Implementing patient navigator programmes within a hospital setting in Toronto, Canada: A qualitative interview study.

OBJECTIVES: This study sought to identify the organisation and system level barriers and facilitators influencing the implementation of patient navigator programmes in one acute care hospital system in Toronto, Canada. METHODS: A qualitative descriptive approach informed by the Consolidated Framework for Implementation Research. Data were collected using in-depth interviews and analysed thematically. RESULTS: Thirty-eight individuals participated in interviews (17 community, 21 acute care hospital), including 24 frontline clinicians and 14 programme directors, health care leaders and managers. Implementation of patient navigator programmes was dependent on: (1) a clear consensus on the unique need for patient navigators; (2) champions to promote patient navigation; (3) programme ownership and accountability; (4) external system and organisational landscape and (5) implementation climate. Appropriate mechanisms of communication were found to have impacted each factor as a barrier or facilitator to programme implementation. CONCLUSION: Strategies for implementing patient navigator programmes into hospital clinical practice should include incorporating evidence to support the programme, considering mechanisms to enable collaborative communication, and the integration of frameworks to facilitate programme integration into the current practices within the organisation.

Assessing readiness to implement patient navigator programs in Toronto, Canada.

OBJECTIVE: To explore factors influencing the implementation of patient navigator programs within a hospital for seniors with complex care needs. METHODS: A qualitative descriptive design using in-depth interviews was conducted. Participant interviews were conducted in Toronto, Ontario between September 2020 and February 2021. Data were analysed using thematic analysis. RESULTS: Thirty-five semi-structured interviews were conducted with 38 participants from a large urban hospital (n = 21) and community healthcare organizations (n = 17), including organizational leaders, and acute care and rehabilitation providers. Follow-up interviews occurred with 16 participants (7 from the community and nine from the hospital). This study identified five key factors influencing organizational readiness for successful implementation of a patient navigator program for seniors with complex conditions, which included: (a) vision from senior leadership, (b) technological infrastructure, (c) existing hospital-community partnerships, (d) well-established process for referrals, and (e) staff capacity. The overarching theme of communication was also identified. CONCLUSIONS: The findings of this study provide a better understanding of hospital and community professionals' needs and challenges when implementing patient navigator programs for seniors with complex care conditions. There are a number of factors that influence an organization's readiness for program uptake and delivery, with the need for clear communication being paramount. Further research to test the effects of readiness on successful implementation outcomes is warranted.

Toxicological findings in fatal motor vehicle collisions in ontario, Canada: a one-year study.

Drug-impaired driving is a complex area of forensic toxicology due in part to limited data concerning the type of drugs involved and the concentrations detected. This study analyzed toxicological findings in drivers from fatal motor vehicle collisions (FMVCs) in Ontario, Canada, over a one-year period using a standardized protocol. Of the 229 cases included in the study, 56% were positive for alcohol and/or drugs. After alcohol, cannabis was the most frequently encountered substance (27%), followed by benzodiazepines (17%) and antidepressants (17%). There were differences in drugs detected by age but no marked difference in drugs detected between single and multiple FMVC's. Not all drugs detected were considered impairing either due to drug type, concentration or case history. The findings indicate the importance of comprehensive drug testing in FMVCs and highlight the need to consider a variety of factors, in addition to drug type and concentration, when assessing the role of drugs in driving impairment.

Nonuse of bicycle helmets and risk of fatal head injury: a proportional mortality, case-control study.

BACKGROUND: The effectiveness of helmets at preventing cycling fatalities, a leading cause of death among young adults worldwide, is controversial, and safety regulations for cycling vary by jurisdiction. We sought to determine whether nonuse of helmets is associated with an increased risk of fatal head injury. METHODS: We used a case-control design involving 129 fatalities using data from a coroner's review of cycling deaths in Ontario, Canada, between 2006 and 2010. We defined cases as cyclists who died as a result of head injuries; we defined controls as cyclists who died as a result of other injuries. The exposure variable was nonuse of a bicycle helmet. RESULTS: Not wearing a helmet while cycling was associated with an increased risk of dying as a result of sustaining a head injury (adjusted odds ratio [OR] 3.1, 95% confidence interval [CI] 1.3-7.3). We saw the same relationship when we excluded people younger than 18 years from the analysis (adjusted OR 3.5, 95% CI 1.4-8.5) and when we used a more stringent case definition (i.e., only a head injury with no other substantial injuries; adjusted OR 3.6, 95% CI 1.2-10.2). INTERPRETATION: Not wearing a helmet while cycling is associated with an increased risk of sustaining a fatal head injury. Policy changes and educational programs that increase the use of helmets while cycling may prevent deaths.

Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis.

BACKGROUND: Platelet-activating factor (PAF) is an important mediator of anaphylaxis in animals, and interventions that block PAF prevent fatal anaphylaxis. The roles of PAF and PAF acetylhydrolase, the enzyme that inactivates PAF, in anaphylaxis in humans have not been reported. METHODS: We measured serum PAF levels and PAF acetylhydrolase activity in 41 patients with anaphylaxis and in 23 control patients. Serum PAF acetylhydrolase activity was also measured in 9 patients with peanut allergy who had fatal anaphylaxis and compared with that in 26 nonallergic pediatric control patients, 49 nonallergic adult control patients, 63 children with mild peanut allergy, 24 patients with nonfatal anaphylaxis, 10 children who died of nonanaphylactic causes, 15 children with life-threatening asthma, and 19 children with non-life-threatening asthma. RESULTS: Mean (+/-SD) serum PAF levels were significantly higher in patients with anaphylaxis (805+/-595 pg per milliliter) than in patients in the control groups (127+/-104 pg per milliliter, P<0.001 after log transformation) and were correlated with the severity of anaphylaxis. The proportion of subjects with elevated PAF levels increased from 4% in the control groups to 20% in the group with grade 1 anaphylaxis, 71% in the group with grade 2 anaphylaxis, and 100% in the group with grade 3 anaphylaxis (P<0.001). There was an inverse correlation between PAF levels and PAF acetylhydrolase activity (P<0.001). The proportion of patients with low PAF acetylhydrolase values increased with the severity of anaphylaxis (P<0.001 for all comparisons). Serum PAF acetylhydrolase activity was significantly lower in patients with fatal peanut anaphylaxis than in control patients (P values <0.001 for all comparisons). CONCLUSIONS: Serum PAF levels were directly correlated and serum PAF acetylhydrolase activity was inversely correlated with the severity of anaphylaxis. PAF acetylhydrolase activity was significantly lower in patients with fatal anaphylactic reactions to peanuts than in patients in any of the control groups. Failure of PAF acetylhydrolase to inactivate PAF may contribute to the severity of anaphylaxis.

Potential organ donors referred to Ontario neurosurgical centres.

PURPOSE: Eleven hospitals in Ontario are adult neurosurgical centres (ONCs). Patients transferred to ONCs from community hospitals with acute intracranial emergencies often have non-survivable injuries, and may be returned to the referring hospital for end-of-life care. These referring hospitals may not be familiar with neurological determination of death, or organ donation. Our objective was to determine the number of patients with severe brain injuries assessed in ONC emergency departments where progression to brain death may be reasonably expected, and to determine their outcome. METHODS: A one-year retrospective cohort study was undertaken using a convenience sample of patients transferred to eight ONCs for neurosurgical assessment, with evidence of either (a) brain death in the emergency department, or (b) severe brain injury who met criteria of a reasonable likelihood of progression to brain death. The outcome of these patients to disposition from the ONC was determined by chart review. RESULTS: Three thousand four hundred and forty-seven patients were identified of whom 141 met inclusion criteria. Eleven patients (7.8%) were pronounced dead in the emergency department, 96 (68.1%) patients were admitted, and 34 (24.1%) were transferred back to their referring hospital. Fourteen patients (9.9%) became organ donors: two died in the emergency department and 12 died following admission. CONCLUSIONS: A significant number of patients transferred to ONCs have an injury with a likelihood of progressing to brain death, but only a small proportion of these patients become organ donors. Emergency department triage, assessment and admission decisions for patients with intracranial catastrophes should consider diagnostic criteria for brain death and recognition of donor potential as part of end-of-life care.

Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation.

BACKGROUND: Lidocaine has been the initial antiarrhythmic drug treatment recommended for patients with ventricular fibrillation that is resistant to conversion by defibrillator shocks. We performed a randomized trial comparing intravenous lidocaine with intravenous amiodarone as an adjunct to defibrillation in victims of out-of-hospital cardiac arrest. METHODS: Patients were enrolled if they had out-of-hospital ventricular fibrillation resistant to three shocks, intravenous epinephrine, and a further shock; or if they had recurrent ventricular fibrillation after initially successful defibrillation. They were randomly assigned in a double-blind manner to receive intravenous amiodarone plus lidocaine placebo or intravenous lidocaine plus amiodarone placebo. The primary end point was the proportion of patients who survived to be admitted to the hospital. RESULTS: In total, 347 patients (mean [+/-SD] age, 67+/-14 years) were enrolled. The mean interval between the time at which paramedics were dispatched to the scene of the cardiac arrest and the time of their arrival was 7+/-3 minutes, and the mean interval from dispatch to drug administration was 25+/-8 minutes. After treatment with amiodarone, 22.8 percent of 180 patients survived to hospital admission, as compared with 12.0 percent of 167 patients treated with lidocaine (P=0.009; odds ratio, 2.17; 95 percent confidence interval, 1.21 to 3.83). Among patients for whom the time from dispatch to the administration of the drug was equal to or less than the median time (24 minutes), 27.7 percent of those given amiodarone and 15.3 percent of those given lidocaine survived to hospital admission (P=0.05). CONCLUSIONS: As compared with lidocaine, amiodarone leads to substantially higher rates of survival to hospital admission in patients with shock-resistant out-of-hospital ventricular fibrillation.

Do hospital E-codes consistently capture suicidal behaviour?

Hospital separation data are used to study suicidal behaviour; however, there is little information about the appropriateness of these data for research and planning activities. The study purpose is to examine how consistently hospital separation E-code data reflect suicidal behaviours. Expert clinicians reviewed medical records of individuals who had a separation for self-poisoning to determine whether the self-poisoning was deliberate. Agreement among clinicians was evaluated and latent class analysis performed to derive a summary estimate of the prevalence of deliberate self-poisoning. This estimate was then compared to the prevalence of deliberate self-poisoning based on the external cause of injury (E-codes). Clinicians estimated the prevalence to be 63% higher than the E-code based prevalence. Much larger discrepancies were apparent among older age groups, those whose care was primarily medical in nature and those with a longer length of hospital stay. In acute care settings, self-poisonings among the elderly may not receive adequate attention and/or documentation. Estimating the prevalence of admissions for suicidal behaviour using hospital separation data is of questionable validity, particularly among older age groups.