationsfortheprovisionofhigh-valuecost-consciousdermatologiccarebydermatologists,non-dermatologistsandresidentphysiciansinpartnershipwiththeCanadianDermatologyAssociation.Thefinalconsensus-drivenDermatology-specificrecommendationswillbepresented.Theresultsofasurveyadministeredtopanelmembersonbarrierstoguidelinedevelopmentwillalsobeshared.
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Bronchiolitis Management in Calgary Emergency DepartmentsShawnDowling,UniversityofCalgaryIneldaGjata,PhysicianLearningProgramAntoniaStang,PhysicianLearningProgramKellyBurak,UniversityofCalgaryKatharineSmart,AlbertaHealthServices
Bronchiolitisisthemostcommonreasonforhospitalizationofinfantsbutpriorstudiessuggestthereissignificantvariationinpracticeandlowvaluecarebeingperformed.Ourobjectivewasto1.establishbaselinemanagementofbronchiolitis,and2.deliverauditandfeedback(A&F)reportstopediatricemergencyphysicians(PEP)toidentifystrategiesforpracticeimprovement.
MethodsThiscohortstudyincludedallpatients?12monthsoldthatpresentedtoaCalgaryemergencydepartmentswithadiagnosisofbronchiolitisfromApril1,2013toMarch31,2017.Usingdatafromvariouselectronicdatasources,wecapturedbaselinecharacteristics,therapeuticinterventionsandinvestigations.Descriptivestatisticswereusedtoreportbaselinecharacteristicsandinterventions.Interhospitalranges(IHR)wereprovidedtocomparehospitalsacrossthezone.FortheA&Fcomponentoftheproject,consentingPEPreceivedareportofboththeirindividualandpeercomparatordataandanin-personmulti-disciplinaryfacilitatedfeedbacksession.
ResultsWeincluded4023patientsfromall6sites(rangefrom28to3316patients).Bronchodilatorusewas27.0%(IHR21-41%).22.0%ofpatientsreceivedaCXR(IHR0-57%)and30.3%hadviralstudiesdone(IHRrange0.8-33%).62%PEPconsentedtoreceivetheirindividualA&Freports.InthefacilitatedfeedbacksessionPEPidentifiedareaswhereimprovementscouldbemadeanddiscussedspecificstrategiestodecreasepracticevariation.
ConclusionSignificantvariabilityexistsinmanagementofpatientswithbronchiolitisacrossdifferenthospitalsinourzone.Thefacilitatedfeedbacksessionidentifiedareasforimprovementandmulti-disciplinarystrategiestoreducedlowvaluecareforpatientswithbronchiolitis.
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How to reduce inappropriate preventive care.JamesDickinson,UniversityofCalgaryAinsleyMoore,McMasterUniversityRolandGrad,McGillUniversityStéphaneGroulx,CISSSdelaMontérégie-Centre
TheCanadianTaskForceonPreventiveHealthCareisre-establishingitselfasanauthorityprovidingevidence-basedpreventiverecommendations.ManyoftheserecommendrefocussingorevenstoppingactivitiesthathavebecomeroutinepracticeformanyCanadianphysiciansandtheirpatients.ChoosingWiselyrecommendationsrunparalleltomany.
However,changesinbehaviourareslow,andappeartobelimitedtoasmallfractionofdoctors,whileothersactivelyopposethechanges.
Inthisworkshop,membersoftheCanadianTaskForcewilldescribe:
• Therecommendationsforchange,• Howsomerecommendationshavebeenegregiously“misunderstood”• Howsomeprovincialguidelineshavechanged,whileotherssupportthestatusquo.• Limitedeffectivenessofeducationalapproaches• Doctorsinpracticeget“guidelinefatigue”andneedsimplewaystocommunicatequicklywithpatients,suchaseffectivescriptsand“infographics”
• Alternatewaysofchangingbehavioursuchasbillingchanges• Measurementsofchangedbehaviourafterguidelinechanges
WewillthendiscusshowChoosingWiselymemberscanworktosupportchangethroughvariousmechanisms:education,changingremunerationapproaches,changedclinicalprotocols.
WeencouragemembersofChoosingWiselytoattendandcontributetheirideasonhowtoadvancetheseevidence-basedideas.
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Choosing Wisely – Engaging our Patients - A Unique Opportunity for Nurse PractitionersJenniferMcDonald,TRFHT
TheNursePractitionerisanautonomousyetcollaborativehealthprofessionalwhointegratesin-depthknowledgeofadvancednursingpracticeandtheory,healthmanagement,healthpromotion,disease/injuryprevention,andotherrelevantbiomedicalandpsychosocialtheoriestoprovidecomprehensivehealthservices.Nursepractitionersworkincollaborationwiththeirclientsandotherhealth-careprovidersintheprovisionofhigh-qualitypatient-centredcare(CanadianNursesAssociation).TheNPcorecompetenciessupportthechoosingwiselyprogrambyincorporatingaholistic,personcentredapproachtoeachpatientencounter.NPscanleveragethisapproachinthecontextofeachpatientvisittochampionthechoosingwiselyinitiatives.ThispresentationwillreviewtheuniquescopeofpracticeandphilosophyofcareNPsbringtopracticeandofferpracticaltipsformakingeachvisit,whetherforanacuteepisodicillness,orachronicongoingconditionanopportunitytopracticewisely
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Implementing Critical Appraisal in the Choosing Wisely Recommendation Writing ProcessKatherineSmith,CanadianAssociationofMedicalRadiationTechnologistsGraceChung,BiomedicalZoneStephanieLea,DalhousieSchoolofHealthSciencesLisaPyke,CADTH
TheCanadianAssociationofMedicalRadiationTechnologists(CAMRT)establisheditsChoosingWiselyCanadaTop6recommendationsbyassemblingacorecommitteeofMedicalRadiationTechnologists(MRTs)fromacrossCanada,spanningallMRTdisciplines.Aninitialmeetingidentifiedtendraftrecommendations.
UsingamodifiedDelphimethod,thelistwasnarrowedto6draftrecommendationstatements.Sub-committeesweresubsequentlyformedtooverseeeachstatement.Throughalensofqualityandrigour,significanteffortsweremadetofindaprocessthatwouldraisethestandardsforcreatingevidence-basedinformedrecommendationsrelatingtoMRTpractice.Comprehensiveliteraturesearchesandreviewsweresimultaneouslyperformedforeachoftherecommendations.
ACriticalAppraisalGuidewasusedtohelpevaluatethequalityoftheevidenceforinclusion.ThetoolwasadaptedandmodifiedfrombrokeredtoolsprovidedbytheCanadianAgencyforDrugsandTechnologiesinHealth(CADTH).Threemembersofeachrecommendationcommitteecompletedthecriticalappraisalformforeachpieceofliteraturereviewed.Theappraisalswerethencomparedtoachieveconsensusforliteratureinclusionandexclusion.Indoingso,thecriticalappraisalaspectbecameanintegralpartofthedecision-makingprocessregardingthequalityofresearchevidenceforinclusion.
ThispresentationoutlinesausefultemplateforothermedicalprofessionalsocietiesandassociationstofollowinthecreationofrecommendationstatementsfortheCWCcampaign.CAMRTwillbeadoptingthiscriticalappraisaltoolandapproachforfutureevidence-basedguidelinesandrecommendationsputforwardbytheassociation.
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The Role of Audit and Feedback In Choosing Wisely: Are Physicians Able to Accurately Predict Their Own Practice?AntoniaStang,PhysicianLearningProgramShawnDowling,UniversityofCalgarySampsonLaw,UniversityofCalgaryIneldaGjata,PhysicianLearningProgram
BackgroundTheobjectivesofthisprojectweretodetermineif:1)therearedifferencesinpracticebetweenphysicianswhodo,anddonot,consenttoreceiveaconfidentialauditandfeedback(A&F)reportontheirpracticeand;2)ifthereisarelationshipbetweenphysiciansself-predictedandactualpractice.
MethodsThiswasaprospective,cross-sectionalstudy.AllphysicianspracticingintheEDofatertiarycarepediatrichospitalwereofferedtheopportunitytoreceivedataontheirpractice.Priortoreceivingtheirdata,consentingphysicianswereaskedtopredicttheproportionofbronchioliticpatientsforwhomtheyordereddiagnostictestsortreatments.Weusedchi-squaredtestingtocomparetheproportionofconsentingandnon-consentingphysicianswhosediagnostictestandtreatmentorderingwasabovethemedianforallEDphysicians.WeusedPearson’scorrelationtoassesstherelationshipbetweenconsentingphysiciansself-predictedandactualpractice.
Results56%(37/66)ofphysiciansconsented.Themedianproportionofpatientswithanx-rayorderedwas20%,63%ofnon-consenterswereabovethemedian,comparedto36%ofconsenters(X2(1,N=66)=4.91p=0.03).Overall,18%ofpatientshadVentolinordered,with60%ofnon-consentersand42%ofconsentersabovethemedian(X2(1,N=66)=2.2p=0.138).TherewasminimalcorrelationbetweenpredictedandactualpracticeforCXR(0.05),steroids(r=0.17)orVentolin(r=0.33).
ConclusionTheconsentprocessmaybeabarriertoA&F,andphysicianshavealimitedabilitytoaccuratelypredicttheirownperformancewhichhighlightstheimportanceofprovidingfeedback.
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Driving Change Using Audit and Feedback: Primary Healthcare Panel ReportsMarkusLahtinenandJodyPowHealthQualityCouncilofAlberta
Auditandfeedbackplayapositiveroleinchangingfamilyphysicianbehaviorthatinturn,impactspatientcareandpatientexperience.TheHQCA’sPrimaryHealthcarePanelReportscontributetothischangeprocessbyprovidingmeaningful,relevant,anddescriptiveclinicalandexperientialinformationthatsupportsreflectivepracticeandqualityimprovement.Foreachreport,thepatientpanelisbasedoneitheraconfirmedpatientlists(CPL)ortheHQCA’sproxypanel.Overthepastyear,weworkedwithkeystakeholderstoreviewthemeasures,layoutandnarrativeofthesereportstoensuretheyoffersoundvaluetoourprimaryhealthcarepartners.Specifically,theHQCAcollaboratedwiththePhysicianLearningProgramtodevelopandreportonthefollowingChoosingWiselymetrics:
• Papanicolaou(Pap)tests–forfemalesagedunder21;21to24;thosebetween25to69;andthoseover70
• DEXAscans–thenumberofpatientsunder50;thoseaged50to64;andover65whohadasingleDEXAscaninthelastyearandthenumberofpatientswhohadmultipleDEXAscansinthelasttwoyears
• Lumbarspinescans–thenumberoflumbarspinescansdonebyCT,andMRI
ThereportsprovideinformationthatisnotavailableinEMRs,presentspeercomparators,andadjustutilizationmetricstocontrolfortheinfluenceofpatientcharacteristics.The2018PrimaryHealthcarePanelReports,alongwithpatientexperiencedata,canbeusedforprimaryhealthcareplanning,evaluation,andservicedevelopment.
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Physician Utilization Scorecards in Primary Care: A Cross-Sector Partnership to Improve Test UtilizationCourtneyPrice,LifeLabsNatalieCeccato,LifeLabsDeepakSharma,NorthYorkGeneralHospitalTracyLindsay,NorthYorkGeneralHospital
GoalAssesstheimpactofutilizationdataprovidedtoindividualphysiciansonorderingofcommonlaboratorytests,focusingonreducingreflexivethyroidtesting.
ImplementationFiveOntarioFamilyHealthTeams(FHTs),NorthYorkGeneralHospitalandLifeLabspartneredtoprovideindividualutilizationdatato104physiciansonthetoptestsorderedanddetaileddataonthyroidtesting.BaselineutilizationreportswereadministeredinJan2017,andthenprovidedquarterly(May,July,andNov).ReportswereprovidedtoeachFHTleadwhocoordinateddistributiontosupportphysicianprivacy.
MeasuresUtilizationreportsshowedtestorderingformostcommontestsandspecificthyroidtests.Itincludedindividualperformancechangesrelativetobaselineaswellaspeercomparatorsusingmedianmonthlyordering,%oftotalTSHorderswithassociatedT3/T4s,andratioofTSHtoT3/T4orders.
ChallengePhysicianconsenttoparticipateatsomeFHTswasinitiallydifficulttoobtain.Dataqualityissuespresentedchallengesinestablishingavalidbaseline,particularlyrelatedtophysician’sorderingacrossmultiplepracticesites.Anappropriatecomparatorwasdifficulttofindintheabsenceofanavailabledenominatorwithwhichtobalanceoutvariationsinphysicianpracticesizes.
Lessons LearnedQualitativefeedbackdemonstratesneedforsimplificationofreportdesigntoimproveactionabilityoffindings.Formalevaluationtoensurereportsprovidetherightlevelofinformationtotherightaudienceinavisuallyintuitivemanneriscritical.Distributionthroughtheresearchteamtositeleadswasaneffectivemodeltoidentifydataqualitychallengesandcoordinatecommunicationamongsiteleads.
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Screening for New Primary Cancers in Patients with Metastatic Breast Cancer: A Provincial Analysis of the Choosing Wisely Canada RecommendationsMeganTesch,MemorialUniversityofNewfoundlandKaraLaing,Dr.H.BlissMurphyCancerCentre
BackgroundAspartofthebroaderChoosingWiselyCanadacampaign,alistwaspublishedinMay2015ofpracticesinoncologythatarecommonlyperformeddespiteevidenceshowingnegligiblebenefitandthepotentialtocauseharm.Oneoftheserecommendationsisforphysicianstoavoidroutinecancerscreeningorsurveillanceforanewprimarymalignancyinpatientswithmetastaticdisease.Theobjectiveofourstudywastoassesswhetherlocalpracticeisinkeepingwiththeserecommendations.
MethodsAretrospectivereviewofscreeningfornewprimarycancerswasconductedinmetastaticbreastcancerpatientsseenattheDr.H.BlissMurphyCancerCentreinSt.John’s,NewfoundlandandLabrador(NL)duringthethree-yearperiodofJanuary1,2014toDecember31,2016.Specificscreeninginvestigationsincludedscreeningmammography,Papanicolaoutest,fecalimmunochemicaltest,andscreeningcolonoscopyorflexiblesigmoidoscopy.
ResultsAtotalof305patientmedicalrecordswerereviewed.Overall,114patients(37.4%)underwentatleastonescreeninginvestigation(mean,2.92investigationsperscreenedpatient).70%ofscreeninginvestigationswereorderedbyprimarycareproviders,incomparisonto14%byoncologistsand12%byotherspecialists.Themedianoverallsurvivalofbreastcancerpatientsafterdiagnosisofmetastaticdiseasewas42months,witha5-yearoverallsurvivalof35.9%.
ConclusionsAsignificantproportionofpatientswithmetastaticbreastcancerinNLandarestillundergoingscreeningfornewprimarycancers,indiscordancewithChoosingWiselyguidelines.Increasededucationalstrategiesareneededifrecommendationsaretobeimplementedintoroutineclinicalpractice.
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Frequency and Utility of Pre-Consultation MRI Use in Patients Referred for Possible Total Knee ArthroplastyStephenPatton,DanielTushinski,JustindeBeer,AngelaAccettura,SherriGavin,SusanMontgomery,DaniellePetruccelli,SampaSamanta,NancyToffoloandMitchellWinemakerHamiltonHealthSciences
PurposeTodeterminethefrequencyandutilityofMRIinpatientsreferredforassessmentandmanagementofkneeosteoarthritis.
Method Prospectiveauditwasconductedon3,598patientsreferredtotheRegionalJointAssessmentProgram.PatientswereassessedbyAdvancedPhysiotherapistPractitioners(APP)whospecializeintheassessmentandtreatmentplanningofpatientswithhipandkneeOA.AllpatientsreferredtooneRJAPovera10-monthperiodunderwentfunctionalassessmentandreviewbytheAPP.FrequencyofMRIanditsutilityindeterminingkneeOAdiagnosisandsubsequenttreatmentplanweredetermined.
Results79.6%ofpatientspresentedwithweightbearingkneeradiographs.ObviousOAwasevidenton83.7%ofradiographicstudiesandwasclearlyclinicallyevidentin91.7%ofpatientsonexamination.20.7%ofpatientspresentedwithakneeMRI;in8.1%ofthesepatients,MRIwasthefirst-linepre-consultationdiagnostictest.In59.0%ofpatientspresentingwithMRI,thefindingsweredeemedtobeofnovalueinsupportingthediagnosis,norweretheyofanyvalueintreatmentplanningfor63.6%ofpatients.
ConclusionOnceweight-bearingx-rayshaveconfirmedadiagnosisofosteoarthritis,furtherinvestigationwithMRIhaslittlevalueinpatientswithkneeosteoarthritis.UnnecessaryuseofMRIamongreferringproviderforpatientswithOAofthekneeconstitutesaburdentothehealthcaresystem.ThereisaneedtoeducatereferringprovidersandpatientstocurtailtheuseofthisdiagnostictestintheassessmentofkneeOA.
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A Data-Driven Approach to Identifying Laboratory Overutilization – Results from the General Medicine Inpatient Initiative (GEMINI)AdinaWeinerman,SunnybrookHealthSciencesCentreYishanGuo,St.Michael’sHospitalFahadRazak,St.Michael’sHospitalAmolVerma,St.Michael’sHospital
BackgroundRecommendationsforresourcestewardshipareoftenbasedonexpertopinionwithrelativelylittleutilizationdatatohelpidentifyorprioritizetargetsforintervention.Thepurposeofthisstudywastodevelopadata-drivenapproachtoidentifyingpotentialsourcesoflaboratoryoverutilization.
MethodsWeextractedelectronicclinicaldataforalllaboratorytestsperformedduring26,469GeneralInternalMedicineinpatientadmissionsatanacademichospitalinTorontobetweenApril1,2010andMarch31,2015.Thecostofeachtestwasobtainedfromthehospitalcasecostingdatabase.Testswithacumulativecostofmorethan$20,000wereanalyzedtodeterminetheproportionofabnormalresults(usingpre-specifiedclinicalandlaboratorythresholds)andphysician-levelvariabilityinordering(definedasthephysician-levelcoefficientofvariationinthenumberoftestsperformedperpatient-day).Eachtestreceivedacumulativerankbasedonhighesttotalcost,highestphysician-levelvariation,andlowestproportionofabnormalresults.
ResultsThefollowingtestshadthehighestcumulativeranksaspotentialresourcestewardshiptargets:1)RBCfolate,2)CSFcellcount,3)serumfolate,4)urineosmolality,5)immunofixationelectrophoresis,6)CK,7)TSH,8)troponin,9)lactate,and10)bilirubin.Inaddition,ANAandferritinwerealsoidentifiedastargetsbasedonlowproportionofabnormalresultsandhighphysicianvariability.
ConclusionsAdata-drivenapproachtostudyinglaboratoryutilizationidentifiednoveltargetsandvalidatedexistingtargetsforresourcestewardshipbasedontotalcost,physician-levelvariation,andproportionofabnormalresults.Thesemethodscanbereplicatedtoprovideinstitution-specificinsights.
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Using Facilitated Audit and Feedback to Support Choosing Wisely Initiatives for Primary Care PhysiciansAshiMehta,AlbertaPhysicanLearningProgramSampsonLaw,UniversityofCalgaryAnthonyTrain,ChoosingWiselyAlbertaEileenPatterson,TowardOptimizedPracticeJuneCooper,AlbertaMedicalAssociation-TowardOptimizedPracticeJohnLester,AlbertaMedicalAssociation-TowardOptimizedPracticeShawnDowling,UniversityofCalgaryKatrinaNicholson,PhysicianLearningProgram,UniversityofCalgaryLaraCooke,UniversityofCalgaryKellyBurak,UniversityofCalgary
Abstract:Receivingfeedbackisacriticalcomponentofimprovingperformance.Physiciansoftenhavelimitedopportunitiestoreceivedirectandrelevantfeedbackrelatedtoadherencetobestpracticeguidelines.Wedevelopedamulti-facetedlearningworkshoptoprovidefamilyphysicianswithanopportunitytoreview,understandanduseindividualizeddatatoself-reflectontheirpractice.
GoalWeaimedtosupportphysiciansindevelopingandimplementingpracticechangeplanstoimprovepatientcarerelatedtoCWrecommendationsonappropriatepapsmeartesting,bonemineraldensityscans,andlumbarspineimaging.
ImplementationOurworkshopswereCFPCMainpro+certifiedeventscomprisedof:(1)didacticlecturewheresubjectmatterexpertssharelatestevidence-basedbestpractices;(2)participantsreceiveandreviewindividualizedpracticereports;(3)facilitatedsmallgroupdiscussionsidentifybarriersandenablerstoachievingbestpractice;and(4)developmentofactionplansandstrategiesforimprovement.
MeasuresOver15months,5primarycarephysiciangroupstotaling207physiciansand60alliedhealth/qualityimprovementprofessionalsparticipated.Wedelivered182individualizeddatareportsdirectly,andover2,500throughpartnershipwiththeHealthQualityCouncilofAlberta.Participantfeedbackhasbeenpositive;97.5%wouldrecommendtheprogramtoacolleague,87.8%felttheprogramdirectlysupportedtheirimprovementinitiatives,and91.2%thoughttheprogramhelpedthemsetandevaluatepersonalimprovementgoals.
ChallengesInvolvingapatient-perspectivecanenhancetheimpactofthisprogram,however,thebeststrategiestodothiscanchallengingtoidentify.
Lessons LearnedDataonactionablemetricsisanextremelystrongphysicianengagementtoolandcandrivephysician-ledimplementationofchangeideas.
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Treatment of Asymptomatic Bacteriuria in Elderly Patients With Delirium: A Systematic ReviewAdamSuleman,UniversityofOttawaJohnKrakovsky,UniversityofOttawaPilJoo,St-FrancisMemorialHospital
IntroductionItistypicaltolookforUTIindeliriouselderlypatients,despiteahighprevalenceofasymptomaticbacteriuria(ASB)inthispopulation.Acommonpresentationofinfectionisdelirium,whichoftenhasanon-specificandmultifactorialetiology.Therefore,whenbacteriuriaispresentwithdeliriumintheabsenceofurinarysymptoms,physiciansprescribeantibioticsforthesuspectedUTI-induceddelirium.WesettodeterminewhetherantibiotictreatmentintheelderlypresentingwithdeliriuminthepresenceofASBresultedinresolutionofdelirium.
Methods LiteraturesearcheswereperformedinMEDLINE,EMBASE,CINAHLandCochraneLibrary.Abstractswereindependentlyreviewedbytwoauthorsfordecisiontoincludeforfull-textreview.Inclusioncriteriaincludedfemalegender,>65yearsofage,presentinginanacutecaresettingwithdeliriumandASB.Theprimaryoutcomewasresolutionofdelirium.Thesecondaryoutcomesweremortality,frequencyofsideeffectsfromantibiotics,lengthofhospitalstayandreadmissionfordelirium.
Results 930abstractspublishedfrom1946-2017werescreened,and42wereincludedforfulltextreview.Nostudieswereeligibleforinclusioninthesystematicreview,asnoneaddressedtheprimaryoutcome.OnestudyaddressedtheoutcomesofpoorfunctionalrecoveryafterdeliriumandtherateofimprovementofdeliriumsymptomsafterpresentationofdeliriumwithASB.
Discussion EventhoughcurrentguidelinesrecommendagainsttreatmentofASB,noguidelinestateswhetherASBshouldbetreatedinelderlypatientswithdelirium.LittleevidenceexiststoelucidatewhethertreatingdeliriouspatientswithASBresultsinimprovementinoutcomes.
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A Database Platform to Monitor In-Hospital Glucometer UseJenniferTaher,UniversityofTorontoJakeCosme,UniversityofTorontoIrvinBromberg,MountSinaiHospital
BackgroundGlucometersareacommonpoint-of-caretestingdeviceusedformanagementofin-hospitalpatientglucoselevels.Thepurposeofthisstudywas:1)toidentifyandimprovemanagementofhypoglycemiapatientsand2)tomonitorin-hospitalutilization/frequencyofglucometermeasurements.
MethodsAdatabaseprogram(GLUM)wasdesignedtoaccessglucometerdatafromthehospitallaboratoryinformationsystem.Visualbasicsoftwarewasusedtodevelopanexcel-baseddigitalapplicationtographthein-hospitalglucometerresultsas1)individualwardsummarystatistics,2)individualpatienttrendchartsoveraspecifieddate/timerangeand3)numberofglucometermeasurementsperpatientperday.TheprogramwasdevelopedandtestedusingdatafromMountSinaiHospitalwithRocheAccu-ChekInformIIglucometers.
ResultsWardplotsprovidedavisualrepresentationofhypoglycemiaincidenceandvolumeofglucometeruseaccordingtospecifieddateranges.Graphicalpointswereselectedonwardplotstoidentifyindividualpatientsandassessrecenthistoryofrecurrenthypoglycemia.Thisdatawascorrelatedwithdailyfrequencyofglucometeruseperpatient.WithintheMountSinaidatabase,patientswereidentifiedtohaveupto23glucometermeasurementsperdaywithoutindicationofhypoglycemiaevents(definedasglucoselessthan4mmol/Linadultsandlessthan3mmol/Linneonates).
ConclusionFrequencyofin-hospitalglucometermeasurementscanbeassessedusingthedevelopedGLUMdatabaseplatform.Thisdatacanbecorrelatedwithadditionalpatientinformation(ie/hypoglycemiaevents)todeterminetheappropriatenessofhighfrequencytesting.Theapplicationaimstoidentifytheappropriateuseandpotentialover-useofin-hospitalglucometertesting.
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The Use of Theories and Frameworks to Understand and Address the Reduction of Low-Value Healthcare Practices: A Scoping ReviewGillianParker,NidaShahid,WhitneyBertaUniversityofToronto
BackgroundEffortssuchasChoosingWiselyhaveinitiatedaparadigmshiftinhealthcarepractice.Researchershavebeguntousetheoryordevelopframeworkstoelucidatethedynamicsofde-implementationandsupporteffortstoreducelow-valuepractices.Thepurposeofthisscopingreviewwastoidentifyandcharacterizetheuseoftheoriesandframeworkstounderstandandaddressthereductionoflow-valuecare.
MethodsWeconductedasystematicreviewofMEDLINE,EMBASE,CINAHLandScopusdatabasesfrominceptiontoDecember2017.Buildingonpreviousresearch,33keytermswereusedtosearchtheliterature.Tobeincluded,papershadtopresentanexplicittheoreticalapproachorframework.
ResultsIntotal55articleswereincludedafterscreening1106citationsand70full-textarticles.Themajorityofstudiesdevelopedanewframeworkortestedanexistingframework.Ofstudieswhichusedatheoreticalapproach,themajorityusedpsychologicaltheories,suchastheTheoryofPlannedBehaviourorappliedBehaviouralScienceconceptstodevelopinterventions.Themajorityofstudiesaddressedlow-valuecareattheproviderlevel,butnumerousstudieswerealsoidentifiedwhichaddressedthereductionoflow-valuecareattheteamandsystemlevels.Antibioticoveruse,polypharmacyandappropriateprescribingpracticeswerethepracticestargetedmostfrequentlyintheincludedstudies.
ConclusionsDe-implementationisanemergingfieldofresearch.Theresultsofthisreviewcanprovidedirectionandinsightforfutureprimaryresearchintheuseoftheorytosupportde-implementationandreductionoflow-valuehealthcarepractices.
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A Scoping Review Exploring Interventions Changing Image Ordering in Pediatric Emergency MedicineLynetteD.Krebs,UniversityofAlbertaLindsayA.Gaudet,UniversityofAlbertaMeaganCarr,UniversityofAlbertaMaureenKruhlak,UniversityofAlbertaNicoleLoewen,UniversityofAlbertaScottW.Kirkland,UniversityofAlbertaAmandaHall,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLSandraCampbell,UniversityofAlbertaBrianH.Rowe,UniversityofAlberta
BackgroundTheintroductionofChoosingWisely®andconcernsoverradiationexposureinpediatricemergencymedicine(PEM)haveresultedinmanystudiesonimageorderingpractices.ThisscopingreviewexplorestheliteratureonimageorderinginterventionsinPEM.
MethodsElectronicdatabasesandgreyliteratureweresearched.Aprioriexclusioncriteriawereestablishedandfollowed.Aminimumoftwoindependentreviewersassessedstudyinclusionbasedonpre-definedcriteriaandextractedthedata.Disagreementswereresolvedthroughdiscussion.DescriptiveresultsforPEMstudiesarereported.
ResultsOfthe389full-textstudiesassessed,135meettheinclusioncriteria,35ofwhichwerePEMstudies.Thesestudiesfocusedontraumatic(14),non-traumatic(19)andmixed(2)presentationsandthemajorityweresinglecentrebefore-afterstudies.Themostcommonimagingmodalityexaminedwascomputedtomography(CT;24studies).Halfofthestudies(18)reportedoutcomesformorethanoneimagingmodality.OfthestudiesreportingonCTordering(26CToutcomes),22reportedadecreaseinordering;15ofwhichwerestatisticallysignificant.Themostcommoninterventionacrossstudieswasintroductionofapathway/protocol(30[86%]),followedbytheuseofinformationoreducation(23[66%]).Moststudieshadmultipleinterventioncomponents(23[66%])andhalf(18[51%])providedimplementationdetails.
ConclusionsInterventionstochangeimagingorderinginPEMappeartobeusefulinreducingimaginguse;however,lowqualitymethodssuggestcautioniswarranted.Systematicreviewstoexploreeffectivenessoftheseinterventions,interventionfidelity,andstudyqualityareneeded.
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Piloting a Tool to Reduce CT for Benign Headache in Alberta Emergency DepartmentsLynetteD.Krebs,CristinaVilla-Roel,MariaOspina,BrianR.HolroydandBrianH.RoweUniversityofAlberta
BackgroundReducingunnecessaryimagingforpatientswithbenignheadache(BHA)isatargetofChoosingWisely®activities.AstructuredhandoutwasdevelopedforpatientswithBHApresentingtotheemergencydepartment(ED)toinformthemofwhencomputedtomography(CT)isneeded.Thetoolwaspilotedwithaconveniencesampleofemergencyphysiciansandpatients.
MethodsAnonlinesurveywasdeliveredviaemailtoemergencyphysicianspracticinginoneAlbertaregion.AdultpatientswithBHApresentingtotwourbanAlbertaEDsprovidedfeedbackonthetool.Descriptiveresultsarereported.
ResultsAtotalof73emergencyphysicians(38%)and160patientscompletedsurveys.Approximately50%ofthephysiciansfeltcomfortableusingthetool.Suggestedchangesincluded:removinginformationonorderingvariationorhealthsystemcosts,andincludingspecificinformationonCTindicationsandrisks.PhysiciansopposedthegeneralityofthefourChoosingWisely®questionsfearingtheywouldincreasepatient’simagingexpectations.Patientsagreed(94%)theyunderstoodtheinformationandthatitappliedtothem(68%).Approximatelyhalfofthepatientsagreedthatbecauseoftheinformationprovided,theywoulddiscusstheirneedforimagingwiththeirphysicianduringthecurrentornextpresentation.PatientrecommendationsfortoolmodificationwerealmostexclusivelyformoreCT-relatedinformation.
ConclusionTheseresultsledtoreconceptualizationofthetool.Informationspecificitywasenhancedtosupportinformedclinician-patientdialogue.ThisstudyreinforcestheimportanceofpilotingandhighlightspotentialconcernswithusingtheChoosingWisely®questionswithoutadjustingthemforcontextandpatientagency.
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Choosing Wisely in Radiation Oncology: Driving Practice Change through Measurement and Quality Improvement KimTran,CanadianPartnershipAgainstCancerJulianKim,CancerCareManitobaPhilipWright,SaskatchewanCancerAgencyRamiRahal,CanadianPartnershipAgainstCancerMaryArgent-Katwala,CanadianPartnershipAgainstCancerJenniferChadder,CanadianPartnershipAgainstCancerAnnemarieEdwards,CanadianPartnershipAgainstCancer
BackgroundAsinglefractionofradiationtherapy(RT)isrecommendedforthepalliativetreatmentofuncomplicatedbonemetastases.AreportreleasedbytheCanadianPartnershipAgainstCancerfoundadherencetothisrecommendationvariedacrossthecountry,withSaskatchewan(SK)andManitoba(MB)havingthelowestuseofsinglefractionRT(31%)forbonemetastases.Asaresult,aqualityimprovement(QI)projectinvolvingthePartnership,SaskatoonCancerCentre,AllanBlairCancerCentreandCancerCareManitobawasimplementedtoincreasetheevidence-baseduseofsinglefractionRTforuncomplicatedbonemetastases.
MethodsThePartnershipconductedaliteraturesearchandheldafocusgroupwithradiationoncologiststoidentifybarrierstoadherencetotherecommendation.Strategiesaimedataddressingbarriers(i.e.,educationaloutreachwithlocalchampions,consensusdevelopmentmeetings)wereimplementedbetweenJanuaryandMarch2017.Post-implementationsurveydatawerecollectedtoidentifytheimpactoftheQIstrategies,andwillinformpotentialspreadandscaleacrossCanada.
Results26of32(81%)radiationoncologistsinSKandMBrespondedtothesurvey.SurveyresultssuggestthattheQIprojectledto:
• increasedawarenessoftherecommendation(MB:86%,SK:83%),• increasedknowledgeoftheevidencesupportingtherecommendation(MB:86%,SK:100%),• practicechangetoincreaseuseofsinglefractionradiationwhereappropriate(MB:90%,SK:100%).
ConclusionsThisworkhasthepotentialtoincreaseevidence-baseduseofradiotherapyforbonemetastases,whichcanreduceunnecessarytreatmentburdenonpatientsandcancontributetowardsmoreefficientuseofresourcesandimprovedhealthsystemsustainability.
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What Behaviour Change Techniques Have Been Used to Reduce Physician’s Image-Ordering for Low Back PainAmandaHall,MemorialUniversityCharlotteAlbury,NuffieldDepartmentofPrimaryCareHealthSciences,UniversityofOxfordJacquelineThompson,UniversityofOxfordJamesMatthews,SchoolofPublicHealth,Physio&PopScience,CenterforSportsStudies,UniversityCollegeDublinHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversityPatrickParfrey,TPMI/MemorialUniversity
BackgroundReviewsofinterventionstoreducephysician’simage-orderingforlowbackpain(LBP)indicatethatdecision-supportandtargetedreminderscouldhaveasmalleffect.Thereviewsdescribedinterventioncontentbutnotthespecifictechniquesusedtochangebehaviour.Therefore,weaimtobuildonexistingliteraturebysynthesizingwhatbehaviourchangetechniques(BCTs)havebeenusedtochangephysician’simage-orderingbehaviourforLBP.Methods:3Electronicdatabasesweresearched.TworeviewersassessedeligibilityandcodedinterventionsusingtheBCTtaxonomy;whichcontains93BCTsorganizedinto16categories.Interventionsweresynthesizedbythosetargetingphysicians(reportedhere),health-systemsorpatients.
Results14interventionswereidentified.Elevenofthe16BCTcategorieswereused:4.0-Shaping-knowledge(10interventions),2.0-Feedback-and-monitoring(7interventions),7.0-Associations(7interventions),8.0-Repetition/substitution(6interventions),6.0-Comparison-of-behavior(5interventions),12.0-Antecedents(5interventions),9.0-Comparison-of-outcomes(4interventions),1.0-Goals-and-planning(4interventions),3.0-socialsupport(3interventions),5.0-Natural-consequence(3interventions)and10.Reward-and-threat(1intervention).Intotal,29ofthe93BTCswereused.ThemostcommonBCTswere4.1-instructiononhowtoperformthebehavior(i.e.redflagassessment)in10interventions,7.1-Prompts-and-cues(i.e.genericpostersaboutwhentouseimaging,reminderstouseinterventionmaterials,orpersonalelectronicmessageswithalternativesforinappropriateimagingorders)in7interventions,and2.2-Feedback-on-Behaviour(i.e.numberofimagesorderedinthepreviousmonths/year)in6interventions.ThenumberofBCTsusedrangedfrom1to17withmoststudiesusing>/=5.
ConclusionMostinterventionsfocusedonknowledge/remindersofwhentouseimagingandpersonalperformancereports.Fewinterventionstargetwell-knownbarriersofsocialinfluence(e.g.patientexpectations),skills(communicatingsatisfactorydiagnosiswithoutimaging)andresources(lackoftimetodiscussdiagnosis,imagingneedsandtreatmentrecommendations),limitingthepotentialforeffect.
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Measuring Benzodiazepine use Among Seniors with In-Hospital DeliriumBrandonWagar,JayO’DonnellandJamesHutchinsonIslandHealth
ChoosingWiselyCanada(CWC)recommendationsforHospitalMedicineandGeriatricsbothincludeDon’tusebenzodiazepinesandothersedative-hypnoticsinolderadultsasfirstchoiceforinsomnia,agitationordelirium.AtVancouverIslandHealthAuthority,in-hospitaldeliriumhasbeenidentifiedasapriorityforQualityandPatientSafety.Itisimportanttotrytopreventdeliriumbyaddressingmodifiableriskfactors.Itisalsoimportantthat,oncedeliriumisestablished,itstreatmentshouldfollowbestpractice.ConsistentwithCWCrecommendations,recommendedbestpracticesfortreatingdeliriumemphasisenon-pharmacologicalstrategies.Pharmacologicalinterventionsmayaugmenttheseapproaches;however,theevidencetosupportthisislimitedandtheiruseiscontroversialbecauseofthelackofevidenceoftheireffectivenessandpotentialforharm.ClinicalordersdatafromIslandHealth’selectronichealthrecordwerelinkedwithCIHI’sDischargeAbstractDatabasetoevaluatebenzodiazepineuseamongseniorswithin-hospitaldelirium.Nearlytwothirds(64%)ofin-hospitaldeliriumcasesatIslandhealthweresurgicalcases.Amongseniors(65+)whoacquiredin-hospitaldeliriumatIslandHealthhospitals,53%ofsurgicalpatientsand44%ofmedicalpatientsweregivenbenzodiazepines.Bothratesarehighgiventherecommendations,andtherateamongsurgicalpatientswassignificantlyhigherthantherateamongmedicalpatients(?2=3.8,p<0.05).
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Assessing the Risk of Intracranial Bleeding in Emergency Department Seniors who have FallenKerstindeWit,McMasterUniversity
BackgroundFallingisthemostcommoncauseofintracranialinjuryamongtheelderly,accountingforalmost80%ofbraininjury.Thenumberofemergencydepartmentvisitsforfallsinseniorsisrising.Ouraimwasto1).determinetheproportionofelderlywhopresenttotheemergencydepartmentafterafall,whoarediagnosedwithintracranialbleedingand2).reportemergencyphysicianuseofheadCTtodiagnoseintracranialbleedinginthispatientgroup.
MethodsWeconductedaprospectivecohortstudyattwoemergencydepartmentswithanannualvolumeof100,000patients.Werecruitedemergencydepartmentpatientsage>65whohadfallenonlevelgroundordown1-2stepswithintheprevious48hours.Wefollowedthepatientbychartreviewandtelephonecallforthenextsixweeks.
ResultsWerecruited890patientsovera10-monthperiod.Overall,34/890(3.8%,95%CI2.7-5.3%)patientswerediagnosedwithanintracranialbleedwithin6weeksofpresentation.469/890(52.9%,49.4-56.0%)hadaheadCToninitialassessmentintheemergencydepartmentofwhich28/469(6%)werepositiveforintracranialbleeding.3/440(0.7%)whohadaCTand3/421(0.7%)whodidnothaveaCTwerediagnosedwithintracranialbleedingduringfollowup.
ConclusionsIntracranialbleedingisnotacommonoccurrenceafterafall.TheheadCTyieldwaslow.Withbetterevidenceonwhomtoscan,emergencyphysicianscouldreducetheiruseofheadCTinthispopulation.
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The Prevalence of Intracranial Bleeding in Elderly who have FallenKerstindeWit,McMasterUniversity
BackgroundTheemergencydepartmentcanbeanuncomfortableandunpleasantplaceforseniors.Elderlyfrequentlypresentwithafall.ThereispracticevariationaroundorderingaheadCTtodiagnoseintracranialbleedingafterafallintheemergencydepartment.CTscansarecostlyandleadtodelayswhichincreasetheriskofacutedeliriumintheelderly.Weaimedtodeterminetoincidenceofintracranialbleedingamongthispopulation.
MethodsWesystematicallysearchedMedline,EMBASEandGooglescholarforpublicationsreportingtheincidenceofintracranialbleedingamongpatients>65yearswhopresentedtotheemergencydepartmentafterafallonlevelground.Twoauthorsreviewedalltitlesusingpredefinedinclusionandexclusioncriteria.Authorswerecontactedwheredatawasmissing.Twoauthorsperformedriskofbiasassessmentandextractedthedata.Therandomeffectsmodelwasusedtoreportapointestimateofintracranialbleedingincidence.
ResultsFromaninitial6036citationsonMedlineandEMBASE,6studieswereincluded.Anadditional2studieswereidentified.Riskofbiaswaslowforonly2studies.Therewere5961patientsincludedinthemeta-analysis.Thepooledestimatefortheincidenceofintracranialbleedingwas5.2%(95%CI2.8-9.2%).
ConclusionsOnly1in20elderlyemergencydepartmentpatientswhohavefallenonlevelgrounddevelopintracranialbleeding.ResearchisneededtodeterminewhichpatientsshouldhaveheadCT.
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Serum Protein Electrophoresis Testing in Northern Alberta: An Audit and Intervention to Curtail OveruseAlbertTsui,AlbertaHealthServicesKarinaRodriguez-Capote,LaboratoryMedicineandPathology,UniversityofAlbertaDylanThomas,DynaLIFEMedicalLabsMathewEstey,DynaLIFEMedicalLabsTreforHiggins,AlbertaHealthServicesDonZhang,DynaLIFEMEDICALLABSIrwindeepSandhu,UniversityofAlberta
GoalDynaLIFEperformsserumproteinelectrophoresisforacatchmentareaof2millionpeopleinNorthernAlberta,Canada.Theprimaryreasonforrequestingserumproteinelectrophoresis(SPE)isintheinvestigationofpatientsinwhomplasmacelldisorderssuspected.Concernsregardingtheperceivedover-utilizationofSPEpromptedustoauditphysicianorderingpatternstoassessandpromoteappropriatetesting.
ImplementationTwofamilyphysiciansresponsibleforthemostSPEordersin2014weredirectlycontactedbyanoncologisttoreduceSPEorders.Additionally,orderingpatternsweretrackedinfamilyphysicianswhoattendedtwolecturesonSPEutilization.Wecomparedtheeffectsbetweendirectpeereducationandsymposiumeducationthroughalecture.
MeasuresAuditofSPEsperformedatDynaLIFEMedicalLabsin2014revealedatotalof40930SPEtestswereperformedin2014,with566SPEsperformedinpatientsyoungerthan19yearsold.90%ofrepeattestingwasrelatedtodiseasemonitoringbyoncologistsand20%oftheseorderswerewithin26days.Directphysicianeducationresultedina90%dropinmonthlySPEordersfromthetwofamilyphysicians.Incontrast,physicianeducationviasymposiumdidnotleadtoasignificantreductionintestorders.Forphysicianswhoattendedbotheducationsessions,SPEordersweregenerallyincreasedfollowingthefirstsessionandSPEorderswerelowerorremainedstablefollowingthesecondsession.
ChallengesHowtosuccessfullydeliverphysicianeducationtobestpromotepracticechange.
Lessons LearnedTest-specificeducationwithcomparisonbyoncologistismosteffectivethandidacticlecture.
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Allergy Testing in Northern Alberta: An Audit and Intervention to Curtail OveruseKarinaRodriguez-Capote,LaboratoryMedicineandPathology,UniversityofAlbertaDylanThomas,TamaraStock,MathewEstey,DonZhang,NormaPage,TerenceAgbor,FayeChambersandKayNgDynaLIFEMEDICALLABS
BackgroundDynaLIFEMedicalLabsisthesolelaboratoryperformingallergytestingforacatchmentareaof2millionpeopleinNorthernAlberta,Canada.InvitroallergenspecificIgEtesting(sIgE)isincreasinginprimarycarewheretheskinprick/puncturetestisimpracticalandwaitingtimesfrompatientreferraltospecialistconsultationareoftenlengthy.However,broadscreeningforallergensmayhaveanegativeimpactonpatientoutcome.Guidelinesrequireselectionofindividualallergensbasedonpatienthistory.
GoalToassessphysicianorderingpatternsandpromoteappropriateuseofdiagnostictesting.Todevelopastrategytoimproveallergytestingutilization.
ImplementationAmultimodalprocesswasimplementedin2015thatincluded:Modifyreflextestingofferedforpositiveinhalantandfoodscreensaccordingtoprevalenceandseason.ProvidingphysicianeducationthroughsymposiaandCMEsessions.DistributingeducationalfaxestophysiciansrequestinganunwarrantednumberofsIgEtestsorundefinedrequests(RAST,allergytesting).
MeasuresThe2013auditrevealedthat168,038sIgEtestswereperformedfor28,464patientswith83%oftherequestsorderedasfoodorinhalantscreens.Modificationstothereflextestingallowedareductionof55,952tests.Prevalenceofexposureandpositivityratesweretakenintoconsiderationinthedecisiontoremovetestsfromtheinhalantscreenreflexpanel.
ChallengesChallengesincludeencouragingpracticechangeandmanualreviewofrequisitions.
Lessons LearnedThereisaneedintheprovinceforelectronictestrequestsystem.Thereisaneedforabettersystemtoprovidephysicianeducationandmonitoringcompliance.
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Curtailing the Inappropriate Urine Hcg Qualitative Testing in a Community Lab SettingKarinaRodriguez-CapoteandAsifaAmin,DepartmentofLaboratoryMedicine&PathologyUniversityofAlbertaDylanThomas,MathewEstey,DebHolmes,TerenceAgbor,DonZhangandMarkMalickDynaLIFEMEDICALLABS
BackgroundTeststodetecthumanchorionicgonadotropin(HCG)orpregnancytests,canbeperformedonurine(uHCG)orserum(sHCG).Selectionoftheoptimaltestisinfluencedbyanalyticalperformance,convenience,andturnaroundtime.WhilesHCGismoresensitive,samplecollectionforuHCGislessinvasiveandresultsmaybeavailablesooner.Inthecommunitysettinghowever,physiciansoftenrequestuHCGconcurrentlywithsHCGand/orotherbloodwork.Inaddition,turnaroundtimeisnotsignificantlydifferentbetweenthetwotestswhensampletransporttimetothelaboratoryisconsidered.ThisstudyaimstodissectthecommunityorderingpatternsforHCGtoassessifordersubstitutionscanbeimplementedtoimprovepatientcare.
Methodsallphysician-orderedqualitativeurineHCGtestsperformedatDynaLIFEin2017werereviewedtodeterminewhetherothertestswererequestedsimultaneously.
Results9031physician-orderedqualitativeuHCGtestswereperformedduringthestudyperiod.Themajorityofpatientswereofreproductiveage,howeversomeuHCGwererequestedinpostmenopausalfemales.Bloodwassimultaneouslydrawnfrom20469(71%)ofthesepatients,5218ofwhichalsohadserumHCGrequested.
ConclusionsAlargeproportionofofuHCGrequestswereperformedinadditiontosHCGorotherbloodwork.Insuchinstances,theuHCGtestoffersnoadvantageoversHCGasabloodspecimenhasalreadybeencollectedandturnaroundtimesaresimilarwhenanalyzedinacommunitylaboratory.SubstitutionofuHCGforsHCGincommunitypatientswouldprovidemoreaccurateresultsanddecreaseunnecessarytesting.
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Stewardship with a Handshake: Impact of Collaborative, Prospective Audit and Feedback Antimicrobial Stewardship Rounds in an Adult, Medical-Surgical Intensive Care Unit in Saskatoon, SaskatchewanShaqilPeermohamed,SaskatchewanHealthAuthorityJustinKosar,SaskatchewanHealthAuthority
Background: Approximately30%ofantimicrobialuseinICUshasbeenshowntobeinappropriate,particularlyduetoprescribingtherapytoobroadinspectrumofactivity.Prospectiveauditandfeedbackisacorestrategyofantimicrobialstewardshipprograms(ASP)withrelevanceinICUs,whichrepresenthigh-acuitycareenvironmentswherehigherproportionsofbroad-spectrumantimicrobialsareoftenprescribed.
Methods: Aquasi-experimentalstudywasperformedtoevaluatetheimpactofcollaborative,prospectiveauditandfeedbackroundsinanadult,medical-surgicalICU.In-personASProundswereperformedthreetimesperweekbyapharmacist-physicianteaminaseventeen-bed,medical-surgicalICU,beginninginmid-November2016.Aseparatefifteen-bed,medical-surgicalICUservedasacontrol.ASPrecommendationswererecordedprospectivelyinthemedcategoriesandacceptanceratesweretracked.Monthlyantimicrobialutilizationdata,collectedforbothICUs,wasmeasuredusingATC/DDDmethodologyduringpre-implementation(November2015toOctober2016)andpost-implementation(December2016toNovember2017)periods.
Results: ASPprovided270recommendationsamongst327patients,withanoverallacceptancerateof91.1%.Themostcommonrecommendationsincludeddurationoptimization(26.3%),de-escalationoftherapy(21.9%)anddiscontinuationoftherapy(21.5%).A19.6%reductionintheuseofantimicrobialswithbroad-spectrumactivityandcoverageofmulti-drugresistantorganismswasobserved(p=0.03).Significantdecreasesinuseofanti-pseudomonalantimicrobials(21.4%,p=0.04)werealsoobserved.Nosignificantdifferencesinantimicrobialusagewereobservedinthenon-interventionICU.
Conclusions: Implementationofcollaborative,prospectiveauditandfeedbackroundsinanadult,medical-surgicalICUiseffectiveinreducinguseofbroad-spectrumantimicrobials,likelyreflectingearlierde-escalationofantimicrobialtherapy.
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Appropriateness of CT and X-ray Ordering by Physicians for Low Back Pain: A Systematic ReviewGabrielleLogan,MemorialUniversityAmandaHall,MemorialUniversity
Background. ChoosingWiselyrecommendsappropriateuseofdiagnosticimagingforlowbackpaintodecreaseunnecessarytesting.Severalstudieshaveinvestigatedtheappropriatenessofimagingwhencomparedtotheguidelines,yetnosynthesishasbeenconductedtodate.ThissystematicreviewsynthesizeswhatisknownregardingtheappropriatenessofCTandx-rayimagingforlowbackpain.
Methods. PubmedandEmbaseweresearchedforderivativetermsof“lowbackpain”,“guidelines”,and“adherence”.Titles,abstractsandfulltextswerereviewedforinclusionbyreviewers.Referencelistsofincludedstudieswerealsoscannedforeligiblestudies.NationalInstituteofHealth’sQualityAssessmentToolforObservationalCohortandCross-SectionalStudieswasusedonincludedstudies.Datawasextractedanddescriptivelysynthesized.
Results. 671publicationswereidentifiedintheelectronicsearchand131underwentfulltextreview.TwostudiesreportedappropriatenessofCTscans,threereportedappropriatenessofx-rays,andeightstudiesreportedcombinedappropriatenessforatotalof13includedstudies.StudieswereconductedinCanada,UnitedStates,Ireland,France,Australia,&Finland.ComparisonguidelinescamefromtheEuropeanCommissionrecommendations,AgencyforHealthcareResearch&Quality,AgencyforHealthCarePolicy&Research,NationalInstituteforHealth&CareExcellence,AmericanCollegeofRadiology,RoyalCollegeofRadiologists,orNationalAgencyforAccreditation&HealthEvaluation.Ratesofappropriatenessrangedfrom2%to96%.
Conclusion. Widevariationintheratesofappropriatenessexistswhichmaybeduetothedifferentguidelinesusedtogenerateappropriatenesscriteria.Thisareawouldbenefitfromfurthercollaborationamongexpertstogenerateastandardizedsetofcriteriawithwhichtojudgeimagingappropriateness.
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MEDICAL EDUCATION
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Incorporating Resource Stewardship into Undergraduate Medical Education at McMaster University BushraKhan,CatherineFriedman,SonjaWakeling,JasmineLiu,andIfrahShahMcMasterUniversity
BackgroundMedicalstudentsreceivelimitedformaleducationinresourcestewardship(RS);withincreasinghealthcarecostsandwait-times,studentsmustbetrainedtomakechoicesthatminimizeunnecessarytestsandtreatmentstodecreasepotentialharmandspending.ChoosingWiselyCanada(CWC)createdStudentsandTraineesAdvocatingforResourceStewardship(STARS)toaddressthisneed.TwoSTARScohortsatMcMasterhaveinitiatedcurricularchange,conferences,interestgroupsandadvocatedforRStobeapriorityoftheirprovincialstudentorganization.
Case StudySTARSmetwithMcMaster’sUndergraduateMedicalEducation(UGME)DeanandthroughhisguidanceformedateamtoidentifyareastoimplementRSinthecurriculum.
Aneedsassessmentwasconductedthroughasurvey,focusingonstudents’exposureto,attitudestowards,andconfidenceapplyingresourcestewardshipprinciples.ApilotstudyincorporatingtheCWCrecommendationsinfivecasesandassessingstudents’confidenceinapplyingresourcestewardshipprinciplesbeforeandaftertheinterventionwasconducted.LearnerswerealsointroducedtoCWClistsforspecialtiesandformedicalstudentsattheirclerkshiporientation.
STARSconnectedwithphysicianchampionsofRSinHamiltonandorganizedanannualconferencetohighlighthowRStranslatedtopractice.Additionally,aninterestgroupwascreatedtofostercontinuedengagementwithlike-mindedpeers.STARSfurtherassistedinestablishingapartnershipbetweenCWCandtheOntarioMedicalStudents’AssociationtoadvocateforRStraininginUGMEacrossOntario.McMasterSTARS’experienceinincorporatingRSintheirUGMEoffersaprimeopportunityforeducatorsacrossCanadatolearnhowtofosterleadershipandengagementinRSintheirownlearners.
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Choosing Wisely Canada STARS: Training the Next Generation of Medical Professionals at UBCMelissaWanandDhruvPandeyUniversityofBritishColumbia
BackgroundUnnecessarytesting,treatments,andproceduresaresrootedinphysicianhabits.Toencouragequalityandcostconscioushabits,wemustactupstreamtointroducetraineestoresourcestewardshipprinciplesearlyintheireducation.Currently,inBC,resourcestewardshipisnotreadilyintegratedintothemedicalschoolcurriculum.
GoalOurgoalistofosteraculturethatallowstraineestoengageinconversationsaboutmedicaltestingandqualityofcare,byeducatingtraineesabouttheimportanceofresourcestewardshipandequipthemwithnecessarytoolstoadvocateforappropriatecare.
InterventionAspartofthestudent-ledcampaign,theUBCSTARShavelaunchedaBC-widecampaign.Thisinvolvesadvocatingforpre-clerkshipcurriculumchangestoincluderesourcestewardshipprinciplesandthecreationofaninterestgroup.Herewewillpresentasummaryofthecurrentknowledgelevelofpre-clerkshipstudents,changesmadetotheUBCcurriculum,andtheactivitiesoftheinterestgroupthusfar.
Challenges/ Lessons LearnedChallengesincludedidentifyingopportunitiestointegrateresourcestewardshipprinciplesintoapacked,clinicalpresentationbased,curriculum.Asaresult,ourLessonsLearnedinclude:distillingdownourambitionstofocusourefforts;recommendingsmall,realistic,andpracticalchanges;andensuringthatwebuildastrongfoundationtoensurethesustainabilityofthecampaign.
ImpactWeanticipatethatthesecurriculumchangesmakealastingimpactontrainees,staff,andpatientsbyincreasingawarenessaboutresourcestewardshiptoimprovethequalityofpatientcare.
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Incorporating Resource Stewardship into the University of Manitoba Undergraduate Medical Education ProgramAndreaKulyk,UniversityofManitobaMing-KaChan,UniversityofManitobaEricBohm,UniversityofManitobaSarahKirby,GeorgeandFayYeeCentreforHealthcareInnovationYounTaeChung,UniversityofManitoba
GoalThemaingoalswere1)enhancetraininginresourcestewardshipprinciplesandintegrateChoosingWiselyCanada(CWC)recommendationsintotheUniversityofManitobaUndergraduateMedicalEducation(UGME)pre-clerkshipcurriculumand2)studytheimpactofthesechangesonstudentattitudesandknowledge.
ImplementationPartoneincludedreviewingtheUGMEPCC,identifyingopportunitiesforenhancedresourcestewardshiptraining.Wedevelopednovellearningmaterials(lecturesandteam-basedsessions)andsuggestedareastointegrateCWCrecommendationsthroughoutthepre-existingcurriculum.Inparttwoweanalyzedtheimpactofthesechangesonstudents’attitudeandknowledge.
MeasuresTheadaptedcurriculumwasreviewedtodetermine1)uptakeofoursuggestionsintoexistinglectures,and2)implementationofnewcontent.Onlinesurveysassessedstudents’attitudeandknowledgetowardsresourcestewardshippreandpostimplementation(September2016,April2017).
ChallengesTwolectureswereaddedforfirstyearandoneintosecondyear.AlthoughauthorshadsupportofthePre-ClerkshipCommittee,overalluptakeofCWCrecommendationswaslessthan20%.Therewasstatisticallysignificantimprovementinstudents’knowledgescores(p
Lessons LearnedStudentsexhibitedpositiveattitudestowardsresourcestewardship.Resourcestewardshiptrainingatthepre-clerkshiplevelshouldfocusonresourcestewardshipprinciples,asopposedtospecificCWCrecommendations,givingstudentstheabilitytodevelopacorefoundation,whichcanfurtherevolveastheybecomeimmersedintheclinicalsetting.Furtherstudiesplantoexaminethechallengesofincorporatingtheaforementionedmaterials,andhowtocontinueintegratingresourcestewardshiptraininginundergraduateyears.
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Time to Forget About DRE? LeenNajiandJasonProfettoMcMasterUniversity
PurposeCurrentrecommendationsregardingprostatecancerscreeningmadebyvariousCanadianguidelinesareconflicting.Surveyshavealsoshownthatwhileover80%ofCanadianfamilyphysiciansofferthedigitalrectalexam(DRE)asascreeningtoolforprostatecancer,onlyaminoritybelievesithasbenefit.Giventheconflictingguidelinesandlackofstandardizedpractice,weaimedtoevaluatethediagnosticaccuracyoftheDREinscreeningforprostatecancerintheprimarycaresetting.
MethodsSixdatabasesweresearchedfrominceptiontoJune2016.Allcitationswereindependentlyscreenedforeligibilitybythreepairsofreviewers.Thepooledsensitivity,specificity,positivepredictivevalue(PPV)andnegativepredictivevalue(NPV)oftheDREinscreeningforprostatecancerintheprimarycaresettingwerecalculatedusingmeta-analysesweightedbyinversevariance.TheGRADEframeworkwasemployedtoassessthequalityofourpooledanalyses.
ResultsOursearchyielded8,217studies,andsevenwereeligibleforinclusion(n=9,241men).AllparticipantsanalyzedreceivedbothaDREandbiopsy.Pooledsensitivitywas0.51(95%confidenceinterval[CI]0.36,0.67;I2=98.4%)andpooledspecificitywas0.59(95%CI0.41,0.76;I2=99.4%).PooledPPVwas0.41(95%CI0.31,0.52;I2=97.2%),andpooledNPVwas0.64(95%CI0.58,0.70;I2=95.0%).Thequalityofevidencewas‘verylow’inaccordancewithGRADE.
ConclusionGiventhelackofevidencesupportingitsefficacy,andtheharmsassociatedwithover-investigationandover-treatment,werecommendagainstroutineperformanceoftheDREasascreeningtoolforprostatecancerinprimarycare.
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Resource Stewardship in Undergraduate Medical Education (UME)SahilSharmaandMatthewRoweSchulichSchoolofMedicine
NewresearchsuggestsCanadianphysiciansordermorethan1,000,000potentiallyunnecessarytestsandtreatmentseachyear.StrategiestoeducatemedicalstudentsabouttheCanMEDsResourceStewardshipdirectiveandjudicioustestingpracticescanhelpthehealthcaresystemmanagefiscalstressandimprovehealthcareexperiencesforpatients.ThispaperoutlinesseveralstrategiesthatcanbeimplementedattheundergraduatemedicaleducationlevelthroughChoosingWiselyCanada’sStudentsandTraineesAdvocatingforResourceStewardship(STARS)program.Theeducationalstrategiesfeaturegroup-basedlearning,lectureintegration,andsupportiveonlinemodules.Educatingmedicalstudentsacrossthecountryaboutjudicioustestingcanproducethegenerationofresource-conscientiousdoctorsthathealthcare’sincreasinglytightbudgetdemands.
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Evaluating Canadian Medical Students’ Interest in and Readiness for Learning and Practicing High-Value Care: Preparing for ChangeAhmadSidiqi,NorenKhamisandGeoffreyBlairUniversityofBritishColumbia
IntroductionTheCanMEDSframeworkwasrecentlyupdatedtoincludehigh-valuecareandresourcestewardshipasacorecompetency.Thisprinciple,whichencouragesappropriateandjudicioususeofdiagnosticandtherapeuticactions,promotespatientsafetyandfostersfinancialsustainability.Whethercurrentundergraduateandresidencytrainingprogramseffectivelyeducatetraineesonhigh-valuecareremainsunknown.Weaimtotest:1)medicalstudents’currentknowledgearoundresourcestewardship;2)theimportancestudentsplaceonhigh-valuecareeducation;3)theidealformattotrainstudentsonthissubject.Resultswillguideappropriatecurriculumadjustments.
MethodsAvalidatedandresearchethics-approved21-itemonlinesurveywaspilotedon43medicalstudentsandsubsequentlydistributedtoallmedicalstudentsattheUniversityofBritishColumbiaviaanelectronicmailinglist.Thesurveywasvoluntary.Studentperspectiveswereanalyzedusingdescriptivestatistics.
ResultsTherewere88surveyresponses.Themajorityofstudents(93%)agreedorstronglyagreedontheimportanceofresourcestewardshipinclinicaldecision-making,howeverallrespondentsfeltthattheirtraininghasinadequatelypreparedthemonthistopicandonly28%feelcomfortablediscussingcostsofcareandovertreatmentwithpatients.Discussinghigh-valuecarewithresidentandstaffsupervisorswasreportedby86%ofclinicalclerkstobeaneffectiveandpreferredteachingstrategy.
ConclusionsParticipantsvalueresourcestewardshipeducation,butlackadequatetrainingonthesubject.Voluntaryresponsebiasmayhaveconfoundedtheseresults.Formallytrainingresidentsinhigh-valuecaremayenablethemtotransferthisknowledgetoclinicalclerks,andrequiresfurtherinvestigation.
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PATIENT ENGAGEMENT
PATIENT ENGAGEMENT - PAGE 107
Engaging Patients as Partners in CWNL: Low Back Imaging Case StudyAmandaHall,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLRobertWilson,TPMI/MUNPatrickParfrey,TPMI/MemorialUniversityHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversity
BackgroundCWNLisunderpinnedbyCIHR’sStrategyforPatientOrientedResearch(SPOR)andIntegratedKnowledgeTranslation(iKT).Thus,engagingpatients/stakeholdersaspartnersiscorecomponentinprojectplanning.Projectsareapprovedbyasteeringcommitteeofpatients,physicians,researchers,anddecision-makers.Approvedprojectsconveneateamincludingpatients/keystakeholdersaspartnerswithresource-assistancefromtheNLSupportUnit.Wepresentanexampleofourstakeholderengagement-processusingtheCWNLproject:reducingunnecessaryimagingforlowbackpain.
MethodsKnowledge-brokering(KB)andknowledge-exchange(KE)wereusedtoinitiateengagement.First,relevantknowledgeusers/stakeholderswereidentifiedandcontactedtoset-upinformalKBdiscussionsto(i)heartheirexperiencetreating/havingLBP,(ii)understandrelevanttacitknowledge,(iii)sharetheCWNL-LBPproject.Second,allstakeholderswereinvitedtoamulti-disciplinaryKEsessionto(i)introducetheprojectaim/researchteam,(ii)shareLessonsLearnedfromKB,(iii)documenttheproblemfromtheirperspective,and(iv)confirmdesiredengagementlevel.
ResultsTelephoneandface-to-faceKBsessionswithover12stakeholdergroups(i.e.patients/communitygroups,radiologists,physicians/specialists,alliedhealth,anddecisionmakers)wereconducted.33participants(organisedinto4groupswithrepresentationfromdifferentperspectives)attendedtheKEsession.AllagreedLBPmanagementneedsimprovementincludingreducingunnecessaryimaging.Desiredengagementlevelsincluded“inform”(n=23),“consult”(n=10)and“collaborate”inprojectplanning(n=16)anddisseminatingresults(n=14).
ConclusionThisprocessallowedustoconfirmthatunnecessaryimagingforLBPisapriorityissueforstakeholders.ItprovidedavenueforopenKEbetweenresearchersandknowledgeusersandwassuccessfulfordevelopingmeaningfulpartnerships.
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Regional Media Strategies: Choosing Wisely in Former Cypress Health RegionKevinWasko,SaskatchewanHealthAuthority
Asalocalphysiciancommunity,theCypressRegionalMedicalAssociationrecognizedthatthesuccessfulimplementationofChoosingWiselydependedonengagementandeducationofpatients.Themedicalassociationapproachedthelocalhealthauthorityleadershiptopartneronanadvertisingcampaigntargetingpatients.
AfterreachingouttoChoosingWiselyCanada,themedicalassociationandthehealthauthoritycreatedalocalmediaandadvertisingstrategy.ThecampaignwaslaunchedwiththecreationofavideofeaturinglocalphysiciansespousingtheprinciplesofChoosingWisely.Itwasdirectedatthelocalpatientpopulationintheareaandcirculatedonsocialmedia.Itwasthoughtthatfeaturinglocalphysicianswouldresonatemorewithpatientsthansimplypromotinggenericmaterials.Thisvideowasaverysuccessfulcommunicationvehicle,withover32,000viewsaroundtheworldand265sharesonFacebook.IthasbeenpostedtotheChoosingWiselyCanadaandCollegeofPhysiciansandSurgeonsofCanadawebsites.Thevideowasfollowedupwithprintadsinthelocalpapers,disseminationofchoosingwiselymaterialsandanothervideofeaturingalocalphysician.Thesecondvideofocusedontheannualphysical.Ithasbeenviewed12,000timesandagainwasfeaturednationally.
Thiscampaignisstillongoingbuthasbeenasuccessfulwaytointroducethemovementamongstthegeneralpopulationandhasallowedforconversationsbetweenphysiciansandpatientsthatwouldhaveotherwisebeendifficulttoinitiate.Wefeelthatthelessonswehavelearnedcouldhelpinformsimilarcampaigns.
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Changing the Way we Understand and Label Behaviour will Reduce the use of Antipsychotics in Dementia CareSusanMacaulay,MyAlzheimersStory.com
BackgroundInthemid-1980s,researcherDr.JiskaCohen-Mansfielddevelopedatooltomeasureagitationinpeoplelivingwithdementia(PLWD)inlong-termcarefacilities(LTCFs).CalledtheCohen-MansfieldAgitationInventory(CMAI),thetoolcomprises29behaviours.Inthelate1990s,theInternationalPsychogeriatricAssociation(IPA)tooktheCMAIandsimilarscalesand“renamed”thebehavioursonthelisttheBehaviouralandPsychologicalSymptomsofDementia(BPSD).TheIPA’snewconstructbecameawayoflabelingnormalbehaviourasaberrantinPLWD.
ObjectivesShowthatBPSDaregenerallynottheresultofdementia,butrathernormalhumanresponsestoparticularsetsofcircumstances,andthatPLWDshouldnotbeinappropriatelymedicatedfornormalbehaviour.
MethodsPersonalobservation,one-on-oneinteractionwithaPLWD(6,850hoursoverfiveyears)hundredsofhoursofaudiovisualdocumentation;reviewandanalysisofnurses’notes;onlinesurveywith1,300+responses.
ResultsAssessingandreportingthebehaviourofPLWDthroughthelensofBPSDisproblematic.UsingBPSDasanassessmenttoolleadsPLWDtobeinappropriatelyprescribedantipsychoticmedications.
ConclusionsWemustreframebehaviouralexpressionsinPLWDinwaysthatenableustoidentifytheirrootcausesand,inturn,informimprovedeffortstoimplementhumane,personalized,andeffectiveapproachesforthecareofPLWD.Betterunderstandingofwhatcausesbehavioursthatdementiacarepartnersandcarestaffexperienceaschallengingwillreducesuchbehavioursandthustheratesatwhichantipsychoticsareprescribedtoaddressthem.
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Deepening Patient Engagement: Sharing the patient voice at all levels of an organization and beyondMelissaGiguere(Presenter),HealthSciencesNorthRosieGraffi,HealthSciencesNorth
Background Onourjourneytoimprovethepatientexperience,HealthSciencesNorthimplementedaframeworktodeepenthelevelofpatientengagementbyimplementingaPatientandFamilyAdvisoryProgram.ItbeganwiththeformationoftheCEOPatientandFamilyAdvisoryCouncilin2012with12members,andhasgrowntoanadditionalpoolof28PatientAdvisors(PA).PAonboardingincludesIntroductiontoLeanManagementasadvisorsparticipateinimprovementwork(36projectsoutofthetotal116theywereinvolvedin2017)acrossthesystem.PatientswhohavegonethroughthepatientrelationsprocessarereferredtoapplytobecomeaPAandtosharetheirpatientstory,furtherdeepeningtheirlevelofengagementwiththeorganization.Fourpatientstoriesarecollectedeachmonth(video,audio,written,speakingengagements)andanalyzedforsharingwiththeBoard,QualityCommitteeoftheBoard,ProgramCouncils,MedicalAdvisoryCommittee,LeadershipDevelopmentSessions,NorthernOntarioMedicalSchooleventsandwithstaffthroughanelectronicpatientstorylibrary.Patientstoriesarealsoprofiledonasocialmediablogcalled“HumansofHSN”,includingtheexperienceofpatientswhohavebeenaffectedbyacriticalincident.
Case Study: Participantsgivenacriticalincident.Usingapatientstoriescollectionguide,participantsaretaskedwithroleplayingtocollectandrecordthepatientstory,toanalyzethepatientstorywiththeanalysisguidewhichincludes:qualitydimensions,learnings,andproblem/improvement/countermeasure/measurement/results.