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IntroductionIneffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500 000).MethodsLinear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers.ResultsTask-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout.DiscussionSpecific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.

\"Policy Work in Canada is an in-depth study into the levels of analytical capacity found within the federal and provincial governments as well as the non-governmental sector. By focusing on the individuals who craft public policy in Canada, this collection of eighteen chapters broadens and deepens our understanding of policy development in Canada. The contributors to this volume examine such topics as: the inherent characteristics of sophisticated policy analysis, the constraints that influence the outcome or style of analysis, the influence of policy analysis on democratic debate, and the lessons that can be learned from different jurisdictions within and outside of Canada. Policy Work in Canada provides a pathway for academics and public managers alike to meet the challenges involved in crafting more nuanced and sophisticated public policy head-on.\"-- Provided by publisher.

Purpose Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension. Methods This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis. Results Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9–98.5) vs.93.8% (87.7–97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88–97.2) vs 93.6% (87.8–97.2)]. Diagnostic performance measures were similar across sub-categories of shock. Conclusion This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.

\"The study of governance may be currently in fashion, but it is also a firmly-established lens through which the complexities of contemporary policy making can be analysed while examining the ways in which a society and its political processes are organized and steered. Governance thus needs to be seen as a general concept within political analysis which offers a necessary heuristic tool for understanding the complexities of political processes, the policies these produce and the outcomes they generate. However, despite a great deal having been written on the subject in recent years, questions remain about many fundamental aspects of governance. This is especially the case when trying to define the modes of governance and their dynamics. Many varieties of governance exist, both cross-nationally and cross-sectorally: Understanding why and how it is important for the future of governance studies is the subject of the cross-national and theoretically-informed case studies presented in this volume\"-- Provided by publisher.

Background The use of health information technology (HIT) to improve patient safety is widely advocated by governmental and safety agencies. Electronic-prescribing and smart-pump technology are examples of HIT medication error reduction strategies. The introduction of new errors on HIT implementation is, however, also recognised. To determine the impact of HIT interventions, clear medication error definitions are required. This study aims to achieve consensus on defining as medication errors a range of either technology-generated, or previously unaddressed infusion-related scenarios, common in the paediatric intensive care setting. Methods This study was conducted in a 23-bed paediatric intensive care unit (PICU) of an Irish tertiary paediatric hospital. A modified Delphi technique was employed: previously undefined medication-incidents were identified by retrospective review of voluntary incident reports and clinical pharmacist interventions; a multidisciplinary expert panel scored each incident using a 9-point Likert scale over a number of iterative rounds; levels of agreement were assessed to produce a list of medication errors. Differences in scoring between healthcare professionals were assessed. Results Seventeen potential errors or ‘scenarios’ requiring consensus were identified, 13 of which related to technology recently implemented into the PICU. These were presented to a panel of 37 participants, comprising of doctors, nurses and pharmacists. Consensus was reached to define as errors all reported smart-pump scenarios ( n  = 6) and those pertaining to the pre-electronic process of prescribing weight-based paediatric infusions ( n = 4). Of 7 electronic-prescribing scenarios, 4 were defined as errors, 2 were deemed not to be and consensus could not be achieved for the last. Some differences in scoring between healthcare professionals were found, but were only significant ( p < 0.05) for two and three scenarios in consensus rounds 1 and 2 respectively. Conclusion The list of medication errors produced using the Delphi technique highlights the diversity of previously undefined medication errors in PICU. The increased complexity of electronic-prescribing processes is evident from the difficulty in achieving consensus on those scenarios. Reducing ambiguity in defining medication errors should assist future research on the impact of HIT medication safety initiatives in critical care. The increasing use of HIT and associated new errors will necessitate further similar studies.

Background: The NUT midline carcinoma (NMC) is a rare but fatal cancer for which systematic testing of therapy options has never been performed. Methods: On the basis of disease biology, we compared the efficacy of the CDK9 inhibitor flavopiridol (FP) with a panel of anticancer agents in NMC cell lines and mouse xenografts. Results: In vitro anthracyclines, topoisomerase inhibitors, and microtubule poisons were among the most cytotoxic drug classes for NMC cells, while efficacy of the bromodomain inhibitor JQ1 varied considerably between lines carrying different BRD4 (bromodomain-containing protein 4) –NUT (nuclear protein in testis) translocations. Efficacy of FP was comparable to vincristine and doxorubicin, drugs that have been previously used in NMC patients. All three compounds showed significantly better activity than etoposide and vorinostat, agents that have also been used in NMC patients. Statins and antimetabolites demonstrated intermediate single-agent efficacy. In vivo , vincristine significantly inhibited tumour growth in two different NMC xenografts. Flavopiridol in vivo was significantly effective in one of the two NMC xenograft lines, demonstrating the biological heterogeneity of this disease. Conclusions: These results demonstrate that FP may be of benefit to a subset of patients with NMC, and warrant a continued emphasis on microtubule inhibitors, anthracyclines, and topoisomerase inhibitors as effective drug classes in this disease.

Introduction The advantages of electronic prescribing systems are well recognised offering superiority over paper-based systems in terms of legibility, dose calculation, assignment of dose limits, and report generation. Such systems do not come with a populated drug file so each institution must design and build their own. This is a substantial project that is complex, labour-intensive and risk-prone. A road-map was not available at the time for how this could be achieved. Aims To describe the process of building an electronic drug file for a paediatric intensive care unit (PICU). Method (1) Commencement: Initial work consisted of setting out certain standards, such as acceptable abbreviations, units of measure and reference sources. As the unit caters for a wide range of patients from premature neonates to teenagers, it was a risk to use one upper dose limit for each drug. Patient categories were created, consisting of (a) premature (b) neonate (c) 1 month to 1 year (d) over 1 year up to 40 kg (e) over 40 kg. For each of these patient categories, a minimum and maximum body weight was assigned which would be used to calculate dose limits. (2) Configuration: Four limits for each drug dose were inputted: minimum, low normal, high normal and maximum. It was decided that all minima would be zero and low normal would reflect the lower end of the normal dose range (hence, dose reduction for renal impairment would be highlighted as abnormal). Drug configuration and corrections were done by one PICU pharmacist, who logged the reference for any unusual decisions. Each draft was checked by a second PICU pharmacist. A selected list of drugs and their various assigned limits was reviewed by a consultant intensivist. An ‘Issues Log’ was maintained for liaison with the vendor where issues were logged as they arose and their progress to resolution noted. (3) Testing: Teams of testers drawn from consultants and senior nursing staff volunteered for testing. They were assigned specific drugs and formulations to test, which they did by prescribing each drug for each patient category. A form was used to log details of the drug tested and any difficulties that arose. Progress of the testing phase was logged on a spreadsheet. (4) Miscellaneous: 556 drug formulations were configured, consisting of 3756 limits in total. Aciclovir alone has 180 limits because of the complexity of dosing for different age groups and indications, as well as different formulations (injection, cream, etc). (5) Time Frame: Work on this project took two pharmacists 9 months to complete, working 3–7 h/day. Testing was conducted over a 14 week period. Conclusions A formal structured approach is key when undertaking a large complex project. Tools, such as issues and progress logs are important to track the multitude of questions that arise. Close working relationships with all stakeholders need to be maintained throughout the process. In times of reduced financial and human resources, sharing of information is critical to reducing waste. This roadmap will help other institutions undertaking a similar project.

Introduction: Crowding is associated with poor patient outcomes in emergency departments (ED). Measures of crowding are often complex and resource-intensive to score and use in real-time. We evaluated single easily obtained variables to establish the presence of crowding compared to more complex crowding scores. Methods: Serial observations of patient flow were recorded in a tertiary Canadian ED. Single variables were evaluated including total number of patients in the ED (census), in beds, in the waiting room, in the treatment area waiting to be assessed, and total inpatient admissions. These were compared with Crowding scores (NEDOCS, EDWIN, ICMED, three regional hospital modifications of NEDOCS) as predictors of crowding. Predictive validity was compared to the reference standard of physician perception of crowding, using receiver operator curve analysis. Results: 144 of 169 potential events were recorded over 2 weeks. Crowding was present in 63.9% of the events. ED census (total number of patients in the ED) was strongly correlated with crowding (AUC = 0.82 with 95% CI = 0.76 - 0.89) and its performance was similar to that of NEDOCS (AUC = 0.80 with 95% CI = 0.76 - 0.90) and a more complex local modification of NEDOCS, the S-SAT (AUC = 0.83, 95% CI = 0.74 - 0.89). Conclusion: The single indicator, ED census was as predictive for the presence of crowding as more complex crowding scores. A two-stage approach to crowding intervention is proposed that first identifies crowding with a real-time ED census statistic followed by investigation of precipitating and modifiable factors. Real time signalling may permit more standardized and effective approaches to manage ED flow.

BackgroundStandard concentration infusions and ‘smart-pumps’ are recognised as best practice in the paediatric setting. Implementation rates in European hospitals remain low. Children’s Health Ireland (CHI) developed a paediatric ‘smart-pump’ drug library using standardised concentrations. At time of development, other Irish hospitals continued to use traditional pumps and weight-based paediatric infusions.AimTo expand best paediatric infusion practices by nationalising use of the CHI drug library.SettingTertiary paediatric, maternity and general acute hospitals, and associated transport services in Ireland.DevelopmentThe CHI drug library was first developed for paediatric intensive care and then adapted over a 10-year period for use in emergency departments, general paediatric wards, neonatal units, adult intensive care and transport services. The original library (42 drug lines, 1 ‘care-unit’) was substantially expanded (223 drug lines, 6 ‘care-units’). A neonatal sub-library was created.ImplementationExecutive support, dedicated resources and governance structures were secured. Implementation and training packages were developed. Implementation has occurred across CHI, in paediatric and neonatal transport services, 58% (n = 11) of neonatal units, and 23% (n = 6) of paediatric sites.EvaluationA before and after study demonstrated significant reductions in infusion prescribing errors (29.0% versus 8.4%, p < 0.001). Direct observation of infusions (n = 1023) found high compliance rates (98.9%) and low programming errors (1.6%). 100% of nurses (n = 132) surveyed 9 months after general ward implementation considered the drug library had enhanced patient safety.ConclusionStrategic planning and collaboration can standardise infusion practices. The CHI drug library has been approved as a National Standard of Care, with implementation continuing.