Sepsis screening protocol implementation: a clinician-validated rapid realist review.

INTRODUCTION: The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur. METHODS: A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms. RESULTS: Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation. CONCLUSION: This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.

Disclosure and Reporting of Abuse Against Older Adults: Perspectives of Older Adults with Abuse Histories and Service Providers in Alberta, Canada.

This exploratory qualitative study seeks to understand the barriers and facilitators of disclosure and reporting of abuse against older adults by conducting interviews with older adults with lived experience of abuse and service providers working directly with this population in Alberta, Canada. Thematic analysis revealed three key themes: (1) Barriers to disclosure and reporting of abuse; (2) Facilitators to disclosure and reporting; and (3) Key tensions between service providers' and older adults' perceptions of the disclosure and reporting process. Based on these findings, we offer recommendations to increase awareness, promote disclosure, and improve services for older adults experiencing abuse.

Communication between consultants providing advice and referring physicians: a scoping review.

OBJECTIVE: Communication during consultations between referring and consultant physicians is often cited as a source of adverse events, medical error and professional incivility. While existing literature focuses on the role of referring physicians, few studies acknowledge the role of consultant physicians in enhancing communication during consultations. This scoping review aims to identify and synthesise available recommendations to enhance the communication practices of consultants during real-time consultations. DESIGN: A scoping review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATA SOURCES: Medline, EMBASE and PsycINFO databases were searched from inception to August 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: English-language publications which describe recommendations, strategies or frameworks to improve the communication practices of consultant physicians during real-time consultations with referring physicians. DATA EXTRACTION AND SYNTHESIS: The search strategy included the following concepts: consultation, physician, communication, interprofessional relations and best practice. Two authors independently performed each phase of title and abstract screening, full-text review and data extraction. Discrepancies were resolved by a third author. Extracted data were iteratively analysed and summarised thematically. RESULTS: Sixteen publications met the inclusion criteria. Synthesis of available recommendations identified organisation, expertise and interpersonal skills as three overarching and interconnected dimensions of communication demonstrated by consultants during effective consultations. Twelve studies identified interpersonal skills as being critical in alleviating the widespread professional incivility that is reported during consultations. Existing recommendations to improve the communication practices of consultants are limited as they lack standardised interventions and fail to comprehensively address all three elements identified in this review. CONCLUSION: This scoping review synthesises available recommendations to improve the communication practices of consultant physicians during real-time consultations. An opportunity exists to develop communication tools or educational interventions based on the findings of this review to enhance interphysician consultation encounters.

Quality of life and well-being during the COVID-19 pandemic: associations with loneliness and social isolation in a cross-sectional, online survey of 2,207 community-dwelling older Canadians.

BACKGROUND: The far-reaching health and social sequelae of the COVID-19 pandemic among older adults have the potential to negatively impact both quality of life (QoL) and well-being, in part because of increased risks of loneliness and social isolation. The aim of this study was to examine predictors of QoL and well-being among Canadian older adults within the context of the pandemic, including loneliness and social isolation. METHODS: This cross-sectional, online survey recruited older adult participants through community organizations and research participant panels. Measures included the: Older People's Quality of Life Scale-B, WHO-5, DeJong Gierveld Loneliness Scale, Lubben Social Network Scale and five COVID-19 specific items assessing impact on loneliness and social isolation. Multiple linear regression models were used to adjust for potential confounders. RESULTS: A total of 2,207 older Canadians (55.7% female, with a mean age of 69.4 years) responded to the survey. Over one-third strongly disagreed that the pandemic had had a significant effect on either their mental (35.0%) or physical health (37.6%). Different patterns of predictors were apparent for QoL and well-being. After adjusting for all variables in the models, the ability of income to meet needs emerged as the strongest predictor of higher QoL, but was not associated with well-being, except for those who chose not to disclose their income adequacy. Age was not associated with either QoL or well-being. Females were more likely to experience lower well-being (ß=-2.0, 95% C.I. =-4.0,-0.03), but not QoL. Reporting three or more chronic health conditions and that the COVID-19 pandemic had a negative impact on mental health was associated with lower QoL and well-being. Loneliness was a predictor of reduced QoL (ß=-1.4, 95% C.I. =--1.6, -1.2) and poor well-being (ß=-3.7, 95% C.I. =-4.3,-3.0). A weak association was noted between QoL and social isolation. CONCLUSIONS: The COVID-19 pandemic is associated with differential effects among older adults. In particular, those with limited financial resources and those with multiple chronic conditions may be at more risk to suffer adverse QoL and well-being consequences. Loneliness may be a modifiable risk factor for decreased QoL and well-being amenable to targeted interventions.

"We're drowning and we're alone": a qualitative study of the lived experience of people experiencing persistent post-COVID-19 symptoms.

BACKGROUND: The "long tail" of the COVID-19 pandemic will be reflected in disabling symptoms that persist, fluctuate or recur for extended periods for an estimated 20%-30% of those who had a SARS-CoV-2 infection; development of effective interventions to address these symptoms must account for the realities faced by these patients. We sought to describe the lived experience of patients living with persistent post-COVID-19 symptoms. METHODS: We conducted a qualitative study, using interpretive description, of the lived experiences of adults experiencing persistent post-COVID-19 symptoms. We collected data from in-depth, semistructured virtual focus groups in February and March 2022. We used thematic analysis to analyze the data and met with several participants twice for respondent validation. RESULTS: The study included 41 participants (28 females) from across Canada with a mean age of 47.9 years and mean time since initial SARS-CoV-2 infection of 15.8 months. Four overarching themes were identified: the unique burdens of living with persistent post-COVID-19 symptoms; the complex nature of patient work in managing symptoms and seeking treatment during recovery; erosion of trust in the health care system; and the process of adaptation, which included taking charge and transformed self-identity. INTERPRETATION: Living with persistent post-COVID-19 symptoms within a health care system ill-equipped to provide needed resources profoundly challenges the ability of survivors to restore their well-being. Whereas policy and practice increasingly emphasize the importance of self-management within the context of post-COVID-19 symptoms, new investments that enhance services and support patient capacity are required to promote better outcomes for patients, the health care system and society.

Health Literacy and Serious or Persistent Mental Illness: A Mixed Methods Study.

BACKGROUND: Health literacy is increasingly recognized as a major determinant of health; however, our insights into the health literacy strengths and needs of adults living with serious or persistent mental illness remain limited by a notable lack of research in this area. Improving our understanding is important because people in this group are especially vulnerable to numerous negative health outcomes, many preventable. OBJECTIVE: To assess the health literacy strengths and needs of people living with serious or persistent mental illness in terms of their ability to acquire, understand, and use information about their illness and the health services they require. METHODS: A cross-sectional convergent mixed methods design guided by the Ophelia Access and Equity Framework. People diagnosed with serious or persistent mental illness were offered participation. Quantitative and qualitative data was collected using questionnaires (Health Literacy Questionnaire [HLQ], World Health Organization [WHO-5]) and semi-structured interviews. Hierarchical cluster analysis identified and grouped participants with similar health literacy scores into mutually exclusive groups, for the development of clinical vignettes. KEY RESULTS: Participants struggled most with the appraisal of health information (HLQ mean 2.72, standard deviation [SD] .63 [scale 1-4]) and navigating what they often perceived to be a confusing health care system (HLQ mean 3.29, SD .79 [scale 1-5]). On the other hand, most participants reported positive experiences with their health care providers (HLQ mean 3.19, SD .62 [scale 1-4]) and generally felt understood and supported. The cluster analysis suggests we should not assume people living with serious or persistent mental illness have homogeneous HL strengths and needs, meaning a one-size-fits-all solution for improving health literacy in this diverse group will likely not be a successful strategy. It will be important to explore solutions that embrace patient-centered care approaches. CONCLUSIONS: This study is one of only a handful assessing the health literacy strengths and needs of people living with serious or persistent mental illness. By collecting both quantitative and qualitative data, then analyzing the results using sophisticated cluster analysis methods, the authors were able to develop clinical vignettes per the Ophelia Framework that offer results in a practical way that can be readily understood and acted upon by stakeholders. We found that the HLQ is a measure of HL that is acceptable to mental health clients, and our findings provide preliminary data on the use of this instrument in the mental health population. [HLRP: Health Literacy Research and Practice. 2023;7(1):e2-e13.] Plain Language Summary: This study explored the health literacy strengths and needs of people living with serious or persistent mental illness. The results showed a mix of strengths and needs among our participants, though several consistent themes emerged. Most of our participants felt understood and supported by their health care providers, but many often struggle with judging the quality of health information and finding their way through the health care system.

A scoping review of asthma and machine learning.

OBJECTIVE: The objective of this study was to determine the extent of machine learning (ML) application in asthma research and to identify research gaps while mapping the existing literature. DATA SOURCES: We conducted a scoping review. PubMed, ProQuest, and Embase Scopus databases were searched with an end date of September 18, 2020. STUDY SELECTION: DistillerSR was used for data management. Inclusion criteria were an asthma focus, human participants, ML techniques, and written in English. Exclusion criteria were abstract only, simulation-based, not human based, or were reviews or commentaries. Descriptive statistics were presented. RESULTS: A total of 6,317 potential articles were found. After removing duplicates, and reviewing the titles and abstracts, 102 articles were included for the full text analysis. Asthma episode prediction (24.5%), asthma phenotype classification (16.7%), and genetic profiling of asthma (12.7%) were the top three study topics. Cohort (52.9%), cross-sectional (20.6%), and case-control studies (11.8%) were the study designs most frequently used. Regarding the ML techniques, 34.3% of the studies used more than one technique. Neural networks, clustering, and random forests were the most common ML techniques used where they were used in 20.6%, 18.6%, and 17.6% of studies, respectively. Very few studies considered location of residence (i.e. urban or rural status). CONCLUSIONS: The use of ML in asthma studies has been increasing with most of this focused on the three major topics (>50%). Future research using ML could focus on gaps such as a broader range of study topics and focus on its use in additional populations (e.g. location of residence).Supplemental data for this article is available online at http://dx.doi.org/ .

Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study.

PURPOSE: Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. METHODS: To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. RESULTS: Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. CONCLUSIONS: This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

A multi-stage process to develop quality indicators for community-based palliative care using interRAI data.

BACKGROUND: Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments-an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families. METHODS: The development efforts took part in multiple stages, between 2017-2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method. RESULTS: Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs. CONCLUSIONS: Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families.

Outcomes of a controlled trial with visiting therapy dog teams on pain in adults in an emergency department.

CONTEXT: Pain is a primary reason individuals attend an Emergency Department (ED), and its management is a concern. OBJECTIVES: Change in symptoms and physiologic variables at 3 time points pre-post a ten-minute St. John Ambulance therapy dog team visit compared to no visit in ED patients who experienced pain. DESIGN, SETTING AND PARTICIPANTS: Using a controlled clinical trial design, pain, anxiety, depression and well-being were measured with the Edmonton Symptom Assessment System (revised version) (ESAS-r) 11-point rating scales before, immediately after, and 20 minutes post- therapy dog team visit with Royal University Hospital ED patients participating in the study (n = 97). Blood pressure and heart rate were recorded at the time points. Control data was gathered twice (30 minutes apart) for comparison (n = 101). There were no group differences in age, gender or ethnicity among the control and intervention groups (respectively mean age 59.5/57.2, ethnicity 77.2% Caucasian/87.6%, female 43.6% /39.2%, male 56.4%/60.8%,). INTERVENTION: 10 minute therapy dog team visit in addition to usual care. MAIN OUTCOME MEASURES: Change in reported pain from pre and post therapy dog team visit and comparison with a control group. RESULTS: A two-way ANOVA was conducted to compare group effects. Significant pre- post-intervention differences were noted in pain for the intervention (mean changeint. = -0.9, SD = 2.05, p = .004, 95% confidence interval [CI] = [0.42, 1.32], ηp2 = 04) but not the control group. Anxiety (mean changeint. = -1.13, SD = 2.80, p = .005, 95% CI = [0.56, 1.64], ηp2 = .04), depression (mean changeint. = -0.72, SD = 1.71, p = .002, 95% CI = [0.39, 1.11], ηp2 = .047), and well-being ratings (mean changeint. = -0.87, SD = 1.84, p < .001, 95% CI = [0.49, 1.25], ηp2 = .07) similarly improved for the intervention group only. There were no pre-post intervention differences in blood pressure or heart rate for either group. Strong responders to the intervention (i.e. >50% reduction) were observed for pain (43%), anxiety (48%), depression (46%), and well-being (41%). CONCLUSIONS: Clinically significant changes in pain as well as significant changes in anxiety, depression and well-being were observed in the therapy dog intervention compared to control. The findings of this novel study contribute important knowledge towards the potential value of ED therapy dogs to affect patients' experience of pain, and related measures of anxiety, depression and well-being. TRIAL REGISTRATION: This controlled clinical trial is registered with ClinicalTrials.gov, registration number NCT04727749.

Top 10 research priorities for people with obstructive sleep apnoea, families and clinicians: James Lind Alliance Priority Setting Partnership.

Obstructive sleep apnoea (OSA) is associated with significant comorbidity, preventable accidents and reduced quality of life. Little is known about the research priorities of patients with OSA, family members and clinicians. A James Lind Alliance research priority setting partnership was conducted. An initial survey (690 respondents who generated 1110 questions), a prioritisation survey (250 respondents), and a final workshop were used to identify the top 10 research priorities. Consensus was achieved on the top-ranked research priorities. Our results will inform the efforts of funders, researchers and policy-makers to align directly with stakeholder priorities related to OSA.

Trauma experiences of rural practitioners: A self assessment.

INTRODUCTION: The purpose of this study was to identify, through self-assessment, how comfortable rural emergency medicine (EM) physicians are in treating critically ill trauma patients, the resources available to treat such patients and their comfort with performing trauma procedures. METHODS: An anonymous self-assessment survey was e-mailed to family physicians practising rural EM in Saskatchewan regarding training, hospital resources, demographics and self-reported comfort with rural trauma management. We included physicians who had provided EM care within the past year in Saskatchewan outside of the major trauma centres. Comfort was measured on a Likert scale. RESULTS: One hundred thirteen physicians out of a total of 479 physicians contacted agreed to participate (23.6%). Thirty-nine percent (n = 31) of respondents were comfortable with paediatric trauma, and 46% (n = 37) were comfortable with vascular trauma. Nineteen percent (n = 15) were comfortable with pericardiocentesis and 25% (n = 19) were comfortable with cricothyroidotomy. In the past 12 months, 21% (n = 17) had performed paediatric endotracheal intubation, 1.3% (n = 1) had performed cricothyroidotomy, 28.8% (n = 23) had performed needle thoracentesis and 20% (n = 16) had performed central venous line access. Those who did their residency training outside of Canada were more comfortable with overall trauma care. Those who had taken emergency department echo were generally more comfortable with trauma procedures. Those who had current advanced trauma life support were more comfortable with less frequently encountered aspects of trauma care. CONCLUSIONS: This self-assessment helped us identify which aspects of rural trauma medicine are the most challenging for rural practitioners. It gave us an understanding of the procedures related to trauma medicine that are the most difficult, which critical resources are available and where training could be focused to benefit rural emergency physicians.

Résumé Introduction: Cette étude avait pour but d'identifier, par l'entremise d'une auto-évaluation, l'aisance des urgentologues en milieu rural à traiter les patients polytraumatisés en état critique, les ressources disponibles pour traiter ces patients et l'aisance avec laquelle ils exécutent les interventions de traumatologie. Méthodes: Un questionnaire d'auto-évaluation anonyme a été envoyé par courriel aux médecins de famille qui pratiquent dans les services d'urgence ruraux de la Saskatchewan; le questionnaire portait sur la formation, les ressources hospitalières, les paramètres démographiques et l'aisance rapportée par les répondants quant à la prise en charge des traumatismes en milieu rural. Nous avons inclus les médecins qui avaient dispensé dans l'année écoulée des soins d'urgence à l'extérieur des grands centres de traumatologie en Saskatchewan. L'aisance était mesurée sur une échelle Likert. Résultats: Sur un total de 479 médecins contactés, 113 ont consenti à participer (23.6%). Trente-neuf pour cent (n = 31) des répondants étaient à l'aise avec les traumatismes pédiatriques et 46% (n = 37) avec les traumatismes vasculaires. Dix-neuf pour cent (n = 15) étaient à l'aise avec la ponction péricardique et 25% (n = 19) avec la cricothyroïdotomie. Dans les 12 mois écoulés, 21% (n = 17) avaient exécuté une intubation endotrachéale pédiatrique, 1.3% (n = 1) une cricothyroïdotomie, 28,8% (n = 23) une thoracentèse à l'aiguille et 20% (n = 16) un accès veineux central. Les médecins qui avaient reçu leur formation en résidence à l'extérieur du Canada étaient plus à l'aise avec les soins de traumatologie en général. Les médecins qui avaient suivi le cours d'échographie du département d'urgence étaient en général plus à l'aise avec les interventions de traumatologie. Les médecins qui avaient une certification advanced trauma life support étaient plus à l'aise avec les aspects moins fréquents des soins de traumatologie. Conclusions: Cette auto-évaluation nous a aidés à déterminer quels aspects de la médecine de traumatologie rurale sont les plus problématiques pour les praticiens en milieu rural. Elle nous a permis de comprendre quelles sont les interventions de traumatologie qui sont les plus difficiles, quelles ressources essentielles sont disponibles et sur quels aspects la formation doit se concentrer pour profiter aux urgentologues en milieu rural. Mots-clés: prise en charge des traumatismes en milieu rural, médecine de traumatologie rurale, Trauma, rural, médecine d'urgence.

Care Considerations in a Patient- and Family-Centered Medical Assistance in Dying Program.

Objective: Medical Assistance in Dying (MAID) became legal in Canada in June 2016. As part of a project designed to improve end-of-life care for those requesting MAID, qualitative data from patients, families, and providers were used to assess opportunities to enhance patient-and family-centered care (PFCC) in this program. Methods: Thirty interviews were conducted with patients, families, and healthcare providers. Five patients who requested an assessment for MAID, 11 family members, and 14 healthcare providers were interviewed about their experiences in 2017. Comparative coding and thematic analysis were completed with the support of NVivo12. Results: Emotional PFCC considerations included: exploring and validating the emotional journey, navigating the uncertain, judgmental experiences, and the emotional impact on families and the care team. Physical PFCC considerations included: sensitivity in eligibility assessments, weaving in interdisciplinary care, provision of anticipatory guidance, and death location. Spiritual PFCC considerations included: honoring choice, listening to life stories, supporting spiritual needs, and acknowledging loss. Relational PFCC considerations included: defining the circle of support, supporting the circle, and relational investments. Conclusion: Fundamental to a PFCC MAID program, practitioners must be afforded time to provide holistic care. Program-related suggestions include incorporating interdisciplinary care early, and throughout the illness trajectory, consistency in care providers, appropriate anticipatory guidance, and bereavement supports for family, and dedicate space for MAID provisions. Patients and families must be included in the ongoing development and re-evaluation of MAID programs to ensure continued focus on quality end-of-life care.

Rural vs urban inequalities in stage at diagnosis for lung cancer.

OBJECTIVES: Early diagnosis of lung cancer increases the chance of survival. The aim of this study was to measure the relationship between geographic residence in Saskatchewan and stage of lung cancer at the time of diagnosis. MATERIALS AND METHODS: Retrospective cohort analysis of 2,972 patients with a primary diagnosis of either non-small cell cancer (NSCLC) or small cell lung cancer (SCLC) between 2007 and 2012 was performed. Incidence proportion of early and advanced stage cancer, and relative risk of being diagnosed with advanced-stage lung cancer relative to early-stage was calculated. RESULTS: Compared to urban Saskatchewan, rural Saskatchewan lung cancer patients had a higher relative risk of advanced stage NSCLC (relative risk [RR] = 1.11, 95% confidence interval [CI]: 1.01-1.22). Rural Saskatchewan was further subdivided into north and south. The relative risk of advanced stage NSCLC in rural north Saskatchewan compared to urban Saskatchewan was even greater (RR = 1.17, 95% CI: 1.03-1.31). Although not statistically significant, there was a trend for a higher incidence of advanced stage SCLC in rural and rural north vs urban Saskatchewan (RR = 1.16, 95% CI: 0.95-1.43 and RR = 1.22; 95% CI: 0.94-1.58, respectively). There was a higher incidence proportion of advanced stage NSCLC in rural areas relative to urban (31.6-34.4 vs 29.5 per 10,000 people). CONCLUSION: Patients living in rural Saskatchewan have higher incidence proportion of and were more likely to present with advanced stage NSCLC in comparison to urban Saskatchewan patients at time of diagnosis. This inequality was even greater in rural north Saskatchewan.

An App-Based Mindfulness-Based Self-compassion Program to Support Caregivers of People With Dementia: Participatory Feasibility Study.

BACKGROUND: The number of persons with dementia is steadily growing, as is the number of individuals supporting persons with dementia. Primary caregivers of persons with dementia are most often family members or spouses of the persons with dementia, and they are more likely to experience increased stress and other negative effects than individuals who are not primary caregivers. Although in-person support groups have been shown to help buffer the negative impacts of caregiving, some caregivers live in isolated or rural communities and are unable to make the burdensome commitment of traveling to cities. Using an interdisciplinary approach, we developed a mobile smartphone support app designed for primary caregivers of persons with dementia, with the goal of reducing caregiver burden and easing stress. The app features a 12-week intervention, largely rooted in mindfulness-based self-compassion (MBSC), because MBSC has been linked to minimizing stress, depression, and anxiety. OBJECTIVE: The primary objectives of our program are twofold: to explore the feasibility of a 12-week mobile support program and to conduct an initial efficacy evaluation of changes in perceived caregiver burden, coping styles, and emotional well-being of caregivers before and after the program. METHODS: Our feasibility study used a 2-phase participatory pretest and posttest design, focusing on acceptability, demand, practicality, implementation, and efficacy. At phase I, we recruited 57 primary caregivers of persons with dementia (mean age 76.3, SD 12.9 years), comprising spouses (21/57, 37%), children (21/57, 37%), and friends or relatives (15/57, 26%) of persons with dementia, of whom 29 (51%) completed all measures at both pre- and postprogram. The content of the program featured a series of MBSC podcasts. Our primary outcome measure was caregiver burden, with secondary outcome measures including coping styles and emotional well-being. Daily ecological momentary assessments enabled us to ask participants, "How are you feeling today?" Phase II of our study involved semistructured follow-up interviews with most participants (n=21) who completed phase I. RESULTS: Our findings suggest that our app or program meets the feasibility criteria examined. Notably, participants generally accepted the program and believed it could be a useful resource. Emotional well-being increased significantly (P=.04), and emotion-based coping significantly decreased (P=.01). Participants generally considered the app or program to be a helpful resource. CONCLUSIONS: Although there were no significant changes in caregiver burden, we were encouraged by the increased emotional well-being of our participants following the completion of our program. We also conclude that our app or program demonstrated feasibility (ie, acceptability, practicality, implementation, and efficacy) and can provide a much-needed resource for primary caregivers of persons with dementia. In the subsequent version of the program, we will respond to participant feedback by incorporating web-based weekly sessions and incorporating an outcome measure of self-compassion.

A rapid realist review of patient engagement in patient-oriented research and health care system impacts: part one.

BACKGROUND: Patient-oriented research affords individuals with opportunities to genuinely contribute to health care research as members of research teams. While checklists and frameworks can support academic researchers' awareness of patient engagement methods, less guidance appears available to support their understanding of how to develop and maintain collaborative relationships with their patient partners. This knowledge is essential as patient partners report that the social atmospheres of research teams significantly impacts the quality of their experiences. This study sought to develop theory regarding how academic researchers support and sustain patient engagement in patient-oriented research. METHODS: A six-step, rapid realist review was conducted: (1) research question development, (2) preliminary theory development, (3) search strategy development; (4) study selection and appraisal, (4) data extraction, analysis and synthesis (5) identification of relevant formal theories, and (6) theory refinement with stakeholders. Findings were additionally distilled by collective competence theory. RESULTS: A program theory was developed from 62 international studies which illuminated mechanisms supporting academic researchers to engage patient partners, contexts supporting these mechanisms, and resources that enabled mechanism activation. Interaction between seven contexts (patient-oriented research belief, prior interaction with a healthcare system, prior interaction with a particular academic researcher, educational background of patient partner, prior experience with patient-oriented research, study type, and time lived in a rural-urban setting) and seven mechanisms (deciding to become involved in patient-oriented research, recognizing valuable experiential knowledge, cultural competence, reducing power differentials, respectful team environment, supporting patient partners to feel valued, and readiness to research) resulted in an intermediate outcome (sense of trust). Trust then acted as an eighth mechanism which triggered the final-level outcome (empowered patient-centred lens). CONCLUSIONS: Our theory posits that if patient partners trust they are a member of a supportive team working alongside academic researchers who authentically want to incorporate their input, then they are empowered to draw upon their experiential knowledge of health care systems and contribute as researchers in patient-oriented research. Our theory extends conceptual thinking regarding the importance of trust on patient-oriented research teams, how patient partners' trust is shaped by team interactions, and the role that academic researchers have within those interactions.

Patient-oriented research gives patients, families, and caregivers opportunities to become members of health care research teams. Although academic researchers may be aware of what patient engagement is, they may not understand how to develop effective relationships with their patient partners. Academic researchers need this guidance because earlier research has shown that patient partners want to be supported to feel like they are important members of research teams. This support empowers them to feel confident to share their lived experiences and make suggestions and decisions about a research study. If patient partners believe their experiences and knowledge were not used or valued by academic researchers, then they may feel that their involvement was tokenistic. Tokenistic experiences discourage patient partners from participating in another research study.We conducted a rapid realist review of 62 international studies to explore what works (and does not work) in patient-oriented research. This methodology supported us to examine existing research and better understand what contexts, how and why patient-oriented research led to outcomes on a health care system. The goal of this type of research study is to develop and refine a program theory that identifies how actions and activities lead to outcomes.Our program theory emphasizes that patient partners need to trust the academic researchers they are working with. Several categories of actions (academic researcher's behavior) helped researchers to gain the trust of their patient partners. Academic researchers were more (or less) likely to act in these ways depending on several contextual factors. Once patient partners trusted academic researchers on the team, they were empowered to draw upon their lived knowledge of health care systems and actively contribute as researchers. These findings are part of our complete theory about patient-oriented research impacts. They highlight why it is important to gain patient partners' trust and how a complex set of actions are required by academic researchers to gain that trust.

Factors influencing practitioners' who do not participate in ethically complex, legally available care: scoping review.

BACKGROUND: Evolving medical technology, advancing biomedical and drug research, and changing laws and legislation impact patients' healthcare options and influence healthcare practitioners' (HCPs') practices. Conscientious objection policy confusion and variability can arise as it may occasionally be unclear what underpins non-participation. Our objective was to identify, analyze, and synthesize the factors that influenced HCPs who did not participate in ethically complex, legally available healthcare. METHODS: We used Arksey and O'Malley's framework while considering Levac et al.'s enhancements, and qualitatively synthesized the evidence. We searched Medline, CINAHL, JSTOR, EMBASE, PsychINFO, Sociological Abstracts, and ProQuest Dissertations and Theses Global from January 1, 1998, to January 15, 2020, and reviewed the references of the final articles. We included articles written in English that discussed the factors that influenced physicians and registered nurses (RNs) who did not participate in end-of-life (EOL), reproductive technology and health, genetic testing, and organ or tissue donation healthcare areas. Using Covidence, we conducted title and abstract screening, followed by full-text screening against our eligibility criteria. We extracted the article's data into a spreadsheet, analyzed the articles, and completed a qualitative content analysis using NVivo12. RESULTS: We identified 10,664 articles through the search, and after the screening, 16 articles were included. The articles sampled RNs (n = 5) and physicians (n = 11) and encompassed qualitative (n = 7), quantitative (n = 7), and mixed (n = 2) methodologies. The care areas included reproductive technology and health (n = 11), EOL (n = 3), organ procurement (n = 1), and genetic testing (n = 1). One article included two care areas; EOL and reproductive health. The themed factors that influenced HCPs who did not participate in healthcare were: (1) HCPs' characteristics, (2) personal beliefs, (3) professional ethos, 4) emotional labour considerations, and (5) system and clinical practice considerations. CONCLUSION: The factors that influenced HCPs' who did not participate in ethically complex, legally available care are diverse. There is a need to recognize conscientious objection to healthcare as a separate construct from non-participation in healthcare for reasons other than conscience. Understanding these separate constructs will support HCPs' specific to the underlying factors influencing their practice participation.

"The system is well intentioned, but complicated and fallible" interviews with caregivers and decision makers about palliative care in Canada.

BACKGROUND: Canadian palliative care (PC) philosophy seeks to support individuals in a person-centered and sensitive manner. Unfortunately, philosophy does not necessarily translate into practice and this divide may leave patients without appropriate care at the end of life, causing distress for some families. The primary goal of the study was to identify key factors affecting perceptions of quality PC from the perspective of informal caregivers and decision makers (e.g., program managers) and to understand how their experiences within the health care system may have influenced their perceptions. METHODS: Nine caregivers and 11 decision makers from Yukon Territory, British Columbia, Alberta, Ontario, & Nova Scotia shared their experiences in PC via interview or focus group. Audio recordings were transcribed verbatim and qualitatively analyzed for themes. RESULTS: Three themes emerged, including the Caregiver as Anchor, Bewildering System, and Patient, Caregiver, and Family-Centered Care. While these results resembled other studies on caregivers and individuals receiving PC, the present study also uncovered systemic concerns. There was agreement between the two participant groups across most subthemes, however only caregivers reported feelings of being trapped by the health care system and a general lack of respect from health care professionals. Additionally, caregivers stressed the importance of preserving some sort of normalcy in daily life despite the individual's illness. CONCLUSIONS: Caregivers are critical. The health care system expects them to help a great deal, but they often do not feel supported or respected and the system is lacking the capacity and resources to meet their needs while they are grieving loss and struggling to meet demands.

Improving hospital safety for patients with chronic kidney disease: a mixed methods study.

BACKGROUND: People living with chronic kidney disease (CKD) require complex medical management and may be frequently hospitalized. Patient safety incidents during hospitalization can result in serious complications which may negatively affect health outcomes. There has been limited examination of how these patients perceive their own safety. OBJECTIVES: This study compared the safety perceptions of patients hospitalized with CKD using two approaches: (a) the Patient Measure of Safety (PMOS) questionnaire and (b) qualitative interviews. The study objectives were to: (1) assess concordance between qualitative and quantitative data on safety perceptions and (2) better understand safety as perceived by study participants. METHODS: A cross-sectional convergent mixed methods design was used. Integration at the reporting level occurred by weaving together patient narratives and survey domains through the use of a joint display. Interview data were merged with results of the PMOS on a case-by-case basis for analysis to assess for concordance or discordance between these approaches to safety data collection. RESULTS: Of the 30 inpatients with CKD, almost one quarter (23.3 %) of participants reported low levels of perceived safety in hospitals. Four major themes emerged from the interviews: receiving safe care; expecting to be taken care of; expecting to be cared for; and reporting safety concerns. Suboptimal communication, delays in care and concerns about technical aspects of care were common to both forms of data collection. Concordance was noted between qualitative and quantitative data with respect to communication/teamwork, respect and dignity, staff roles, and ward type/lay-out. While interviews allowed for participants to share specific concerns related to safety about quality of interpersonal interactions, use of the questionnaire alone did not capture this concern. CONCLUSIONS: Safety issues are a concern for in-patients with CKD. Both quantitative and qualitative approaches provided important and complementary insights into these issues. Narratives were mostly concordant with questionnaire scores. Findings from this mixed methods study suggest that communication, interpersonal interactions, and delays in care were more concerning for participants than technical aspects of care. Eliciting the concerns of people with CKD in a systematic fashion, either through interviews or a survey, ensures that hospital safety improvement efforts focus on issues important to patients.

Unidentified patients in the emergency department: a historical cohort study.

OBJECTIVES: To characterize unidentified patients presenting to a single, urban emergency department (ED) in Canada. We report their demographics, ED course, post-ED discharge outcomes, and mode of identification. METHODS: We performed a retrospective chart review using descriptive analyses to assess unidentified patients admitted to Royal University Hospital and St. Paul's Hospital EDs between May 1, 2018, and April 30, 2019, in Saskatoon, Saskatchewan, Canada. We assessed demographic data, clinical presentation, mode of identification, discharge information, and major clinical outcomes. RESULTS: Unidentified patients were disproportionately male (64.9%), and mostly presented as Canadian Triage and Acuity Scale (CTAS) 1 (41.6%) and CTAS 2 (44.2%). Most patients arrived via emergency medical services (80.7%). The most common presenting complaints were substance misuse (33.3%) and trauma (24.6%). The average ED length of stay was 8.7 h (SD 18.6). Many patients received an inpatient consult (58.8%), and 22.3% received support services (e.g., social work). The 30-day mortality of all patients was 13.2%. Of those patients who survived to ED discharge, common dispositions included: home (36.0%), police services (3.5%), or emergency shelters (3.5%). Four (3.5%) patients returned to the hospital unidentified within the study period, and 6.7% of patients discharged from the ED returned within 48 hours. CONCLUSION: Unidentified patients are a high-needs demographic that present mostly with substance misuse or trauma. Repeat ED attendance, sometimes as unidentified patients again, calls for initiatives that facilitate prompt identification, better discharge planning, and linkage to social supports.

RéSUMé: OBJECTIFS: Caractériser les patients non identifiés se présentant à un seul service d'urgence urbain au Canada. Nous rapportons leurs données démographiques, leur parcours aux urgences, leurs résultats après leur sortie de l'urgence et leur mode d'identification. MéTHODES: Nous avons effectué un examen rétrospectif des dossiers à l'aide d'analyses descriptives pour évaluer les patients non identifiés admis à Royal University l'hôpital et St. Paul's Hospital aux urgences de l'hôpital entre le 1er mai 2018 et le 30 avril 2019, Saskatoon, Saskatchewan, au Canada. Nous avons évalué les données démographiques, la présentation clinique, le mode d'identification, les informations de sortie et les principaux résultats cliniques. RéSULTATS: Les patients non identifiés étaient en grande partie des hommes (64.9 %) et se présentaient principalement sous la forme d'une échelle canadienne de triage et de gravité (ÉTG) 1 (41.6 %) et ÉTG 2 (44.2 %). La plupart des patients sont arrivés via les services médicaux d'urgence (80.7 %). Les plaintes les plus courantes étaient l'abus de substances (33.3 %) et le traumatisme (24.6 %). La durée moyenne du séjour à l'urgence était de 8,7 heures (écart-type : 18.6). De nombreux patients ont reçu une consultation interne (58.8 %) et 22.3 % ont reçu des services de soutien (p. ex., travail social). La mortalité sur 30 jours de tous les patients était de 13.2 %. Parmi les patients qui ont survécu à la sortie du service d'urgence, les dispositions courantes comprenaient : domicile (36.0 %), services de police (3.5 %) ou refuges d'urgence (3.5 %). Quatre (3.5 %) patients sont retournés à l'hôpital sans être identifiés pendant la période d'étude, et 6.7 % des patients sortis des urgences sont revenus dans les 48 heures. CONCLUSION: Les patients non identifiés constituent un groupe démographique à besoins élevés qui se présente principalement avec un abus de substances ou de traumatisme. La fréquentation répétée des urgences, parfois en tant que patients non identifiés à nouveau, nécessite des initiatives qui facilitent une identification rapide, une meilleure planification de la sortie et la mise en relation avec des soutiens sociaux.