Generalized Tetanus in a Canadian Farmer Following Orthopedic Surgery.

Tetanus is extremely rare in developed countries. We report the first documented case of tetanus in the province of Alberta since 2016: a farmer that developed trismus, shoulder stiffness, and fevers eight days following orthopedic surgery. Tetanus immunoglobulin elicited rapid recovery. We highlight risk factors, pathogenesis, epidemiology, and diagnostic challenges.

SARS-CoV-2 outbreak in a Canadian suburban tertiary hospital necessitating full facility closure: a descriptive observational study.

BACKGROUND: SARS-CoV-2 can cause outbreaks in community- and hospital-based settings. The aim of this study was to provide a detailed epidemiologic account of a hospital-wide SARS-CoV-2 outbreak and provide a description of case evaluations, transmission networks and the interventions implemented to stem the outbreak. METHODS: We conducted a retrospective descriptive study of a hospital-wide SARS-CoV-2 outbreak at the Misericordia Community Hospital (Edmonton) from June 21 to Aug. 14, 2020. We reviewed hospital chart, public health and occupational health records to determine demographics, case type (community- or hospital-acquired), need for critical care and outcome for each case linked to the outbreak (patients, hospital staff, and community and patient visitors). We developed detailed transmission networks using epidemiologic data to determine what variables may have contributed to transmission. RESULTS: Fifty-eight cases of SARS-CoV-2 infection were linked to this hospital outbreak (31 patients, 25 staff members and 2 visitors; 66% female, age range 19-97 years). One patient required critical care, and 11 deaths were recorded (all among inpatients). Most cases were hospital-acquired (91%), and 28% were asymptomatic at the time of diagnosis. The outbreak was composed of 2 clusters driven by protective equipment breaches, premature removal of precautions, transmission in small staff quarters and infection of a staff member after exposure to a wandering patient with dementia and asymptomatic, undetected SARS-CoV-2 infection. INTERPRETATION: A detailed epidemiologic review of this hospital-wide outbreak shows that a SARS-CoV-2 outbreak can involve complex transmission chains and clusters. Multipronged bundled approaches, aggressive contact tracing, and patient and staff prevalence screening are important to help bring such outbreaks under control, along with ongoing vigilance in detecting delayed cases.

Impact of Adding a Pictorial Display to Enhance Recall of Cancer Patient Histories: A Randomized Trial.

CONTEXT: Current health care delivery models have increased the need for safe and concise patient handover. Handover interventions in the literature have focused on the use of structured tools but have not evaluated their ability to facilitate retention of patient information. OBJECTIVES: In this study, mock pictorial displays were generated in an attempt to create a snapshot of each patient's medical and social circumstances. These pictorial displays contained the patient's photograph and other disease- and treatment-related images. The objective of this randomized trial was to assess the ability of these snapshots to enhance delayed information recall by care providers. METHODS: Participating physicians were given four advanced cancer patient histories to review, two at a time over two weeks. Pictorial image displays, referred to as the Electronic Whiteboard (EWB) were added, in a randomized manner to half of the textual histories. The impact of the EWB on information recall was tested in immediate and delayed time frames. RESULTS: Overall, patient information recall declined significantly over time, with or without the EWB. Still, this trial demonstrates significantly higher test scores after 24 hours with the addition of pictures to textual patient information, compared with textual information alone (P = 0.0002). A more modest improvement was seen with the addition of the EWB for questionnaires administered immediately after history review (P = 0.008). Most participants agreed that the EWB was a useful enhancement and that seeing a patient's photograph improved their ability to retain information. CONCLUSION: Most studies examining the institution of handover protocols in the health care setting have failed to harness the power of pictures and other representative images. This study demonstrates the ability of pictorial displays to improve both immediate and delayed recall of patient histories without increasing review time. These types of displays may be amenable to generation by software programs and have the potential to enhance information transfer in various settings.

Improving residents' handovers through just-in-time training for structured communication.

In a recent quality assurance project we learned that nearly half of the handovers we examined were characterized as unsatisfactory by our residents, who provided examples in which their anxiety had been piqued and patient care had been affected. These reports substantiated a growing body of literature on the relationship between the quality of handover and the quality of patient care, so we sought to improve the quality and consistency of the in-hosptial handovers undertaken by our internal medicine residents. Senior residents attended morning report for three consecutive month long blocks and evaluated the quality of the handovers using an observational protocol comprised of 16 aspects of effective handover. During the first block, the resident observed a median of eight of the 16 practices occurring across the 46 handovers, and a large amount of variability. At the beginning of the subsequent block we presented a concise introduction to a structured handover procedure (SBARR). The median quality of the subsequent 33 handovers rose to 11, and the variability decreased considerably. In the next block we refined the SBARR orientation to focus on the errors observed in the previous blocks, and the improvement in the quality and variability was sustained. The minor change, which requires few resources to sustain, had a favourable impact on the quality of our residents' in-hospital handovers.

A workshop to introduce residents to effective handovers.

BACKGROUND: Patient safety is associated with the quality of handover, yet many residents train in settings that lack a formal procedure for handover. Thus, they have few opportunities to observe or participate in effective practices. The purpose of our project was to design an educational experience that would introduce residents to the essentials of an effective handover. CONTEXT: Through a review of the literature, conversations with our residents and teaching doctors, and needs analysis survey, we determined that a formal, didactic, large group, face-to-face educational experience focusing on lower-level educational objectives would meet the needs of our learners. INNOVATION: Our curriculum development culminated in a 90-minute, multifaceted workshop comprising a brief introduction to handover, a dramatisation of effective and ineffective practices, and a role-play activity, followed by a debriefing session. IMPLICATIONS: Objective, constructed response tests, administered before and after the workshop, suggested that the workshop provided residents with the knowledge that a good handover is structured, free of distraction and prioritised. Some of the misconceptions that were apparent at the beginning of the workshop, however, were unchanged by the learning activities.

Antimicrobial resistance in gonorrhea: the influence of epidemiologic and laboratory surveillance data on treatment guidelines: Alberta, Canada 2001-2007.

OBJECTIVES: To describe the impact of surveillance for antimicrobial resistance (AMR) in Neisseria gonorrhoeae over a 7-year period on treatment guidelines in Alberta, Canada. METHODS: AMR testing data from gonorrhea cases were combined with demographic and risk behavior information collected through surveillance to describe trends and sequential changes to treatment guidelines. RESULTS: Ciprofloxacin resistant gonorrhea (CRG) cultures rose from 1.4% in 2001 to 27.7% in 2007. Of 200 CRG cases, 90% were men, 77% white, median age 29 years (interquartile range: 23-29 years) and 60% were men who have sex with men (MSM). In 2005, only 1 of 28 cases did not fit into travel or MSM categories and treatment guidelines were changed to recommend oral cefixime as the preferred agent in MSM or those with a travel history. Continuous rise in CRG together with locally acquired cases among heterosexuals resulted in ciprofloxacin being removed as a recommended agent for gonorrhea in 2007. CONCLUSIONS: Our data underscores the importance of surveillance in monitoring trends in AMR in gonorrhea so that timely changes to treatment recommendations can be made in response to changing epidemiology.