Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use.

BACKGROUND: The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation. METHODS: Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses. RESULTS: Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation. CONCLUSIONS: ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.

Improving health care efficiency through the integration of a physician assistant into an infectious diseases consult service at a large urban community hospital.

BACKGROUND: Physician assistants (PAs) have recently been introduced into the Canadian health care system in some provinces; however, there are little data demonstrating their impact. METHODS: A retrospective case-control study was conducted between January 2010 and December 2013. Length of stay (LOS) and mortality were examined in the infectious diseases consult service (IDCS) compared with hospital-wide controls. The two-year period before the introduction of the PA to the IDCS of a large urban community hospital in Canada (2010 to 2011) was compared with the two-year period following the introduction of the PA (2012 to 2013). RESULTS: Following the introduction of a PA to the IDCS, there was a decrease in time to consultation from 21.4 h to 14.3 h (P<0.0001). LOS was significantly decreased among IDCS patients by 3.6 days more than that seen in matched hospital-wide controls (P=0.0001). Mortality did not significantly change after PA introduction in either cases or controls. DISCUSSION/CONCLUSION: PAs can improve health efficiencies in the Canadian health care setting, leading to reduction in LOS.

HISTORIQUE: Les auxiliaires médicaux (AM) ont récemment été intégrés au système de santé de certaines provinces canadiennes, mais on possède peu de données pour en évaluer les répercussions. MÉTHODOLOGIE: Les chercheurs ont réalisé une étude rétrospective cas-témoins entre janvier 2010 et décembre 2013. Ils ont comparé la durée de séjour (DdS) et la mortalité au service de consultation en infectiologie (SCI) à celles de sujets témoins de tout l'hôpital. Ils ont comparé la période de deux ans avant l'arrivée des AM au SCI d'un grand hôpital général urbain du Canada (2010 et 2011) à la période de deux ans suivant leur arrivée (2012 et 2013). RÉSULTATS: Après l'arrivée des AM au SCI, les chercheurs ont constaté une diminution du délai avant la consultation, qui est passé de 21,4 h à 14,3 h (P<0,0001). La DdS a régressé d'au moins 3,6 jours chez les patients du SCI par rapport à celle des sujets témoins de l'ensemble de l'hôpital (P=0,0001). La mortalité ne changeait pas de manière significative après l'arrivée des AM, que ce soit pour les cas ou les sujets-témoins. INTERPRÉTATION: Les AM peuvent améliorer l'efficacité du milieu canadien de la santé et réduire la DdS.

Injury rates, types, mechanisms and risk factors in female youth ice hockey.

BACKGROUND: The objectives of this cohort study were to examine the rate, types, mechanisms and risk factors for injury in female youth (ages 9-17) ice hockey players in the Girls Hockey Calgary Association. METHODS: The main outcome was ice hockey injury, defined as any injury occurring during the 2008/2009 season that required medical attention, and/or removal from a session and/or missing a subsequent session. Potential risk factors included age group, level of play, previous injury, ice hockey experience, physical activity level, weight, height, position of play and menarche. Incidence rate ratios (IRR) were estimated with Poisson Regression adjusted for cluster (team). Exposure data were collected for every session for each participating player. RESULTS: Twenty-eight teams (n=324) from Atom (ages 9-10), PeeWee (11-12), Bantam (13-14) and Midget (15-17) participated with 53 reported injuries. The overall injury rate was 1.9 injuries/1000 player-hours (95% CI 1.4 to 2.7). Previous injury (IRR=2.7, 95% CI 1.7 to 4.3), games (IRR=2.1, 95% CI 1.1 to 4.2), menarche (PeeWee) (IRR=4.1, 95% CI 1.0 to 16.8) were significant risk factors. In Midget, the more elite divisions were associated with a lower injury risk (A-IRR=0.2, 95% CI 0.1 to 0.5) (AAA-IRR=0.5, 95% CI 0.2 to 0.9). CONCLUSIONS: Injury rates were lower in this study than previously found in male youth and women's ice hockey populations. Previous injury and game play as risk factors are consistent with the literature. Menarche as a risk factor is a new finding in this study. This research will inform future studies of the development of injury prevention strategies in this population.

Interaction of perceived neighborhood walkability and self-efficacy on physical activity.

OBJECTIVES: Few social ecological studies have considered the joint effects of intrapersonal and environmental influences on physical activity. This study investigated the interaction of self-efficacy and perceived neighborhood walkability in predicting neighborhood-based physical activity and how this relationship varied by gender and body mass index. METHODS: Data were derived from a cross-sectional investigation of environmental and psychosocial correlates of physical activity among adults (n = 585). Participants completed a detailed 7-day physical activity log booklet, along with a questionnaire that included measures of neighborhood walkability, self-efficacy, and several sociodemographic items. Factorial analysis of variance tests were used to examine the main effects of and interaction between walkability and self-efficacy. RESULTS: In predicting neighborhood-based physical activity, significant interactions were observed between self-efficacy and neighborhood walkability for females (but not for males) and for overweight/obese participants (but not for healthy weight individuals). Women and overweight/obese individuals with low self-efficacy demonstrated substantially greater physical activity when living in a high walkable neighborhood. CONCLUSIONS: Physical activity research and promotion efforts should take into account both environmental and personal factors and the interrelationships between them that influence active living.

Risk factors for injury and severe injury in youth ice hockey: a systematic review of the literature.

OBJECTIVE: To identify risk factors for injury in youth ice hockey (ie, body checking, age, player position, player experience and level of play). STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the literature, including a meta-analysis component was completed. Ten electronic databases and the American Society for Testing and Materials Safety in Ice Hockey series (volumes 1-4) were systematically searched with strict inclusion and exclusion criteria to identify articles examining risk factors for injury in youth ice hockey. RESULTS: Participation in games, compared with practices, was associated with an increased risk of injury in all studies examined. Age, level of play and player position produced inconsistent findings. Body checking was identified as a significant risk factor for all injuries (summary rate ratio: 2.45; 95% CI 1.7 to 3.6) and concussion (summary odds ratio: 1.71; 95% CI 1.2 to 2.44). CONCLUSIONS: Findings regarding most risk factors for injury remain inconclusive; however, body checking was found to be associated with an increased risk of injury. Policy implications regarding delaying body checking to older age groups and to only the most elite levels requires further rigorous investigation.