Sustaining and spreading quality improvement: Decreasing intrapartum malpractice risk.

BACKGROUND: Malpractice liability is an ongoing problem in obstetrics. However, developing, sustaining, and spreading effective interventions is challenging. The aim of this study is to examine the spread and sustainability of a multilevel integrated practice and coordinated communication model 66 months after its original implementation. METHODS: Data on labor and delivery patients from 37 hospitals (5 beta sites and 32 expansion sites) were analyzed for the 81-month time period from January 2010 through September 2016. RESULTS: High-risk occurrence rates per 1000 live births decreased by over 70% at both beta and expansion sites. The likelihood of a high-risk occurrence was statistically significantly lower during the final study period than in the preintervention period at both beta sites (odds ratio [OR] = 0.218; p < .0001) and expansion sites (OR = 0.288; p < .001). CONCLUSION: The multilevel integrated practice and coordinated communication model was successfully spread and sustained. Key elements contributing to this success included developing and maintaining evidence-based guidelines, ensuring leadership buy-in and support, collecting and reporting performance measures, holding teams accountable, providing training, and ensuring transparent communication.

Mental health problems in people living with HIV: changes in the last two decades: the London experience 1990-2014.

Mental health problems continue to be a significant comorbidity for people with HIV infection, even in the era of effective antiretroviral therapy. Here, we report on the changes in the mental health diagnoses based on clinical case reports amongst people with HIV referred to a specialist psychological medicine department over a 24-year period, which include the relative increase in depressive and anxiety disorders, often of a chronic nature, together with a decline in acute mental health syndromes, mania, and organic brain disorders. In addition, new challenges, like the presence of HIV and Hepatitis C co-infection, and the new problems created by recreational drugs, confirm the need for mental health services to be closely involved with the general medical services. A substantial proportion of people with HIV referred to specialist services suffer complex difficulties, which often require the collaboration of both psychiatrists and psychologists to deal effectively with their difficulties.

Documentation of daily sit-to-stands performed by community-dwelling adults.

No information exists about how many sit-to-stands (STSs) are performed daily by community-dwelling adults. We, therefore, examined the feasibility of using a tally counter to document daily STSs, documented the number of daily STSs performed, and determined if the number of STSs was influenced by demographic or health variables. Ninety-eight community-dwelling adults (19-84 years) agreed to participate. After providing demographic and health information, subjects used a tally counter to document the number of STSs performed daily for 7 consecutive days. All but two subjects judged their counter-documented STS number to be accurate. Excluding data from these and two other subjects, the mean number of STSs for subjects was 42.8 to 49.3, depending on the day. The number was significantly higher on weekdays than weekends. No demographic or health variable was significantly related to the number of STSs in univariate or multivariate analysis. In conclusion, this study suggests that a tally counter may be a practical aid to documenting STS activity. The STS repetitions recorded by the counter in this study provide an estimate of the number of STSs that community-dwelling adults perform daily.

Functional mobility training for individuals admitted to acute care following a stroke: a prospective study.

PURPOSE: This study describes current stroke care within hospital acute care settings. METHOD: Twenty-two acute care hospital sites in Central South Ontario were mailed a survey exploring the prevalence of stroke admissions, use of protocols and policies, staff resources, stroke-specific training, and available equipment. Corresponding site data from the Canadian Institute for Health Information were also analyzed. RESULTS: An 82% survey response rate was obtained. In 2003-2004, stroke admissions represented 1.9% of total admissions, with a mean admitting resource intensity weight of 1.99. Average length of stay was 12.5 days, with 3.4 of these days designated awaiting an alternate level of care. One third of the sites reported that they had no written guidelines on how to position or mobilize individuals following a stroke, and very few of the sites reported providing stroke-specific education. CONCLUSION: The lack of a consistent coordinated approach to early mobilization and physical care for individuals admitted to an acute care setting following a stroke necessitates that new opportunities to coordinate educational resources and services to promote evidence-based practice in acute stroke care be pursued.

Comparing 2 versions of the Chedoke Arm and Hand Activity Inventory with the Action Research Arm Test.

BACKGROUND AND PURPOSE: The Chedoke Arm and Hand Activity Inventory (CAHAI) is a new, validated upper-limb measure that uses a 7-point quantitative scale in order to assess functional recovery of the arm and hand after a stroke. The purposes of this study were: (1) to determine whether the longitudinal validity of scores on 2 versions of a new upper-limb measure, the CAHAI (CAHAI-9 and CAHAI-13), was greater than that of scores on the Action Research Arm Test (ARAT) and (2) to determine whether the cross-sectional and longitudinal validity of the CAHAI-13 scores was greater than that of the CAHAI-9 scores. SUBJECTS: One hundred five people with upper-limb dysfunction following a stroke were stratified into 2 impairment groups (mild to moderate and severe), which were expected to change by different amounts. METHODS: The CAHAI-13 and ARAT were administered twice (time between assessments varied from 2 to 6 weeks). Receiver operating characteristic curves, Pearson product moment coefficient of correlation, and regression analyses were used. RESULTS: Receiver operating characteristic curve areas (CAHAI-13=0.86, CAHAI-9=0.82, ARAT=0.72) were significantly greater for the CAHAI versions. Scores on both CAHAI versions had identical levels of cross-sectional validity. DISCUSSION AND CONCLUSION: Both CAHAI versions demonstrated more sensitivity to change than the ARAT. It remains unclear whether the CAHAI-9 provides precise estimates of CAHAI-13 scores at the individual level.

Test-retest reliability, validity, and sensitivity of the Chedoke arm and hand activity inventory: a new measure of upper-limb function for survivors of stroke.

OBJECTIVES: To estimate the test-retest reliability and validity of the Chedoke Arm and Hand Activity Inventory (CAHAI) and to test whether the CAHAI was more sensitive to change in upper-limb function than the Impairment Inventory of the Chedoke-McMaster Stroke Assessment (CMSA) and the Action Research Arm Test (ARAT). DESIGN: Construct validation process. SETTING: Inpatient/outpatient rehabilitation facilities. PARTICIPANTS: Stratified sample of 39 survivors of stroke: 24 early (mean age, 71.4 y; mean days poststroke, 27.3) and 15 chronic (mean age, 64.0 y; mean days poststroke, 101.7). INTERVENTION: Regular therapy. MAIN OUTCOME MEASURES: Intraclass correlation coefficients (ICCs), receiver operating characteristic (ROC), standard error of measurement, and correlation coefficients. RESULTS: High interrater reliability was established with an ICC of .98 (95% confidence interval [CI], .96-.99). The minimal detectable change score was 6.3 CAHAI points. Higher correlations were obtained between the CAHAI and the ARAT and CMSA scores compared with the CMSA shoulder pain scores (1-sided, P=.001). Areas under the ROC curves were as follows: CAHAI, .95 (95% CI, 0.87-1.00); CMSA, .76 (95% CI, .61-.92); and ARAT, .88 (95% CI, 0.76-1.00). CONCLUSIONS: High interrater reliability and convergent and discriminant cross-sectional validity were established for the CAHAI. The CAHAI is more sensitive to clinically important change than the ARAT.

Development of the Chedoke Arm and Hand Activity Inventory: theoretical constructs, item generation, and selection.

The Chedoke Arm and Hand Activity Inventory (CAHAI) was developed to address the need for a valid, clinically relevant, responsive functional assessment of the recovering paretic upper limb. The purpose of this article is to describe the development of the measure including its theoretical constructs, item generation, and item selection. From the literature, survivors of stroke, and their caregivers, 751 items were generated. Using factor analyses stem leaf plots, clinical judgment, and pilot testing on individuals with stroke, the list was reduced to 13 bilateral, real-life items. Research continues to provide evidence of the CAHAI's test-retest and interrater reliability as well as construct, concurrent, and longitudinal validity.