Background: ANCA Associated Vasculitis (AAV) is a relatively rare autoimmune condition with the potential to cause life-threatening organ inflammation and failure. Due to the relative rarity, and the heterogenous way in which the disease may present, delay to diagnosis is common. Although initial immunosuppressive treatment is usually effective at controlling disease, morbidity associated with treatment is high and disease relapses frequent, necessitating further immunosuppression exposure. Aims and Objectives: This body of work therefore seeks to address 2 of the main challenges faced by the AAV population; 1) identifying factors that may contribute to a delay to diagnosis and disease recognition 2) reducing morbidity associated with the disease and the treatment. Methods: Patient pathways, knowledge and uptake of protective therapy were explored through a national patient report study. Patient care guidelines to assist with morbidity prevention were informed through Delphi consensus methodology and comprehensive literature review. The development of software to support implementation of a rigorous systematic approach to the assessment of the vasculitis patients was achieved through collaboration with information technology, business development and system architecture and design experts. Results: Patient presentation including symptoms, initial mis-diagnosis and eventual diagnosis appear to influence time to diagnosis. There is substantial delay from symptom onset to diagnosis demonstrating the need for increased awareness and education. Equally patient awareness of treatment related morbidity is low with variable uptake of protective therapy. A Delphi study has produced consensus on which guidelines can be based to address some of these inadequacies. A software programme: "Vasculitis Care Optimisation Tool (VasCOT)", has been designed to support implementation of these guidelines. Discussion: The various approaches used in this body of work have so far allowed evaluation of areas where patient care needs to be improved. This in part will be addressed through the publication of national vasculitis care guidelines, informed by this work and the ongoing development of VasCOT.

Class of 2017 Abstract / Objectives: Our working hypothesis is that patients who opt in to pharmacist counseling will have a higher medication possession ratio and longer length on therapy than patients who opt out of pharmacist counseling. Methods: Using data extracted from patient’s charts we retrospectively calculated medication possession ratio and length on therapy in relation to the patient receiving or not receiving counseling. Results: The patients analyzed were receiving 8 specific oral oncolytic medications provided by Avella Specialty Pharmacy in 2015. There were no significant differences found in MPR values for any of the 8 oral oncolytic medications included in the study. Iressa (p=0.826), Lonsurf (p=0.392), Stivarga (p=0.838), Zydelig (p=0.633), Zykadia (p=0.077), Tagrisso (p=0.060), Imbruvica (p=0.263) and Tarceva (p=0.326). No statistically significant differences were found in LOT values for any of the 8 oral oncolytic medications included in the study. Iressa (p=0.885), Lonsurf (p=0.868), Stivarga (p=0.326), Zydelig (p=0.502), Zykadia (p=0.212), Tagrisso (p=0.089), Imbruvica (p=0.540), Tarceva (p=0.129). Conclusions: Pharmacist counseling does not appear to affect MPR or LOT for patients taking oral oncolytic medications. Further research is warranted targeting other chronic disease states with complex oral regimens where medication adherence has not already been established from prior therapy options and adequate disease state knowledge.

In this case study, we present a patient with preexistent posttraumatic stress disorder and psychosis who has been recently diagnosed with Dementia with Lewy Bodies. He is experiencing vivid hallucinations. What went wrong between him and his wife as a result of these hallucinations is presented. Alternative actions that could have been used are suggested.

No description available.

Introduction: Acute Care Surgery (ACS) is a new model of emergency general surgery care developed to provide prompt, comprehensive, and evidence-based care to acutely ill non-trauma surgical patients. Our objective was to determine the impact of implementing ACS on efficiency of care (EOC) and patient outcomes. Methods: A retrospective review was performed for patients with acute appendicitis (AA) and biliary tract disease (BTD). EOC measures and patient outcomes were compared over two time periods: pre-ACS (2007) and ACS (2011). Results: n=1,229 patients were included in this study; n=507 (pre-ACS), and n=722 (ACS). Surgical response times and acquisition of imaging were significantly faster with ACS. Time to OR and total LOS were similar between cohorts. Similar rates of daytime operating were present. With ACS and AA, there were more perforations, more ORs were performed at night and patients were readmitted more frequently. Conclusions: Increased volumes of patients were seen with ACS, but surgical assessments and imaging were significantly faster. Inpatient EOC measures were unchanged with ACS; outcomes for AA were worse. / October 2015

<p>Care of patients with chronic conditions is complicated and usually includes large number of healthcare providers. Understanding the team structure and networks of healthcare providers help to make informed decisions for health policy makers and design of wellness programs by identifying the influencers in the network. This work presents a novel approach to assess the collaboration of healthcare providers involved in the care of patients with chronic conditions and the impact on patient outcomes. </p> <p>In the first study, we assessed a patient population needs, preventive service utilization, and impact of an onsite clinic as an intervention on preventive service utilization patterns over a three-year period. Classification models were developed to identify groups of patients with similar characteristics and healthcare utilization. Logistic regression models identified patient factors that impacted their utilization of preventive health services in the onsite clinic vs. other providers. Females had higher utilizations compared to males. Type of insurance coverages, and presence of diabetes/hypertension were significant factors that impacted utilization. The first study framework helps to understand the patient population characteristics and role of specific providers (onsite clinic), however, it does not provide information about the teams of healthcare providers involved in the care process. </p> <p>Considering the high prevalence of diabetes in the patient cohort of study 1, in the second study, we followed the patient cohort with diabetes from study 1 and extracted their healthcare providers over a two-year period. A framework based on the social network analysis was presented to assess the healthcare providers’ networks and teams involved in the care of diabetes. The relations between healthcare providers were generated based on the patient sharing relations identified from the claims data. A multi-scale community detection algorithm was used to identify groups of healthcare providers more closely working together. Centrality measures of the social network identified the influencers in the overall network and each community. Mail-order and retail pharmacies were identified as central providers in the overall network and majority of communities. This study presented metrics and approach for assessment of provider collaboration. To study how these collaborative relations impact the patients, in the last study, we presented a framework to assess impacts of healthcare provider collaboration on patient outcomes. </p> <p>We focused on patients with diabetes, hypertension, and hyperlipidemia due to their similar healthcare needs and utilization. Similar to the second study, social network analysis and a multi-scale community detection algorithm were used to identify networks and communities of healthcare providers. We identified providers who were the majority source of care for patients over a three-year period. Regression models using generalized estimating equations were developed to assess the impact of majority source of care provider community-level centrality on patient outcomes. Higher connectedness (higher degree centrality) and higher access (higher closeness centrality) of the majority source of care provider were associated with reduced number of inpatient hospitalization and emergency department visits. </p> <p>This research proposed a framework based on the social network analysis that provides metrics for assessment of care team relations using large-scale health data. These metrics help implementation experts to identify influencers in the network for better design of care intervention programs. The framework is also useful for health services researchers to assess impact of care teams’ relations on patient outcomes. </p> <br> <p> </p>

There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with ‘alcohol-related liver disease’ and ‘other CLD’ were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while ‘chronic viral hepatitis’ subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and ‘alcohol-related liver disease’ and ‘other CLD’ etiologic subgroups.

Healthcare quality remains a significant issue due to fragmentation of care in our complex U.S. healthcare systems. While coordination of care is foundational to healthcare quality as well as identified as a National Priority, fragmentation and uncoordinated care continues to afflict our systems. The purpose of this study was to explore the relationship between relational coordination and adverse nurse sensitive patient outcomes, namely hospital acquired pressure ulcers, patient falls with injury, catheter- associated urinary tract infection, and central line-associated blood stream infection. A retrospective correlational survey design using cross sectional data was used to conduct this quantitative study. An electronic relational coordination survey was sent to 1124 eligible registered nurses from 43 nursing units within a 5-hospital magnet-designated healthcare system to gather their perception of the strength of relationship and communication ties of their work team. The nurse practice environment as well as nurse education were control variables. With 406 nurses who completed the survey (36% response rate), findings revealed that the stronger relational coordination ties are amongst the healthcare team, the lower the rate of adverse nurse sensitive patient outcomes as indicated by their inverse relationship. (rs=-.31, p=.050). In a Negative Binomial Regression model, relational coordination was a significant predictor (?-1.890, p=.034) of nurse sensitive patient outcomes whereas nurse education level (p=.859) and nurse practice environment (p=.230) were not. Data affirms that relational coordination, a relationship and communication intensive form of coordination does impact patient outcomes. This research provides significant information to health care leaders and institutions with goals of improving patient care outcomes through enhancement of coordination of care and optimization of healthcare teams.

Background: Nursing overtime is being integrated into the normal landscape of practice to ensure optimal staffing levels and address variations in patient volume and acuity. This is particularly true in critical care where fluctuations in either are difficult to predict. Research exploring nurses’ perceptions of the outcomes of overtime has not been conducted, and studies exploring the relationship between nursing overtime and patient outcomes have produced conflicting results. Objectives: This study aims to explore critical care nurses’ perceptions of the outcomes of overtime, their reasons for working or not working it, and to determine the relationship between critical care nursing overtime and specific nurse (sick time) and patient (infections/mortality) outcomes. Methods: This thesis is comprised of two discrete components. Thorne’s interpretive description guided the qualitative component and multilevel regression models tested relationships in the quantitative portion. Qualitative and quantitative methods were selected because of their complementarity and ability to explore both perceptions of overtime in addition to the relationship between nursing overtime and outcomes for nursing staff and their patients. Results: Participants’ reasons for working overtime included: (a) financial gain, (b) helping and being with colleagues, (c) continuity for nurses and patients, and (d) accelerated career development. Their reasons for not working overtime were: (a) tired and tired of being there, (b) established plans, and (c) not enough notice. Major themes highlighting the perceived outcomes of overtime included: (a) physical effects, (b) impact on patient centered care, (c) the issue of respect, (d) balancing family and work, (e) the issue of guilt, (f) financial gain, and (g) safety is jeopardized. Regression analysis revealed that for every 10 hours of nursing overtime, sick time increased by 3.3 hours (p<0.0001). Overtime was not associated with patient outcomes (infections and mortality). Conclusion: There are negative and positive consequences of nursing overtime for nurses and patients. Future research needs to focus on the collection of accurate patient level data, as well as tracking and exploring the effects of unpaid overtime (missed breaks/staying late). Nurses should work to proactively lobby governments to fund adequate staffing in order to reduce the need for overtime and provide safer patient care. / Dissertation / Doctor of Philosophy (PhD) / This study explores critical care nurses’ perceptions of the outcomes of working overtime, their reasons for working or not working overtime, and the relationship between nursing overtime and specific nurse and patient outcomes. Qualitative and quantitative methods were used involving 28 nurses on 11 units in three tertiary care academic health science centers. The four original contributions to nursing knowledge are: (a) physical effects overtime has on nurses, (b) feelings of disrespect overtime engenders, (c) loss of patient-centered care that results from overtime, and, (d) the positive relationship between nursing overtime and nursing sick time. Quantitative findings revealed that for every 10 hours of nursing overtime, sick time increased by 3.3 hours (p<0.0001), which participants attested to qualitatively. It will be important to track both paid and unpaid overtime hours per individual nurse to enhance future research, ensure institutional accountability and staff well-being.

Objective: The researcher replicated 12 questions from a previous user satisfaction study for the C-HOBIC assessment tool at St. Boniface Hospital in Winnipeg Manitoba. The research questions were: (a) what is user satisfaction regarding the C-HOBIC assessment tool 20 months after implementation, (b) has user satisfaction changed since the first evaluation, and (c) do user demographics correlate with user satisfaction and the C-HOBIC assessment tool? Method: 20 months after the previous study (Canadian Nurses Association, 2015), a convenience sample of 71 participants from a pool of approximately 700 clinicians completed an online survey comprised of 12 questions taken from the previous study. Results: The data were analyzed using Shapiro-Wilk, descriptive statistics, chi-square test for independence, and Spearman’s correlation. The Likert-style survey produced discrete, ranked data that did not follow a normal distribution. Overall user satisfaction with the C-HOBIC assessment tool was rated higher in the previous group (n=59) as compared to user satisfaction in the current group (n=71). There was a significant but weak correlation with gender and C-HOBIC patient outcomes positively influencing patient care directions, and improving patient care planning. A significant but weak correlation existed between the years of a participant's clinical experience and the ease of integrating C-HOBIC into practice. Conclusions: There were more participants not satisfied with the use of the C-HOBIC assessment tool than were satisfied. Participants in this study had less user satisfaction with the C-HOBIC assessment tool and associated outcomes than participants from a similar study 20 months before. Gender and years of clinical experience are correlated with user satisfaction. The small sample size, the non-normally distributed data, and convenient sampling method do not support generalization of the results beyond the data set. / Graduate / 0569 / alshunt@gmail.com