Evaluating an Integrated Local System Response to the COVID-19 Pandemic: Case Study of East Toronto Health Partners

Introduction: East Toronto Health Partners (ETHP) is a network of organizations that serve residents of East Toronto, Ontario, Canada. ETHP is a newly formed integrated model of care in which hospital, primary care, community providers and patients/families work together to improve population health. We describe and evaluate the evolution of this emerging integrated care system as it responded to a global health crisis. Description: This paper begins by describing ETHP’s pandemic response mapping out over two years of data. To evaluate the response, semi-structured interviews were conducted with 30 decision makers, clinicians, staff, and volunteers who were part of the response. The interviews were thematically analyzed, and emergent themes mapped onto the nine pillars of integrated care. Discussion: The ETHP pandemic response evolved rapidly. Early siloed responses gave way to collaborative efforts and equity emerged as a central priority. New alliances formed, resources were shared, leaders emerged, and community members stepped forward to contribute. Interviewees identified positives as well as many opportunities for improvement post-pandemic. Conclusion: The pandemic was a catalyst for change in East Toronto that accelerated existing initiatives to achieve integrated care. The East Toronto experience may serve as a useful guide for other emerging integrated care systems

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Improving Health Care Efficiency Through the Integration of a Physician Assistant into an Infectious Diseases Consult Service at a Large Urban Community Hospital

BACKGROUND: Physician assistants (PAs) have recently been introduced into the Canadian health care system in some provinces; however, there are little data demonstrating their impact.METHODS: A retrospective case-control study was conducted between January 2010 and December 2013. Length of stay (LOS) and mortality were examined in the infectious diseases consult service (IDCS) compared with hospital-wide controls. The two-year period before the introduction of the PA to the IDCS of a large urban community hospital in Canada (2010 to 2011) was compared with the two-year period following the introduction of the PA (2012 to 2013).RESULTS: Following the introduction of a PA to the IDCS, there was a decrease in time to consultation from 21.4 h to 14.3 h (Pud_less_than0.0001). LOS was significantly decreased among IDCS patients by 3.6 days more than that seen in matched hospital-wide controls (P=0.0001). Mortality did not significantly change after PA introduction in either cases or controls.DISCUSSION/CONCLUSION: PAs can improve health efficiencies in the Canadian health care setting, leading to reduction in LOS.Peer Reviewe

Reducing co-administration of proton pump inhibitors and antibiotics using a computerized order entry alert and prospective audit and feedback

Abstract Background Antibiotics and proton pump inhibitors (PPIs) are associated with Clostridium difficile infection (CDI). Both a computer order entry alert to highlight this association as well as antimicrobial stewardship directed prospective audit and feedback represent novel interventions to reduce the co-administration of antibiotics and PPIs among hospitalized patients. Methods Consecutive patients admitted to two General Internal Medicine wards from October 1, 2010 until March 31, 2013 at a teaching hospital in Toronto, Ontario, Canada were evaluated. The baseline observation period was followed by the first phase, which involved the creation of a computerized order entry alert that was triggered when either a PPI or an antibiotic was ordered in the presence of the other. The second phase consisted of the introduction of an antibiotic stewardship-initiated prospective audit and feedback strategy. The primary outcome was the co-administration of antibiotics and PPIs during each phase. Results This alert led to a significant reduction in the co-administration of antibiotics and PPIs adjusted for month and secular trends, expressed as days of therapy per 100 patient days (4.99 vs. 3.14, p < 0.001) The subsequent introduction of the antibiotic stewardship program further reduced the co-administration (3.14 vs. 1.80, p <0.001). No change was observed in adjusted monthly CDI rates per 100 patient care days between the baseline and alert cohorts (0.12 vs. 0.12, p = 0.99) or the baseline and antibiotic stewardship phases (0.12 vs. 0.13, p = 0.97). Conclusions Decreasing the co-administration of PPIs and antibiotics can be achieved using a simple automatic alert followed by prospective audit and feedback

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use

<div><p>Background</p><p>The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation.</p><p>Methods</p><p>Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of <i>C</i>. <i>difficile</i> infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses.</p><p>Results</p><p>Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation.</p><p>Conclusions</p><p>ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.</p></div

Results of segmented regression analyses evaluating the impact of prospective audit and feedback on systemic antibiotic use^a in the surgical, respiratory, and medical wards.

<p>Results of segmented regression analyses evaluating the impact of prospective audit and feedback on systemic antibiotic use<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0178434#t003fn002" target="_blank">^a</a> in the surgical, respiratory, and medical wards.</p

Baseline characteristics of patients in the surgical, respiratory, and medical wards before and after prospective audit and feedback.

<p>Baseline characteristics of patients in the surgical, respiratory, and medical wards before and after prospective audit and feedback.</p

Patient outcomes before and after prospective audit and feedback in the surgical, respiratory, and medical wards.

<p>Patient outcomes before and after prospective audit and feedback in the surgical, respiratory, and medical wards.</p