Evaluating an inpatient deprescribing initiative at a rural community hospital in Ontario.

BACKGROUND: Deprescribing is an effective means to reduce polypharmacy in elderly patients. However, geriatric day care deprescribing services are challenging to implement in rural regions. In this study, we examined whether a subacute care unit of a rural hospital could deliver a comprehensive and multidisciplinary intervention to promote deprescribing in patients and whether this intervention would succeed in achieving significant and lasting deprescribing results. METHODS: We conducted a cross-sectional analysis of a deprescribing program at a rural hospital in Eastern Ontario, Canada. Participants were 11 patients, aged 65 or older, who were admitted to the hospital's medical/surgical unit or who presented to the emergency department. Clinicians followed a structured, comprehensive and multidisciplinary approach designed to facilitate deprescribing, which concluded with an outcome evaluation at discharge and follow-up phone calls. Outcomes included the frequency and total number of medications successfully removed, reduced, substituted and restarted after discharge and emergency department visits and hospitalizations 6 months before and after the intervention. RESULTS: Of a total 57 deprescribed medications, 38 were eliminated, 8 were switched to a safer alternative, and 11 were dose reduced. Postdischarge deprescribing reversal occurred in only 5 of 57 deprescribed medications. Among the study population, a 59.2% reduction was observed in the combined number of emergency department visits and hospitalizations 6 months after deprescribing. CONCLUSIONS: This feasibility study was successful in showing the potential added value for offering a rehabilitative, subacute care, inpatient, comprehensive and multidisciplinary approach toward patients with complex deprescribing needs. It also showed proof of concept in reducing polypharmacy-induced adverse health outcomes. Can Pharm J (Ott) 2020:153:xx-xx.

Refractory Unforeseen Anaphylaxis Case in a Rural OR Unit.

A 35-year-old female patient with no previously documented allergies who was admitted for elective gynaecological surgery, developed rapid onset, severe anaphylaxis, with dyspnea and cardiovascular collapse, in the operating theatre after receiving routine IV cefazolin prior to induction of anesthesia. She failed to improve with two doses of intramuscular epinephrine followed by two boluses of intravenous epinephrine, but responded to an epinephrine infusion. She was assessed by Internal Medicine and discharged home the following day. This event demonstrates the speed, severity, and profound hypotension in an allergic reaction from intravenous medication, challenges in managing anaphylaxis, and importance of prompt administration of epinephrine via IM route, followed by IV if necessary, in the OR. The case highlighted the inability to ascertain the causative agent through typical allergy testing.

Implementation of a closed-loop medication reconciliation process for ambulatory oncology patients at Winchester District Memorial Hospital.

Medication Reconciliation (MedRec) is a proven method of optimizing pharmacotherapy and decreasing incidence of Adverse Drug Events (ADEs); however, consistent and correct execution is often a challenge in the setting of outpatient oncology. Ambulatory chemotherapy patients are particularly susceptible to polypharmacy and ADEs and their medication management is often complicated due to gaps in communication between an increased volume of non-co-located, multidisciplinary, healthcare providers. Acknowledging these challenges, Winchester District Memorial Hospital (WDMH) led an initiative to create an ambulatory chemotherapy MedRec process using behavioural change approaches. Prior to the intervention, ambulatory chemotherapy MedRec at WDMH was conducted informally via an "open-loop" process. Through an iterative quality improvement process which involved understanding and communicating failure points in the transmission of patients' medication information directly with the frontline medical staff, a practical and sustainable "closed-loop" system evolved, which improved rates to 97.8% overall completion post-intervention.

Improving patient preparedness for the operating room: A quality improvement study in Winchester District Memorial Hospital - A rural hospital in Ontario.

INTRODUCTION: Full completion of the pre-operative checklist is important for proper preparation of patients before they enter the operating room (OR), thus increasing OR efficiency. It is also critical for patient safety and successful outcomes. According to various literature, full completion of pre-operative checklists varies widely between institutions and occurs anywhere between 21% and 92% of cases.[1],[2] Our pre-project audits revealed a suboptimal patient preparedness for the Winchester District Memorial Hospital (WDMH) OR, since only 25% of cases arriving at the OR had their pre-operative checklist completed in its entirety, with no omissions. METHODS: WDMH performed a 12-month long quality improvement (QI) study to improve patient preparedness for the OR. Multiple QI initiatives were used to induce behavioural change by incorporating process mapping, enabling communication, adjusting the pre-operative checklist based on qualitative staff feedback and implementing a staff education plan. Interventions also included two post-implementation audits. RESULTS: Remarkably, completion of the pre-operative checklist increased from 25% to 67% and finally to 94%. Furthermore, the previous chart's presence and completion of pre-operative orders improved from 87% to 100% and from 82% to 99%, respectively. Another significantly important secondary outcome was improvement in interdepartmental relationships and collaboration. With better communication and checklist completion rates, there came increased patient preparedness and improved efficiency. CONCLUSIONS: Multiple significant improvements and many additional minor improvements strongly suggest that the approaches were used were effective at improving patient preparedness.

Introduction au résumé: Il importe de remplir complètement la liste de vérification préopératoire afin de bien préparer les patients avant leur entrée dans la salle d'opération, ce qui favorise l'efficacité dans la salle d'opération. Cela est aussi essentiel à la sécurité des patients et à l'obtention de résultats positifs chez eux. Selon diverses publications, la réalisation complète de la liste de vérification préopératoire varie considérablement d'un établissement à l'autre, soit de 21 à 92 % des cas[1],[2]. Nos vérifications d'avant-projet ont révélé que les patients du bloc opératoire du Winchester District Memorial Hospital (WDMH) étaient préparés de façon sous-optimale, puisque à peine 25 % des listes de vérification préopératoire étaient complètes et sans omissions à l'arrivée des patients à la salle d'opération. Méthodes: L'hôpital WDMH a réalisé une étude d'amélioration de la qualité (AQ) de 12 mois dans le but d'améliorer la préparation des patients pour la salle d'opération. De nombreuses initiatives d'AQ ont été mises de l'avant pour changer les comportements, soit incorporer la schématisation du processus, favoriser la communication, ajuster la liste de vérification préopératoire en fonction des commentaires qualitatifs du personnel et mettre à exécution un plan d'éducation du personnel. Les interventions comptaient aussi deux vérifications après exécution. Résultats: Remarquablement, la réalisation complète de la liste de vérification préopératoire est passée de 25 à 67% et finalement à 94%. En outre, la présence du dossier et l'exécution des ordonnances préopératoires se sont améliorées, pour passer de 87 à 100 % et de 82 à 99 %, respectivement. L'amélioration des relations et de la collaboration entre services était un autre paramètre d'évaluation secondaire significativement important. La meilleure préparation des patients et une meilleure efficacité ont suivi l'amélioration des communications et des taux de réalisation de la liste de vérification. Conclusions: Les nombreuses améliorations significatives et mineures pointent fortement vers l'efficacité de l'approche utilisée pour améliorer la préparation des patients. Mots-clés: Liste de vérification, efficacité, Ontario, préopératoire, amélioration de la qualité, hôpital rural, service de chirurgie.

Effect of stress on female-specific ornamentation.

Signal honesty is theorized to be maintained by condition-dependent trait expression. However, the mechanisms mediating the condition dependence of sexually selected traits are often unknown. New work suggests that elevated glucocorticoid levels during physiological stress may play a role in maintaining signal honesty. Here, we experimentally examine the effect of both chronic and acute stress on the expression of the condition-dependent ornamentation of female striped plateau lizards, Sceloporus virgatus. Females were stressed either chronically via corticosterone implants or relatively acutely via autotomy, were sham manipulated or were left unmanipulated. Both stressors resulted in elevations in corticosterone within physiologically relevant levels, though the implants resulted in significantly higher levels than did autotomy. Corticosterone-implanted females were less likely to produce a clutch of eggs, but those individuals that did reproduce had reproductive output similar to that of females from other treatment groups. Compared with females in other groups, the corticosterone-implanted females tended to develop smaller ornaments that had less UV and orange-to-red wavelength reflectance relative to medium wavelength reflectance. The sex steroid hormones testosterone and estradiol were correlated to corticosterone levels, but did not appear to underlie the effect on ornament expression; of the steroids measured, only corticosterone levels were negatively related to ornament size and coloration. Thus, the condition-dependent ornamentation of female lizards is sensitive to chronic elevations in stress hormones, supporting their importance in the maintenance of signal honesty.