A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting.

BACKGROUND: Many emergency departments (EDs) have used the Lean methodology to guide the restructuring of their practice environments and patient care processes. Despite research cautioning that the layout and design of treatment areas can increase patients' vulnerability to privacy breaches, evaluations of Lean interventions have ignored the potential impact of these on patients' informational and physical privacy. If professional regulatory organizations are going to require that nurses and physicians interact with their patients privately and confidentially, we need to examine the degrees to which their practice environment supports them to do so. OBJECTIVE: This study explored how a Lean intervention impacted the ability of emergency medicine physicians and nurses to optimize conditions of privacy and confidentiality for patients under their care. METHODS: From July to December 2017, semistructured interviews were iteratively conducted with health care professionals practicing emergency medicine at a single teaching hospital in Ontario, Canada. The hospital has 1000 beds, and approximately 128,000 patients visit its 2 EDs annually. In response to poor wait times, in 2013, the hospital's 2 EDs underwent a Lean redesign. As the interviews proceeded, information from their transcripts was first coded into topics and then organized into themes. Data collection continued to theoretical sufficiency. RESULTS: Overall, 15 nurses and 5 physicians were interviewed. A major component of the Lean intervention was the construction of a three-zone front cell at both sites. Each zone was outfitted with a set of chairs in an open concept configuration. Although, in theory, professionals perceived value in having the chairs, in practice, these served multiple, and often, competing uses by patients, family members, and visitors. In an attempt to work around limitations they encountered and keep patients flowing, professionals often needed to move a patient out from a front chair and actively search for another location that better protected individuals' informational and physical privacy. CONCLUSIONS: To our knowledge, this is the first qualitative study of the impact of a Lean intervention on patient privacy and confidentiality. The physical configuration of the front cell often intensified the clinical work of professionals because they needed to actively search for spaces better affording privacy and confidentiality for patient encounters. These searches likely increased clinical time and added to these patients' length of stay. We advocate that the physical structure and configuration of the front cell should be re-examined under the lens of Lean's principle of value-added activities. Future exploration of the perspectives of patients, family members, and visitors regarding the relative importance of privacy and confidentiality during emergency care is warranted.

Easier and Faster Is Not Always Better: Grounded Theory of the Impact of Large-Scale System Transformation on the Clinical Work of Emergency Medicine Nurses and Physicians.

BACKGROUND: The effectiveness of Lean Thinking as a quality improvement method for health care has been contested due, in part, to our limited contextual understanding of how it affects the working conditions and clinical workflow of nurses and physicians. Although there are some initial indications, arising from prevalence surveys and interviews, that Lean may intensify work performed within medical environments, the evidence base still requires detailed descriptions of the changes that were actually introduced to individuals' clinical workflow and how these changes impacted health care professionals. OBJECTIVE: The aim of this study was to explore ways in which a Lean intervention may impact the clinical work of emergency medicine nurses and physicians. METHODS: We used a realist grounded theory approach to explore the clinical work of nurses and physicians practicing in 2 emergency medicine departments from a single teaching hospital in Canada. The hospital has 1000 beds with 128,000 emergency department (ED) visits annually. In 2013, both sites began a large-scale, Lean-driven system transformation of their practice environments. In-person interviews were iteratively conducted with health care professionals from July to December 2017. Information from transcripts was coded into categories and compared with existing codes. With repeated review of transcripts and evolving coding, we organized categories into themes. Data collection continued to theoretical sufficiency. RESULTS: A total of 15 emergency medicine nurses and 5 physicians were interviewed. Of these, 18 individuals had practiced for at least 10 years. Our grounded theory involved 3 themes: (1) organization of our clinical work, (2) pushed pace in the front cell, and (3) the toll this all takes on us. Although the intervention was supposed to make the EDs work easier, faster, and better, the participants in our study indicated that the changes made had the opposite impact. Nurses and physicians described ways in which the reconfigured EDs disrupted their established practice routines and resulted in the intensification of their work. Participants also identified indications of deskilling of nurses' work and how the new push-forward model of patient care had detrimental impacts on their physical, cognitive, and emotional well-being. CONCLUSIONS: To our knowledge, this is the first study to describe the impact of Lean health care on the working conditions and actual work of emergency medicine nurses and physicians. We theorize that rather than support health care professionals in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to further complicate their working environment. We have illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of health care professionals. We identify some areas for reconsideration by the departments and put forward ideas for future research.

Measuring Electronic Health Record Use in Primary Care: A Scoping Review.

BACKGROUND: Simple measures of electronic health record (EHR) adoption may be inadequate to evaluate EHR use; and positive outcomes associated with EHRs may be better gauged when varying degrees of EHR use are taken into account. In this article, we aim to assess the current state of the literature regarding measuring EHR use. OBJECTIVE: This article conducts a scoping review of the literature to identify and classify measures of primary care EHR use with a focus on the Canadian context. METHODS: We conducted a scoping review. Multiple citation databases were searched, as well as gray literature from relevant Web sites. Resulting abstracts were screened for inclusion. Included full texts were reviewed by two authors. Data from the articles were extracted; we synthesized the findings. Subsequently, we reviewed these results with seven EHR stakeholders in Canada. RESULTS: Thirty-seven articles were included. Eighteen measured EHR function use individually, while 19 incorporated an overall level of use. Eight frameworks for characterizing overall EHR use were identified. CONCLUSION: There is a need to create standardized frameworks for assessing EHR use.

The development and assessment of an online microscopic anatomy laboratory course.

Increasing enrollment in post-secondary institutions across North America, along with an increase in popularity of and demand for distance education is pressuring institutions to offer a greater number and variety of courses online. A fully online laboratory course in microscopic anatomy (histology) which can be taught simultaneously with a face-to-face (F2F) version of the same course has been developed. This full year course was offered in the Fall/Winter (FW) terms in both F2F and online formats. To ensure that the online course was of the same quality as the F2F format, a number of performance indicators were evaluated. The same course, offered exclusively online during the summer with a compressed time frame, was also evaluated. Senior undergraduate students self-selected which version of the course they would enroll in. Course assessment outcomes were compared while incoming grades were used as a predictor for course performance. There were no significant differences between the incoming grades for the F2F FW and Online FW courses; similarly, there were no significant differences between outcomes for these formats. There were significant differences between the incoming grades of the F2F FW and Summer Online students. However, there were no significant differences among any of the outcomes for any of the formats offered. Incoming grades were strong, significant predictors of course performance for both formats. These results indicate that an online laboratory course in microscopic anatomy is an effective format for delivering histology course content, therefore giving students greater options for course selections.

Detection of cytomegalovirus in whole blood using three different real-time PCR chemistries.

Several different primer-probe chemistries have been produced commercially for real-time PCR detection and quantification of cytomegalovirus, but there are few studies evaluating their relative performance. We assessed three such commercial reagents with respect to analytical and clinical operating characteristics. The samples included 149 clinical whole blood specimens that were de-identified and assayed in parallel with all primer-probe systems. Individual methods used TaqMan, dual fluorescence resonance energy transfer hybridization probes, and labeled primer chemistries. Method comparability was determined both qualitatively, based on pair-wise assessment of concordance, and quantitatively, based on pair-wise linear regression analysis. Analytical sensitivity and the lower end of the linear dynamic range reached 10 target copies per reaction for the TaqMan and labeled primer systems and 100 target copies per reaction for the dual fluorescence resonance energy transfer probe system. Quantitative linearity reached an upper limit of 10(5) copies per reaction for all methods. No assay cross-reactivity was seen with other common viral pathogens (100% analytical specificity). Pair-wise analysis of qualitative results from clinical samples showed no significant differences in sensitivity between the three sets of reagents, and linear regression analysis indicated that the quantitative values achieved were comparable in all positive specimens. The findings demonstrate that similar analytical and clinical performance characteristics can be demonstrated for quantitative detection of cytomegalovirus in clinical whole blood extracts using a wide variety of real-time PCR chemistries.

Functional characterisation of the regulatory subunit of cyclic AMP-dependent protein kinase A homologue of Giardia lamblia: Differential expression of the regulatory and catalytic subunits during encystation.

To understand the functional roles of protein kinase A (PKA) during vegetative and differentiating states of Giardia parasites, we studied the structural and functional characteristics of the regulatory subunit of PKA (gPKAr) and its involvement in the giardial encystment process. Molecular cloning and characterisation showed that gPKAr contains two tandem 3'5'-cyclic adenosine monphosphate (cyclic AMP) binding domains at the C-terminal end and the interaction domain for the catalytic subunit. A number of consensus residues including in vivo phosphorylation site for PKAc and dimerisation/docking domain are present in gPKAr. The regulatory subunit physically interacts with the catalytic subunit and inhibits its kinase activity in the absence of cyclic AMP, which could be partially restored upon addition of cyclic AMP. Western blot analysis showed a marked reduction in the endogenous gPKAr concentration during differentiation of Giardia into cysts. An increased activity of gPKAc was also detected during encystation without any significant change in the protein concentration. Distinct localisations of gPKAc to the anterior flagella, basal bodies and caudal flagella as noted in trophozoites were absent in encysting cells at later stages. Instead, PKAc staining was punctate and located mostly to the cell periphery. Our study indicates possible enrichment of the active gPKAc during late stages of encystation, which may have implications in completion of the encystment process or priming of cysts for efficient excystation.

Zinc supplementation decreases hepatic copper accumulation in LEC rat: a model of Wilson's disease.

The effect of dietary zinc (Zn) supplementation on copper (Cu)-induced liver damage was investigated in Long-Evans Cinnamon rats (LEC), a model for Wilson's disease (WD). Four-week-old LEC (N=64) and control Long-Evans (LE) (N=32) female rats were divided into two groups; one group was fed with a Zn-supplemented diet (group I) and the other was given a normal rodent diet (group II). LEC rats were killed at 6, 8, 10, 12, 18, and 20 wk of age; the LE control rats were killed at 6, 12, 18, and 20 wk of age. Cu concentration in the liver was reduced in LEC rats fed the Zn-supplemented diet compared with LEC rats on the normal diet between 6 and 18 wk of age. Metallothionein (MT) concentration in the livers of LEC rats in group I increased between 12 and 20 wk of age, whereas hepatic MT concentration in LEC rats from group II decreased after 12 wk. Hepatocyte apoptosis, as determined by TUNEL, was reduced in Zn-supplemented LEC rats at all ages. Cholangiocellular carcinoma was observed only in LEC rats in group II at wk 20. These results suggest that Zn supplementation can reduce hepatic Cu concentration and delay the onset of clinical and pathological changes of Cu toxicity in LEC rats. Although the actual mechanism of protection is unknown, it could be explained by sequestration of dietary Cu by intestinal MT, induced by high dietary Zn content.