Barriers and Facilitators to the Use of Personal Protective Equipment in Long-Term Care: A Scoping Review.

OBJECTIVE: To review existing literature evaluating barriers and facilitators to the use of personal protective equipment (PPE) by health care workers in long-term care (LTC). DESIGN: Scoping review. SETTING AND PARTICIPANTS: Health care workers in LTC settings. METHODS: Several online databases were searched and a gray literature search was conducted. Study inclusion criteria were (1) conducted in nursing homes or LTC settings, (2) focused on LTC health care workers as the study population, and (3) identified barriers and/or facilitators to PPE use. The Theoretical Domains Framework (TDF), which assesses barriers to implementation across 14 behavioral change domains, was used to extract and organize data about barriers and facilitators to appropriate use of PPE from the included studies. RESULTS: A total of 5216 references were screened for eligibility and 10 studies were included in this review. Eight of the 10 studies were conducted during the COVID-19 pandemic. Several barriers and facilitators to PPE use were identified. The most common TDF domain identified was environmental context and resources, which was observed in 9 of the 10 studies. Common barriers to PPE use included supply issues (n = 7 studies), the cost of acquisition (n = 3 studies), unclear guidelines on appropriate use of PPE (n = 2 studies), difficulty providing care (n = 2 studies), and anxiety about frightening patients (n = 2 studies). Having PPE readily available facilitated the use of PPE (n = 2 studies). CONCLUSIONS AND IMPLICATIONS: Further research is necessary to identify barriers and facilitators more extensively across behavior change domains to develop effective strategies to improve PPE use and prevent infection transmission within LTC.

The primary care COVID-19 integrated pathway: a quantitative study of rapid response to health and social impacts of COVID-19.

Context: The first wave of COVID-19 in Calgary, Alberta health zone accelerated Primary Care (PC) integration. Specifically, it connected Family Physicians (FPs) with their counterparts in the broader health system to deliver wraparound patient care through a COVID-19 Integrated Pathway (CIP). A key element of the CIP included a data sharing platform that facilitated the provision of test results directly to the FP identified by patients. Public Health provided test results for all patients to the primary care system so they could be followed up by primary care to improve their outcomes. Objectives: To evaluate the CIP by describing its function and capacity to facilitate FP follow-up with COVID positive patients; and to inform refinement of the CIP for future use. Study Design: This abstract reports on the quantitative arm of a mixed methods study. Setting/Dataset: The Calgary Health Zone. Primary data were drawn from the Calgary COVID-19 Care Clinic (C4), a designated hub clinic for COVID-19 patients. Secondary data were drawn from provincially maintained records of hospitalization, emergency department visits, and FP claims. Participants: FPs and COVID-19 patients. Intervention: The data platform and PC attachment elements of the CIP. Outcome Measures: The characteristics of patients cared for via the CIP (age, sex, ethnicity, and risk-level); the proportion of patients without a FP who were attached to an FP; the number of patients followed by their FP in the community, and the number of specialist consultations made by FPs to support care, time from diagnosis to follow-up with PC/FP; ED and acute care utilization. Results: Between Apr. 16 and Sep. 27, 2020, 7706 patients were referred by the Public Health team to the C4 clinic. Of those, 51.4% were male, the median age was 36 y., and 86 deaths were reported. The majority of patients were referred to local PC networks where follow-up was conducted using the CIP: 3223 (43%) already had their own FP, 2448 (32%) were successfully attached to an FP, and 1899 (25%) of these patients were monitored by C4 physicians - these patients either did not have FP or their FP was not available to follow the patient. 8.6% of these patients visited ED and 3.1% were hospitalized. More than 80% of these patients had at least of 5 visits with their FP. Conclusion: Data suggest that the CIP facilitated primary care based management of patients with COVID-19.

Building a Data Bridge: Policies, Structures, and Governance Integrating Primary Care Into the Public Health Response to COVID-19.

PURPOSE: The effective integration of primary care into public health responses to the COVID-19 pandemic, particularly through data sharing, has received some attention in the literature. However, the specific policies and structures that facilitate this integration are understudied. This paper describes the experiences of clinicians and administrators in Alberta, Canada as they built a data bridge between primary care and public health to improve the province's community-based response to the pandemic. METHODS: Fifty-seven semistructured qualitative interviews were conducted with a range of primary care and public health stakeholders working inside the Calgary Health Zone. Interpretive description was used to analyze the interviews. RESULTS: SARS-CoV-2 test results produced by the local public laboratory were, initially, only available to central public health clinicians and not independent primary care physicians. This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients' COVID-19 status and unable to offer in-community follow-up care. Stakeholders from both central public health and independent primary care were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap. CONCLUSIONS: Primary care systems looking to draw lessons from the data bridge's construction may consider ways to: leverage care model commitments to integration and adjust or create organization and governance structures which actively draw together primary care and non-primary care stakeholders to work on common projects. Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place.

The primary care COVID-19 integrated pathway: a rapid response to health and social impacts of COVID-19.

BACKGROUND: The first wave of COVID-19 in Calgary, Alberta accelerated the integration of primary care with the province's centrally managed health system. This integration aimed to deliver wraparound in-community patient care through two interventions that combined to create the COVID-19 Integrated Pathway (CIP). The CIP's interventions were: 1) a data sharing platform that ensured COVID-19 test results were directly available to family physicians (FPs), and 2) a clinical algorithm that supported FPs in delivering in-community follow up to improve patient outcomes. We describe the CIP function and its capacity to facilitate FP follow-up with COVID-19 patients and evaluate its impact on Emergency Department (ED) visits and hospitalization. METHOD: We generated descriptive statistics by analyzing data from a Calgary Zone hub clinic called the Calgary COVID-19 Care Clinic (C4), provincially maintained records of hospitalization, ED visits, and physician claims. RESULTS: Between Apr. 16 and Sep. 27, 2020, 7289 patients were referred by the Calgary Public Health team to the C4 clinic. Of those, 48.6% were female, the median age was 37.4 y. 97% of patients had at least one visit with a healthcare professional, where follow-up was conducted using the CIP's algorithm. 5.1% of patients visited an ED and 1.9% were hospitalized within 30 days of diagnosis. 75% of patients had a median of 4 visits with their FP. DISCUSSION: Our data suggest that information exchange between Primary Care (PC) and central systems facilitates primary care-based management of patients with COVID-19 in the community and has potential to reduce acute care visits.

Considering context: Adaptive elements of a simulation program to improve primary care safety during the COVID-19 pandemic in Alberta, Canada.

BACKGROUND: Globally, primary care (PC) has been central to the COVID-19 response. The pandemic has strained PC systems and introduced novel infection prevention and control (IPC) risks to the provision of safe, accessible in-person care. Specifically, the implementation of IPC guidance developed outside of PC into its operational context has proved challenging. METHODS: Our team of "action researchers" developed an innovative virtual tabletop simulations (TTS) intervention which assisted PC teams as they adapted, implemented, and integrated IPC guidance into their specific clinical contexts. While we have detailed the "technical" elements of the TTS program elsewhere, this paper examines the specific "adaptive" elements that made this intervention successful in the high-income country context of Alberta, Canada. RESULTS: Multiple factors influenced the uptake of this program in our Albertan setting, including: cultural geography; approach to financing and delivering PC; and policies and cultural norms supporting PC integration, medical education and research, and egalitarian teamwork. CONCLUSIONS: Virtual TTS may provide substantial benefits to IPC and safety improvements in PC settings globally. However, the specific technical and adaptive elements of our Albertan TTS program might, or might not, make these a viable IPC intervention for adapting, spreading, and scaling to other settings.

Improving Conversations With COVID-19 Vaccine Hesitant Patients: Action Research to Support Family Physicians.

Vaccination delivery and efforts to counter vaccine hesitancy have become focal issues for family medicine teams as the COVID-19 pandemic has evolved. Conducting action research, our team developed an interactive web-based guide to improve clinical conversations around a broad range of vaccine hesitancies presented by patients. The paper presents a step-by-step account of the guide being codesigned with family physicians-its targeted end users-in a process that included validation interviews; role-play interviews; and user-tested design. The validation interviews sought to understand the pragmatic realities of vaccine hesitancy in family medicine clinical practice relative to relevant psychological theories. The role-play interviews drew out conversational strategies and advice from family physicians. The principles of motivational interviewing-an evidence-based approach to vaccine hesitancy conversations that supplements information deficit approaches-were used to codesign the content and layout of the guide. User counts, stakeholder engagement, and web-based analytics indicate the guide is being used extensively. Formal evaluation of the guide is presently underway.Originally published as Annals "Online First" article.

The impact of COVID-19 on patient engagement in the health system: Results from a Pan-Canadian survey of patient, family and caregiver partners.

INTRODUCTION: The COVID-19 pandemic has had an impact on all aspects of the health system. Little is known about how the activities and experiences of patient, family and caregiver partners, as a large group across a variety of settings within the health system, changed due to the substantial health system shifts catalysed by the pandemic. This paper reports on the results of a survey that included questions about this topic. METHODS: Canadian patient, family and caregiver partners were invited to participate in an online anonymous survey in the Fall of 2020. A virtual snowballing approach to recruitment was used. Survey invitations were shared on social media and emailed to health system and governmental organizations with the request that they share the survey with patient partners. This paper focuses on responses to two questions related to patient partner experiences during the COVID-19 pandemic. RESULTS: The COVID-19 questions were completed by 533 respondents. Over three quarters of respondents (77.9%, n = 415) indicated their patient engagement activities had been impacted by COVID-19. The majority (62.5%, n = 230) experienced at least a temporary or partial reduction in their patient engagement activities. Some respondents did see increases in their patient engagement activities (11.4%, n = 42). Many respondents provided insights into their experience with virtual platforms for engagement (n = 194), most expressed negative or mixed experiences with this shift. CONCLUSIONS: This study provides a snapshot of Canadian patient, family and caregiver partners' perspectives on the impact of COVID-19 on their engagement activities. Understanding how engagement unfolded during a crisis is critical for our future planning if patient engagement is to be fully integrated into the health system. Identifying how patient partners were engaged and not engaged during this time period, as well as the benefits and challenges of virtual engagement opportunities, offers instructive lessons for sustaining patient engagement, including the supports needed to engage with a more diverse set of patient, family and caregiver partners. PATIENT CONTRIBUTION: Patient partners were important members of the Canadian Patient Partner Study research team. They were engaged from the outset, participating in all stages of the research project. Additional patient partners were engaged to develop and pilot test the survey, and all survey respondents were patient, family or caregiver partners. The manuscript is coauthored by two patient partners.

Person-centered care for family caregivers of people living with dementia: Co-designing an education program for the healthcare workforce.

BACKGROUND: Recent research recommends the healthcare workforce receive competency-based education to identify, assess, support and partner with family-caregivers [FCGs} across the care trajectory.[1 2] Although the risk of FCG anxiety, burden, and loneliness to FCG's wellbeing is widely documented, typically education has been targeted towards FCG's to increase their care skills rather to educate healthcare providers to support FCG's caregiving and wellbeing.[3] OBJECTIVES: We will present the co-design process used to create a competency-based education program for the healthcare workforce that ensures a person-centered focus on FCGs and introduce our Health Workforce Caregiver-Centered Care Education focused on dementia. Co-design is the act of creating with stakeholders to ensure the results meet their needs and are usable. PROJECT DESCRIPTION: We began by coining the concept "caregiver-centered care," defining it as: a collaborative working relationship between families and healthcare providers aimed at supporting FCGs in their caregiving role, decisions about services, care management, and advocacy [4 5] . From this definition, and working with multi-level interdisciplinary stakeholders we designed[6] and validated[7] a Caregiver-Centered Care Competency Framework in a Modified Delphi Process. Stakeholders (n= 101) including FCGs, health providers, policy makers, community organizations, research team, script writer, and educational designers then used effective practices for dementia education for the health workforce [8-11] to co-design the first or 'foundational' level of a Caregiver Centered Care education program. RESULTS: Teaching and learning resources include six competency-aligned educational modules with videos and interactive exercises that encourage reflection. With the COVID-19 pandemic, we moved the education online (caregivercare.ca). In the first two months online, November 9, 2020-January 9, 2021, 352 healthcare providers completed the education. To date, learners' qualitative evaluations have been positive, "Very good information for professionals working with caregivers; especially relevant to homecare, geriatricians, allied health, and others working within the Seniors' Health realm. Engaging format that really evokes empathy for caregivers." DISCUSSION: We continue to use mixed methods to evaluate the Caregiver-Centered Care Education, for acceptability and effectiveness, in five care contexts (primary, acute, home, supportive living, long-term care). CONCLUSION: We expect that our education will support caregiver-centered care in all settings providing dementia-related care.

A "Shock Test" to Primary Care Integration: COVID-19 Lessons from Alberta.

The COVID-19 pandemic exposed primary care (PC), and policies aimed at integrating it into provincial health systems, to a "shock test." This paper draws on documentary analysis and qualitative interviews with PC and health system stakeholders to examine shifts in Alberta's pre-pandemic PC integration model during the first nine months of the pandemic. We begin with an account of three elements of the province's pre-pandemic model: finance, health authority activity and community activity. We describe these elements as they shifted, focusing on two indicators of change: novel virtual care billing codes and personal protective equipment (PPE) distribution channels. We draw out policy planning lessons for improving PC integration under normal and future pandemic conditions, namely, by facilitating rapid updates of virtual care billing codes, analyses of the impact of care delivery and backstopping of PPE markets and supply chains for PC.

Achieving Resilience in Primary Care during the COVID-19 Pandemic: Competing Visions and Lessons from Alberta.

The COVID-19 pandemic has tested the resilience of health systems broadly and primary care (PC) specifically. This paper begins by distinguishing the technical and political aspects of resilience and then draws on a documentary analysis and qualitative interviews with health system and PC stakeholders to examine competing resilience-focused responses to the pandemic in Alberta, Canada. We describe the pre-existing linkages between the province's central service delivery agency and its independent PC clinics. Together, these central and independent elements make up Alberta's broader health system, with the focus of this paper being on PC's particular vision of how resilience ought to be achieved. We describe two specific, pandemic-affected areas of activity by showing how competing visions of resilience emerged in the central service delivery agency and independent PC responses as they met at the system's points of linkage. At the first point of linkage, we describe the centralized activation of an incident management system and the replies made by independent PC stakeholders. At the second point of linkage, we describe central efforts to disseminate infection prevention and control guidance to PC clinics and the improvisational efforts of staff at those independent clinics to operationalize the guidance and ensure continuity of operations. We identify gaps between the resilience visions of the central agency and independent PC, drawing broadly applicable policy lessons for improving responses in present and future public health emergencies. Finding ways to include PC in centralized resilience policy planning is a priority.

Virtual tabletop simulations for primary care pandemic preparedness and response.

INTRODUCTION: The COVID-19 pandemic prompted widescale use of clinical simulations to improve procedures and practices. We outline our deployment of a virtual tabletop simulation (TTS) method in primary care (PC) clinics across Alberta, Canada. We summarise the quality and safety improvements from this method and report end users' perspectives on key elements. METHODS: Our virtual TTS used teleconferencing software alongside digital whiteboards to walk clinic stakeholders through patient scenarios. Participants reviewed and rehearsed their workflows and care practices. The goal was for staff to take ownership over gaps and codesigned solutions. After simulation sessions, follow-up interviews were conducted to collect feedback. RESULTS: These sessions helped PC staff identify and codesign solutions for clinical hazards and threats. These included the flow of patients through clinics, communications, redesignation of physical spaces, and adaptation of guidance for cleaning and personal protective equipment use. End users reported sessions provided neutral spaces to discuss practice changes and built confidence in delivering safe care during the pandemic. DISCUSSION: TTS has not been extensively deployed to improve clinical practice in outpatient environments. We show how virtual TTS can bridge gaps between knowledge and practice by offering a guided space to rehearse clinical changes. We show that virtual TTS can be used in multiple contexts to help identify hazards, improve safety and build confidence in professional teams adapting to rapid changes in both policies and practices. While our sessions were conducted in Alberta, our results suggest this method may be deployed in other contexts, including low-resource settings.

Rapid conversion of an in-patient hospital unit to accommodate COVID-19: An interdisciplinary human factors, ethnography, and infection prevention and control approach.

BACKGROUND: In response to the Coronavirus disease-19 (COVID-19) pandemic, in-patient units in hospitals around the world have altered their patient care routines and Infection Prevention and Control (IPC) practices. Our interdisciplinary team of applied Human Factors (HF), ethnography, and IPC experts assisted one Unit, normally serving general surgical and orthopedic patients, as it rapidly converted to deliver COVID-19-specific care. This paper describes the conversion experience of the Unit, and outlines broader lessons for other acute care teams faced with similar issues. METHODS: We deployed walkthroughs, simulations, and ethnography to identify important safety gaps in care delivery processes on the Unit. These interventions were undertaken using interdisciplinary theories of implementation that combined systems-level HF perspectives, ethnographic approaches, and individual-level IPC perspectives. Timely recommendations were developed and delivered to Unit staff for feedback and implementation. RESULTS: We describe three interventions on the Unit: 1) the de-cluttering and re-organization of personal protective equipment (PPE); 2) the reconfiguring of designated 'dirty' tray tables and supplies; and 3) the redesign of handling pathways for 'dirty' linens and laundry. Each of these interventions was implemented to varying degrees, but all contributed to discussions of safety and IPC implementation that extended beyond the Unit and into the operations of the broader hospital. CONCLUSIONS: Leveraging our team's interdisciplinary expertise and blended approaches to implementation, the interventions assisted in the Unit's rapid conversion towards providing COVID-19-specific care. The deployment and implementation of the interventions highlight the potential of collaboration between HF, ethnography, and IPC experts to support frontline healthcare delivery under pandemic conditions in an effort to minimize nosocomial transmission potential in the acute healthcare setting.

Integrating the social sciences into the COVID-19 response in Alberta, Canada.

This paper outlines the rapid integration of social scientists into a Canadian province's COVID-19 response. We describe the motivating theory, deployment and initial outcomes of our team of Organisational Sociologist ethnographers, Human Factors experts and Infection Prevention and Control clinicians focused on understanding and improving Alberta's responsiveness to the pandemic. Specifically, that interdisciplinary team is working alongside acute and primary care personnel, as well as public health leaders to deliver 'situated interventions' that flow from studying communications, interpretations and implementations across responding organisations. Acting in real time, the team is providing critical insights on policy communication and implementation to targeted members of the health system. Using our rapid and ongoing deployment as a case study of social science techniques applied to a pandemic, we describe how other health systems might leverage social science to improve their preparations and communications.