Ebola preparedness: a rapid needs assessment of critical care in a tertiary hospital.

BACKGROUND: The current outbreak of Ebola has been declared a public health emergency of international concern. We performed a rigorous and rapid needs assessment to identify the desired results, the gaps in current practice, and the barriers and facilitators to the development of solutions in the provision of critical care to patients with suspected or confirmed Ebola. METHODS: We conducted a qualitative study with an emergent design at a tertiary hospital in Ontario, Canada, recently designated as an Ebola centre, from Oct. 21 to Nov. 7, 2014. Participants included physicians, nurses, respiratory therapists, and staff from infection control, housekeeping, waste management, administration, facilities, and occupational health and safety. Data collection included document analysis, focus groups, interviews and walk-throughs of critical care areas with key stakeholders. RESULTS: Fifteen themes and 73 desired results were identified, of which 55 had gaps. During the study period, solutions were implemented to fully address 8 gaps and partially address 18 gaps. Themes identified included the following: screening; response team activation; personal protective equipment; postexposure to virus; patient placement, room setup, logging and signage; intrahospital patient movement; interhospital patient movement; critical care management; Ebola-specific diagnosis and treatment; critical care staffing; visitation and contacts; waste management, environmental cleaning and management of linens; postmortem; conflict resolution; and communication. INTERPRETATION: This investigation identified widespread gaps across numerous themes; as such, we have been able to develop a set of credible and measureable results. All hospitals need to be prepared for contact with a patient with Ebola, and the preparedness plan will need to vary based on local context, resources and site designation.

A study of the efficacy of flashing lights to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance.

BACKGROUND: Many interventions have been implemented to improve hand hygiene compliance, each with varying effects and monetary costs. Although some previous studies have addressed the issue of conspicuousness, we found only 1 study that considered improving hand hygiene by using flashing lights. METHOD: Our attention theory-based hypothesis tested whether a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance, would increase hand hygiene compliance over the baseline rate. Baseline and intervention observations were completed over five 60-minute periods (Monday-Friday) from 7:30 to 8:30 AM using a covert observation method. RESULTS: Baseline hand hygiene compliance was 12.4%. Our intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather. Overall, our pooled compliance rate increased to 25.3% (P < .0001). CONCLUSIONS: A simple, inexpensive flashing red light affixed to alcohol gel dispensers was sufficiently salient to approximately double overall hand hygiene compliance within the main hospital entrance. We hypothesize that our intervention drew attention to the dispensers, which then reminded employees and visitors alike to wash their hands. Compliance was worse during cold days, presumably related to more individuals wearing gloves.

Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study.

BACKGROUND: Electronic medical records are becoming an integral part of healthcare delivery. OBJECTIVE: The goal of this study was to compare paper documentation versus electronic medical record for non-traumatic chest pain to determine differences in time for physicians to complete medical records using paper versus electronic mediums. We also assessed physician satisfaction with the electronic format. METHODS: We conducted this before-after study in a single large tertiary care academic emergency department. In the 'Before Period', stopwatches determined the time for paper medical recording. In the 'After Period', a template-based electronic medical record was introduced and the time for electronic recording was measured. The time to record in the before and after periods were compared using a two-sided t test. We surveyed physicians to assess satisfaction. RESULTS: We enrolled 100 non-traumatic patients with chest pain in the before period and 73 in the after period. The documentation time was longer using electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians participating in the after period completed surveys. Physicians were not satisfied with the electronic patient recording for non-traumatic chest pain. CONCLUSIONS: This is the first study that we are aware of which compared paper versus electronic medical records in the emergency department. Electronic recording took longer than paper records. Physicians were not satisfied using this electronic record. Given the time pressures on emergency physicians, a solution to minimise the charting time using electronic medical records must be found before widespread uptake of electronic charting will be possible.

Is this subarachnoid hemorrhage significant? A National Survey of Neurosurgeons.

BACKGROUND: Previously all subarachnoid hemorrhage (SAH) patients were admitted, whereas now patients with angiography may be discharged. OBJECTIVE: To survey neurosurgeons to determine current practice and what constitutes a clinically significant subarachnoid hemorrhage. METHODS: We surveyed all neurosurgeons listed in the Canadian Medical Directory. We used a modified Dillman technique with up to five mailed surveys plus a pre-notification letter. Neurosurgeons rated the significance of 13 scenarios of subarachnoid hemorrhage. Scenarios varied from aneurysmal subarachnoid hemorrhage to patients with isolated xanthochromia in cerebrospinal fluid. Each scenario was rated for clinical significance using a 5-point scale [1(always) to 5(never)]. RESULTS: Of the 224 surveyed, 115 neurosurgeons responded. Scenarios with aneurysms requiring intervention, arteriovenous malformations, death or any surgical intervention all had median responses of 1 (IQR 1, 1). Scenarios having xanthochromia and few red blood cells in cerebrospinal fluid with negative computerized tomogram (CT) and angiography had median responses of 3 (IQR 1, 4). Scenarios with perimesencephalic pattern on CT with negative angiography had median of 3 (IQR 2, 4). Scenarios where patient is discharged from the emergency department had median of 4 (IQR 3, 5). CONCLUSION: Subarachnoid hemorrhages due to aneurysms or arteriovenous malformations causing death or requiring surgical intervention are always clinically significant. Other types of nonaneurysmal subarachnoid hemorrhages had inconsistent ratings for clinical significance. These survey results highlight the need for further discussions to standardize the diagnosis of what constitutes a clinically significant subarachnoid hemorrhage and what care should be afforded to these patients.

National survey of Canadian neurologists' current practice for transient ischemic attack and the need for a clinical decision rule.

BACKGROUND AND PURPOSE: Four percent to 10% of patients with transient ischemic attack (TIA) have a stroke or die within 1 week of their diagnosis. This national survey examined Canadian neurologists' current practice for managing TIA, the need for a clinical decision rule to identify high-risk patients, and the required sensitivity of such a rule. METHODS: We surveyed 650 neurologists registered in a national physician directory. We used a modified Dillman technique with a prenotification letter and up to 5 survey attempts using a mailed letter. Neurologists were asked 33 questions about demographics, current management of adult patients with TIA, if a clinical decision rule is required to identify high-risk patients with TIA for impending stroke/death, and the required sensitivity of this rule. RESULTS: We had a response rate of 49.8% (324 of 650). Respondents were 78.3% male and had a mean age of 50.3 years. Of respondents, 49.2% (95% CI: 45.3% to 53.1%) reported using an existing clinical tool to risk-stratify patients. Overall, 95.0% (95% CI: 93.3% to 96.7%) reported they would consider using a sensitive, validated clinical decision rule for risk-stratifying patients with TIA. The median required sensitivity of a rule was 92% (interquartile range, 90 to 95). CONCLUSIONS: We found that Canadian neurologists would use a highly sensitive clinical decision rule to risk-stratify patients with TIA. The median required sensitivity of 92% is higher than the high risk category of any existing tool. Our results indicate a clinical decision rule to predict high-risk TIA needs to be more sensitive than the currently available rules.