Delivering improved patient and system outcomes for hospitalized older adults through an Acute Care for Elders Strategy.

Acute care hospitals are widely recognized as potentially high-risk environments for older adults. In 2010, Mount Sinai Hospital conceived its Acute Care for Elders (ACE) Strategy as a multi-component intervention to improve the care of hospitalized older adults. In order to determine its effectiveness, we conducted a quasi-experimental time series analysis of 12,008 older patients admitted non-electively for acute medical issues over a 6-year period. Despite a 53% increase in annual admissions of older patients between 2009/2010 and 2014/2015, Mount Sinai decreased total lengths of stay and readmissions and reduced the direct cost of care per patient, leading to net savings of CDN$4.2 million in 2014/2015. This article presents Mount Sinai's ACE Strategy and discusses the benefits of implementing integrated evidence-based models across the continuum of care and how it is supporting the implementation of ACE Strategy models of care and care practices across Canada and beyond.

Healthcare for the Aging Citizen and the Aging Citizen for Healthcare: Involving Patient Advisors in Elder-Friendly Care Improvement.

With an aging population and a healthcare system that is overly reliant on providing expensive and sometimes problematic hospital-based care for older Canadians, driving improvements that promote elder-friendly care has never been more critical. The Acute Care for Elders (ACE) Strategy at Toronto's Mount Sinai Hospital is the focus of a pan-Canadian collaborative delivered by the Canadian Foundation for Healthcare Improvement in partnership with the Canadian Frailty Network. The intent is to spread the ACE Strategy's elder-friendly models of care and practices to 18 participating healthcare delivery organizations. A key element of the ACE Collaborative is the inclusion of patient advisors as members of the 18 teams. This article considers the development of elder-friendly care models and practices, with lessons for patient advisors and organizations on the necessary skill-mix, as well as lessons for providers and managers on ways to more effectively engage patient advisors in health system improvement to better serve an aging population.

Hardwiring improvement to achieve exceptional outcomes: Staff as leaders driving performance.

This article will discuss the experiences of two organizations who have driven process improvement through frontline ownership using the National Health Services' Releasing Time to Care (RTC) program. Through the implementation of RTC, frontline staff learn how to gather information from colleagues, stakeholders, and literature to design potential improvements.

Critical care services in Ontario: a survey-based assessment of current and future resource needs.

PURPOSE: In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada. METHODS: In June 2006, self-administered questionnaires were mailed to the Chief Executive Officers of all acute care hospitals, identified through the Ontario government's hospital database. The questionnaire solicited information on the number and type of critical care units, number of beds, technological resources and management of each unit. RESULTS: Responses were obtained from 174 (100%) hospitals, with 126 (73%) reporting one or more critical care units. We identified 213 critical care units in the province, representing 1789 critical care beds. Over half (59%) of these beds provided mechanical ventilation on a regular basis, representing a capacity of 14.9 critical care and 8.7 mechanically ventilated beds per 100,000 population. Sixty-three percent of units with capacity for mechanical ventilation involved an intensivist in admission and coordination of care. Based on current utilization, the demand for mechanically ventilated beds by 2026 is forecast to increase by 57% over levels available in 2006. Assuming 80% bed utilization, it is estimated that an additional 810 ventilated beds will be needed by 2026. CONCLUSION: Current utilization suggests a substantial increase in the need for the highest-level critical care beds over the next two decades. Our findings also indicate that non-intensivists direct care decisions in a large number of responding units. Unless major investments are made, significant improvements in efficiency will be required to maintain future access to these services.

The standardization of critical care nursing education and training: strategies for advancing clinical practice in Ontario's adult ICUs.

In 2004/2005, the Ontario Ministry of Health and Long-Term Care (MOHLTC) launched a critical care transformation strategy with a goal to enhance service delivery through improved access, quality and system resource management. Health human resources planning was seen as essential to the success of the strategy, particularly recruitment, education/training and retention of critical care nurses. A nursing task group was invited to articulate core competencies and practice standards that can be applied across Ontario's adult ICUs and to make recommendations for implementation and the training needed to encourage compliance with the initiative. In this article, the opportunity to position nursing within the Ontario MOHLTC vision is described, as well as the work undertaken to prepare for a province-wide approach to critical care nursing education and training.

Improving medication administration systems: an evaluation study.

Medication errors are a universal health-care concern, and improving medication administration systems is important to enhance safety. The purpose of this study was to compare the effectiveness of an existing unit dose system using a medication cart to a new system where medications are decentralized to a locked cupboard at the patient's bedside. Quantitative and qualitative approaches were used to determine the effectiveness and efficiency of the medication administration systems. Data was collected using time studies to evaluate the efficiency of the two systems. This data included medication errors, missing doses and interruptions occurring during the medication preparation and administration process. Focus groups were conducted with nurses, pharmacists and pharmacy technicians to better understand the impact of changing systems. Study results demonstrated benefits associated with decentralizing the medication distribution to the bedside, including nurses spending more time with patients, nurses investing less time preparing and distributing medication and fewer interruptions for nurses as they prepared and distributed medication. Nurses and pharmacists associated the new system with enhanced patient safety and work satisfaction.

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.

About critical thinking.

Although a universally accepted definition of critical thinking has yet to be determined, there is much discussion in the literature about its meaning and, in particular, how it can be expressed in professional nursing practice. The simultaneous use of related terms such as reflective thinking, problem solving and clinical decision-making contributes to the lack of clarity around exactly what critical thinking is and, subsequently, how it can be taught and evaluated in the clinical setting. The purpose of this article is to provide an overview of the various components of critical thinking and to discuss barriers, facilitators and strategies that can enhance nurses' attainment of this core competency. Few would argue that registered nurses today must be able to think critically in order to effectively communicate a nursing perspective that reflects a meaningful clinical grasp and preparedness to act.

Patterns of handwashing behavior and visits to patients on a general medical ward of healthcare workers.

OBJECTIVE: To obtain accurate data regarding the handwashing behavior and patterns of visits to patients by healthcare workers (HCWs). METHODS: All visits by HCWs to selected patient rooms were recorded for 3 days and 2 nights. Additionally, 5 nurses were observed for 1 day each and 2 nurses were observed for 1 night each. Nurses were observed for their entire shifts and all of their activities were recorded. SETTING: A general medical ward in a tertiary-care hospital. PARTICIPANTS: Convenience samples of HCWs and patients. RESULTS: Patients were visited every 25 minutes on average. Monitoring rooms and observing nurses resulted in similar rates of patient visits. The highest level of risk was contact with body fluids in 11% of visits and skin in 40% of visits. The overall rate of handwashing was 46%; however, the rate was higher for visits involving contact with body fluids (81%) and skin (61%). Nurses returned immediately to the same patient 45% of the time. The rate of handwashing was higher for the last of a series of visits to a patient's room (53% vs 30%, P < .0001). CONCLUSIONS: Nurses adjusted their handwashing rates in accordance with the risk level of each visit. Monitoring patient rooms and observing nurses yielded similar estimates of patient visits and proportions of visits involving contact with skin or body fluids. Education programs about hand hygiene may be more effective if patterns of care and levels of risk are incorporated into recommendations.

The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital.

BACKGROUND: The outbreak of severe acute respiratory syndrome (SARS) in Toronto, which began on Mar. 7, 2003, resulted in extraordinary public health and infection control measures. We aimed to describe the psychological and occupational impact of this event within a large hospital in the first 4 weeks of the outbreak and the subsequent administrative and mental health response. METHODS: Two principal authors met with core team members and mental health care providers at Mount Sinai Hospital, Toronto, to compile retrospectively descriptions of the experiences of staff and patients based on informal observation. All authors reviewed and analyzed the descriptions in an iterative process between Apr. 3 and Apr. 13, 2003. RESULTS: In a 4-week period, 19 individuals developed SARS, including 11 health care workers. The hospital's response included establishing a leadership command team and a SARS isolation unit, implementing mental health support interventions for patients and staff, overcoming problems with logistics and communication, and overcoming resistance to directives. Patients with SARS reported fear, loneliness, boredom and anger, and they worried about the effects of quarantine and contagion on family members and friends. They experienced anxiety about fever and the effects of insomnia. Staff were adversely affected by fear of contagion and of infecting family, friends and colleagues. Caring for health care workers as patients and colleagues was emotionally difficult. Uncertainty and stigmatization were prominent themes for both staff and patients. INTERPRETATION: The hospital's response required clear communication, sensitivity to individual responses to stress, collaboration between disciplines, authoritative leadership and provision of relevant support. The emotional and behavioural reactions of patients and staff are understood to be a normal, adaptive response to stress in the face of an overwhelming event.