Quality improvement initiative for improved patient communication in an ED rapid assessment zone.

INTRODUCTION: Patient-clinician communication in the Emergency Department (ED) faces challenges of time and interruptions, resulting in negative effects on patient satisfaction with communication and failure to relieve anxiety. Our aim was to improve patient satisfaction with communication and to decrease related patient anxiety. METHODS: A multistage quality improvement (QI) initiative was conducted in the ED of Toronto General Hospital, a quaternary care centre in Ontario, Canada, from January to May 2018. We engaged stakeholders widely including clinicians, allied health and patients. We developed a 5-point Likert scale survey to measure patient and clinician rating of their communication experience, along with open-ended questions, and a patient focus group. Inductive analyses yielded interventions that were introduced through three Plan-Do-Study-Act (PDSA) cycles: (1) a clinician communication tool called Acknowledge-Empathize-Inform; (2) patient information pamphlets; and (3) a multimedia solution displaying patient-directed material. Our primary outcome was to improve patient satisfaction with communication and decrease anxiety by at least one Likert scale point over 6 months. Our secondary outcome was clinician-perceived interruptions by patients. We used statistical process control (SPC) charts to identify special cause variation and two-tailed Mann-Whitney U tests to compare means (statistical significance p<0.05). RESULTS: A total of 232 patients and 104 clinicians were surveyed over baseline and three PDSA cycles. Communication about wait times, ED process, timing of next steps and directions to patient areas were the most frequently identified gaps, which informed our interventions. Measurements at baseline and during PDSA 3 showed: patient satisfaction increased from 3.28 (5 being best; n=65) to 4.15 (n=59, p<0.0001). Patient anxiety decreased from 2.96 (1 being best; n=65) to 2.31 (n=59, p<0.001). Clinician-perceived interruptions by patients changed from 4.33 (5 being highest; n=30) to 4.18 (n=11, p=0.98) and did not meet significance. SPC charts showed special cause variation temporally associated with our interventions. CONCLUSIONS: Our pragmatic low-cost QI initiative led to statistically significant improvement in patient satisfaction with communication and decreased patient anxiety while narrowly missing our a priori improvement aim of one full Likert scale point.

A novel high-amylose barley cultivar (Hordeum vulgare var. Himalaya 292) lowers plasma cholesterol and alters indices of large-bowel fermentation in pigs.

Hordeum vulgare var. Himalaya 292 is a new barley cultivar with altered starch synthesis and less total starch but more amylose, resistant starch (RS) and total and soluble NSP including beta-glucan. To determine its nutritional potential, young pigs were fed diets containing stabilised wholegrain flours from either Himalaya 292, Namoi (a commercial barley), wheat bran or oat bran at equivalent dietary NSP concentrations for 21 d. Serum total cholesterol was significantly lowered by the Himalaya 292 diet relative to wheat bran, indicating that Himalaya 292 retained its hypocholesterolaemic potential. In all groups SCFA concentrations were highest in the proximal colon and decreased towards the rectum. Digesta pH was lowest in the proximal colon and highest in the distal colon. Large-bowel and faecal pH were significantly lower in the pigs fed the barley and oat diets, indicating greater bacterial fermentation. Caecal and proximal colonic pH was lowest and SCFA pools highest in the pigs fed Himalaya 292. Total and individual SCFA were lowest in the mid- and distal colon of the pigs fed Himalaya 292 or oat bran. These data suggest the presence of more RS in Himalaya 292 and suggest that its fermentation was rapid relative to transit. Differences in faecal and large-bowel anaerobic, aerobic, coliform and lactic acid bacteria were relatively small, indicating a lack of a specific prebiotic action. These data support the potential of this novel barley cultivar to improve health through plasma cholesterol reduction and increased large-bowel SCFA production.

A novel barley cultivar (Himalaya 292) with a specific gene mutation in starch synthase IIa raises large bowel starch and short-chain fatty acids in rats.

Himalaya 292 (Hordeum vulgare, var. himalaya 292) is a novel, hull-less barley cultivar with a single nucleotide change in the gene encoding starch synthase IIa (EC 2.4.1.21). This leads to loss of enzyme activity, resulting in a grain with less total starch and a higher proportion of amylose. These changes, plus higher total and soluble nonstarch polysaccharides (NSP), could increase its resistant starch (RS) content. Accordingly, rats were fed a diet containing stabilized whole-grain barley flours from Himalaya 292 or two commercial varieties (Namoi or Waxiro) or wheat or oat bran at equivalent NSP concentrations for 14 d. There were favorable significant changes in a number of bowel health-related indices. Fecal output by rats fed Himalaya 292 was higher than by those fed Namoi or oat bran, whereas total large bowel digesta mass was higher than in those fed WAXIRO: Cecal starch concentrations and pools were higher in rats fed Himalaya 292 than in all other groups. Fecal and cecal digesta pH was lower in rats fed Himalaya 292 than in all other groups except that fed oat bran. Colonic digesta pH was lower in rats fed Himalaya 292 than in those fed wheat bran or NAMOI: Fecal total SCFA excretion was higher in rats fed Himalaya 292 than in those fed Namoi or oat bran. Although cecal total SCFA pools did not differ among groups, colonic SCFA were higher in rats fed Himalaya 292 than in those fed Namoi or WAXIRO: These data indicate that changes in Himalaya 292 grain composition result in greater RS with consequent alterations in large bowel SCFA and pH when fed to rats.