Improving access to emergent spinal care through knowledge translation : an ethnographic study

Background: For patients and family members, access to timely specialty medical care for emergent spinal conditions is a significant stressor to an already serious condition. Timing to surgical care for emergent spinal conditions such as spinal trauma is an important predictor of outcome. However, few studies have explored ethnographically the views of surgeons and other key stakeholders on issues related to patient access and care for emergent spine conditions. The primary study objective was to determine the challenges to the provision of timely care as well as to identify areas of opportunities to enhance care delivery. Methods: An ethnographic study of key administrative and clinical care providers involved in the triage and care of patients referred through CritiCall Ontario was undertaken utilizing standard methods of qualitative inquiry. This comprised 21 interviews with people involved in varying capacities with the provision of emergent spinal care, as well as qualitative observations on an orthopaedic/neurosurgical ward, in operating theatres, and at CritiCall Ontario’s call centre. Results: Several themes were identified and organized into categories that range from inter-professional collaboration through to issues of hospital-level resources and the role of relationships between hospitals and external organizations at the provincial level. Underlying many of these issues is the nature of the medically complex emergent spine patient and the scientific evidentiary base upon which best practice care is delivered. Through the implementation of knowledge translation strategies facilitated from this research, a reduction of patient transfers out of province was observed in the one-year period following program implementation. Conclusions: Our findings suggest that competing priorities at both the hospital and provincial level create challenges in the delivery of spinal care. Key stakeholders recognized spinal care as aligning with multiple priorities such as emergent/critical care, medical through surgical, acute through rehabilitative, disease-based (i.e. trauma, cancer), and wait times initiatives. However, despite newly implemented strategies, there continues to be increasing trends over time in the number of spinal CritiCall Ontario referrals. This reinforces the need for ongoing inter-professional efforts in care delivery that take into account the institutional contexts that may constrain individual or team efforts

Barriers to addressing the social determinants of health: Insights from the Canadian experience. Health Policy 88(2-3):

To date, Ontario public health units (PHUs) have generally neglected the social determinants of health (SDH) concept in favor of risk aversion and behaviorally oriented health promotion approaches. Addressing SDH and responding to the presence of health inequities is required under the Ontario Public Health Standards and is a component of provincial public health documents and reports. Nevertheless, units vary in their understanding and application of the SDH concept in their activities. The authors conducted 18 interviews with Medical Officers of Health and lead staff persons from nine Ontario PHUs, in order to better understand how these differences in addressing the SDH among health units come about. The findings suggest that differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and understandings concerning the validity of differing forms of evidence and expected outcomes. Drawing from Bachelard's concept of epistemological barriers and Raphael's seven discourses on the SDH, we examine the ways in which the participating units discuss and apply the SDH concepts. We argue that a substantial barrier to further action on the SDH is the internalization of discourses and traditions that treat health as individualized and depoliticized. Keywords: social determinants of health; public health; epistemological barriers; Canada Introduction Despite Canada's reputation for developing concepts related to the social determinants of health (SDH), government agencies, professional health organizations, and local public health units (PHUs) have struggled with how to apply the concept to improve the health of the Canadian public The French philosopher and historian Gaston Bachelard introduced the concept of 'epistemological obstacles' or 'epistemological barriers' to explain the intellectual hurdles that scientists may face when they approach new scientific problems. He claimed that in order to develop new approaches to a problem, scientists must overcome the barriers posed by their prior views Raphael We apply the notion of epistemological barriers in our discussion of OntarioCanada's most populous province -PHUs and their efforts to address the SDH. In this case, the barriers may stem from particular discourses about health and society and the appropriate role for the public health community in addressing these issues. To date, Ontario PHUs have generally neglected the SDH in favor of risk aversion and behaviorally oriented health promotion approaches (NCCDH 2010). Addressing SDH and responding to the presence of health inequalities is required under the Ontario Public Health Standards Downloaded by [109.174.179.68] at 09:21 22 July 2013 how these differences came about. Our findings suggest that these differences in practice result largely from varying conceptions of: the nature of SDH, the perceived role of public health in addressing them, and understandings concerning the validity of differing forms of evidence and expected outcomes. Based on Raphael's (2011) model of SDH discourses and the ways in which the participating units discussed the SDH, we categorized them into three clusters, those that take functional, analytical, and structural approaches. These approaches are defined in the results section. Background and specific goals of this researc