2018 National Meeting LEADING AND IMPLEMENTING CHANGEDoes Emergency Physician (EP) Diagnostic...

Abstract Book

LEADING AND IMPLEMENTING CHANGE

2018 National Meeting

LEAD SPONSOR SPONSORS

In partnership with the Canadian Medical Association

OverallProgramGoals

• EngagewiththeChoosingWiselycommunityinanenergizedexchangeofideasonoveruse

• Hearaboutpracticalandimplementablestrategiesforreducingoveruse,andunderstandtheirimpact

• Networkwithcolleagueswhoshareyourpassion

OverallLearningObjectives

Attheendofthismeeting,participantswillbeableto:

• Exchangeknowledgeandbestpracticesforreducinglow-valuecarewithintheclinicalsetting

• Learnaboutstrategiestomeasureandevaluateinterventions

• Acquiretoolsandskillsofimplementationscienceastheyrelatetoreducinglow-valuecare

STUDY CREDITSCollege of Family Physicians of Canada – Mainpro+:ThisGroupLearningprogrammeetsthecertificationcriteriaoftheCollegeofFamilyPhysiciansofCanadaandhasbeencertifiedbyContinuingProfessionalDevelopment,FacultyofMedicine,UniversityofTorontoforupto6.0Mainpro+credits.

Royal College of Physicians and Surgeons of Canada – Section 1:ThiseventisanAccreditedGroupLearningActivity(Section1)asdefinedbytheMaintenanceofCertificationProgramoftheRoyalCollegeofPhysiciansandSurgeonsofCanada,approvedbyContinuingProfessionalDevelopment,FacultyofMedicine,UniversityofToronto.Youmayclaimamaximumof6hours(creditsareautomaticallycalculated).

ContentsProgramGoalsandObjectives 2Chair’sForeword 6Agenda 7

DEPRESCRIBINGPromotingAppropriatePrescribing:AntipsychoticStewardshipforOlderPatientsinAcuteCare 10ExploringDeprescribingOpportunitiesforCommunityPharmacists 11UseofaStandardizedProcessforProtonPumpInhibitor(PPI)DeprescribingatMarkhamStouffvilleHospital 12DevelopingaSustainableCultureforaDeprescribingProgramatMichaelGarronHospital(MGH) 13PAACT(PartnersforAppropriateAnti-infectiveCommunityTherapy):25YearsofAntimicrobialStewardship 14ImplementationofaFamilyMedicineGuideforPainManagement 15

QUALITY IMPROVEMENT PositivelyChangingRedBloodCellTransfusionPracticeUsingEducationalStrategies 17ChoosingWiselyintheEmergencyDepartmenttoReduceUnnecessaryTests 18BetterTogether:WorkingAcrossPrimaryCareOrganizationstoImplementChoosingWisely 19ReducingBenzodiazepines&Sedative-HypnoticsAmongHospitalizedPatients:LessonsLearnedfromaMulti-SiteImplementationJourney 20ARTICChoosingWisely:AnIdeaWorthSpreadingAcrossFiveOntarioHospitalsandAffiliatedFamilyHealthTeams 21ReducingUnnecessaryBUNTestingatNorthYorkGeneralHospital 22AnIdeaWorthSustaining:EvaluatingtheSustainabilityPotentialoftheChoosingWiselyInitiativeAcrossFiveOntarioCommunityHospitals&AffiliatedFamilyHealthTeams 23GainingMomentumThroughtheUseofChoosingWiselyCanada:OntarioTransfusionQualityImprovementPlan(OTQIP) 24DoubleEdgedSword:OrderSetModificationtoReduceTwoUnitRedCellTransfusionsonanOncologyWard 25AnInnovativeDigitalStrategyforDisseminationofChoosingWiselyCanadaGuidelinesInTransfusionMedicine 26De-ImplementingWisely:PlanningyourImplementationStrategy 27ReducingtheRateofPostoperativeUrinaryTractInfectionAmongstOrthopaedicPatientsinaCommunityTeachingHospital 28LosetheTubeatHumberRiverHospital 29CollabwiththeLab:ImplementingChoosingWiselywithLaboratory 30ComparingPhysicianandNurseOrderinginEmergencyDepartments:AQualitativeStudy 31APharmacistLedStrategytoReduceUnnecessaryLabTestsforNewAdmissionsintoLongTermCare 32EvaluatingHealthcareProviders’UnderstandingofCBT-IinanInterdisciplinaryFamilyHealthTeam 33EngageatEveryStage,LearnatEveryTurn:HowSaskatchewanisBuildingContinuousClinicalQualityImprovementLearningPathwaysforPhysicians 34ExaminingtheImplementationofPreoperativeDiagnosticTestingGuidelinesinManitoba 35LeveragingAudit&FeedbacktoSupportPracticeChange 36TheChecklistforHeadInjuryManagementEvaluationStudy(CHIMES):AQIInitiativeintheEmergencyDepartment 37ImplementingChoosingWiselyRecommendationsAcross5AlbertaEmergencyDepartmentsThroughElectronicDecisionSupport 38ReducingUnnecessaryBloodTestsinaDowntownEmergencyDepartment 39

Pilotinga“chestx-rayforacuteasthma”knowledgedisseminationtoolinAlbertaemergencydepartments 40DoIReallyNeedAntibiotics?AskYourDoctororNursePractitioner 41RandomizedControlledTrialofAuditandFeedbackInterventiontoImproveAdherencetotheChoosingWiselyRecommendationsinPrimaryCare 42Implementationofchangesincervicalscreeningrecommendations. 43PrimedforSuccess:UsingImplementationSciencetoImplementChange 44AssessingtheCompletionandAppropriatenessofHeadacheandLowBackMRIandCTRequisitions:ACanadianPerspectiveonPatient-CentredReferrals 45TheJoysandSorrowsofImplementing 46ElectiveLumbarLaminectomy:RoutinePerioperativePracticesandPostoperativeOutcomes 47UnnecessaryUltrasoundintheManagementofSubcutaneousLipomas 48ByeByeBedrest:ShiftingICUCulturefrom‘TooSicktoGetOutofBed’to‘TooSicktoStayinBed’ 49UnnecessaryUltrasoundintheManagementofUmbilicalandInguinalHernias 50ACollaborative,DiagnosticStewardshipInitiativetoImproveUrineCultureUtilizationInAlberta 51DoesEmergencyPhysician(EP)DiagnosticImaging(DI)useAffectClinicalProductivity? 52InfluenceofLabTests(LT)OrderingonEmergencyPhysician(EP)Productivity(PP) 53ImprovingAppropriatenessofMgTestinginICU 54TheRoadTraveled-NPAC’sJourneyinDevelopmentofthe“NineThingsNursePractitionersandPatientsShouldQuestion” 55ExploringPhysician-ReportedBarriersandFacilitatorstoUsingEvidence-BasedRecommendationsRegardingImagingforLowBackPain:AMeta-SynthesisUsingtheTheoreticalDomainsFramework 56FundamentalsofHealthEvidence:PracticalApproachestoCriticalAppraisal 57ReducingRadiationandCostAssociatedwithFollow-UpImagingforPneumothorax 58BladderMatters:ACorporateStrategytoReduceUrinaryTractInfectionsandUrinaryRetentionRates 59ElectronicReferralFormsandDecisionSupportToolsIntegratedintoElectronicMedicalRecordSystemsForVascularTestOrderingbyPhysiciansinPrimaryCareSettingsinNewfoundlandandLabrador(NL) 60InfluencingEmergencyDepartmentManagementandImagingPracticesforTwoCommonPresentations:DevelopingandImplementingaTheoryandData-InformedIntervention 61ImplementationofaNewDiagnosticAlgorithmforAnti-NeutrophilCytoplasmicAntibody(ANCA)Testing 62Conceptualizing‘UnnecessaryCare’inEmergencyDepartments(ED):QualitativeInterviewswithEdPhysiciansandSiteChiefs 63TheUseofClinicalDecisionSupportToolsintheEmergencyDepartmenttoOptimizeClinicalPractice:ASystematicReviewandMeta-Analysis 64ReducedCD4MeasurementsinStableHIVPatientsisAssociatedwithSignificantCostSavings 65LHINCollaboration&StandardizationImprovingImagingPractices 66EndometrialBiopsyinanOutpatientGynaecologicalSetting:OverInvestigation 67OptimizingtheuseofEndoscopyforYoung,OtherwiseHealthyPatientswithDyspepsia 68ImprovingAppropriatenessofOxygenSaturationMonitoringinPaediatricPatientsWithAcuteRespiratoryIllness:aQIInitiative 69MergingInitiatives:ChoosingWiselyandAntimicrobialStewardship–AnUnderutilizedConnection 70DermatologyGuidelinesforChoosingWiselyCanada:FiveThingsPatientsandProvidersShouldQuestion 71BronchiolitisManagementinCalgaryEmergencyDepartments 72Howtoreduceinappropriatepreventivecare. 73ChoosingWisely–EngagingourPatients-AUniqueOpportunityforNursePractitioners 74ImplementingCriticalAppraisalintheChoosingWiselyRecommendationWritingProcess 75

MEASUREMENT & EVALUATION TheRoleofAuditandFeedbackInChoosingWisely:ArePhysiciansAbletoAccuratelyPredictTheirOwnPractice? 77DrivingChangeUsingAuditandFeedback:PrimaryHealthcarePanelReports 78PhysicianUtilizationScorecardsinPrimaryCare:ACross-SectorPartnershiptoImproveTestUtilization 79ScreeningforNewPrimaryCancersinPatientswithMetastaticBreastCancer:AProvincialAnalysisoftheChoosingWiselyCanadaRecommendations 80FrequencyandUtilityofPre-ConsultationMRIUseinPatientsReferredforPossibleTotalKneeArthroplasty 81AData-DrivenApproachtoIdentifyingLaboratoryOverutilization–ResultsfromtheGeneralMedicineInpatientInitiative(GEMINI) 82UsingFacilitatedAuditandFeedbacktoSupportChoosingWiselyInitiativesforPrimaryCarePhysicians 83TreatmentofAsymptomaticBacteriuriainElderlyPatientsWithDelirium:ASystematicReview 84ADatabasePlatformtoMonitorIn-HospitalGlucometerUse 85TheUseofTheoriesandFrameworkstoUnderstandandAddresstheReductionofLow-ValueHealthcarePractices:AScopingReview 86AScopingReviewExploringInterventionsChangingImageOrderinginPediatricEmergencyMedicine 87PilotingaTooltoReduceCTforBenignHeadacheinAlbertaEmergencyDepartments 88ChoosingWiselyinRadiationOncology:DrivingPracticeChangethroughMeasurementandQualityImprovement 89WhatBehaviourChangeTechniquesHaveBeenUsedtoReducePhysician’sImage-OrderingforLowBackPain 90MeasuringBenzodiazepineuseAmongSeniorswithIn-HospitalDelirium 91AssessingtheRiskofIntracranialBleedinginEmergencyDepartmentSeniorswhohaveFallen 92ThePrevalenceofIntracranialBleedinginElderlywhohaveFallen 93SerumProteinElectrophoresisTestinginNorthernAlberta:AnAuditandInterventiontoCurtailOveruse 94AllergyTestinginNorthernAlberta:AnAuditandInterventiontoCurtailOveruse 95CurtailingtheInappropriateUrineHcgQualitativeTestinginaCommunityLabSetting 96StewardshipwithaHandshake:ImpactofCollaborative,ProspectiveAuditandFeedbackAntimicrobialStewardshipRoundsinanAdult,Medical-SurgicalIntensiveCareUnitinSaskatoon,Saskatchewan 97AppropriatenessofCTandX-rayOrderingbyPhysiciansforLowBackPain:ASystematicReview 98

MEDICAL EDUCATION IncorporatingResourceStewardshipintoUndergraduateMedicalEducationatMcMasterUniversity 100ChoosingWiselyCanadaSTARS:TrainingtheNextGenerationofMedicalProfessionalsatUBC 101IncorporatingResourceStewardshipintotheUniversityofManitobaUndergraduateMedicalEducationProgram102TimetoForgetAboutDRE? 103ResourceStewardshipinUndergraduateMedicalEducation(UME) 104EvaluatingCanadianMedicalStudents’InterestinandReadinessforLearningandPracticingHigh-ValueCare:PreparingforChange 105

PATIENT ENGAGEMENTEngagingPatientsasPartnersinCWNL:LowBackImagingCaseStudy 107RegionalMediaStrategies:ChoosingWiselyinFormerCypressHealthRegion 108ChangingtheWayweUnderstandandLabelBehaviourwillReducetheuseofAntipsychoticsinDementiaCare 109DeepeningPatientEngagement:Sharingthepatientvoiceatalllevelsofanorganizationandbeyond110

Chair’s ForewordDearChoosingWiselyCanada2018NationalMeetingAttendees,

Welcome to the third annual Choosing Wisely Canada National Meeting!

Weareexcitedtobehostingthisyear’sNationalMeetinginTorontoattheGlobeandMailCentre.TheNationalMeetingisacelebrationofwhatwehaveaccomplishedtogetherinpartnershipwithyou,ourcollaboratorsfromacrossthecountry,andanopportunitytolookforwardanddiscusshowwecansustainthemomentumforourcampaign.

Thisyear’stheme,LeadingandImplementingChange,wasinspiredbythefantasticeffortsofourChoosingWiselycommunity.WehopethismeetingwillprovideanopportunitytoshowcasepracticalandimplementableexamplesofChoosingWiselyprojectsfromacrossCanada.

Thecontentsofthisabstractbookareatestamenttothebreadthofclinicianleadership,engagement,anddedicationofourstakeholdersthatareleadingchangeandimprovingthequalityofhealthcareintheirownorganizationsorpracticesettings.Browsethecontentsofthisabstractbookbytopic,whichinclude:deprescribing,medicaleducation,patientengagement,qualityimprovementandmeasurement.

Wehopethisbookwillserveasacontinuedsourceofinspiration,innovationandideasthatengagethegrowingcommunityofclinicians,individualsandorganizationscommittedtotheChoosingWiselyCanadacampaignbeyondtheNationalMeeting.Thiswillbeathought-provokingmeetingthatwillinspireandcontinuetobuilduponourcollectiveeffortsintheareasofqualityandappropriateness.

IsincerelythankallofyourforthecommitmentyouhavemadetoChoosingWiselyandyourcontinuedeffortsinimprovingourhealthcaresystem.

Yours,

WendyLevinson,MDOCChair,ChoosingWiselyCanada&InternationalProfessorofMedicine,UniversityofToronto

Itinerary

8:00AM-8:30AM

8:30AM-9:00AM

9:00AM-9:50AM

9:50AM-10:10AM

10:10AM-11:10AM

11:10AM-11:25AM

11:25AM-12:25PM

12:25PM-1:25PM

Registration and Breakfast

Welcome and Opening RemarksTheHonourableGinettePetitpasTaylor,FederalMinisterofHealthDr.LaurentMarcoux,President,CanadianMedicalAssociationDr.JoshuaTepper,PresidentandChiefExecutiveOfficer,HealthQualityOntario

Morning Keynote: Common Pitfalls in Quality Improvement: Lessons for Choosing Wisely ProjectsDr.KavehShojania,Director,CentreforQualityImprovement&PatientSafety,UniversityofTorontoandEditor-in-chief,BMJQuality&Safety

SessionLearningObjectives:• Appreciatethesharedgoalsofqualityimprovementactivities;• Understandcommonwaysqualityimprovementprojectsgowrong;• Identifyeffectivestrategiesfortranslatingevidenceintopractice.

Networking Break

Successful Tales of Choosing Wisely From Coast-to-Coast TheplenarywillhighlightChoosingWiselyimplementationprojectsfromourabstractsubmissions.Panelistswillbeaskedtopresentontheirtopicandtakequestionsfromtheaudience.

1. Positively changing red blood cell transfusion practice using educational strategies• Dr.SusanWitt,AlbertaHealthServices

2. Choosing Wisely in the emergency department to reduce unnecessary tests• Dr.SamCampbell,QEIIHealthSciencesCentre

3. Better Together: Working across primary care organizations to implement Choosing Wisely• Dr.KimberlyWintemute,ChoosingWiselyCanada,NorthYorkFamilyHealth

4. Reducing benzodiazepines and sedative-hypnotics among hospitalized patients: Lessons Learnedfrom a multi-site implementation journey• Dr.ChristineSoong,SinaiHealthSystem

Networking Break

Concurrent Sessions 1ConcurrentsessionsfeaturebreakoutandworkshopsessionsthatwillhighlightChoosingWiselyimplementationprojectsandinteractivediscussionswithpresenters.

Lunch and Networking

1:25PM-2:25PM

2:25PM-2:45PM

2:45PM-3:45PM

3:45PM-3:55PM

3:55PM-4:05PM

4:05PM-4:55PM

4:55PM-5:00PM

Networking Break

Remarks from the Canadian Medical Protective Association (CMPA) Dr.HartleyStern,CanadianMedicalProtectiveAssociation

Afternoon Keynote: Choosing Wisely and Medicine’s Third EraDr.DeeMangin,Professor,DavidBraley&NancyGordonChairinFamilyMedicine,McMasterUniversity

SessionLearningObjectives:• Appreciatethepastandcurrentinfluencesshapingthechangingframeworkof

medicine;• Understandtheimplicationsforthethirderaofmedicine;• ConsidertheopportunitiesforChoosingWisely.

Closing Remarks

DEPRESCRIBING - PAGE 9

DEPRESCRIBING

Promoting Appropriate Prescribing: Antipsychotic Stewardship for Older Patients in Acute CareDeborahBrown,SunnybrookHeathSciencesCentreJesikaContreras,RegionalGeriatricProgramofTorontoMireilleNorris,SunnybrookHealthSciencesCentreDovGandell,SunnybrookHealthSciencesCentreRobertJaunkalns,SunnybrookHealthSciencesCentreJoyMakari,SunnybrookHealthSciencesCentreRominaMarchesano,SunnybrookHealthSciencesCentreBarbaraLiu,SunnybrookHealthSciencesCentre,UniversityofToronto

BackgroundInhospital,olderpatientswithdementiaordeliriummayexhibitbehaviourssuchasagitationorhallucinations,thatmayleadtopharmacologicalintervention.Evidencetoguideappropriateuseofantipsychoticsinolderpatientsislackingandasaclass,antipsychoticshavesignificantadverseeffects.

ObjectiveToimplementandevaluateanantipsychoticstewardshipprogramwiththeaimofoptimized,appropriateuseofneurolepticsforresponsivebehavioursinolderpatientsinacutecare.

InterventionWereviewedpatients(>70years)whohadantipsychoticsorderedon3acutecareunits.Thestewardshipprocessincluded:• Reviewofthechartandassessmentofthepatient• Determiningiftheantipsychoticwasnecessary;theappropriatedruganddoseordered;determinationof

theantipsychoticeffectonthetargetbehaviour• Ensuringappropriatemedicalassessmentandinvestigations• Reinforcingtheuseofnon-pharmacologicalinterventions• Ensuringthatthepatient’sresponsewasmonitored

Results120patientswerereviewed,meanage82years,55%aremale;86%fromcommunity.Wediscontinuedordecreasedantipsychoticsin64%oforders.Inpatientsonantipsychoticsathome,wereducedordiscontinuedthedrugsin53%oforders.Weincreasedawarenessofappropriatedosinginolderpatientsandcreatedapositiveimpactondeliriumawareness.Wehavedevelopedaweb-basedappforantipsychoticdosingandeducationalmaterialstosupportnon-pharmacologicalstrategiesforresponsivebehaviours.

Lessons LearnedAvaluableopportunitytoreinforcenon-pharmacologicalapproachestobehaviourmanagement;prescriberengagementiscrucialandthereisneedforsystematiccareplanningwithresponsivebehaviours.Asfollowup,adeliriumordersethasbeencreated.

Exploring Deprescribing Opportunities for Community Pharmacists ClaraKorenvain,Women’sCollegeHospitalLindaMacKeigan,UniversityofTorontoKatieDainty,NorthYorkGeneralHospitalSaraGuilcher,UniversityofTorontoLisaMcCarthy,Women’sCollegeHospital

BackgroundDeprescribingcanreducetheuseofharmfulorunnecessarymedicationsbutisachallengingprocessforpatientsandprescribers.Communitypharmacistshavepotentialopportunitiestobeinvolvedwithdeprescribingbutfewstudieshaveexploredtheirroleinthedeprescribingprocess.WesoughttodescribeOntariocommunitypharmacists’involvementwithdeprescribingandpotentialopportunitiesforenhancingdeprescribing.

MethodsWeconductedqualitativetelephoneinterviewswithaconveniencesampleofOntariocommunitypharmacistsselectedtoachievevariabilityinexperience,pharmacyposition,andurban/rurallocation.Threeinterviewtranscriptswerecodedindependentlybyfourinvestigatorstodevelopacodebook,andtheremainderwerecodedandanalyzedthematicallybyoneinvestigator.

ResultsAll17participantswereinvolvedwithdeprescribingintheirpracticesbuttovariableextents.Threethemeswereidentified:(1)pharmacists’conceptualizationofdeprescribingaffectshowtheyidentifyandactondeprescribingopportunities;(2)communitypharmacists’professionalandbusinessroleschallengetheirabilitytoprioritizedeprescribingindailypractice;and(3)suboptimalaccesstoinformationfromprescribersinfluencespharmacists’willingnesstoassumeresponsibilityfordeprescribing.

ConclusionRecommendationsforenhancingcommunitypharmacists’involvementindeprescribingincludefocusingpharmacists’timeonstepsintheprocessthattheycancontributetoefficientlyandeffectively(suchasmonitoring),andincreasingpatientengagementinthedeprescribingprocesstohelppharmacistsgainaccesstoinformationtheyareotherwisechallengedtoobtain.Futureresearchiswarrantedexaminingbroaderstrategiessuchasintegratingeducationaboutdeprescribingwithexistingeducationaboutbestprescribingpractices.

Use of a Standardized Process for Proton Pump Inhibitor (PPI) Deprescribing at Markham Stouffville HospitalAliceHogg,MarkhamStouffvilleHospital

GoalThegoaloftheprojectwastoreducethenumberofpatientsdischargedfromhospitaloninappropriatePPIprescriptions.

ImplementationAprocesswasdevelopedtoteachpharmacystudentstouseastandardizedassessmenttoidentifypatientsadmittedtotherehab/medicineunitsatMarkhamStouffvilleHospitalthatarecandidatesfordeprescribing.OnceidentifiedthepharmacystudentdiscussespotentialPPIdeprescribingwiththepatientandprovideswritteninformation.Ifthepatientisdeterminedtobeeligible,thestudentcompletesaPPIDeprescribingPreprintedOrderSet(PPO)providingtherationalefordeprescribingandtherecommendeddeprescribingregimen.ThecompletedPPOisleftonthepatientchartforphysicianreviewandsignoffifagreeable.ThestudentfollowsthepatientwhileinhospitalandassessestoleranceofPPIdeprescribing.

MeasuresAtbaseline,11%ofassessedpatientsthatwerecandidatesforPPIdeprescribingwereinitiatedonadeprescribingregimenpriortodischarge.Aftertheinterventionthisincreasedto45%representinga62%decreaseininappropriatePPIprescriptionsatdischarge.

ChallengesThemainchallengesofthisprojectwere1)missedopportunitiestocompletetheintervention2)completedPPO’snotbeingsignedbythephysicianand3)PPIprescriptionsbeingwrittenincorrectlyatdischarge.LessonsLearned:Toaddresstheabovechallengessomeadjustmentsweremadetotheprocess.TheseincludedaddingacommentssectiononthePPOforphysiciantoindicateareasonfordisagreeingwiththerecommendationanddevelopmentofalettertosendtothefamilyproviderdetailingtheinterventionandrequestingfollow-upwiththepatient.

Developing a Sustainable Culture for a Deprescribing Program at Michael Garron Hospital (MGH)JohnAbrahamson,MichaelGarronHospitalHeatherSampson,MichaelGarronHospitalPatrickDarragh,MichaelGarronHospitalAndrewLiu,MichaelGarronHospitalCaraTannenbaum,UniversityofMontrealStephanieVoong,UniversityofTorontoNazigGabriel,UniversityofTorontoAjanthiyThayalan,UniversityofTorontoMayuriMahenth,UniversityofToronto

ObjectivesDevelopasustainabledecision-makingframeworkfordeprescribingprojectsguidingreproducibleprogramdevelopmentsapplicabletootheracutecaresettings

BackgroundUpto50%ofpatientsprescribedinhaledcorticosteroids(ICS)areunlikelytobenefitfromtheiruse.ICSarenotbenignmedicationswithsubstantialevidenceforadverseeffects.Thesecostlymedications,whenprescribedinappropriatelyresultinsignificantpatientandhealthcaresystemburden.Lastyear,MGHspent$120,000onICS.

MethodsDeprescribingprincipleswereintroducedatMGHin2016.ExtrapolatingthesesuccessfulcomponentsencouragedMGHtoruna“real-life”prospectiveQIprojectdeprescribingICS.ElectronicstopondispensingICSwasutilizeduntiltheappropriatenessofICSwasdeterminedforMedicinepatientsadmittedwithanon-respirologydiagnosis.Patients/familieswereengagedintheshareddecision-makingprocesswiththepharmacist/physicianteam.WheretheappropriatenessofICSwasnotclear,respirologyconsultandpulmonaryfunctiontestswererequested.Primarycarephysicianandcommunitypharmacistswereelectronicallynotifiedonrecommendations

ResultsPatientpopulationwascharacterizedi.e.demographics,comorbidities,smokinghistory,respiratoryexacerbationsandadmissions.TheproportionoftotaladmittedpatientsusingICSandtheproportionofthosethatcanhaveICSdeprescribedweredetermined.ImpactonsevendayreadmissionsandpatientadherencetodeprescribingrecommendationscontinuestobeevaluatedusingMinistryrecordsandphonecallfollowup.

ConclusionICSdeprescribingreducescostanddiseaseburdentothehealthcaresystem.PrototypingICSstewardshipinacollaborativemulti-professionalmodeldevelopedsystems-basedchangesrequiredforasustainablehospitalbaseddeprescribingprogram.AbusinessplanbasedonsavingsaccruedthroughdeprescribingisunderwayatMGH.

PAACT (Partners for Appropriate Anti-infective Community Therapy): 25 Years of Antimicrobial StewardshipLaurieDunn,PArtnersforAppropriateCommunityTherapy(PAACT)AlexandraBarany,MUMSHealthJohnStewart,PortPerryMedicalAssociatesJohnPilla,PArtnersforAppropriateCommunityTherapy(PAACT)

Goal: PAACTisanationaleducationnetworkoffamilyphysiciansthatfocusesonappropriatetreatmentofcommunity-acquiredinfectiousdiseasewhosemainreferenceistheAnti-infectiveGuidelinesforCommunity-acquiredInfections(“OrangeBook”).Thegoalsaretheimplementationofacommunity-basedantimicrobialstewardshipprogramandthereductionofunecessaryantibioticprescriptions.Thishascurtailedantimicrobialresistanceratesandpreserveantibioticsforfutureuse.

Implementation: Twophases:1)Developmentofevidence-based,user-friendlyclinicalguidelines.2)Disseminationofguidelinerecommendationsthroughsmallgroupcasebasedworkshops.

Measures: Datawasobtainedfromon-siteprograms(e.g.,accreditedCFPCsessions)evaluationsandpost-reflectiveexercises.Quantitativeandcontentanalyseswereperformed.

Challenges: Variouschallegesweredescribedbypractitionersincludingpatientpressuretoprescribeantibiotics,lackofsuccint,user-friendlytools(e.g.,guidelines,patienteducationalmaterials),andenvironmental(e.g.,walk-inclinics).

Lessons Learned: Anumberofbroadthemesemergedfromthedata.Post-program,participantsfelttheywereprescribingfewerantibioticsandthattheyhadshiftedawayfromuseofsecondlineantibiotics.Thischangeinantibioticusewasconfirmedinapublishedquantitativestudies.Changesinpatienteducationtechniquesandincreasedconfidencewithrespecttodialoguearoundantibioticresistancewasreported.Properlydesignedguidelinesforoptimalknowledgetranslationwereessentialandtoolstoassist(e.g.,viralprescribingpad)withthepatient-physicianencounterprovedtobevaluable.

Implementation of a Family Medicine Guide for Pain ManagementLaurieDunn,PartnersforAppropriateCommunityTherapy(PAACT)AlexandraBarany,MUMSHealthJohnPilla,PartnersforAppropriateCommunityTherapy(PAACT)

BackgroundChronicandacutepainisacommonpresentationintheprimarycaresetting.OneoutcomeofaCanadianexpertreviewpanelonopioids,convenedbyISMPCanada,wasthatdevelopmentofaknowledgetranslationversionofpreviouslypublishedCanadianandinternationalpainmanagementguidelineswouldbeuseful.AModified-Delphiprocess,includingapeer-reviewedcomponent,wasusedtoproduceanevidence-basedresourceforfront-lineclinicians.

GoalsToimplementthePainManagementGuideforFamilyPractice.

Development/ImplementationThedocumentwasinitiallyimplementedusingamulti-faceteddistributionandeducationalapproachwhichincludedprovisionatnationalmedicalconferences;aCFPCaccredited,case-basedCPDprogramandaccessibilitythroughawebsite.

ChallengesItisachallengetoimplementaknowledgetranslationdocumentforfamilypractitionersunlessithasundergonearobust,peer-reviewedprocessandismadeaccessibleviamultipleplatforms.

Lessons LearnedAnydocumentthataimstosetoutclinicalpracticeobjectivesshouldbefieldtestedextensivelywithfront-lineclinicians.Amulti-prongedapproachisthemostsuccessfulinimplementingtheguidelines,themosteffectivebeingaccesstoaprintversionofthedocumentandsmall-group,case-based,accreditedlearning.Itisalsoessentialthattheguidewillbecontinuallyrevisedbasedonuserfeedbackandtheemergingevidence.

QUALITY IMPROVEMENT - PAGE 16

QUALITY IMPROVEMENT

Positively Changing Red Blood Cell Transfusion Practice Using Educational StrategiesSusanWittandKenWouAlbertaHealthServices

BackgroundRedbloodcells(RBCs)arealimitedresourceandtransfusionposespotentialpatientharms.ChangesinRBCtransfusionbestpracticepromoteaconservativeapproachinstablenon-bleedingpatients.Anecdotalevidencesuggestedtheserecommendationshadnotbeenincorporatedintolocalphysicianpractices.Wesoughttoimproveclinicians’understandingofthesenewguidelinesanddemonstrateameasurablereductioninunnecessaryandtotalRBCtransfusionrates.

MethodsInpartnershipwithlab/transfusionphysiciansandChoosingWiselyCanada’s“WhyGiveTwoWhenOneWillDo?”campaign,wecollectedmonthlydatafromApril2015toOctober2017.PercentageofRBCtransfusionswhenhemoglobinMultifacetededucationalinterventionstargetedphysicians,nursesandlabstaff.Theseincluded:multi-siteTelehealthworkshop;succinctposterhighlightingnewguidelines(prominentlydisplayedinkeylocations);repeateddataandinformationfeedbackusingexistingcommunicationstreams(newsletters,bulletins,meetings).

ResultsAftertheinterventions,thefollowingimprovementswerenoted:104%increaseofpercentagesingleunitRBCtransfusionorders,41%increaseinRBCtransfusionswhenpre-transfusionhemoglobin

ConclusionsWerealizedsignificantimprovementinphysicianRBCtransfusionpracticesutilizingsimplelowcosttechniquesandsurrogatemeasuresfortransfusionappropriateness.

QUALITY IMPROVEMENT - PAGE 18QUALITY IMPROVEMENT - PAGE 18

Choosing Wisely in the Emergency Department to Reduce Unnecessary Tests SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversityManalElnenaei,DalhousieUniversityBassamNassar,DalhousieUniversityAmyLou,NovaScotiaHealthAuthority,DalhousieUniversityBryanCrocker,NovaScotiaHealthAuthorityNancyConnor,NovaScotiaHealthAuthority

BackgroundInaresponsetoEDover-crowding,guidelinescommonlyexisttoguidebloodtestorderingusing‘ordersets’forpatientswaitingforcare.Inmanycases,thisincreasestheuseoftestswithoutbenefittingpatients.Wedescribeaqualityimprovementprojectdesignedtoreducethenumberoflaboratorytestsconsidered‘routine’forwaitingpatients.

MethodsAmultidisciplinarygroupreviewedexistingsymptom-promptednursingbloodtestguidelinesforserumelectrolytesandglucose,renalfunctiontests,livertests,lipase,toxicologicaltestsandbetaHumanChorionicgonadotrophinlevels.Ordersetswererevisedwithtestseliminatedfromthe‘routine’panelsthatwerenotfeltto‘routinely’contributetopatientcare.Thenewguidelineswerecommunicatedtonursingstaffinaseriesofeducationalsessions,andtherevisedguidelineswerepostedatnursingstations.Physicianorderingpracticewasnotaddressed.Apre-postevaluationcomparedtheperiod1December2014,-30November2015with1December2015-30November2016.Clinicaloutcomesandpatientwaittimeswerenotevaluated.

ResultsTheuseoftestsinthesecategoriesdecreased32%betweenthetwoperiods,atanetsavingof$210,246.Thelargestsavingscamefromtotalprotein(73%decrease),Creatinekinase(68%),chloride(64%),glucose(49%),andalbumin(47%).Sodium/Potassiumtestingdecreasedbyonly13%.TheonlyincreaseintestorderingrecordedwasAST(3%increase).

ConclusionSimplychangingordersetsresultedinsignificantsavingstothesystem.Furtherstudyisneededtoassesstheeffectofthesechangesonpatientflowandonclinicaloutcome.

Better Together: Working Across Primary Care Organizations to Implement Choosing Wisely KarunaGupta,HealthforAllFamilyHealthTeamBettyHum,SouthEastTorontoFamilyHealthTeamTracyLindsay,NorthYorkGeneralHospital

GoalAspartoftheAdoptingResearchtoImproveCare(ARTIC)-ChoosingWiselyproject,sixFamilyHealthTeams(FHTs)workedcollaborativelytoimplementfourcommonChoosingWiselyrecommendations:reducingunnecessarythyroidfunctiontesting,andde-prescribingProtonPumpInhibitors,Glyburide,andSedativeHypnotics.

ImplementationOvertwoyears,theFHTschosetwocommonrecommendationstoaddresseachyear.LeadPhysiciansfromeachFHTbrainstormedinterventionstotestandimplement,sharinglearningsandtoolsfromtheirrespectiveorganizationsthroughouttheprocess.

MeasuresTheFHTsmeasuredasetofcommonindicators,includingthebaselinenumberofpatientstargetedforeachrecommendation,thenumberofpatientssuccessfullyde-prescribedorthenumberoftestsreduced,andthenumberofphysiciansinvolvedinimplementingchange.Positivereductionsintestorderingandde-prescribingwereobservedacrossallfourselectedrecommendations.

ChallengesFHTsexperiencedchallengestovaryingdegreesdependingontheircontextandtherecommendationbeingimplemented.Challengesincludedstaffturnover,competingprioritieswithinFHTsanddatarelatedissues.TheFHTssharedideasandresourcestotacklethesechallenges,includingconductingsharedstafftraining,andfocusingtheirQualityImprovementPlans(QIPs)onChoosingWiselywork.

Lessons LearnedTheFHTsdidthingscollectivelythatwouldnothaveoccurredhadtheyworkedalone.Sharedcoordinationofworkandsharedtimelines/deadlineshelpedkeepChoosingWiselyworkmovingforward.Inhindsight,theFHTswouldhavebroadenedsharingandlearningopportunitiestootherteammembers,changedthetimingofonerecommendationtoenablegreaterplanningandimplementationtimeandadjustedthereportusedtoimplementanotherrecommendation.

Reducing Benzodiazepines & Sedative-Hypnotics Among Hospitalized Patients: Lessons Learned from a Multi-Site Implementation JourneyChristineSoong,SinaiHealthSystemCherylEthier,SinaiHealthSystemDeborahBrown,SunnybrookHealthSciencesCentreLisaBurry,SinaiHealthSystemJesikaContreras,RegionalGeriatricProgramofTorontoYunaLee,StMichael’sHospitalKarenNg,SinaiHealthSystemZahraSyavashVahabi,SinaiHealthSystemPeterWu,St.Michael’sHospitalBarbaraLiu,SunnybrookHealthSciencesCentre,UniversityofToronto

BackgroundInappropriateuseofbenzodiazepinesandsedative-hypnotics(BSH)forsleepisprevalent.WedescribetheimplementationandLessonsLearnedfromamulti-siteChoosingWiselyproject.

Goal ToreducetheproportionofnewprescriptionsofBSHmedicationsusedforsleepinselecthospitalizedpatientsby20%acrossfivehospitalsinoneyear.

Methods ImplementtheSedativeReductionBundlethroughiterativePDSAcyclesStep-wedgeevaluationdesign

InterventionSedativeReductionBundle:Sleephygieneandpromotion,patientandcaregivereducation,ordersetamendments,pharmacyreviewsofneworders,auditfeedbacktofrontlinestaffandincorporatingsleepandsedativeconversationsintodailynursinghuddles.

Metrics Outcomemeasure:ProportionofBSH-naïvepatientsprescribedanynewBSHinhospitalfortheprimaryindicationofsleep.PROM:PatientreportedsleepqualityBalancingmeasure:aggregateprescribingpatternsofothersedatives.

Lessons LearnedSuccessenablers:alignmentwithorganizationalstrategytoreducehigh-riskmedicationuseandfalls,empoweringnurses

Challenges1. Synchronizingimplementationacross5sites:amendmentofelectronicordersetswaschallenging.

achievingconsensustochangelong-standingprocess,complexapprovalsandclinicianresistance.2. Context:Variabilityinleadershipandcultureacrosshospitalsshapedtheeffectivenessofthe

implementation.AmbiguousrolesandprocesseswereclarifiedthroughknowledgegainedfromPDSAcycles.

3. Staffchanges:personnelchangeswhenateammemberlefttheproject,constantreminderstonewtrainees

4. Sustainability:labour-intensiveaudit-feedbackdatacollection5. “ResearchvsQI”:frontlinestaffattimesviewedtheworkas“research”ratherthanqualityimprovement.

ARTIC Choosing Wisely: An Idea Worth Spreading Across Five Ontario Hospitals and Affiliated Family Health TeamsDeepakSharmaandDonnaMcRitchieNorthYorkGeneralHospital

GoalThisprojectaimedtoreduceunnecessarytesting,treatmentandproceduresin5hospitalsand6FamilyHealthTeams(FHT)servingtheGreaterTorontoArea,Markham,andNewmarket.CollectivelyreferredtoastheJointCentresforTransformativeHealthcaretheselike-mindedorganizationsstrivetodevelop,evaluateandimplementinnovativeimprovementsinhealthcaredelivery.

ImplementationImplementationfocusedoncreatingawarenessbyformalizingclinicianinvolvement,sparkinginspirationbysharingstoriesandinvolvingpatients,buildingasustainableinfrastructurethroughlocalleadership,andcontinuingspreadbysharingandpublishinglearnings.

MeasuresPurposeorientedmeasuresweredevelopedtomeettheneedsoflocalimprovementteams(e.g.,labtestsreducedandpatientsde-prescribedcomparedtobaseline),externalprojectreporting(i.e.,patientslesslikelytohaveanunnecessarytestandprovidersawareofChoosingWisely),andfuturefocusedsustainability(e.g.,throughaSustainabilitySub-Studyconductedwithinthisproject).

ChallengesChallengesexperiencedvarieddependingonthesite,thesector,andtherecommendationimplemented.CommonchallengesexperiencedacrosssitesincludedtimeandcapacitytodoChoosingWiselywork,competingwithotherorganizationalpriorities,humanresourcesavailabilityandexpertiseanddataavailability/qualitychallenges.

Lessons Learned1. Contextmatters.HospitalsandFHTsapproachedChoosingWiselyrecommendationimplementation

differentlytoreflecttheirorganizationalneedsandareasoffocus:FHTsconcurrentlyimplementedcommonrecommendations;hospitalseachimplementeddifferentrecommendations,withonlysomeoverlappingacrosssites.

2. Dataisimportantbutshouldservetheultimategoalofculturechange.BecauseChoosingWiselyworkoftenrequiresnon-traditionaldatasets,dataworkcanconsumetimeandattention.

Reducing Unnecessary BUN Testing at North York General HospitalManuelGiraldo,NorthYorkGeneralHospital

GoalToreduceunnecessarytestingofBloodUreaNitrogen(BUN)byatleast50%atNorthYorkGeneralHospital(NYGH).

ImplementationAmongthepillarsofCWCisimprovingtheappropriatenessofLaboratorytesting.In2016,weproposedrevisionstoourordersetscontainingBUNinordertoimprovetheappropriateutilizationofthistest.ThiswasbasedontheknowledgethatCreatinineisabettermeasureofrenalfunctioneventhoughmosthealthcareprovidersstillusebothmarkerstoevaluaterenalfunction.FundsfromtheAdoptingResearchtoImproveCare(ARTIC)projectfacilitateditsadoptionandimplementation.

MeasuresAbaselinereportconductedinsummer2016showedthatBUNwasorderedonaverage6,000permonthandCreatinine5,400.AfterMACapproval,amulti-specialtyNYGHphysiciangroupwithlaboratoryrepresentationwasorganizedtoreviewourOrderEntryalgorithms.ItwasagreedtoremoveBUNfrom90%oftheOrderSets,100%ofCareSetsandfromfouroftheeightEmergencyDepartment’sMedicalDirectives.Thesechangeshavenotaffectedpatientcareandhavenotchangedthetriageprocessorlengthofstay.OverallBUNtestingdecreasedhospital-wideby50%.

ChallengesAlthoughsomephysiciangroupsrequestedre-institutionofBUNandthenumbersofAdd-onsincreasedslightly,wehavesustainedthereductionsmade.

Lessons LearnedEngagingphysicians,otherleadersandkeystakeholderswascriticaltothesuccessofthisinitiative.Westronglyrecommendaphysicianchampiontoleadtheconversationswithotherclinicians.Usingelectronictoolsfororderentry(i.e.CPOE)facilitatesthereviewandimplementationofthisintervention.

An Idea Worth Sustaining: Evaluating the Sustainability Potential of the Choosing Wisely Initiative Across Five Ontario Community Hospitals & Affiliated Family Health TeamsMonikaKastner,JulieMakarski,KateMossman,KeganHarrisandDeepakSharmaNorthYorkGeneralHospital

BackgroundEvaluatingthesustainabilitypotentialofinnovationsiscriticaltomaximizingtheirpotentialforimpact.WeevaluatedthesustainabilitypotentialofCWatfiveOntariocommunityhospitalsandaffiliatedfamilyhealthteams(FHTs)aspartofaCWspreadproject.

MethodsWeconductedamixed-methodsstudy:1)avalidatedsustainabilitysurveywithCWimplementationteamsatT0(baseline),T1(6months),andT2(12months)toidentifysustainabilitydeterminants;2)focusgroupswithteamsfollowingsurveycompletionatT0(todiscussidentifiedchallengesfromthesurvey,andtoco-createanactionplantoaddressthem)andatT1(todiscussactionplanimplementation,andanynewchallenges).Sessionswereaudio-recordedandtranscriptswereanalyzedusingcontentanalysis.

Results78participantsrepresenting15teams(5hospitals;6FHTs)completedsurveysandparticipatedin30focusgroups.ThreeCWde-adoptionpriorityareaswereinvestigated:protonpumpinhibitor(PPI)de-prescribing;reducingpre-optesting,BUN/Urealabtests.Themeanteamsustainabilityscoresranged61-73%(PPI),87-89%(BUN/Urea),and82-92%(Pre-Op),whichwereabovethethresholdofwhatisconsideredasustainableinnovation(55%).Topsustainabilityfacilitatorswereclinicalleadershipengagementandfitwithorganization’sstrategicaims/culture;topchallengeswereadaptabilityofimprovedprocessesandinfrastructureforsustainability.Allteamsidentifiedatleastonechallengeforwhichtheyco-designedandimplementedanactionplan.

ConclusionsOurworkcontributestoadvancingsustainabilitymethodsandhighlightsthatimplementationteamscanbeempoweredtoinfluencetheirimplementationefforts,andtorealizepositiveoutcomesfortheirservicesandpatients.

Gaining Momentum Through the Use of Choosing Wisely Canada: Ontario Transfusion Quality Improvement Plan (OTQIP)DeniseEvanovitch,OntarioRegionalBloodCoordinatingNetworkYuliaLin,SunnybrookHealthSciencesCentreAllisonCollins,OntarioRegionalBloodCoordinatingNetworkSheenaScheuermann,OntarioRegionalBloodCoordinatingNetwork

BackgroundTheOntarioRegionalBloodCoordinatingNetwork(ORBCoN)inconjunctionwiththeOntarioTransfusionQualityImprovementPlan(OTQIP)CommitteedevelopedaqualityimprovementtoolkitthatwaslaunchedinApril2016.Theplan’sgoalistoreducepatientharmbyimprovingtransfusionpracticeinhospitals.

Design/MethodologyTheOTQIPCommitteehasbroadrepresentationfromthetransfusioncommunityinallregionsofOntario.TheCommitteealsocollaboratedwithHealthQualityOntario(HQO),ChoosingWiselyCanada,theLocalHealthIntegrationNetworks(LHIN),CanadianSocietyforTransfusionMedicineandtheHealthcareInsuranceReciprocalofCanada.SeveralhospitalsurveysrevealedastronginterestanddesiretoimplementallorportionsoftheOTQIP.

ResultsThetoolkitcontains:• AnarrativetemplatebasedonHQO’smodel• Clinicalpracticerecommendations• Transfusionordersettemplate• ChoosingWiselyCanadascreensaver• SOP,algorithm,andtrainingaidfortechnologistprospectivebloodorderscreening

Post-launch,othertoolswereaddedtofurtherassisthospitalsinadvancingtheirQIPs:atechnologistprospectivescreeningeducationalmoduleandanelectronictrackingtool.Bothhospitalandprovincialreportscanbegeneratedfromthetrackingtool.Twelvehospitalsareusingthetoolandhaveconducted72audits.

ConclusionHelpinghospitalsthroughthedevelopmentofstandardizedtemplates,instructions,educationandothertoolsfortransfusionqualityimprovementincreasestheabilityofhospitalstouptakequalityimprovementinitiatives.Takingastandardizedapproachacrosstheprovinceallowsforbothaggregateandhospitaldatacomparisonanalyses.

Double Edged Sword: Order Set Modification to Reduce Two Unit Red Cell Transfusions on an Oncology WardAlanGob,AnuragBhallaandIanChin-YeeWesternUniversity

IntroductionChoosingWiselyCanadawasintroducedin2014tohelpguideconscioushealthcarepracticestoreduceunnecessarytests,proceduresandtreatments.Aspartofthecampaign,CanadianSocietyforTransfusionMedicinerecommendsoneovertwopackedredbloodcellunit(pRBCs)transfusions.

ObjectiveAimofthestudywastodevisestrategiestolimitunnecessary2pRBCstransfusions.

MethodsWeconductedreal-timeandretrospectiveaudits,andsurveyoffrontlinestaffononcologyinpatientwardatLondonHealthSciencesCentretoidentifyfactorsassociatedwith2pRBCstransfusions.Basedonthesurveys,weimplementedtwomaintargetedinterventionsincludingeducatinghealthcareprovidersthroughpostersandbulletins,andremovalofautomatic2pRBCscomputerizedtransfusionsorders.WemonitorednumberofpRBCsorderedonamonthlybasisfromOctober2015toNovember2016.

ResultsAfterimplementationofproposedstrategiesinApril2016,therewasa50%reductioninproportionof2pRBCsorderedinMay2015.Inaddition,thereductionin2pRBCsorderedwassustainedforremainedofthemonitoringperiod.Thenumberof2pRBCstransfusiondecreasedby89%from71unitspermonth(51.1%oftotaltransfusionsordered)inOctober2015to6unitspermonth(5.6%oftotaltransfusionsordered)inNovember2016.

ConclusionThereductioninproportionof2pRBCsorderedwassecondarytotheproposedintervention,andwassustainedoveraperiodofsixmonths.Theseinitiativeshighlightanovelwayoflimitingoverutilizationattheleveloffrontlineprovidersandhealthcaresystem.

An Innovative Digital Strategy for Dissemination of Choosing Wisely Canada Guidelines In Transfusion MedicineClintonCampbell,QEIIHealthSciencesCentre

ChoosingWiselyCanada(CWC)hashighrelevancetothetransfusionofhumanbloodproducts,whichcarriessignificantrisksandisbasedonahighlylimitedsupply.OneconcernraisedaboutCWCisthatitmayrequiremoreeffectivedisseminationstrategiestoimplementsystemicpracticechange.Manyhealthcareprofessionalsnowusevideo-basedplatformssuchasYouTubeforcontinuedprofessionaleducation.Specifically,YouTubeallowsvideoproducerstolearnfromviewers’watchinghabitsthroughdatametrics,leadingtoimprovedvideoefficacy.WesummarizedCWCbloodtransfusionguidelinesasaseriesofshort,entertainingandinformativeanimatedvideosonYouTube,withtheaimthatthiswillenhanceguidelinedisseminationtowardthesafestandmostresponsibletransfusionpractice.

ImplementationWeproducedfivedigitallyanimatedvideosencompassingkeyCWCtransfusionmedicineguidelines.VideoswereproducedbetweenMayandDecember2017,anduploadedontoYouTubeinJanuary2018.

MeasuresYouTubedatametricsincludingviewmetrics,watchtimemetrics,engagementmetrics,playlistmetricsandaudienceretentionmetricsarebeingcollected.Datametricswillbemeasuredafter6months.

ChallengesChallengesincludedtranslatingcomplexmedicalknowledgeintoasimplifiedformatacrossdisciplines(transfusionmedicinetodigitalanimation).ThemostsignificantongoingchallengeisknowledgetranslationtoaugmentphysicianawarenessofthevideosonYouTube.

Lessons LearnedTranslationofCWCtransfusionmedicineguidelinesintoavideoformatwasahighlychallengingyetrewardingprocess.Initialfeedbackhasbeenhighlypositive;however,theefficacyofdisseminationwillbeevaluatedafterseveralmonthsofYouTubewatchdatametricsarecollated.

De-Implementing Wisely: Planning your Implementation Strategy JeremyGrimshaw,OttawaHospitalResearchInstituteAndreaPatey,OttawaHospitalResearchInstituteStefanieLinklater,OttawaHospitalResearchInstituteFrançoiseKo,ChoosingWiselyCanadaSachaBhatia,ChoosingWiselyCanadaWendyLevinson,ChoosingWiselyCanada

BackgroundLowvaluecareiscommoninhealthcaresystemsinCanadaandgloballyresultingindirectharmtopatientsandthreateninghealthcaresystemsustainability.Thereisconsiderableuncertaintyabouthowbesttoreducelow-valuecare,suggestingtheurgentneedforimplementationresearchinthisarea.ToaddressthisissueCWChasestablishedtheCWCImplementationResearchNetwork(CWC-IRN)involving12provincialandterritorialCWcampaignstoestablishaCanadianlearninghealthcaresystemonde-implementation.ThisNetworkbringstogetherCWC,CWprovincialcampaigns,patientandhealthsystempartnersandinternationallyleadingimplementationresearchers.

AimTheoverallgoaloftheCWC-IRNistodevelopthescientificbasistosupportimplementationofCWCrecommendationsinCanadianhealthcaresettings.WewillbuildcapacityininnovativeCRTsandimplementationresearchwithpatientpartners,early-andmid-careerscientistsandtrainees.Patientpartnerswillbegiventheopportunitytoparticipateinawiderangeofresearchtrainingandpatientengagementactivities.IndividualswithintheCWC-IRNwillreceivetailoredadvancedtrainingactivitiesandengagewiththescientistsontheteam(e.g.,webinarsandtrainingonimplementationscience,patientengagementstrategies).WewillengageinawiderangeofdisseminationactivitiestargetingCWC-IRN,provincialhealthcaresystemsandinternationalCWgroups.

ConclusionImplementationscienceaimstounderstandtheunderlyingreasonsforhealthcareprocessesandtodevelopandtestpotentialsolutionstoimprovethem.TheCWC-IRNlinksCWC,provincialandterritorialpatientandhealthsystempartnerswithleadingCanadianimplementationscientiststodevelopandtestsolutionsforde-implementationoflow-valuecare.

Reducing the Rate of Postoperative Urinary Tract Infection Amongst Orthopaedic Patients in a Community Teaching HospitalHannahBrooks,DavidSmith,LindaJussaume,KomalPatel,PaulinaFerreira,HosseinMehdian,ShawnGarbedian,SanjhoSrikandarajah,LindsayTaam,MaryKapetanos,NicoleGolda,JenniferPage,ValeriaThompson,DavidHajek,JanetMoffat,MichellRichardsonandMariaSalangaNorthYorkGeneralHospital

BackgroundPostoperativeurinarytractinfections(UTI)areacommonlyavoidablecomplication,withassociatednegativepatientandadministrativeimplications.During2016,NorthYorkGeneralHospital(NYGH)inTorontoCanadaidentifiedUTIasaqualityimprovementopportunitywithinthesurgicalorthopedicpatientpopulation.Atbaseline,NYGHidentifiedanoddsratioof1.50,placingitin9thdecilein2016asreportedbytheHealthQualityOntario-NationalSurgicalQualityImprovementProgram(NSQIP).

ObjectiveToreduceUTIinsurgicalorthopedicpatientstoanoddsratio

MethodsAninter-professionalteamdevelopedandimplementeda“bladderbundle”changeprotocolreflectiveofbestevidenced-basedpractices,ChoosingWiselyCanadarecommendationsandlocalstakeholderinput.Theprimaryfocusofthebundleincluded1)Proceduralinsertioncriteria2)Earlyremovalofcatheter3)Thedevelopmentofaurinaryretentionalgorithmand4)multi-professionaleducationonappropriatesteriletechniqueandcathetercare.TheprimarymetricwasidentifiedastheUTIrateasdefinedbyNSQIP.ThesecondarymetricwasthetotalcatheterizationrateamongstNSQIPabstractedpatientsandthebalancingmetricwasretentionrates.

ResultsFromMay2017-October2017,thesurgicalorthopedicpopulationhadanUTIoddsratioof0.91.Inconclusion,theorthopedicbladderbundlehasshownearlyindicationsofbeingeffectiveinreducingurinarytractinfectionsinsurgicalorthopedicpatients.

Lose the Tube at Humber River HospitalNarendraSingh,EktaKhemani,RosemaryMulock,SarahBranton,ChristinaMoldovan,MichaelGardam,BarbCollins,VanessaBurkoski,JenniferYoon,TrevorHall,NicoletteCaccia,LauraCopeland,KenLee,AndreaLo,RajiniSinghal,JohnHagen,SonuGaind,QuocHuynh,AtoosaRezvanpour,TinaKerelska,AlbertKaras,PaulineGiancroce,MaryOseiandAmritaTyagiHumberRiverHospital

BackgroundHumberRiverHospital(HRH),NorthAmerica’sfirstfullydigitalhospital,recognizestheimportanceofreducingunnecessarytreatmentsaspartoftheChoosingWiselyCanada(CWC)campaign.Aspartofthisinitiative,HRHembarkedonahospital-widestrategytoreduceunnecessaryurinarycatheterizationusingtheCWC“LosetheTube”toolkit.Bymonitoringurinarycatheterizationusingelectronicordersoneighttargetedinpatientunits,weestablishedatbaselineaveragecatherizationrateof22%atourinstitution.Assuch,HRHembarkedonamulti-disciplinaryqualityimprovement(QI)projecttoreduceunnecessaryurinarycatheterinsertion.

MethodsUsingthemodelforimprovement,anumberofinterventionsweretakentoreducetherateofunnecessaryurinarycatheterizationatHRHincluding:1)establishingaCWCsteeringcommitteewithrepresentativesfrommedicalandsurgicalspecialties,2)modifyingdigitalordersetstoincludereassessmentofcatheterneedforhospitalizedpatients,3)implementingmulti-disciplinaryeducationalactivitiessuchasaCWCnewsletterandmulti-disciplinarygrandrounds,and4)introducingstandardizedequipmentforFoleycatheterizationwithteachingonpropercatheterinsertionandindicationsdiscussedwithnursingstaff.

ResultsFromAugust2016toOctober2017,HRHwasabletoreducetheurinarycatheterizationglobalaveragerateto10%ontargetedinpatientunits.

ConclusionsTherateofurinarycatheterizationatHRHhassignificantlyreducedinjustoverayearthroughmultipleQIstrategiesaimedateducation,promotion,standardizedequipment,andforcedfunctionsthroughtheuseofcomputerizeddecisionsupport.FuturerecommendationsincludeexploringthecostofqualitytodemonstrateannualsavingsasaresultofCWCimplementation.

Collab with the Lab: Implementing Choosing Wisely with LaboratoryKun-YoungSohn,TrilliumHealthPartners

BackgroundEvenaftertheintroductionofTroponinasthemostspecificmarkerofmyocardialinjury,CreatinineKinase(CK)hadstillbeenincludedinlaboratorytestprofilesandclinicalordersets.InadditiontoorderingCKandTroponintogetherintentionally,bundledCK-Troponinalsohindersorderingtheappropriatetest.Testutilizationauditwasperformedtoestimatetheimpactofeducationalmemoandinterventionatthetestprofileandorderset.

MethodFortheimprovementofutilization,thetwohospitalsites(A&B)ofTrilliumHealthPartnersapproachedintwostages:1)sendingoutofaneducationalmemo;2)removalofCKfromtestprofilesandordersets.Toassesstheirimpacts,CKandTroponinresultsweredownloadedfromtheLISfortheyears2011-2017.TheCK/TroponinIndex,numberofCKtestsper100Troponintests,wasusedastheutilizationindicator.

ResultTheCK/Troponinindexbeforesendingoutofamemowas103atsiteAand93atsiteB.Evenaftersendingoutthememo,theindexremainedsameat105atthesiteA,whiledecreasedto55atthesiteB.AfterremovalofCKfromthetestprofilesandordersets,theindexdroppedsignificantlyto6atthesiteAand12atthesiteB.

ConclusionTheresultsimpliedthattheeducationalmemohelpedphysiciansinchoosinglaboratorytestwiselyandtheconcertedeffortsattheoperationallevel,suchaslaboratorytestprofilesandclinicalordersets,producedagreaterimpact.

Comparing Physician and Nurse Ordering in Emergency Departments: A Qualitative StudyLeanneDelaney,DalhousieUniversityAllysonGallant,DalhousieUniversityJanetCurran,DalhousieUniversitySamCampbell,NovaScotiaHealthAuthority,DalhousieUniversity

BackgroundAlthoughLTorderinginEDsisavaluablediagnostictool,italsohasimplicationssuchasincreasedsystemcostsandpatientlengthofstay.WeaimedtoidentifyandcomparepatternsandperceptionsassociatedwithLTorderingbyemergencyphysicians(EP)andemergencynurses(ERN)attwoEDs.

MethodsUsingtheTheoreticalDomainsFrameworktodevelopaquestionnaireaimedtosortcontentinto14broaddomains,weconductedinterviewswith25EpsandERNstoexploreinfluencesindecisionstoorderLTs.Qualitativedatawasanalyzedbytwoindividualsusingaconsensusmethodologytohighlightkeythemesthatwereassociatedwithdifficultorinconsistentclinicaldecisionmaking.

ResultsWhileEPsandERNsagreedthatLTorderingcouldimprovepatientflow,theydifferedinperceptionsaboutflowdisruption,busyEDs,andpatientanxietyasmotivatingfactorsfororderingLTs.Additionally,ERNsreportedtobemostinfluencedbythestaffEPs,whileEPsreportedmostinfluencebyconsultingservices.Finally,moreEPsorderedLTsbasedontestresultinterpretation,whileERNsweremorelikelytoorderbasedonpatientsymptoms.

ConclusionERNsandEPsdifferinfactorsinfluencingLTordering,especiallyinthebroaddomainsofbeliefsaboutconsequences,environmentalcontextandresources,socialinfluence,emotions,andknowledge.FurtherresearchwilldeterminehowthisinformationcanbeusedtosupportdecisionmakingaroundLTuse.

A Pharmacist Led Strategy to Reduce Unnecessary Lab Tests for New Admissions into Long Term Care ParnianGhafari,MedicalPharmacies

Growingevidenceshowsinappropriatelaboratorytestingisacontributortowasteinhealthcareandit’sacommonproblem.Longtermcaresettingisnotimmunetosuchwastefulpractice.Inalongtermcaresetting,routinelaboratorytestingonnewadmissionshasbecomethenorm.Infact,therearefacilitiesthathaveablanketmedicaldirectiveforroutinenewadmissionbloodwork.

TheBetterCoordinatedCrossSectoralMedicationReconciliation(BOOMR)project,whichisaqualityimprovementinitiativethatinvolvesaclinicalpharmacistremotelyleadinganovelinterdisciplinarymedicationreconciliation(MedRec)processhascreatedanewopportunitytointerveneandinterceptunnecessarylaboratorytestorders.Priortotheadmission,thepharmacistretrievesrecentpertinentbloodworkfromtheOntariolaboratoriesinformationsystem(OLIS)andotherorganizationsthatmaynotbecontributingdataintoOLIS.ThisinformationalongwithotherclinicalconcernsaresharedwiththepractitionersatthetimeofMedRectoguideclinicaldecisionmakinginatimelymannerandminimizere-orderingofunnecessarybloodwork.

Thisuniqueinformationsharingatthetimeofadmissionhaschallengedthestatusquooforderingroutinebloodtestsfornewadmissionsinlongtermcarewithpotentialtoimproveclinicaloutcomesandreducecosts.

Evaluating Healthcare Providers’ Understanding of CBT-I in an Interdisciplinary Family Health TeamNicolaYang,MarkhamStouffvilleHospital

BackgroundInsomniaisthemostcommonlydiagnosedsleepdisorderandonethatcanhavesignificantpersonalandeconomicconsequences.Moreover,itisbothasymptomandindependentriskfactorformultiplephysicalandmentalhealthconditions.CognitiveBehaviouralTherapyforInsomnia(CBT-I)isaneffectivetreatmentforchronicinsomnia,andduetoitslow-riskprofile,isrecommendedasthefirst-linetreatmentofchoice.HealthforAll(HFA)isacommunity-basedacademicteachingunitandoneofsixfamilyhealthteamsthatimplementedtheChoosingWiselyrecommendationofdeprescribingsedativehypnoticsaspartoftheARTIC-ChoosingWiselyProject.Althoughreferralstothedeprescribeprogramcommencedin2017,aneedsassessmenthadyettobedonetoassessperceivedneedorinterestintheprogram,healthcareproviders’approachtochronicinsomniamanagement,understandingofCBT-Iandperceptionofitseffectiveness.ThisstudywillprovidebaselinedatatosupportsuccessfulimplementationoftheCBT-IProgramatHFA.

MethodsAformalneedsassessmentsurveywasdistributedelectronicallytoallhealthcareprovidersatHFA(i.e.staffphysicians,familymedicineresidents,nursepractitioner,andphysicianassistant).Thesurveyevaluatesproviders’demographics,currentapproachtoinsomniamanagement,knowledgeandperceptionofCBT-IandinterestinfurtherCBT-Ieducation.

ResultsResultsarepending(currentresponserate:87%).

ConclusionsThecollectedresponseswillhopefullyimprovethedesignandexecutionoftheCBT-I/hypnoticdeprescribeprogramatHFA.Analysisofdatawillhelpidentifyknowledgegapsininsomniamanagementandguidefurtherdevelopmentofeducationaltoolsandcurriculumonthesubject.

Engage at Every Stage, Learn at Every Turn: How Saskatchewan is Building Continuous Clinical Quality Improvement Learning Pathways for PhysiciansGaryGroot,UniversityofSaskatchewanTanyaVerrall,HealthQualityCouncil

GoalHowdoyouchangetheconversationaroundimprovingAppropriatenessofCare(AC)?Howdoyouengagephysiciansinleadingculturalchange?Saskatchewanisusingaunified,comprehensiveapproachtophysiciandevelopmentinleadershipandqualityimprovement.

ImplementationWorkingfromacollaboratively-designedACframework,theprovincehasmobilizedtobuildcapacitythroughbothinformalandformallearningopportunities,suchas:• Informallearning–provincialACprogram(withtopicssuchaspre-operativetesting),SaskatchewanMedicalAssociationAppropriatenessofCareInitiative(SACI)physiciancoachingsupport.

• Formallearning–ResidentQualityImprovementProgram,ClinicalQualityImprovementProgram,undergraduatequalityimprovementcourses.

MeasuresInadditiontotheACprogramevaluationmatrix,presentationwillshareearlyresultsfromthepilotCQIPcohort– includingwhyoneparticipantdescribeditas“oneofthebestlearningexperiencesinmyworkinglife”.Theevaluationframeworkincludesresultsfromparticipantexperience,coach/facultyexperience,andprojectprogress.

Challenges• Accessto/supportwithdata.• Findingtimeforbusyclinicianstolearn.• Long-termfinancialinvestmentfromfunders–buildingforthenextdecade,notthenextday.

Lesson Learned• Managingexpectationsregardingpaceofchange,returnoninvestment.• Powerofcollaboration–uniquepartnershipoftheSMAandMinistryofHealth.• Systembuy-inandalignment–startwiththewilling,engagemorestrategically.• Benefitsofinvestinginphysiciansaspeercoaches.• Potentialforspread–severalprojectsshowstrongpotentialforgreaterprovincialimpact.

Examining the Implementation of Preoperative Diagnostic Testing Guidelines in ManitobaSarahKirby,GeorgeandFayYeeCentreforHealthcareInnovationEricBohm,UniversityofManitobaAshleyStruthers,George&FayYeeCentreforHealthcareInnovationThomasMutter,UniversityofManitoba

GoalInManitobaauditshaveshownthatmanypatientscontinuetoreceiveunnecessarypreoperativetestsdespiteprovincewideguidelines.ThisprojectaimedtoidentifythebarriersandfacilitatorstoeffectiveguidelineadoptionandimplementationinManitobainordertodevelopimplementationstrategiestoreduceinappropriatepreoperativetestinginlowrisksurgeries.

ImplementationImplementationstrategiesincludedphysicianengagement,guidelinerevision,standardizingandremovingcuesfrompreoperativedocuments(i.e.patientcoverletters,preoperativehistoryandphysicalforms)andauditandfeedback.

MeasuresTheprojectisbeingevaluatedusingqualitative,quantitativeandsurveymethods.Datacollectioninvolvedaccessingexistingadministrativeandchartdataandcollectingnewdataintheformofinterviewsandsurveyswithpatients,healthcareprovidersandstakeholders.

ChallengesThequantitativeevaluationisongoing.Preliminaryauditresultsrevealthatoutofasampleof1769surgeries,inappropriatetestswereorderedin722cases(41%).Theseinitialresultsunderscorethechallengeofchangingindividualphysicianbehaviourdespiteextensivestakeholderengagementandmultiplesystemlevelinterventions.Qualitativeandsurveydatademonstratethatmanyofthechallengeslayinuptakeandcommunicationthatwasnotalignedwithguidelines.

Lessons LearnedImplementationmethodsmustbemultifaceted,involveestablishedleadersandengagealldisciplinesinvolvedinpreoperativecare.Preliminaryresultsofsurgicalauditsforauditandfeedbackrevealthatthereislargevariationinthenumberofinappropriatetestsbeingorderedbetweensurgeonsandsurgicalspecialties(22%-72%),indicatinganeedfortargetedfeedback.

Leveraging Audit & Feedback to Support Practice ChangeDavidZago,HealthQualityOntario

Background ChoosingWiselyCanadahasdevelopedrecommendationstoavoidunnecessarytestsortreatments.HealthQualityOntariohasproducedarangeofcomparativeauditandfeedbackproductsandsupportsalignedwiththeserecommendationstoenableimprovementacrossOntario.

Areas of FocusAvoidroutinepre-operativetestingforasymptomaticpatientsundergoinglow-risksurgery.Avoidinappropriateuseofantipsychoticsinlongtermcare.Manageappropriateuseofopioidsinprimarycare.Reduceurinarytractinfectionperioperatively.

MethodsComparativeutilizationrateindicatorsaredefinedforeachareaoffocus.Usingavailableadministrativedatasources,organizationorpractice-levelratesaregeneratedandtrendedovertimeinaquarterlyorbiennialreporttotheorganizationorclinician.Ifappropriate,abetterperformingrateortargetisincludedforcomparisonpurposes.Actionsorchangeideas(includingCWCToolkits)accompanytheindicatorstopromptorganizationsorcliniciansonapproachestoimprovement.Collaboratives/communitiesofpracticeengageorganizations/clinicianstoshareideasandsuccesswithchangingpracticeleadingtoimprovement.

ResultsFourauditandfeedbackapproachesregularlyprovidecomparativedata,evidence-basedchangeideasandopportunitiestoconnectwithpeerstoinitiatechange.

HospitalPerformanceSeriesReport–127hospitalorganizationsreceivethisreport

MyPracticeLong-TermCarereport-over300primarycarephysiciansworkinginlong-termcaresubscribetothisreport

MyPracticePrimaryCarereport-over2200primarycarephysicianssubscribetothisreport

OntarioSurgicalQualityImprovementNetwork-31hospitalsparticipate

The Checklist for Head Injury Management Evaluation Study (CHIMES): A QI Initiative in the Emergency DepartmentSameerMasood,UniversityHealthNetworkLucasChartier,UniversityHealthNetworkJooYoon,UniversityofToronto

BackgroundOver90%ofpatientswithheadinjuries(HIs)seenatemergencydepartments(EDs)areminorHIs.Over-utilizationofcomputedtomography(CT)scansresultsinunnecessaryexposuretoradiationandincreaseshealth-careutilization.UsingrecommendationsfromtheChoosingWiselyCampaign(CWC)andqualityimprovement(QI)methodology,ouraimwastoreducetheCT-scanrateforpatientspresentingwithHIsby10%overa6-monthperiodattwoacademicEDs.

MethodsBaselineCT-scanratesweredeterminedthrougha10-monthretrospectivecohortreview.OurPDSAcyclesincluded:1)ImprovingproviderknowledgeabouttheCWCrecommendations;2)Testing,refiningandimplementingamodifiedCanadianCTHeadRulechecklist;3)DevelopingandgivingpatientsCWC-themedHIhandouts;4)BimonthlyreportingofCT-scanratestoproviders.OurprimaryoutcomemeasurewasthenumberofCT-scansperformedforpatientswithHIs.ProcessmeasuresincludedthenumberofchecklistscompletedandEDlength-of-stay(LOS).OurbalancemeasurewasreturnEDvisitswithin72hours.

ResultsWeobserveda16%relativedecreaseinCT-scansat3months(47.9%to40.5%,P=0.005)and10.4%at8months(47.9%to43.1%,P=0.02.Overallbefore-and-aftermediantimeswerenotsignificantlydifferent(237minto225min,P=0.18).33%oftotalchecklistswerecompleted.72-hrreturnvisitsdidnotchangeduringthe8-monthstudyperiod(4.0%to4.16%,P=0.85).

ConclusionsOurlocalQIinitiativewassuccessfulindecreasingCTratesforpatientspresentingwithaHI.Thedecreaseineffectat8monthssuggeststheneedforcontinuedfeedbackandreminderstoensurelong-termsustainability.

Implementing Choosing Wisely Recommendations Across 5 Alberta Emergency Departments Through Electronic Decision SupportDanielGrigat,JamesAndruchow,AndrewMcRae,GrantInnesandEddyLangAlbertaHealthServices

GoalToimplementChoosingWiselyCanadarecommendationsforappropriateCTuseforpatientswithmildtraumaticbraininjury(MTBI)andsuspectedpulmonaryembolism(PE).

ImplementationEmergencyphysicians(EPs)at5Calgarysiteswererandomizedtoreceiveelectronicclinicaldecisionsupport(CDS)forCTimagingofpatientswithMTBIorsuspectedPE.CDSwaslaunchedinanexternalwindowwheneveraCTwasorderedfromcomputerizedorderentry.Physicianinteractionwasvoluntary.

MeasuresDuringthefirst8monthsoftheintervention102EPsrandomizedtoMTBICDSsaw2,189eligiblepatients,usingCDS36.2%ofthetime,andorderingheadCTfor38.5%.Among100controlEPswhosaw1,707eligiblepatients,CTheadwasorderedfor45.1%.Therewasnodifferencein30-dayEDreturnvisits,hospitalizations,ortraumaticheadinjurydiagnosesbetweengroups.4EPsrandomizedtoPECDSsaw9,609eligiblepatientsandusedCDS43.2%ofthetime.CTPulmonaryAngiogram(CTPA)utilizationwas9.7%amongEPsreceivingCDS,comparedto8.2%among91controlphysicianswhosaw9,498eligiblepatients.Therewasnodifferencein90-dayEDreturnvisitsorvenousthromboembolismdiagnosesbetweengroups.

ChallengesCDSusewasvariable,rangingfrom0-100%amongphysicians,likelyowingtothevoluntarynatureoftheintervention.

Lessons LearnedCDSimplementationwasassociatedwithreducedheadCTuseforpatientswithMTBI,butincreaseduseforpatientswithsuspectedPE.ThevoluntarynatureoftheinterventionaswellastriggeringonlyonCTorderinglikelycontributedtoitsmodestimpact.

Reducing Unnecessary Blood Tests in a Downtown Emergency DepartmentPatrickO’Brien,HinaChaudhry,SholzbergMichelle,MikeFralick,AlunAckryandLisaHicksSt.Michael’sHospital

LaboratorytestingisacorecomponentofpatientassessmentintheEmergencyDepartment(ED).However,sometestingmaybeunnecessary.WeaimedtoidentifyunnecessarylabtestingintheEDandtoreduceitby30%.

Ourchangestrategyincludedengagementofkeystakeholders,education(aroundappropriateuseofPT/aPTT)andchangestoEDlabpanels.ThemajorityoflabtestingintheEDistriggeredbymedicaldirectiveswhereinEDnursesorderfromlabspanelsforcommonpresentations.IncollaborationwithED,LabMedicineandwithreferencetobestpractices,wereviewedalloftheSMHlabpanels.Fourtestswereidentifiedthatwereuninformativeincertainsettings(PT,aPTT,urea,albumin),andtwotestswereidentifiedthatwereredundantwithnewertests(CK,amylase).Thesetestswereremovedfromfivelabpanels.Measurementfocusedonthemeantestingratepermonthoftargetedtestsandthereagentcosts.

Immediatelysubsequenttoourinitiative,dramaticchangesinthetestingratesoftargetedtestswereobserved.Asillustratedbelow,monthlytestvolumesdecreasedby47%to93%dependingonthetest.Thechangesresultedinaprojectedannualsavingsof$77,000inreagentcosts.BalancemetricsincludingEDlengthofstayandtransfusionratesshowednochange.Add-ontestrateswereassessedpreandpostpanelchangesforasubsetoftests(PT/aPTT)andwerestable.

PT aPTT Urea AlbuminCK AmylasePre-MeanTestVol./Mth 2341 2308 2948 1504 1204 1080Post-MeanTestVol./Mth 918 872 198 800 634 380%Decrease -61% -62% -93% -47% -47% -65%

RevisionofEDlabpanelsisarelativelysimplechangestrategythatcanresultindramaticreductionsintestvolumeswithoutadverselyimpactingpatientcare.

Piloting a “chest x-ray for acute asthma” knowledge dissemination tool in Alberta emergency departmentsLynetteD.Krebs,CristinaVilla-Roel,MariaOspina,BrianR.HolroydandBrianH.RoweUniversityofAlberta

BackgroundTofacilitateclinician-patientdialogue,apatientknowledgedisseminationtoolwasdesignedtoportraywhenchestx-rays(CXR)areneededforacuteasthma(AA)care.ThistoolwaspilotedwithpatientsandemergencyphysicianspracticinginAlbertapriortouseinanimplementationtrial.

MethodsAnonlinesurveywasdistributedtoemergencyphysiciansviaemail.Patients(17-55years)withAAwereenrolledinanemergencydepartment(ED)studyattwourbancentres.Bothpopulationsprovidedfeedbackonthetool.

ResultsAtotalof55physicians(29%)and38patientsresponded.Approximately55%ofphysiciansfeltcompletelyormostlycomfortableusingthetool.SuggestedchangesweretoincludeinformationonCXRradiationriskandrefrainfromdiscussingimagingvariation.Mostpatients(92%)agreedtheyunderstoodtheinformationand68%felttheinformationappliedtothem.Nearlyhalfofthepatients(45%)agreedthatbecauseofthetooltheyknewmoreaboutwhenapatientwithAAshouldhaveaCXRand71%agreedthattheywoulddiscusstheirCXRneedwiththeiremergencyphysician.Tenpatients(26%)suggestedtoolmodifications,including:additionaldetailsabouttheCXRs(i.e.,risks,indications),removingthestatementthatCXRsareoverused,andincludinganinstructionforpatientsnottoshyawayfromaskingtheirphysicianquestions.

ConclusionTheseresultsindicatetheneedtoensurepatientsunderstandhowtheinformationindecisionaides/toolsappliestothem.FurtherresearchisneededtouncoverwhetherpatientswouldactontheinformationandwhetherthoseactionswouldinfluenceEDmanagement.

Do I Really Need Antibiotics? Ask Your Doctor or Nurse PractitionerRobertWilson,PatrickParfreyandBrendanBarrettTranslationalandPersonalizedMedicineInitiative

GoalToreduceunnecessaryprescribingofantibioticsbyFamilyPhysicians&NursePractitionersinNewfoundland&Labrador(NL).

ImplementationNLusesmoreantibioticsthananyotherprovinceinCanada.In2016,NLprovided955prescriptionsper1,000inhabitants,19%morethanthesecondhighestprovince.CWNL,incollaborationwiththeNLMedicalAssociation(NLMA)andtheAssociationofRegisteredNursesofNL(ARNNL)createdapeercomparisonprogramforGP’sandNPsantibioticprescribingratesusingdatafromtheNLPrescriptionDrugProgram(NLPDP).

MeasuresAtotalof502GPsand84NP’sinNLweresentbyemail,individualizedde-indentifiedreportsontheirantibioticprescribingvolumeandratesplustypeofantibioticprescribedduringthe2015/6fiscalyearcomparedtotheirpeers.TheChoosingWiselyCanadarecommendationsforantibioticusewereprovided,andalinktoresourcescreatedbyQualityofCareNLtoreduceantibioticoveruse.Datawillbeanalyzed6monthsafterthereleaseofthereporttoseetheeffectoftheintervention

Challenges(1)AccesstoprovincialpharmacynetworkforallresidentsofNLonlyavailablefrom2017,(2)ethicalandbureaucraticbarriersfordatasharing,(3)constructingclearandconcisemessagingwiththereportforeasyunderstanding.

Lessons LearnedThePharmacyNetworkdatabaseisactivethereforefutureanalysiswillincludeprescriptionsforalldemographics.AdatasharingagreementhasbeenconstructedandacceptedbytheNLMA,ARNNLandMemorialUniversitytoallowethicalandconfidentialdatasharingamongstCHIAandtheGPsandNPs

Randomized Controlled Trial of Audit and Feedback Intervention to Improve Adherence to the Choosing Wisely Recommendations in Primary CareAlexanderSinger,UniversityofManitobaLeanneKosowan,UniversityofManitobaKheiraJolin-Dahel,UniversityofManitobaAlbertMota,CentreforHealthcareInnovationLisaLix,CentreforHealthcareInnovationAlanKatz,ManitobaCentreforHealthCareInnovation(MCHP),UniversityofManitoba

BackgroundTheeffectivenessofauditandfeedbackinterventionsinprimarycareisunclear.TheManitobaPrimaryCareResearchNetwork(MaPCReN)providesquarterlypracticefeedbackreportstoprimarycareproviders.UsingMaPCReN,thisstudyassessedtheimpactofanauditandfeedbackprogramregarding4ChoosingWiselyrecommendations:antimicrobialprescriptionsforviralinfection,antipsychoticprescriptionsforpatientswithdementia,screeningserumvitaminDandannualbloodscreening(i.e.PSA).

Methods243cliniciansfrom46clinicswererandomizedintooneofthreegroups:(1)currentpracticefeedbackreports(controlgroup),(2)currentfeedbackreportswithnon-personalizedinformationonCWrecommendations,or(3)modifiedfeedbackreportswithpractice-basedinformationrelatedtoCWrecommendations.Followingimplementation,descriptivestatisticsandmultivariatemodelsexploreddifferencesinprescribingandscreeningbetweengroups.

ResultsPriortoimplementationoftheauditandfeedbackprogram,15.6%(N=25,629)oftheprimarycareencountershadanoutcomecontrarytotheCWrecommendationsevaluated.Ofthese,65.4%wereprescribedanantibioticforaviralinfection,28.7%receivedaPSAscreenand9.0%hadaVitaminDtest.Amongpatientsdiagnosedwithdementia,17.0%wereprescribedanantipsychoticmedication.Statisticalanalysisofthestudydataiscurrentlybeingconducted.Thispresentationwillexploredifferencesinprescribingandscreeningfollowingimplementationoftheauditandfeedbackprogram.

ConclusionOurstudyaimstoevaluatetheeffectivenessofalowcostandaccessibleauditandfeedbackmechanismforprimarycareproviders.Byreducingunnecessarycare,wecanimprovepopulationhealthandreducehealthcarecosts.

Implementation of changes in cervical screening recommendations.JamesDickinson,UniversityofCalgary

GoalTochangeCanadiancervicalscreeningpracticestoevidencebase.

ImplementationTheCanadianTaskForcereportoncervicalscreeningmadestrongrecommendationsagainstscreeningwomenunderage20,weakrecommendationsagainstfor20-25,weakrecommendationsforscreeningwomen25-29years,strongrecommendationstoscreenfrom30to69,Weakrecommendationagainstscreeningafterage70.

MeasuresTheTaskForcereportwaspublishedin2013,butprovincialguidelinesseemtodominate,anddidnotchangefromtheirexistingstartageof21.BCandAlbertaguidelineschangedin2016,andsincethenbehaviourchangeshavebeenobservedinthoseprovinces.

ChallengesMostFamilyPhysiciansfocusontheirprovincialguidelines,andtheTaskForceisnotyetabletoencouragethemtochangeagainsttheirlocalguidelines.Currentguidelinecommitteesinmostprovincesareentrenchedintheirideas,andunwillingtoconsiderchange.SomehavemisquotedtheTaskForceguidelinesandinterpretedtheirapproachasbeingcongruent.

Lessons LearnedWemustunderstandhowtochangelocalguidelines,notsimplyprovideevidence-basedrecommendations.

Primed for Success: Using Implementation Science to Implement ChangeShusmitaRashid,SobiaKhan,JuliaMoore,MelissaCourvoisier,andSharonStrausSt.Michael’sHospital

Knowledgetranslation(KT)involvestheimplementationofresearchevidenceintoreal-worldpractice.ThescienceandpracticeofKThasbecomerecognizedasincreasinglyimportantwithinhealthcaresystemsthatcontinuouslystrivetointegrateevidence-basedpractices,recommendations,andpoliciesintoroutinehealthcare.Inanefforttofacilitatetheseobjectives,wedevelopedacourse,entitledPracticingKT(PKT)https://knowledgetranslation.net/education-training/pkt/,toprovideindividualsandorganizationswiththeknowledgeandsupporttoapplyimplementationsciencetodevelop,implement,andevaluateevidence-basedprograms.

Drawingfromourexperienceofdeliveringmorethan15implementationtrainingcourses,weproposedeliveringaworkshoptoprovideanoverviewonhowtouseimplementationsciencetonavigateimplementationchallengesandplanforenhancedoutcomesforChoosingWiselyrecommendations.Participantswillthinkthroughidentifyingandengagingstakeholdersinvolvedinimplementation;challengesattheindividual,organizationalandsystemlevel;andhowtooperationalizestrategiestofosterchange.Thisworkshop,informedbybestpracticesinorganizationallearningandadulteducation,willfacilitateopportunitiesforparticipantstolearnandapplyconceptsthroughaninteractivepresentation,smallgroupactivity,andasummaryofimplementationtipsandresources.Participantswillhaveexamplesofhowtouserelevanttheories,models,andframeworkstohelpunderstandimplementationissues,stakeholders,resources,andregulationsatorganizationandsystemlevels.Ourgoalistomakeimplementationscienceaccessibletopractitionersinavarietyofhealth-relateddisciplinesandthisworkshopwillbebeneficialforindividualsandorganizationsworkingtoimplementevidenceandde-implementunnecessarycareacrossclinical,publichealthandpolicysettings.

Assessing the Completion and Appropriateness of Headache and Low Back MRI and CT Requisitions: A Canadian Perspective on Patient-Centred ReferralsMarkKhoury,BrockUniversity/I-EQUIPMichaelTolentino,BrockUniversity

InappropriatediagnosticimagingisaburgeoningproblemwithintheCanadianhealthcaresystemandimposesconsiderableburdenstoefficiency,timeliness,andcost-effectivenessofcare.Apreliminaryreviewof267patientchartsindicatesthat55%ofMRIreferralsforheadache(HA)andlowbackpain(LBP)fromtheDiagnosticImagingDepartmentatNiagaraHealth(NH)weredeemedinappropriateorincompletebasedonChoosingWiselyCanada(CWC)guidelines.TheubiquityofLBPandHA,concomitantwithinefficientuseofresources,hascontributedtorisesinMRIandCTscansinCanada.Therein,improvingtheappropriatecompletionofMRIandCTrequisitionswouldallowNHtoreducewaittimesandimprovepatientsatisfaction.ThequalityimprovementobjectiveistodecreaseinappropriateorincompletereferralsforheadandlumbarMRIandCTscansintheNiagaraRegionfrom55%to20%,asdefinedbytheCWCguidelines,byApril2018.WeintendtoaccomplishthisobjectivethroughmodificationoftheMRIandCTrequisitionforms.

ChangestotherequisitionformreflectCWCguidelinesandareexpectedtoimprovecompletionrates;changesincludechecklistsforredflagindications,completionof6weeksofconservativemanagement,andsupplementaryinformationincaseswheretestsarenotindicated.NewrequisitionformshavebeendistributedtoasamplegroupofprimarycarephysiciansintheNiagaraRegionandpost-interventiondataiscurrentlybeingcollected.Ultimately,thisinterventionaimstofacilitateapatient-centredapproachtodiagnosticreferralsthroughaffirmationthatthepatient’ssymptomsappropriatelyindicateascanaccordingtoCWCguidelines.

The Joys and Sorrows of Implementing CatherineKohm,FraserHealth

FraserHealthisthelargestRegionalHealthAuthorityinBritishColumbiaservingapopulationof1.7millionpeople.Careareasincludehospital,residential,homehealth,mentalhealthandaddictions,andpublichealthservices.OurservicesareasareorganizedintotencommunitieswithanExecutiveDirectorleadingtheoperationsofthecommunity.TheExecutiveDirectorforBurnabyCommunityrequestedaChoosingWiselyCampaigndesignedtosupportelevenresidentialcarehomes,housing1428residents.BurnabyCommunityhasthehighestunscheduledtransferrateinFraserHealthtotheEmergencyDepartment,andthiswasidentifiedasaspecificobjectivetomeetFraser’stargetof7.5transferspermonthper100residents.WiseuseoftheEmergencydepartmentforthevulnerablelongtermcareresidentensurestherighttreatmentfortherightpersonattherightplace.

AninterdisciplinarytaskforcewhichincludedfamilymemberscollaboratedtodevelopaBurnabyfocusedcampaignaimingtoimprovethecareofresidentsthroughappropriatetransferstotheED.Theteamdevelopeddocumentswiththreespecificgoalsinmind:enhancecommunicationswithresidents&families,supportourcommunityphysicianstoprovideservicesatlongtermcaresites,andarticulatetoouracutecarepartnersthetypesofservicesthataresafelyavailableinlongtermcarehomes.

ThenextstepsforthiscampaignaretosharewithFraser’snineothercommunitiesthelessonslearned,thechallengesandsuccesses.Aplanhasbeendevelopedtomeasuretheresultsofthisinitiativeinmeetingthethreedefinedgoals.

Elective Lumbar Laminectomy: Routine Perioperative Practices and Postoperative OutcomesMinaTohidi,TiffanyLungandDavidYenQueen’sUniversity

BackgroundRoutineinvestigationsforasymptomaticpatientsundergoinglow-risk,non-cardiacsurgerycontributelittlevaluetoperioperativecare,butthesetestsarestillorderedinmanycentres,includingours.Theprimarypurposeofthisstudywastodeterminetheprevalenceofpreoperativebloodworkforelectivelumbarlaminectomy.Secondaryobjectivesweretodeterminetheprevalenceofintraoperativetranexamicacidadministration,intraoperativecomplications,lengthofstay,and30-dayreadmission.

MethodsThestudysampleincludedallpatients18yearsofageandolderwhounderwentelectivelumbarlaminectomybyoneOrthopaedicspinesurgeonbetweenJuly1,2013andJune30,2017.AllprocedureswereperformedattheUniversityHealthSciencesCentre.

Results256patientsunderwentelectivelumbarlaminectomyofoneormorelevelsduringthestudyperiod.Amongthesepatients,89.5%underwentatleastonepreoperativebloodtest.Theintraoperativecomplicationratewas2.34%.Inthe30daysfollowingsurgery,therewerenohospitalre-admissionsrelatedtocomplications.Lengthofstaywaslowerforpatientstreatedwithbilateraldecompressionusingalessinvasive,unilateralapproachcomparedtothetraditionalbilateralapproach(p=0.0063).Estimatedbloodlossanddurationofsurgerydidnotdiffersignificantlybetweenthesetwogroups(p=0.86,p=0.30,respectively).

ConclusionHospitalpoliciesshouldbere-evaluatedtoaddresstheoveruseofpreoperativeinvestigationsforelectivelumbarlaminectomies,whichhavelowperioperativetransfusionandcomplicationrates.Theuseofalessinvasivesurgicalapproach,whichisassociatedwithshorterhospitallengthofstaywithoutincreasedriskofcomplications,offerscost-savingopportunitiesandwarrantsfurtherinvestigation.

Unnecessary Ultrasound in the Management of Subcutaneous LipomasHarisImsirovic,EmilyZehnderandTrevorBardellQueen’sUniversity

BackgroundLipomasarecommonbenigntumourswhichsometimesrequireremovalbecauseofsymptomsorrapidgrowth.Oftenpatientsarereferredforsurgicalexcisionhavingundergoneadiagnosticultrasound;however,itisusuallypossibletodiagnoselipomasbyhistoryandphysicalexaminationalone.Theaimofthecurrentstudyistoexaminetheprevalenceofunnecessaryultrasounduseinthediagnosisoflipomas.

MethodsAretrospectivereviewusingelectronicmedicalrecorddatawasconductedforallpatientsassessedbyasinglecommunitygeneralsurgeonwiththediagnosticcodeforlipomafromJanuary2015toDecember2017.Demographicinformation,diagnosis,ultrasounduse,andwhetherthediagnosiswasclinicallyapparentwithoutanultrasoundwerecollected,aswellasreferringpractitionerinformation.Referringpractitionerswereclassifiedintothreegroups:nursepractitioners,recentlygraduatedphysicians(10orlessyearsofexperience),andexperiencedphysicians(morethan10yearsofexperience).

ResultsInformationpertainingto115patientswasanalyzed.Ofthepatientsreferred,48.7%hadanultrasoundattached.Ofthosewhohadreceivedanultrasoundfordiagnosticpurposes,98.2%weredeemedunnecessary.Fifty-ninepercentofnursepractitioners,46.8%ofrecentlygraduatedphysicians,and45.1%ofexperiencedphysiciansorderedanunnecessaryultrasound.Thesedifferenceswerenotstatisticallysignificant(p=0.61).

ConclusionAlmosthalfofallpatientsreferredforassessmentofalipomacamewithanultrasound,whichwasalmostalwaysunnecessary.Reducingunnecessaryimagingofbenignlesionscouldhelpreducehealthcareexpenses,inconvenienceandlossofproductivityforpatients.

Bye Bye Bedrest: Shifting ICU Culture from ‘Too Sick to Get Out of Bed’ to ‘Too Sick to Stay in Bed’KarenWebb-Anderson,MarleneAsh,PatriciaDaley,DouglasVincent,CynthiaIsenor,GiselleDavis,ElinorKelly,TaraMercier,RobertGreenandSarahMcMullenNovaScotiaHealthAuthority

Numerousadvancementsincriticalcarehaveresultedinimprovedmortalitydespitesicker,morecomplexpatients.However,thishasalsoexposedICU-associatedmorbidityinsurvivors,includinglong-termcomplicationssuchasneurocognitivedeclineandprofoundphysicaldeconditioning.Alongwiththeseadverseevents,evidencehasdemonstratedthat“lessismore”inseveralkeyareas:sedation,ventilationdays,polypharmacy,andbedrest.OrganizationsincludingtheSocietyofCriticalCareMedicinesupportanevidence-basedapproachtocare.Inaddition,ChoosingWiselyCanada(CriticalCare)identifiestheoveruseofbedrestasapriorityforaction.

WehaveusedourEarlyMobilityProgramtoshiftourparadigmofcarefrom“toosicktogetoutofbed“to“toosicktoNOTgetoutofbed”.Indoingso,manyinsightshavebeenappreciated.Earlymobilitymitigatesseveraldeleteriouseffectsofsurvivingcriticalillness,andsupportspatientsandfamiliesingettingbacktothelifetheywantwithimprovedqualityoflife.Adoptingateam-basedapproachtomovingpeopleearlyandoften,hascontributedtoanoverallreductioninICUdeliriumby25%.Withinourtraumasubpopulationwehaveseena33%dropinintubationdays,10%fewercomplications,andadecreaseinmortalityfrom26.5%to16.5%.Ourexperienceisanexcellentexampleofmakingsmartchoicestolimitunnecessarytreatmentsandtheiruntowardimpacts.

Unnecessary Ultrasound in the Management of Umbilical and Inguinal HerniasEmilyZehnder,HarisImsirovicandTrevorBardellQueen’sUniversity

AbstractBackground:Althoughclinicallysignificantherniascanusuallybediagnosedbyphysicalexaminationalone,medicalpractitionersoftenorderanultrasoundpriortoreferraltoasurgeon.Unnecessaryultrasoundsresultinneedlessinconveniencetopatients,inadditiontothecosttothesystem.Theobjectiveofthisstudywastoassessfactorsassociatedwithunnecessaryultrasoundsinpatientsreferredtogeneralsurgeryforherniaassessment.

MethodAretrospectivereviewofelectronicmedicalrecorddatawasperformedforallpatientsreferredwithanumbilicaloringuinalherniabetweenJanuary1,2014andDecember31,2015.Onehundredandeightpatients(22withumbilicalhernia,84withinguinalherniaand2withbothumbilicalandinguinalhernias)wereidentified.Patientswithherniasnotidentifiableonphysicalexaminationwereconsideredtorequireanultrasound,otherwiseitwasconsideredunnecessary.Referringpractitionerswereclassifiedasnursepractitioners,recentlygraduatedphysicians(10orlessyearsofexperience)orexperiencedphysicians(greaterthan10yearsinpractice).Thenumberofunnecessaryultrasoundswascomparedbetweenthesegroups.

ResultsFifty-onepercentofherniapatientsarrivedhavinghadanultrasound,ofwhich83.9%weredeemedunnecessary.Therewasnosignificantdifferencefoundinthenumberofunnecessaryultrasoundrequestsbetweenthethreegroups(p=0.196).Additionally,nosignificantdifferencewasfoundinthenumberofunnecessaryultrasoundsbetweenumbilicalandinguinalhernias(p=0.840).

ConclusionNearlyhalfofpatientsreferredhadanunnecessaryultrasound.Reducingunnecessaryimaginginthemanagementofinguinalandumbilicalherniashaspotentialtoreducecostsubstantially.

A Collaborative, Diagnostic Stewardship Initiative to Improve Urine Culture Utilization In AlbertaShobhanaKulkarni,DynalifeDiagnosticLaboratoriesMichaelGroeschel,CalgaryLaboratoryServices

GoalTomandatetheprovisionofrelevantclinicalinformationforurineculturerequeststothelaboratoryanddeveloplaboratorymechanismsthatwillrestrictrequestsintheabsenceofaclinicalindication.

ImplementationTheCollegeofPhysiciansandSurgeonsofAlbertaReferralConsultationStandardstipulatesthattestrequestsareaformofclinicalconsultationandthataccompanyingrelevantclinicalhistoryshouldbeprovidedsincethisisvitalforinterpretationofresultsbylaboratoryphysicians.Currently,themajorityofrequisitionslackthisimportantinformation.Aprovincialurineculturestewardshipworkinggroupisdevelopingaframeworktosupportcompliancewiththisstandard,whichincludes:

• Establishingclearindicationsforurineculturerequests• Communicationtostakeholdersthatprovisionofclinicalinformationonrequisitionswillbemandatory• Developingprocessesforlaboratoriestobestcapturesubmitterprovidedclinicalinformation• Developingprocessesallowinglaboratoriestorestrictrequestsintheabsenceofaclinicalindication• Developingpost-implementationstrategiestomonitortheimpactofthisinitiativeonpatientcare,testutilization,andstakeholderresponse

ChallengesAsignificantchangeinmindsetandcurrentpracticeswillbeneededforbothcareprovidersandlaboratories.LaboratorysystemsarealsotechnicallyandoperationallyheterogeneousinAlberta,whichposeschallengestotheimplementationofthisinitiativeonaprovincialscale.Effortstoovercomethesechallengeswillbemadeworthwhilebybetterensuringtheclinicalrelevanceofurinecultureresultswithconsequentimprovementsinpatientcareandsafety,antimicrobialstewardshipandtestutilization.

Does Emergency Physician (EP) Diagnostic Imaging (DI) use Affect Clinical Productivity?SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversitySwarnaWeerasinghe,DalhousieUniversityDavidUrquhart,DalhousieUniversity

IntroductionConsiderablevariationexistsintestusebyEPs.Weexaminedtheassociationbetweenphysicianproductivity(PP)anddiagnosticimaging(DI)use.

MethodsUsingprincipalcomponentanalyses,weanalysedPPusingpatientsperhour(pt/hr),percentageofreturnvisitsandadjustedworkloadmeasurement(AWM),assigninghigherscorestoCTAS1-3patients,of85EPsatanacademicED,June1,2013-May31,2017.DIutilizationincludedultrasound(US),CTscan(CT)andx-ray(XR).

ResultsMeanpt/hr(1.8;range1.2-2.5)andAWM(6.9;4.4-9.7)variedsignificantly.AnincreaseofDIwasassociatedwithlowerpt/hrandAWM.Forpt/hr:40%CTreduction,doubledthemean(p=0.001);50%x-rayreduction,increasedthemeanto2.3(27%)ForAWM:40%CTreduction,doubledthemean(p=0.001),50%Xrayreductionincreasedthemeanby30%(p=0.0001)and10%reductionofUS,increaseditby20%(p=0.02).Pt/hrwasbettercorrelatedwithDI(R2=38%)thanAWM(R2=30%).ThebenchmarkofPPwithcombinationsofpositivept/hr,positiveAWMandnegative%ofreturnvisitswasbetterpredictedbyDIuse(R2=42%).LessDI(p=0.0001),CCFP(EM)training(p=0.01),Malegender(p=0.02),youngerage(p=0.04),lessCTAS4decisiontime(p=0.01)andlesspatientsbyalearner(p=0.07)wereallassociatedwithhigherPP.

ConclusionIncreaseduseofDIwereassociatedwithlowerpt/hrandAWMandlikelycontributestoEDovercrowding.FurtherresearchisneededtoassesstheassociationbetweenDIuseandclinicaloutcome.

Influence of Lab Tests (LT) Ordering on Emergency Physician (EP) Productivity (PP)SamCampbell,NovaScotiaHealthAuthority,DalhousieUniversitySwarnaWeerasinghe,DalhousieUniversityDavidUrquhart,DalhousieUniversity

IntroductionEmergencyDepartment(ED)overcrowdingincreasestheimportanceoftheabilityofEmergencyPhysicians(EPs)toseepatientsasrapidlyasissafelypossible.Weexaminedtheassociationbetweenphysicianproductivity(PP)andlabtest(LT)use.

MethodsWeanalyzedthepracticevariablesof42EPsworkingatanacademicED,fromJune1,2015-May31,2017.PPwasmeasuredbypatientsperhour(pt/hr)andadjustedworkloadmeasurement(AWM),assigninghigherscorestohigheracuitypatients.LTwasmeasuredbytheorderrateofcommontests.

ResultsPPvariedsignificantly:meanpt/hr(1.8;range1.2-2.5)andmeanAWM(6.9,4.4-9.7).LTwassignificantlyassociatedwithPt/hr,butnotwithAWM.50%reductioninLTforCTAS2and3patientsincreasedpt/hrby32%whilethesamereductionforCTAS4testsorderedincreasedby5%.Decisiontimeissignificantlycorrelated(R2=50%)withthecombinationofCTAS2-4labtestsorderedand50%increasecoulddoublethedecisiontime.NostaticallysignificantdifferencesofLTorderingacrossdemographicfactors(training,ageandgender).DiagnosticimagingandlabtestsorderingarebothcorrelatedwithPP,howeverdiagnosticimagingwasmorestronglyassociatedwithPP(R2=41%)thanLT(R2=7%).

ConclusionWefoundasignificantassociationbetweenLTuseonPP.IncreaseduseoflabtestsforCTAS2-4wereassociatedwithlowerpt/hrandincreaseddecisiontimeandlikelycontributestoEDovercrowding.Furtherresearchisneededtoassesstheassociationbetweenlabuseandclinicaloutcome.

Improving Appropriateness of Mg Testing in ICUAdaLo,UniversityofBritishColumbiaPeterDodek,St.PaulsHospitalTonyZhao,UniversityofBritishColumbiaFacultyofMedicine

BackgroundMgis99%intracellularandserumtotalMgconcentrationdoesnotcorrelatewithintracellularMgconcentration.However,serumtotalMgismeasuredroutinely.

MethodsWeaimedtodecreasethenumberofroutineserumtotalMgtestsina15-bedmedical-surgicalICU.First,wesummarizedcurrentevidenceandworkedwithICUphysicianstoagreeonindicationsforMgtesting:1.suspectedhypomagnesemiainthesettingofrenalfailure,2.optionalinsuspectedhypermagnesemia.Thenweimplemented:educationforclinicalstaffaboutthelackofevidencesupportingroutineMgtests,promptsintheelectronicordersystemtoencourageourindications,andpostersremindingstaffofthisimprovementinitiative.PatientdatawereacquiredfromanICUdatabase.NumberofserumtotalMgtests12monthsbeforeimplementation(Dec19th,2016)and5monthsafterwardwerecollectedfromtheorderentrysystem.

Results1yearbeforeintervention,ameanof69(SD16)tests(55(SD13)routineand14(SD5)non-routine(stat))wereorderedweekly.Afterinterventions,56(SD16)tests(42(SD15)routineand14(SD5)non-routine)wereorderedweekly.Thiswasa24%reductioninroutinetestswithoutanychangeinnon-routinetests.SeverityofillnessandlengthofICUstaywerenotdifferentbetweenbaselineandpost-interventionperiods.

ConclusionRepeatededucationsessionsandapromptintheorderentrysystemwereassociatedwithasignificantdecreaseinthenumberofroutineserumtotalMgtestsorderedinanICUwithoutcompromisingpatientoutcomes.

The Road Traveled-NPAC’s Journey in Development of the “Nine Things Nurse Practitioners and Patients Should Question” CathyScofield-SInghandJenniferFournierNursePractitionerAssociationofCanada

TheNursePractitionerAssociationofCanada(NPAC)isanationalorganizationwithamembershipofnursepractionersfromacrossCanada.TheNPACpresentationwilllookatthejourneyfromthefirstcontactofNPACwithChoosingWiselyCanada(CWC),andcollaboratingwithCWCtoexplorethepotentialdevelopmentofaNPACCWClistandtherationalefordoingso.ThepresentationwillfollowthepathofthedevelopmentoftheNPACCWCworkinggroup,tothepublicationofthe“NineThingsNursePractitionersandPatientsShouldQuestion”.ThispresentationwillalsoexploretheopportunitiesformovingforwardtoencouragedialoguearoundtheNPACCWClist,encouragediscussionaboutnecessaryandunnecessarycareamongnursepractitionersandpatientsandincreaseawarenessofChoosingWiselyCanada’scampaigntopromoteawarenessofbestpracticesandcurrentevidence.

Exploring Physician-Reported Barriers and Facilitators to Using Evidence-Based Recommendations Regarding Imaging for Low Back Pain: A Meta-Synthesis Using the Theoretical Domains FrameworkSamanthaScurrey,MemorialUniversityofNewfoundlandCharlotteAlbury,NuffieldDepartmentofPrimaryCareHealthSciences,UniversityofOxfordHelenRichmond,RehabilitationResearchinOxford(RRIO),OxfordClinicalTrialsResearchUnit,UniversityofOxfordHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLPatrickParfrey,TranslationalandPersonalizedMedicineInitiativeMemorialUniversityJamesMatthews,SchoolofPublicHealth,Physio&PopScience,CenterforSportsStudies,UniversityCollegeDublinJillHayden,DepartmentofCommunityHealth&Epidemiology,DalhousieUniversityAmandaHall,MemorialUniversity

BackgroundSeveralqualitativestudieshaveexploredphysicians’reasonsforusingimagingforlowbackpain(LBP).Weconductedameta-synthesisaboutbarriersandfacilitatorsofappropriateimagingforLBPusingtheTheoreticalDomainsFramework(TDF).

MethodsWesearched3electronicdatabasestoJuly2017forEnglish-languagequalitativestudiesofPhysicianswhotreatLBPandassessedtheirbarriers/facilitatorstousingimaging.Tworeviewersselectedstudies,extracteddataintoNVivoandindependentlycodedthemesusingtheTDF.

ResultsWeincluded9studies;eachusedfocusgroups/interviewsanalysedusingthematicanalysis.Weidentified4overarchingdomains:Socialinfluence–includingsocialpressurefromthepatientseitherrequestinganimageorwantingadiagnosisandtheGPfeltthatanimagewouldprovidethisinformation.Beliefsaboutconsequence–includingoutcomeexpectancywhereGPsbelievedthatthescanwouldreassurethepatientandotherconsequencesincludingfearofblameorlegalactioniftheydonotrequesttheimage.Skills–whereGPsreportedtheylackedsufficientcommunicationskillstoexplainwhyatestisnotnecessaryforpatientsrequestinganimage.Environmentalcontextandresources–includedlackoftimetohaveafullconversationwithpatientsaboutdiagnosis,andorganisationalcultureinwhichscansareorderedasarequirementforsickcertificates,treatmentreferrals,orlegalcases.Knowledgeaboutwhentouseimagingwasnotidentifiedasabarrier.

ConclusionsInterventionsmustincludestrategiesthattargetpatientexpectations,communicationaboutdiagnosiswithoutimaging,andappropriatetreatmentstrategies.

Fundamentals of Health Evidence: Practical Approaches to Critical Appraisal LisaPyke,JenniferHartellCADTH

HealthcareProfessionalsworkingonChoosingWiselyRecommendationsdemonstrateleadershipinevidence-basedmedicinewhentheyseekoutcrediblesourcesofinformationandapplyrigorousmethodologiestodevelopstrongevidencebasestosupportrecommendationdevelopment,toolsandapproaches.Yet,dowereallyknowhowtofindandevaluatetheevidence?Weareincreasinglytaskedtoreviewbestavailableevidenceandtobeskepticaloftheinformationprovided.Yet,howdoweevaluateevidence:Isitreliable?Isthesourceunbiased?Isitbasedonhigh-qualityevidence?Evidenceisaccessedinmanyforms,throughjournalsandonwebsitesforconsiderationaspartofevidence-informedpractice.Someformsofevidence,however,maycontainbias,inaccurateinformation,orbebasedonopinionandconjecture.Notallcontent,definitions,orsummarizedresearchinterpretationsmaybenecessarilyaccurateortrulyrelevanttoourclinicalneeds.Wherewefindresearchisanotherfactor—somewebsiteshavegreatercredibility,structure,andpre-screeningforvaliditythanothers.Withincreasedaccessanduseofweb-basedinformation,professionalsneedasimplifiedapproachtocriticalappraisalofevidencethatcanbeusedquicklyandefficientlytodeterminequalityandvalueinresearchtheylocateontheinternetorreceiveinotherforms.Thisinteractiveoralsessionwillprovideasimplified,straight-forwardstep-by-stepapproachtocriticalappraisalandwebsitequalityassessmentthatanyonecanusetodetectpotentialbiasinwhattheyread.Severalexampleswillbeusedthroughoutthepresentationtoillustratecommonbiasissuesthatareunfortunatelymorecommonthanwerealize!

Reducing Radiation and Cost Associated with Follow-Up Imaging for PneumothoraxUsamaMalik,UniversityofCalgary,CummingSchoolofMedicinePeterDickhoff,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgarySimonChi,DiagnosticImaging,CalgaryZone,AlbertaHealthServices(AHS)SandraHovey,DiagnosticImaging,CalgaryZone,AlbertaHealthServices(AHS)GeoffSchneider,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgaryMarkMacMillan,DiagnosticImaging,AlbertaHealthServicesRichardWalker,DepartmentofRadiology,CummingSchoolofMedicine(CSM),UniversityofCalgary

IntroductionManagementofpneumothorax(PTX)typicallyincludesserialfollow-upchestx-ray(CXR)exams.Multipleguidelinesrecommendanerectpostero-anterior(PA)CXRforfollow-upofprimaryspontaneouspneumothorax(PSP),withalateralviewrecommendedonlywhenadditionaldiagnosticinformationisrequired.Thisstudyaimstodeterminewhethertheseguidelinesarebeingfollowedattwotertiaryacademiccentresinourregion.

MethodsDepartmentanalystsretrospectivelyidentified260patientsdiagnosedwithPTXandatleastonefollow-upCXRbetweenJanuary1andMarch31,2017.Inclusioncriteriaincludedage?18-yearsandspontaneouspneumothoraxorpneumothoraxassociatedwithminortrauma.Consensusreviewofimageswasperformedbyastaffradiologistandmedicalstudent.Datacollectedincludedpatientage,gender,CXRorder(2-view,1-view,1-viewportable),orderingphysician,patientlocation(inpatientoremergencydepartment),andPTXetiology.

Results35patientsmeetingtheinclusioncriteriaunderwent226follow-upCXRs.2-viewswereperformed71.7%(162/226)anda1-viewor1-viewportable28.3%(64/226).Therewasnodifferencewhethertheorderingphysicianwasaresidentorattending(p=0.161).Inpatientsweremorelikelytoreceivea2-viewfollow-upexam(p=0.00012).Theincrementalcostassociatedwithorderinga2-viewfollow-upwas$1,989.36andresultedin2.0mSvofadditionalradiationexposuretotheaveragePTXpatient.

ConclusionOurstudydemonstratesanopportunitytodecreasecostandradiationexposureforinpatientandemergencydepartmentpatientsbeingfollowedforPTX.Aneducationactionplandirectedtowardsdepartmentsmanagingpatientswithpneumothoraxisplannedwithcompliancere-evaluatedbetweenFebruary1andApril30,2018.

Bladder Matters: A Corporate Strategy to Reduce Urinary Tract Infections and Urinary Retention RatesMaryKapetanos,DonnaRuffo,PrateekKhatriandLindaJussaumeNorthYorkGeneralHospital

GoalTodevelopandimplementacorporateapproachforreducingcatheter-associatedurinarytractinfections(CAUTI)andurinaryretentionratesatNorthYorkGeneralHospital(NYGH).

ImplementationAworkinggroupwithrepresentationthatcrossedmedicalservices,clinicalprograms,andprofessionswasestablished.LearningsfromtheChoosingWiselyLosetheTubeToolkit(2017)wereleveraged,inadditiontoNYGH’sCAUTIworkaspartoftheNationalSurgicalQualityImprovementProgram(NSQIP).Theteambeganwithareviewofcurrentpracticesrelatedtourinarycatheterizations,themanagementofurinaryretention,anditsimpactonpatientcare.Strategiesimplementedincluded:1)developmentofastandardizedurinaryretentionmanagementprotocol,2)revisionofelectronicordersrelatedtourinarycatheterization,3)revisionofmedicaldirectivesthatauthorizedinsertionandremovalofurinarycatheters,and4)broadeducationandcommunicationtoprovidersandnursingstaff.

MeasuresKeymetricsinclude:1)urinarycatheterdays,2)indwellingurinarycatheterrates,3)urinarytractinfectionrates,and4)urinaryretentionrates.

ChallengesDiscussionpointsinclude:1)engagingabroadgroupofstakeholderstostandardizeacorporateurinaryretentionprotocol,2)operationalizingthechangesacrossclinicalprograms,includingchangestoordersetsandmedicaldirectives,3)sustainabilityofthestrategy,and4)ensuringdataqualitytoallowformeasurementofkeyoutcomes.

Lessons LearnedEarlyandongoingengagementofstakeholdersfrominceptionofprogramdevelopmentiskeytothesuccessofanycorporateinitiative.

Electronic Referral Forms and Decision Support Tools Integrated into Electronic Medical Record Systems For Vascular Test Ordering by Physicians in Primary Care Settings in Newfoundland and Labrador (NL)KristaMahoney,ChoosingWiselyNLandQualityofCareNLBrendanBarrett,TPMI/MemorialUniversityGregBrowne,EasternHealthAmandaHall,MemorialUniversityOwenParfrey,MemorialUniversityofNewfoundlandPatrickParfrey,TPMI/MemorialUniversity

BackgroundOveruseofdiagnostictestinghasbeendemonstratedtobeasignificantprobleminCanada.AnalysisoftestutilizationpatternsattheprovincialvascularreferralcentreindicatesthatthisissueisprevalentinNL;Of17,600carotidarterytestsand15,858peripheralarterytestsundertakenfrom2007to2015,60%(10,560)and56%(8,901)werenotindicated,respectively.

AimToreduceunnecessaryvasculartestingattheonlytertiaryvascularreferralcentreinNL.

MethodTheintroductionofelectronicorderingindiagnosticvasculartests,withbuilt-indecisionsupportstoguideappropriatereferringbehaviourscanhelpmitigatethispatternofoveruse.Usingclinicalguidelinesandalgorithms,wewillembeddecisiontreeswithine-referralforms.Physicianresponsestoasetofcheckboxesincludingpatienthistory,symptomsandprevioustestingwilldeterminewhethertestingisneededurgently,recommended,ornotrecommended.Inadditiontodecidingonpriorityfortesting,thetoolwillconnecttoane-schedulertoautomaticallyprovideatestdate.Allorderingforvascularlabtestingwillbeelectronic,elinimatingallpaperforms.Accessfore-orderingwillbethroughtheprovincialelectronichealthrecord,Health-eNL.Ananalyticscomponentwillreportappropriateorderingbydoctorandindividualizedfeedbackwillbeaccessibleonline.Theelectronicreferralwillnotprohibitorderingbutwillensurespecificrationalefororderingisprovidedifnotrecommendedbythetool.Appropriatenesswillbeevaluatedtodeterminetheeffectivenessofthesee-referralformsinreal-worldsettings.Wewillbuilduponexistingtechnologyinfrastructureintheprovincetodesignanddeliverthisreferralsystem.

Influencing Emergency Department Management and Imaging Practices for Two Common Presentations: Developing and Implementing a Theory and Data-Informed Intervention LynetteD.Krebs,UniversityofAlbertaCristinaVilla-Roel,UniversityofAlbertaNicoleHill,UniversityofAlbertaScottW.Kirkland,UniversityofAlbertaChrisAlexiu,AlbertaHealthServicesPatrickMcLane,AlbertaHealthServicesBrianR.Holroyd,UniversityofAlbertaMariaOspina,UniversityofAlbertaBrianH.Rowe,UniversityofAlberta

GoalThegoalofthisstudywastodevelopatheoreticallygroundedanddata-informedinterventiontoimproveemergencydepartment(ED)managementofpatientswithacuteasthma(AA)andbenignheadache(BHA),specificallyasitrelatestoimagingandvariationinimageordering.

ImplementationPrecedingtheinterventiondevelopment,studieswereundertaken,asfollows:1)systematicreviews,2)administrativedataanalyses,3)surveyswithpatientsintheEDaswellasemergencyphysicianswithqualitativefollow-up,4)sitechiefinterviews,and5)nurseinterviews.UsingtheBehaviourChangeWheel,preliminarydatafromthesestudiesidentifiedtheinterventionfunctions:education,incentivizationandenvironmentalrestructuring.Contentofinterventionmaterialswasinformedbyparticipatingsitedata.ImplementationatAlberta’slargesturbanandregionalEDsisongoingusingasteppedwedgedesign.

MeasuresSeveralinterventionfidelitymeasureswereimplemented.Theprimaryoutcomesforthestudy(e.g.,imaging,lengthofstay,dispositionstatus)arebeingtrackedthroughadministrativedata.

ChallengesSiteclinicianengagementcontinuestobeasubstantialchallengeathigh-volumeurbanandregionalEDs,includingacademicEDs.Newertechnologies,suchasQRcodesforclinicalorpatientengagementhavebeenrelativelyunsuccessful.

Lessons LearnedThisinterventiondevelopmentapproachrevealedtheneedforasystematicunderstandingofthesourcesofcurrentimageorderingbehaviour.LocalEDswillingnesstoengageinthestudyhasvariedconsiderablyandcanlimitsuccessfulimplementation.CollectingdataoninterventionfidelitymaybekeytounderstandingwhyandhowinterventionsintheEDfailtoachievetheintendedordesiredresults.

Implementation of a New Diagnostic Algorithm for Anti-Neutrophil Cytoplasmic Antibody (ANCA) Testing MariaPasic,St.Joseph’sHealthCentreandSt.Michael’sHospitalAdrianaKrizova,St.Michael’sHospitalJeffCompanion,St.Joseph’sHealthCentreCathyStreutker,St.Michael’sHospitalDrakeYip,St.Michael’sHospitalJeffZaltzman,St.Michael’sHospitalDanielBeriault,St.Michael’sHospitalMalgorzataKisiel,St.Michael’sHospitalBeverleyYoung,St.Michael’sHospitalDawn-MarieKing,St.Joseph’sHealthCentreandSt.Michael’sHospitalVictorTron,St.Joseph’sHealthCentreandSt.Michael’sHospital

Anti-neutrophilcytoplasmicantibodies(ANCAs)areanimportantdiagnostictoolforANCA-associatedvasculitides.Thedominantautoantigensintheseconditionsareproteinase3(PR3)andmyeloperoxidase(MPO).ANCAtestingalsohasaroleindiagnosisofinflammatoryboweldiseases(IBD)andautoimmuneliverdiseases.Historically,thegold-standardtestforANCAvasculitisscreeninghasbeenindirectimmunofluorescence(IIF),withsubsequentantigen-specificimmunoassay/ELISAforMPOandPR3.RecentevidencesuggeststhatELISAisaseffectiveasthetwo-stepalgorithmpreviouslyproposed.Forlabsthatdonotperformthesespecializedtestson-site,turnaroundtimesmaybeprolongedduetosend-outandbatchtestingrestraints.Furthermore,performingmultiplemanualtestscanbecostlyandpotentiallyunnecessary.Inordertoensurethattheappropriatepatientsarebeingtestedandresultsarereceivedinatimelymanner,weaimedto:1)restrictorderingtosubspecialtiesthattreatANCAvasculitis/IBD/hepatitis;and2)optimizethediagnosticalgorithmfororderingANCAs.Basedonnewdevelopmentsinmethodologiesanddiscussionswithclinicalcolleagues,wecreatedtwotypesoforders:ANCAvasculitis(tobetestedbyELISA),andANCAIBD/hepatitis(tobetestedbyIIF,withnoreflextoMPO/PR3).As99%ofANCAordersatourinstitutionsareforANCAvasculitis,wedecidedtorestrictorderingofANCAIBD/hepatitistogastroenterologistsandhepatologists.

TheexpectedoutcomesareareductionininappropriateANCAordering,fasterturnaroundtimes,andimprovedusageoflabresources.Thesechangeshavebeenimplemented(January2018)andwillbefollowed-upprospectivelytoobserveiftheexpectedoutcomesaremet.

Conceptualizing ‘Unnecessary Care’ in Emergency Departments (ED): Qualitative Interviews with Ed Physicians and Site ChiefsLynetteD.Krebs,UniversityofAlbertaNicoleHill,UniversityofAlbertaCristinaVilla-Roel,UniversityofAlbertaBrianH.Rowe,AlbertaHealthServices

Background“Unnecessarycare”(UC)isanincreasinglycommonterminmedicineandfrequentlyassociatedwithChoosingWisely®literatureandinterventions.PrevioussurveyresearchindicatesdefinitionsofUCvaryamongemergencydepartment(ED)stakeholders.Thisresearchexploreshowemergencyphysicians(EPs)andsitechiefs(SCs)understandUC.

MethodsSCsandEPsinAlbertawererecruitedthroughemailandonlinesurveysforonehourone-on-onein-depthinterviewsexploringUCconceptualizationswithintheED.Transcriptsunderwentthematicanalysis.

ResultsFiveEPsandsevenSCscompletedinterviews.Twokeythemesemerged.First,intervieweesconceptualizedUCasinappropriate/non-urgentpresentations.Thispatient-centricviewraisednon-urgentpresentationsasasystemproblemresultingfrom:alackofpublicknowledgeand/orwillingnesstouseotherresourcesandshrinkingcomfort/scopeofcommunityproviders.Despitenon-urgentvisitconcerns,intervieweesexpressedthatthesepatientsrequiredassessment/management.Thesecondconceptualizationfocusedonover-investigation(andtolesserextent,treatment).Thisphysician-centricconceptualizationidentifiedissuesaround:variationinphysicianrisktolerance,establisheddecisionruleswithallowable“missrates”,patientexpectationfortestingorphysicianfeelingthatthepatientwas“owed”something.IntervieweeswereconcernedbyconnectionsbetweenUCandwastedresources.IntervieweesemphasizedthatpatientconversationsareoutsidethescopeofUCdespitetheirpossibleimplicationsforlimitedtimeresources.

ConclusionArangeofconceptssurroundingUCintheEDwereidentified.Exploringnuancesoftheseconceptualizationsmayenhancetheeffectivenessofcampaignsseekingtoimproveefficiencyandreduceinappropriatecare.ThisworkprovidesanimpetusfordevelopingclearerconceptsofcarewithintheED.

The Use of Clinical Decision Support Tools in the Emergency Department to Optimize Clinical Practice: A Systematic Review and Meta-AnalysisKatherineMemedovich,UniversityofCalgaryLauraDowsett,HTAUnit,UniversityofCalgaryDanielGrigat,AlbertaHealthServicesDianeLorenzetti,HTAUnit,UniversityofCalgaryJamesAndruchow,AlbertaHealthServicesAndrewMcRae,AlbertaHealthServicesGrantInnes,AlbertaHealthServicesEddyLang,AlbertaHealthServicesFionaClement,HTAUnit,UniversityofCalgary

BackgroundChoosingWiselyCanadahasidentifiedthat30%oftestsandproceduresperformedinCanadaarepotentiallyunnecessary.ClinicalDecisionSupport(CDS)toolsofferevidence-based,actionablerecommendationstoimprovedecisionmaking.WeundertookasystematicreviewofCDSimplementationsintheemergencydepartmenttoevaluateeffectivenessinchangingphysicianbehavior.

MethodsMEDLINE,EMBASE,PsychINFO,theCochraneCentralRegisterofControlledTrials,andCochraneDatabaseofSystematicReviewsweresearched.IncludedstudiesexaminedCDSintheED,reportedonphysicianadherencetooruseofCDS,utilizedacomparativestudydesign,andreportedprimarydata.Meta-regressionassessedtheeffectofcharacteristicsofthetool.

ResultsSeventy-twoarticlesmetinclusioncriteria;forty-sixreportedoutcomesappropriateformeta-regression.AtrendofincreasedCDSusewasfound(RCTOR:1.36[95%CI:0.97-1.89];observationalOR:2.12[95%CI:1.75-2.56]).Overall,physicianinteractionwithCDSrangedfrom0.37%to100%;adherencetorecommendationsrangedfrom16.2%to93.5%.Clinicalpracticeguidelinesweresuperiorcomparedtootherinterventions(p=.150).Multi-modaltoolswerenotmoresuccessfulthatsingleinterventions(p=.810).Lastly,voluntarytoolsmaybesuperiortomandatorytools(p=.148).Noneoftheresultswerestatisticallysignificant.

ConclusionOurreviewsuggeststhatCDSmayhavesmallbutmeaningfulimpactsonphysicianpractice.CDSmaybemostacceptableandimpactfulwithimplementationsintegratedintoworkflowafterconsultationwithphysicians.Futureresearchshouldexaminephysician’sperspectivesduringCDStoolstooldevelopmentandimplementationandwhattheyperceivetobemostuseful.

Reduced CD4 Measurements in Stable HIV Patients is Associated with Significant Cost SavingsAhmedGhaly,LiseDupuis,GordonDowandDanielSmythHorizonHealthNetwork

MonitoringofCD4countshasbeenpartofHIVmanagementforyears.In2015,ChoosingWiselyCanadastated“Don’troutinelyrepeatCD4measurementsinpatientswithHIVinfectionwithHIV-1RNAsuppressionfor>2yearsandCD4counts>500/µL,unlessvirologicfailureoccursorintercurrentopportunisticinfectiondevelops.”ThepurposeofthisstudywastoidentifyhowmuchCD4testingcouldbereducedandtoidentifythecostsavingsassociatedwiththisovera12monthperiod.ThisstudywasconductedinasmallhospitalbasedHIVclinicwherepatientswerehavingCD4countsperformedevery3to4months.CD4testingwasdoneonlywhenrecommendedbuttheremainderofourfollowup(viralloadtesting,hematologyandbiochemistrymonitoring,andclinicalassessments)didnotchange.WekepttrackofallHIVpatientvisitsandwhenCD4testingwasorderedandthereason.Therewereatotalof381recordedpatientvisits.Ofthese,250(65.6%)hadCD4countsmeasured.131patientvisits,whereroutineCD4testingwouldhavepreviouslybeendone,didnothaveCD4measurementsdone.Ofthe250patientvisitswhereCD4testingwascompleted,themostcommonreason(130;52%)wasaCD4count<500.OurlocalcostforCD4testingwas$133.TheactualcostsavingsfromreducedCD4monitoringwas$17,290(131x$133)overa12monthperiod..Insummary,reducedCD4testinginstableHIVpatientswasassociatedwithasignificantcostsavingsandnoharmtothepatient.

LHIN Collaboration & Standardization Improving Imaging PracticesWaltRomano,St.ThomasElginGeneralHospitalChristianBaldauf,GreyBruceHealthServicesMichellePierce,LondonHealthSciencesCentre/SouthWestLHINBrendonPilgrim,LondonHealthSciencesCentre/SouthWestLHIN

TheSouthWestLHINMedicalImagingIntegratedCareProjectwaslaunchedin2016toaddressthedemandissuesandstrainonthesystemsothatpatientexperienceandpatientcarecanbesustainablyimprovedwithregardstoMedicalImagingservices.Oneofthekeybarrierstoefficiencyoccurswhenthereisalackofconsistencyintoolsanprocesses.AsofNov2017,theSWLHINisthefirstLHINtoimplementastandardMRIrequisitionthatisusedbyallhospitalsitesintheregion.SupportingtheMRIrequisitionformsaretwoappropriatenesschecklistsforkneeandspine,whichhelpphysicianstodetermineifanMRIisnecessaryandwhichconditionsmaynotbenefitfromascan.AnadvisorycommitteeofLHINRadiologistsalsocollaboratedonastandardMRIprotocolsetforthemostcommonscans,tocreatefurtherefficienciesandeliminaterepeatscansforpatientsthatmovebetweensites.Therearechallengesachievingengagementandagreementofallstakeholderteamsacrosssuchabroadgeographicregion.Creatingandsustainingproductivecollaborationtakestimeandawillingnesstocollaborate.StrongleadershipandengagementoftheLHINteam,comprisedoftechniciansandphysicianleadersinradiology,familymedicineandmedicalandsurgicalspecialtieshasproducedwellthoughtout,highqualityworkwithChoosingWiselyatitscentre.Ensuringpatientsreceivethesamequalityservicesandexperiencenomatterwhatsitetheyvisitistheprimarygoal.Byintroducingonerequisitionformandensuringeachhospitaldeliversthesamequalityofimaging,theregionwillbeabletoreduceandeliminateunnecessaryduplicationoforderingandtesting.CTisnext.

Endometrial Biopsy in an Outpatient Gynaecological Setting: Over InvestigationLaurenceSimard-Émond,CHUM

ObjectiveWereviewedtheindicationsforendometrialbiopsyatthegeneralgynecologyoutpatientclinicoftheUniversitédeMontréalHospitalCenterandmeasuredtheircompliancewiththeSocietyofObstetriciansandGynaecologistsofCanadaandotherinternationalguidelines.

Methods371filesofpatientswhohadanendometrialbiopsybetweenJanuaryandOctober2015werereviewed.Indicationforendometrialbiopsyandpathologyresultswerenoted.Fileswereseparatedintofourcategories.

ResultsInthepostmenopausalbleedingcategory,allfilescompliedwiththeSOGC.Wefoundhyperplasiaorneoplasiain13%ofpatients.Intheasymptomaticendometrialthickeningcategory,9%ofthefilesdidnotshowsufficientindicationforbiopsy.Noneofthepatientspresentedhyperplasiaorneoplasia.Intheabnormaluterinebleeding(AUB)–under41yearsoldcategory,therewasnoindicationforbiopsyin23%ofthefiles.Wefoundhyperplasiaorneoplasiain13%ofpatients,butonlyinpatientswithanindicationforbiopsy.InpatientswithAUB–over40,noncompliancewithSOGCwas3%.Butaccordingtointernationalguidelines,42%ofpatientswithAUBbetween41and45yearsolddidnothaveanindicationforbiopsyandnoneshowedhyperplasiaorneoplasia.

ConclusionWedemonstratedclinicallysignificantoverinvestigationinpatientswithAUB.Indicationsshouldbereviewedcarefullybeforeperforminganendometrialbiopsyinwomenunder41.Inaddition,thevalueofendometrialbiopsiesinpatientsbetween41and45yearsoldwithmenorrhagiaandnoadditionalriskfactorshouldbereevaluated.

Optimizing the use of Endoscopy for Young, Otherwise Healthy Patients with DyspepsiaJenniferHalasz,BrennaMurray,SampsonLaw,ShawnDowling,KellyBurak,MarkSwain,GilaadKaplan,TarunMisra,JenniferWilliams,LindaSlocombeandKerriNovakUniversityofCalgary

BackgroundDyspepsiaisacommonreferraltoGastroenterology(GI).CollaborationbetweenprimarycareandGIinCalgaryhelpeddevelopadyspepsiapathwayandatelephoneadviceservice“SpecialistLink”.ChoosingWiselyCanada(CWC)recommendsagainsttheuseofesophagogastroduodenoscopy(EGD)inpatients<55yearswithoutalarmsymptoms,asclinicallysignificantfindingarerareinthesepatients.TheaimofthisstudywastomeasureandimproveadherencetotheCWCguidelinesfordyspepsiainCalgary.

MethodsEthicsapprovalwasobtained.EGDreportsandpathologyforproceduresperformedfordyspepsiainCalgarywereevaluated(April1-June31in2015,2016,2017).Onlyproceduresafterclinicconsultationwereincluded.ReferralsdeclinedthroughCentralTriagesinceJanuary1st2015werealsoreviewed.Laboratorydatafurtherrefinedthecohort.Physiciansconsentedtoreceiveindividualreportswithpeercomparators.Afacilitatedaudit&feedbacksessionwasheldtodevelopchangeplans.

ResultsTherewere12,184EGDsevaluatedwith1358performedtoinvestigatedyspepsiainpatients.

ConclusionThenumberoflowyieldEGDstoinvestigatedyspepsiaissignificant.Opportunitiesexisttobetterinvestigatedyspepsia.Partnershipswithprimarycareareimportanttoenhanceappropriateresourceutilization.

Improving Appropriateness of Oxygen Saturation Monitoring in Paediatric Patients With Acute Respiratory Illness: a QI InitiativeBrigitteParisien,DarylCheng,MariaMarano,JulieJohnstone,NicoleCarmichael,AliAl-MaawaliandBethGamulkaHospitalforSickChildren

BackgroundOxygensaturationmonitoring(OSM)isakeyaspectintheassessmentofpaediatricpatientswithacuterespiratoryillnessessuchasbronchiolitis,asthmaandpneumonia.Itoftenservesasaproxyforillnessseverity.However,thereisapaucityofguidelinesaroundappropriateOSM.Existingevidenceshowsintermittentpulseoximetryisassafeascontinuousoximetrymonitoringinchildrenwithbronchiolitis.Furthermore,inappropriateOSMmayleadtooverdiagnosisandovertreatmentofmildhypoxiaandcontributetoprolongedlengthofstay.

MethodsAspartofthelocalChoosingWiselyCampaign,ouraimistoincreasetheappropriateuseofOSMinpaediatricinpatientswithasthma,bronchiolitisorpneumoniato90%byApril2018.AppropriatemonitoringwasdefinedasintermittentOSMwhenapatientisoffoxygenfor>2hoursandcontinuousOSMwhilstthepatientisreceivingsupplementaloxygen.A4-weekpre-interventionchartreviewshowed62%(23/37)hadappropriateOSM.Aseriesofinterventionswerethenchosentoimprovethemainoutcomemeasure:• Educationalsessionsorientedatmedicalandnursingstaff• Visualcuesdisplayedinpatientrooms• WeeklyelectronicremindersandperformanceupdatesPost-interventiondatacollectionbyprojectleadersoccurredfromJanuarytoApril2018.

ResultsOSMappropriatenessincreasedto77%(56/72)inthefirstmonthpost-intervention.TherewerenorecordedsafetyeventsassociatedwithappropriateOSM.

ConclusionThisQIinitiativewillimprovetheappropriateuseofOSMinpatientsadmittedforbronchiolitis,pneumoniaorasthmaatourpaediatrictertiaryhospitalwithoutincreasingthenumberofsafetyevents.Furtherinterventionsareplannedtoensuregreatersustaineduptake.

Merging Initiatives: Choosing Wisely and Antimicrobial Stewardship – An Underutilized Connection.OliviaOstrow,KathrynTimberlake,LaurenWhitney,JeremyFriedmanandMichelleScienceTheHospitalforSickChildren

BackgroundRationaluseofantibioticsisaglobalpriority.Inappropriateorunnecessaryuseofantibioticsdrivesselectionofantibioticresistantorganismsandmayleadtopatientharm.TheChoosingWisely(CW)campaignatourhospital,withitsrecordofsignificantimprovementinmetricsforpastrecommendations,providedanovelopportunitytopromoteantimicrobialstewardship(AS).

GoalTodescribetheexpansionofahospital-wideCWcampaigntoincludeafocusonASatalargeCanadianchildren’shospital.

ImplementationTheASandCWprogramscombinedeffortstoidentifytargetsforimprovement.AntimicrobialusagedatawasreviewedandkeystakeholdersandsubspecialtysocietyCWlistswereconsulted.Asurveywasdevelopedandbroadlyadministered.Prioritywasgiventoinitiativesthatalignedwithorganizationalpriorities.

MeasuresThreeASinitiativeswereselected:1)improvingpost-operativeprophylacticantibioticuse,2)limitingbroadspectrumantibioticuseand3)improvingoutpatientantibioticuseforsuspectedurinarytractinfections(UTI).Baselinedrugutilizationevaluations(DUE)identifiedopportunitiesintheseareas.Anauditofpostoperativeantibioticuseshowed70%adherencetotheguidelines(ranging0%to100%).DUEsofvancomycinandmeropenemidentifieddurationoftreatmentasakeycontributortoinappropriateuse.Finally,areviewofpatientsdischargedfromtheEmergencyDepartmentwithasuspectedUTIshowedthatalmost50%receivedantibioticsdespitesubsequentnegativecultures,leadingto530unnecessaryantibioticdays.

Lessons LearnedDevelopingaCWlistwithanASfocuswasfeasibleandincreasedawarenessandpublicityfortheprogram.Similarinitiativescouldeasilybeadoptedbyotherinstitutions.

Dermatology Guidelines for Choosing Wisely Canada: Five Things Patients and Providers Should QuestionSabrinaNurmohamed,UniversityofCalgaryLindaZhou,UniversityofOttawaRégineMydlarski,UniversityofCalgary

Dermatologistsdiagnoseandtreatdiseaseofthehair,nailsandskin.Thesepresentationscommonlypresenttobothprimarycareandspecialistphysicians.Thespecialistreferralsystemandrelativeshortageofdermatologistscontributetoapracticegapforappropriatemanagementofcommondermatologicconditions.TodatenoChoosingWiselyCanada(CWC)guidelinesexistforthespecialtyofDermatology.TheUSAandAustralianChoosingDermatologyguidelineswerereviewedindepthtoidentifymanagementprincipleswithsubstantialevidencebasis.Afocusedliteraturereviewwasperformedtogenerateanexhaustivelistofcommontests,proceduresandtreatmentsfordermatologicconditionssuchas:cellulitis,urticaria,fungalnailinfections,stasisdermatitisandsurgicalwounds.Across-Canadianpanelofdermatologistsinacademicandcommunitypracticeweretheninvitedtocontributetheirinputtodevelopafinallistoffiverecommendations.Thisprojectdevelopedrecommendationsfortheprovisionofhigh-valuecost-consciousdermatologiccarebydermatologists,non-dermatologistsandresidentphysiciansinpartnershipwiththeCanadianDermatologyAssociation.Thefinalconsensus-drivenDermatology-specificrecommendationswillbepresented.Theresultsofasurveyadministeredtopanelmembersonbarrierstoguidelinedevelopmentwillalsobeshared.

Bronchiolitis Management in Calgary Emergency DepartmentsShawnDowling,UniversityofCalgaryIneldaGjata,PhysicianLearningProgramAntoniaStang,PhysicianLearningProgramKellyBurak,UniversityofCalgaryKatharineSmart,AlbertaHealthServices

Bronchiolitisisthemostcommonreasonforhospitalizationofinfantsbutpriorstudiessuggestthereissignificantvariationinpracticeandlowvaluecarebeingperformed.Ourobjectivewasto1.establishbaselinemanagementofbronchiolitis,and2.deliverauditandfeedback(A&F)reportstopediatricemergencyphysicians(PEP)toidentifystrategiesforpracticeimprovement.

MethodsThiscohortstudyincludedallpatients?12monthsoldthatpresentedtoaCalgaryemergencydepartmentswithadiagnosisofbronchiolitisfromApril1,2013toMarch31,2017.Usingdatafromvariouselectronicdatasources,wecapturedbaselinecharacteristics,therapeuticinterventionsandinvestigations.Descriptivestatisticswereusedtoreportbaselinecharacteristicsandinterventions.Interhospitalranges(IHR)wereprovidedtocomparehospitalsacrossthezone.FortheA&Fcomponentoftheproject,consentingPEPreceivedareportofboththeirindividualandpeercomparatordataandanin-personmulti-disciplinaryfacilitatedfeedbacksession.

ResultsWeincluded4023patientsfromall6sites(rangefrom28to3316patients).Bronchodilatorusewas27.0%(IHR21-41%).22.0%ofpatientsreceivedaCXR(IHR0-57%)and30.3%hadviralstudiesdone(IHRrange0.8-33%).62%PEPconsentedtoreceivetheirindividualA&Freports.InthefacilitatedfeedbacksessionPEPidentifiedareaswhereimprovementscouldbemadeanddiscussedspecificstrategiestodecreasepracticevariation.

ConclusionSignificantvariabilityexistsinmanagementofpatientswithbronchiolitisacrossdifferenthospitalsinourzone.Thefacilitatedfeedbacksessionidentifiedareasforimprovementandmulti-disciplinarystrategiestoreducedlowvaluecareforpatientswithbronchiolitis.

How to reduce inappropriate preventive care.JamesDickinson,UniversityofCalgaryAinsleyMoore,McMasterUniversityRolandGrad,McGillUniversityStéphaneGroulx,CISSSdelaMontérégie-Centre

TheCanadianTaskForceonPreventiveHealthCareisre-establishingitselfasanauthorityprovidingevidence-basedpreventiverecommendations.ManyoftheserecommendrefocussingorevenstoppingactivitiesthathavebecomeroutinepracticeformanyCanadianphysiciansandtheirpatients.ChoosingWiselyrecommendationsrunparalleltomany.

However,changesinbehaviourareslow,andappeartobelimitedtoasmallfractionofdoctors,whileothersactivelyopposethechanges.

Inthisworkshop,membersoftheCanadianTaskForcewilldescribe:

• Therecommendationsforchange,• Howsomerecommendationshavebeenegregiously“misunderstood”• Howsomeprovincialguidelineshavechanged,whileotherssupportthestatusquo.• Limitedeffectivenessofeducationalapproaches• Doctorsinpracticeget“guidelinefatigue”andneedsimplewaystocommunicatequicklywithpatients,suchaseffectivescriptsand“infographics”

• Alternatewaysofchangingbehavioursuchasbillingchanges• Measurementsofchangedbehaviourafterguidelinechanges

WewillthendiscusshowChoosingWiselymemberscanworktosupportchangethroughvariousmechanisms:education,changingremunerationapproaches,changedclinicalprotocols.

WeencouragemembersofChoosingWiselytoattendandcontributetheirideasonhowtoadvancetheseevidence-basedideas.

Choosing Wisely – Engaging our Patients - A Unique Opportunity for Nurse PractitionersJenniferMcDonald,TRFHT

TheNursePractitionerisanautonomousyetcollaborativehealthprofessionalwhointegratesin-depthknowledgeofadvancednursingpracticeandtheory,healthmanagement,healthpromotion,disease/injuryprevention,andotherrelevantbiomedicalandpsychosocialtheoriestoprovidecomprehensivehealthservices.Nursepractitionersworkincollaborationwiththeirclientsandotherhealth-careprovidersintheprovisionofhigh-qualitypatient-centredcare(CanadianNursesAssociation).TheNPcorecompetenciessupportthechoosingwiselyprogrambyincorporatingaholistic,personcentredapproachtoeachpatientencounter.NPscanleveragethisapproachinthecontextofeachpatientvisittochampionthechoosingwiselyinitiatives.ThispresentationwillreviewtheuniquescopeofpracticeandphilosophyofcareNPsbringtopracticeandofferpracticaltipsformakingeachvisit,whetherforanacuteepisodicillness,orachronicongoingconditionanopportunitytopracticewisely

Implementing Critical Appraisal in the Choosing Wisely Recommendation Writing ProcessKatherineSmith,CanadianAssociationofMedicalRadiationTechnologistsGraceChung,BiomedicalZoneStephanieLea,DalhousieSchoolofHealthSciencesLisaPyke,CADTH

TheCanadianAssociationofMedicalRadiationTechnologists(CAMRT)establisheditsChoosingWiselyCanadaTop6recommendationsbyassemblingacorecommitteeofMedicalRadiationTechnologists(MRTs)fromacrossCanada,spanningallMRTdisciplines.Aninitialmeetingidentifiedtendraftrecommendations.

UsingamodifiedDelphimethod,thelistwasnarrowedto6draftrecommendationstatements.Sub-committeesweresubsequentlyformedtooverseeeachstatement.Throughalensofqualityandrigour,significanteffortsweremadetofindaprocessthatwouldraisethestandardsforcreatingevidence-basedinformedrecommendationsrelatingtoMRTpractice.Comprehensiveliteraturesearchesandreviewsweresimultaneouslyperformedforeachoftherecommendations.

ACriticalAppraisalGuidewasusedtohelpevaluatethequalityoftheevidenceforinclusion.ThetoolwasadaptedandmodifiedfrombrokeredtoolsprovidedbytheCanadianAgencyforDrugsandTechnologiesinHealth(CADTH).Threemembersofeachrecommendationcommitteecompletedthecriticalappraisalformforeachpieceofliteraturereviewed.Theappraisalswerethencomparedtoachieveconsensusforliteratureinclusionandexclusion.Indoingso,thecriticalappraisalaspectbecameanintegralpartofthedecision-makingprocessregardingthequalityofresearchevidenceforinclusion.

ThispresentationoutlinesausefultemplateforothermedicalprofessionalsocietiesandassociationstofollowinthecreationofrecommendationstatementsfortheCWCcampaign.CAMRTwillbeadoptingthiscriticalappraisaltoolandapproachforfutureevidence-basedguidelinesandrecommendationsputforwardbytheassociation.

MEASUREMENT & EVALUATION - PAGE 76

MEASUREMENT & EVALUATION

The Role of Audit and Feedback In Choosing Wisely: Are Physicians Able to Accurately Predict Their Own Practice?AntoniaStang,PhysicianLearningProgramShawnDowling,UniversityofCalgarySampsonLaw,UniversityofCalgaryIneldaGjata,PhysicianLearningProgram

BackgroundTheobjectivesofthisprojectweretodetermineif:1)therearedifferencesinpracticebetweenphysicianswhodo,anddonot,consenttoreceiveaconfidentialauditandfeedback(A&F)reportontheirpracticeand;2)ifthereisarelationshipbetweenphysiciansself-predictedandactualpractice.

MethodsThiswasaprospective,cross-sectionalstudy.AllphysicianspracticingintheEDofatertiarycarepediatrichospitalwereofferedtheopportunitytoreceivedataontheirpractice.Priortoreceivingtheirdata,consentingphysicianswereaskedtopredicttheproportionofbronchioliticpatientsforwhomtheyordereddiagnostictestsortreatments.Weusedchi-squaredtestingtocomparetheproportionofconsentingandnon-consentingphysicianswhosediagnostictestandtreatmentorderingwasabovethemedianforallEDphysicians.WeusedPearson’scorrelationtoassesstherelationshipbetweenconsentingphysiciansself-predictedandactualpractice.

Results56%(37/66)ofphysiciansconsented.Themedianproportionofpatientswithanx-rayorderedwas20%,63%ofnon-consenterswereabovethemedian,comparedto36%ofconsenters(X2(1,N=66)=4.91p=0.03).Overall,18%ofpatientshadVentolinordered,with60%ofnon-consentersand42%ofconsentersabovethemedian(X2(1,N=66)=2.2p=0.138).TherewasminimalcorrelationbetweenpredictedandactualpracticeforCXR(0.05),steroids(r=0.17)orVentolin(r=0.33).

ConclusionTheconsentprocessmaybeabarriertoA&F,andphysicianshavealimitedabilitytoaccuratelypredicttheirownperformancewhichhighlightstheimportanceofprovidingfeedback.

Driving Change Using Audit and Feedback: Primary Healthcare Panel ReportsMarkusLahtinenandJodyPowHealthQualityCouncilofAlberta

Auditandfeedbackplayapositiveroleinchangingfamilyphysicianbehaviorthatinturn,impactspatientcareandpatientexperience.TheHQCA’sPrimaryHealthcarePanelReportscontributetothischangeprocessbyprovidingmeaningful,relevant,anddescriptiveclinicalandexperientialinformationthatsupportsreflectivepracticeandqualityimprovement.Foreachreport,thepatientpanelisbasedoneitheraconfirmedpatientlists(CPL)ortheHQCA’sproxypanel.Overthepastyear,weworkedwithkeystakeholderstoreviewthemeasures,layoutandnarrativeofthesereportstoensuretheyoffersoundvaluetoourprimaryhealthcarepartners.Specifically,theHQCAcollaboratedwiththePhysicianLearningProgramtodevelopandreportonthefollowingChoosingWiselymetrics:

• Papanicolaou(Pap)tests–forfemalesagedunder21;21to24;thosebetween25to69;andthoseover70

• DEXAscans–thenumberofpatientsunder50;thoseaged50to64;andover65whohadasingleDEXAscaninthelastyearandthenumberofpatientswhohadmultipleDEXAscansinthelasttwoyears

• Lumbarspinescans–thenumberoflumbarspinescansdonebyCT,andMRI

ThereportsprovideinformationthatisnotavailableinEMRs,presentspeercomparators,andadjustutilizationmetricstocontrolfortheinfluenceofpatientcharacteristics.The2018PrimaryHealthcarePanelReports,alongwithpatientexperiencedata,canbeusedforprimaryhealthcareplanning,evaluation,andservicedevelopment.

Physician Utilization Scorecards in Primary Care: A Cross-Sector Partnership to Improve Test UtilizationCourtneyPrice,LifeLabsNatalieCeccato,LifeLabsDeepakSharma,NorthYorkGeneralHospitalTracyLindsay,NorthYorkGeneralHospital

GoalAssesstheimpactofutilizationdataprovidedtoindividualphysiciansonorderingofcommonlaboratorytests,focusingonreducingreflexivethyroidtesting.

ImplementationFiveOntarioFamilyHealthTeams(FHTs),NorthYorkGeneralHospitalandLifeLabspartneredtoprovideindividualutilizationdatato104physiciansonthetoptestsorderedanddetaileddataonthyroidtesting.BaselineutilizationreportswereadministeredinJan2017,andthenprovidedquarterly(May,July,andNov).ReportswereprovidedtoeachFHTleadwhocoordinateddistributiontosupportphysicianprivacy.

MeasuresUtilizationreportsshowedtestorderingformostcommontestsandspecificthyroidtests.Itincludedindividualperformancechangesrelativetobaselineaswellaspeercomparatorsusingmedianmonthlyordering,%oftotalTSHorderswithassociatedT3/T4s,andratioofTSHtoT3/T4orders.

ChallengePhysicianconsenttoparticipateatsomeFHTswasinitiallydifficulttoobtain.Dataqualityissuespresentedchallengesinestablishingavalidbaseline,particularlyrelatedtophysician’sorderingacrossmultiplepracticesites.Anappropriatecomparatorwasdifficulttofindintheabsenceofanavailabledenominatorwithwhichtobalanceoutvariationsinphysicianpracticesizes.

Lessons LearnedQualitativefeedbackdemonstratesneedforsimplificationofreportdesigntoimproveactionabilityoffindings.Formalevaluationtoensurereportsprovidetherightlevelofinformationtotherightaudienceinavisuallyintuitivemanneriscritical.Distributionthroughtheresearchteamtositeleadswasaneffectivemodeltoidentifydataqualitychallengesandcoordinatecommunicationamongsiteleads.

Screening for New Primary Cancers in Patients with Metastatic Breast Cancer: A Provincial Analysis of the Choosing Wisely Canada RecommendationsMeganTesch,MemorialUniversityofNewfoundlandKaraLaing,Dr.H.BlissMurphyCancerCentre

BackgroundAspartofthebroaderChoosingWiselyCanadacampaign,alistwaspublishedinMay2015ofpracticesinoncologythatarecommonlyperformeddespiteevidenceshowingnegligiblebenefitandthepotentialtocauseharm.Oneoftheserecommendationsisforphysicianstoavoidroutinecancerscreeningorsurveillanceforanewprimarymalignancyinpatientswithmetastaticdisease.Theobjectiveofourstudywastoassesswhetherlocalpracticeisinkeepingwiththeserecommendations.

MethodsAretrospectivereviewofscreeningfornewprimarycancerswasconductedinmetastaticbreastcancerpatientsseenattheDr.H.BlissMurphyCancerCentreinSt.John’s,NewfoundlandandLabrador(NL)duringthethree-yearperiodofJanuary1,2014toDecember31,2016.Specificscreeninginvestigationsincludedscreeningmammography,Papanicolaoutest,fecalimmunochemicaltest,andscreeningcolonoscopyorflexiblesigmoidoscopy.

ResultsAtotalof305patientmedicalrecordswerereviewed.Overall,114patients(37.4%)underwentatleastonescreeninginvestigation(mean,2.92investigationsperscreenedpatient).70%ofscreeninginvestigationswereorderedbyprimarycareproviders,incomparisonto14%byoncologistsand12%byotherspecialists.Themedianoverallsurvivalofbreastcancerpatientsafterdiagnosisofmetastaticdiseasewas42months,witha5-yearoverallsurvivalof35.9%.

ConclusionsAsignificantproportionofpatientswithmetastaticbreastcancerinNLandarestillundergoingscreeningfornewprimarycancers,indiscordancewithChoosingWiselyguidelines.Increasededucationalstrategiesareneededifrecommendationsaretobeimplementedintoroutineclinicalpractice.

Frequency and Utility of Pre-Consultation MRI Use in Patients Referred for Possible Total Knee ArthroplastyStephenPatton,DanielTushinski,JustindeBeer,AngelaAccettura,SherriGavin,SusanMontgomery,DaniellePetruccelli,SampaSamanta,NancyToffoloandMitchellWinemakerHamiltonHealthSciences

PurposeTodeterminethefrequencyandutilityofMRIinpatientsreferredforassessmentandmanagementofkneeosteoarthritis.

Method Prospectiveauditwasconductedon3,598patientsreferredtotheRegionalJointAssessmentProgram.PatientswereassessedbyAdvancedPhysiotherapistPractitioners(APP)whospecializeintheassessmentandtreatmentplanningofpatientswithhipandkneeOA.AllpatientsreferredtooneRJAPovera10-monthperiodunderwentfunctionalassessmentandreviewbytheAPP.FrequencyofMRIanditsutilityindeterminingkneeOAdiagnosisandsubsequenttreatmentplanweredetermined.

Results79.6%ofpatientspresentedwithweightbearingkneeradiographs.ObviousOAwasevidenton83.7%ofradiographicstudiesandwasclearlyclinicallyevidentin91.7%ofpatientsonexamination.20.7%ofpatientspresentedwithakneeMRI;in8.1%ofthesepatients,MRIwasthefirst-linepre-consultationdiagnostictest.In59.0%ofpatientspresentingwithMRI,thefindingsweredeemedtobeofnovalueinsupportingthediagnosis,norweretheyofanyvalueintreatmentplanningfor63.6%ofpatients.

ConclusionOnceweight-bearingx-rayshaveconfirmedadiagnosisofosteoarthritis,furtherinvestigationwithMRIhaslittlevalueinpatientswithkneeosteoarthritis.UnnecessaryuseofMRIamongreferringproviderforpatientswithOAofthekneeconstitutesaburdentothehealthcaresystem.ThereisaneedtoeducatereferringprovidersandpatientstocurtailtheuseofthisdiagnostictestintheassessmentofkneeOA.

A Data-Driven Approach to Identifying Laboratory Overutilization – Results from the General Medicine Inpatient Initiative (GEMINI)AdinaWeinerman,SunnybrookHealthSciencesCentreYishanGuo,St.Michael’sHospitalFahadRazak,St.Michael’sHospitalAmolVerma,St.Michael’sHospital

BackgroundRecommendationsforresourcestewardshipareoftenbasedonexpertopinionwithrelativelylittleutilizationdatatohelpidentifyorprioritizetargetsforintervention.Thepurposeofthisstudywastodevelopadata-drivenapproachtoidentifyingpotentialsourcesoflaboratoryoverutilization.

MethodsWeextractedelectronicclinicaldataforalllaboratorytestsperformedduring26,469GeneralInternalMedicineinpatientadmissionsatanacademichospitalinTorontobetweenApril1,2010andMarch31,2015.Thecostofeachtestwasobtainedfromthehospitalcasecostingdatabase.Testswithacumulativecostofmorethan$20,000wereanalyzedtodeterminetheproportionofabnormalresults(usingpre-specifiedclinicalandlaboratorythresholds)andphysician-levelvariabilityinordering(definedasthephysician-levelcoefficientofvariationinthenumberoftestsperformedperpatient-day).Eachtestreceivedacumulativerankbasedonhighesttotalcost,highestphysician-levelvariation,andlowestproportionofabnormalresults.

ResultsThefollowingtestshadthehighestcumulativeranksaspotentialresourcestewardshiptargets:1)RBCfolate,2)CSFcellcount,3)serumfolate,4)urineosmolality,5)immunofixationelectrophoresis,6)CK,7)TSH,8)troponin,9)lactate,and10)bilirubin.Inaddition,ANAandferritinwerealsoidentifiedastargetsbasedonlowproportionofabnormalresultsandhighphysicianvariability.

ConclusionsAdata-drivenapproachtostudyinglaboratoryutilizationidentifiednoveltargetsandvalidatedexistingtargetsforresourcestewardshipbasedontotalcost,physician-levelvariation,andproportionofabnormalresults.Thesemethodscanbereplicatedtoprovideinstitution-specificinsights.

Using Facilitated Audit and Feedback to Support Choosing Wisely Initiatives for Primary Care PhysiciansAshiMehta,AlbertaPhysicanLearningProgramSampsonLaw,UniversityofCalgaryAnthonyTrain,ChoosingWiselyAlbertaEileenPatterson,TowardOptimizedPracticeJuneCooper,AlbertaMedicalAssociation-TowardOptimizedPracticeJohnLester,AlbertaMedicalAssociation-TowardOptimizedPracticeShawnDowling,UniversityofCalgaryKatrinaNicholson,PhysicianLearningProgram,UniversityofCalgaryLaraCooke,UniversityofCalgaryKellyBurak,UniversityofCalgary

Abstract:Receivingfeedbackisacriticalcomponentofimprovingperformance.Physiciansoftenhavelimitedopportunitiestoreceivedirectandrelevantfeedbackrelatedtoadherencetobestpracticeguidelines.Wedevelopedamulti-facetedlearningworkshoptoprovidefamilyphysicianswithanopportunitytoreview,understandanduseindividualizeddatatoself-reflectontheirpractice.

GoalWeaimedtosupportphysiciansindevelopingandimplementingpracticechangeplanstoimprovepatientcarerelatedtoCWrecommendationsonappropriatepapsmeartesting,bonemineraldensityscans,andlumbarspineimaging.

ImplementationOurworkshopswereCFPCMainpro+certifiedeventscomprisedof:(1)didacticlecturewheresubjectmatterexpertssharelatestevidence-basedbestpractices;(2)participantsreceiveandreviewindividualizedpracticereports;(3)facilitatedsmallgroupdiscussionsidentifybarriersandenablerstoachievingbestpractice;and(4)developmentofactionplansandstrategiesforimprovement.

MeasuresOver15months,5primarycarephysiciangroupstotaling207physiciansand60alliedhealth/qualityimprovementprofessionalsparticipated.Wedelivered182individualizeddatareportsdirectly,andover2,500throughpartnershipwiththeHealthQualityCouncilofAlberta.Participantfeedbackhasbeenpositive;97.5%wouldrecommendtheprogramtoacolleague,87.8%felttheprogramdirectlysupportedtheirimprovementinitiatives,and91.2%thoughttheprogramhelpedthemsetandevaluatepersonalimprovementgoals.

ChallengesInvolvingapatient-perspectivecanenhancetheimpactofthisprogram,however,thebeststrategiestodothiscanchallengingtoidentify.

Lessons LearnedDataonactionablemetricsisanextremelystrongphysicianengagementtoolandcandrivephysician-ledimplementationofchangeideas.

Treatment of Asymptomatic Bacteriuria in Elderly Patients With Delirium: A Systematic ReviewAdamSuleman,UniversityofOttawaJohnKrakovsky,UniversityofOttawaPilJoo,St-FrancisMemorialHospital

IntroductionItistypicaltolookforUTIindeliriouselderlypatients,despiteahighprevalenceofasymptomaticbacteriuria(ASB)inthispopulation.Acommonpresentationofinfectionisdelirium,whichoftenhasanon-specificandmultifactorialetiology.Therefore,whenbacteriuriaispresentwithdeliriumintheabsenceofurinarysymptoms,physiciansprescribeantibioticsforthesuspectedUTI-induceddelirium.WesettodeterminewhetherantibiotictreatmentintheelderlypresentingwithdeliriuminthepresenceofASBresultedinresolutionofdelirium.

Methods LiteraturesearcheswereperformedinMEDLINE,EMBASE,CINAHLandCochraneLibrary.Abstractswereindependentlyreviewedbytwoauthorsfordecisiontoincludeforfull-textreview.Inclusioncriteriaincludedfemalegender,>65yearsofage,presentinginanacutecaresettingwithdeliriumandASB.Theprimaryoutcomewasresolutionofdelirium.Thesecondaryoutcomesweremortality,frequencyofsideeffectsfromantibiotics,lengthofhospitalstayandreadmissionfordelirium.

Results 930abstractspublishedfrom1946-2017werescreened,and42wereincludedforfulltextreview.Nostudieswereeligibleforinclusioninthesystematicreview,asnoneaddressedtheprimaryoutcome.OnestudyaddressedtheoutcomesofpoorfunctionalrecoveryafterdeliriumandtherateofimprovementofdeliriumsymptomsafterpresentationofdeliriumwithASB.

Discussion EventhoughcurrentguidelinesrecommendagainsttreatmentofASB,noguidelinestateswhetherASBshouldbetreatedinelderlypatientswithdelirium.LittleevidenceexiststoelucidatewhethertreatingdeliriouspatientswithASBresultsinimprovementinoutcomes.

A Database Platform to Monitor In-Hospital Glucometer UseJenniferTaher,UniversityofTorontoJakeCosme,UniversityofTorontoIrvinBromberg,MountSinaiHospital

BackgroundGlucometersareacommonpoint-of-caretestingdeviceusedformanagementofin-hospitalpatientglucoselevels.Thepurposeofthisstudywas:1)toidentifyandimprovemanagementofhypoglycemiapatientsand2)tomonitorin-hospitalutilization/frequencyofglucometermeasurements.

MethodsAdatabaseprogram(GLUM)wasdesignedtoaccessglucometerdatafromthehospitallaboratoryinformationsystem.Visualbasicsoftwarewasusedtodevelopanexcel-baseddigitalapplicationtographthein-hospitalglucometerresultsas1)individualwardsummarystatistics,2)individualpatienttrendchartsoveraspecifieddate/timerangeand3)numberofglucometermeasurementsperpatientperday.TheprogramwasdevelopedandtestedusingdatafromMountSinaiHospitalwithRocheAccu-ChekInformIIglucometers.

ResultsWardplotsprovidedavisualrepresentationofhypoglycemiaincidenceandvolumeofglucometeruseaccordingtospecifieddateranges.Graphicalpointswereselectedonwardplotstoidentifyindividualpatientsandassessrecenthistoryofrecurrenthypoglycemia.Thisdatawascorrelatedwithdailyfrequencyofglucometeruseperpatient.WithintheMountSinaidatabase,patientswereidentifiedtohaveupto23glucometermeasurementsperdaywithoutindicationofhypoglycemiaevents(definedasglucoselessthan4mmol/Linadultsandlessthan3mmol/Linneonates).

ConclusionFrequencyofin-hospitalglucometermeasurementscanbeassessedusingthedevelopedGLUMdatabaseplatform.Thisdatacanbecorrelatedwithadditionalpatientinformation(ie/hypoglycemiaevents)todeterminetheappropriatenessofhighfrequencytesting.Theapplicationaimstoidentifytheappropriateuseandpotentialover-useofin-hospitalglucometertesting.

The Use of Theories and Frameworks to Understand and Address the Reduction of Low-Value Healthcare Practices: A Scoping ReviewGillianParker,NidaShahid,WhitneyBertaUniversityofToronto

BackgroundEffortssuchasChoosingWiselyhaveinitiatedaparadigmshiftinhealthcarepractice.Researchershavebeguntousetheoryordevelopframeworkstoelucidatethedynamicsofde-implementationandsupporteffortstoreducelow-valuepractices.Thepurposeofthisscopingreviewwastoidentifyandcharacterizetheuseoftheoriesandframeworkstounderstandandaddressthereductionoflow-valuecare.

MethodsWeconductedasystematicreviewofMEDLINE,EMBASE,CINAHLandScopusdatabasesfrominceptiontoDecember2017.Buildingonpreviousresearch,33keytermswereusedtosearchtheliterature.Tobeincluded,papershadtopresentanexplicittheoreticalapproachorframework.

ResultsIntotal55articleswereincludedafterscreening1106citationsand70full-textarticles.Themajorityofstudiesdevelopedanewframeworkortestedanexistingframework.Ofstudieswhichusedatheoreticalapproach,themajorityusedpsychologicaltheories,suchastheTheoryofPlannedBehaviourorappliedBehaviouralScienceconceptstodevelopinterventions.Themajorityofstudiesaddressedlow-valuecareattheproviderlevel,butnumerousstudieswerealsoidentifiedwhichaddressedthereductionoflow-valuecareattheteamandsystemlevels.Antibioticoveruse,polypharmacyandappropriateprescribingpracticeswerethepracticestargetedmostfrequentlyintheincludedstudies.

ConclusionsDe-implementationisanemergingfieldofresearch.Theresultsofthisreviewcanprovidedirectionandinsightforfutureprimaryresearchintheuseoftheorytosupportde-implementationandreductionoflow-valuehealthcarepractices.

A Scoping Review Exploring Interventions Changing Image Ordering in Pediatric Emergency MedicineLynetteD.Krebs,UniversityofAlbertaLindsayA.Gaudet,UniversityofAlbertaMeaganCarr,UniversityofAlbertaMaureenKruhlak,UniversityofAlbertaNicoleLoewen,UniversityofAlbertaScottW.Kirkland,UniversityofAlbertaAmandaHall,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLSandraCampbell,UniversityofAlbertaBrianH.Rowe,UniversityofAlberta

BackgroundTheintroductionofChoosingWisely®andconcernsoverradiationexposureinpediatricemergencymedicine(PEM)haveresultedinmanystudiesonimageorderingpractices.ThisscopingreviewexplorestheliteratureonimageorderinginterventionsinPEM.

MethodsElectronicdatabasesandgreyliteratureweresearched.Aprioriexclusioncriteriawereestablishedandfollowed.Aminimumoftwoindependentreviewersassessedstudyinclusionbasedonpre-definedcriteriaandextractedthedata.Disagreementswereresolvedthroughdiscussion.DescriptiveresultsforPEMstudiesarereported.

ResultsOfthe389full-textstudiesassessed,135meettheinclusioncriteria,35ofwhichwerePEMstudies.Thesestudiesfocusedontraumatic(14),non-traumatic(19)andmixed(2)presentationsandthemajorityweresinglecentrebefore-afterstudies.Themostcommonimagingmodalityexaminedwascomputedtomography(CT;24studies).Halfofthestudies(18)reportedoutcomesformorethanoneimagingmodality.OfthestudiesreportingonCTordering(26CToutcomes),22reportedadecreaseinordering;15ofwhichwerestatisticallysignificant.Themostcommoninterventionacrossstudieswasintroductionofapathway/protocol(30[86%]),followedbytheuseofinformationoreducation(23[66%]).Moststudieshadmultipleinterventioncomponents(23[66%])andhalf(18[51%])providedimplementationdetails.

ConclusionsInterventionstochangeimagingorderinginPEMappeartobeusefulinreducingimaginguse;however,lowqualitymethodssuggestcautioniswarranted.Systematicreviewstoexploreeffectivenessoftheseinterventions,interventionfidelity,andstudyqualityareneeded.

Piloting a Tool to Reduce CT for Benign Headache in Alberta Emergency DepartmentsLynetteD.Krebs,CristinaVilla-Roel,MariaOspina,BrianR.HolroydandBrianH.RoweUniversityofAlberta

BackgroundReducingunnecessaryimagingforpatientswithbenignheadache(BHA)isatargetofChoosingWisely®activities.AstructuredhandoutwasdevelopedforpatientswithBHApresentingtotheemergencydepartment(ED)toinformthemofwhencomputedtomography(CT)isneeded.Thetoolwaspilotedwithaconveniencesampleofemergencyphysiciansandpatients.

MethodsAnonlinesurveywasdeliveredviaemailtoemergencyphysicianspracticinginoneAlbertaregion.AdultpatientswithBHApresentingtotwourbanAlbertaEDsprovidedfeedbackonthetool.Descriptiveresultsarereported.

ResultsAtotalof73emergencyphysicians(38%)and160patientscompletedsurveys.Approximately50%ofthephysiciansfeltcomfortableusingthetool.Suggestedchangesincluded:removinginformationonorderingvariationorhealthsystemcosts,andincludingspecificinformationonCTindicationsandrisks.PhysiciansopposedthegeneralityofthefourChoosingWisely®questionsfearingtheywouldincreasepatient’simagingexpectations.Patientsagreed(94%)theyunderstoodtheinformationandthatitappliedtothem(68%).Approximatelyhalfofthepatientsagreedthatbecauseoftheinformationprovided,theywoulddiscusstheirneedforimagingwiththeirphysicianduringthecurrentornextpresentation.PatientrecommendationsfortoolmodificationwerealmostexclusivelyformoreCT-relatedinformation.

ConclusionTheseresultsledtoreconceptualizationofthetool.Informationspecificitywasenhancedtosupportinformedclinician-patientdialogue.ThisstudyreinforcestheimportanceofpilotingandhighlightspotentialconcernswithusingtheChoosingWisely®questionswithoutadjustingthemforcontextandpatientagency.

Choosing Wisely in Radiation Oncology: Driving Practice Change through Measurement and Quality Improvement KimTran,CanadianPartnershipAgainstCancerJulianKim,CancerCareManitobaPhilipWright,SaskatchewanCancerAgencyRamiRahal,CanadianPartnershipAgainstCancerMaryArgent-Katwala,CanadianPartnershipAgainstCancerJenniferChadder,CanadianPartnershipAgainstCancerAnnemarieEdwards,CanadianPartnershipAgainstCancer

BackgroundAsinglefractionofradiationtherapy(RT)isrecommendedforthepalliativetreatmentofuncomplicatedbonemetastases.AreportreleasedbytheCanadianPartnershipAgainstCancerfoundadherencetothisrecommendationvariedacrossthecountry,withSaskatchewan(SK)andManitoba(MB)havingthelowestuseofsinglefractionRT(31%)forbonemetastases.Asaresult,aqualityimprovement(QI)projectinvolvingthePartnership,SaskatoonCancerCentre,AllanBlairCancerCentreandCancerCareManitobawasimplementedtoincreasetheevidence-baseduseofsinglefractionRTforuncomplicatedbonemetastases.

MethodsThePartnershipconductedaliteraturesearchandheldafocusgroupwithradiationoncologiststoidentifybarrierstoadherencetotherecommendation.Strategiesaimedataddressingbarriers(i.e.,educationaloutreachwithlocalchampions,consensusdevelopmentmeetings)wereimplementedbetweenJanuaryandMarch2017.Post-implementationsurveydatawerecollectedtoidentifytheimpactoftheQIstrategies,andwillinformpotentialspreadandscaleacrossCanada.

Results26of32(81%)radiationoncologistsinSKandMBrespondedtothesurvey.SurveyresultssuggestthattheQIprojectledto:

• increasedawarenessoftherecommendation(MB:86%,SK:83%),• increasedknowledgeoftheevidencesupportingtherecommendation(MB:86%,SK:100%),• practicechangetoincreaseuseofsinglefractionradiationwhereappropriate(MB:90%,SK:100%).

ConclusionsThisworkhasthepotentialtoincreaseevidence-baseduseofradiotherapyforbonemetastases,whichcanreduceunnecessarytreatmentburdenonpatientsandcancontributetowardsmoreefficientuseofresourcesandimprovedhealthsystemsustainability.

What Behaviour Change Techniques Have Been Used to Reduce Physician’s Image-Ordering for Low Back PainAmandaHall,MemorialUniversityCharlotteAlbury,NuffieldDepartmentofPrimaryCareHealthSciences,UniversityofOxfordJacquelineThompson,UniversityofOxfordJamesMatthews,SchoolofPublicHealth,Physio&PopScience,CenterforSportsStudies,UniversityCollegeDublinHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversityPatrickParfrey,TPMI/MemorialUniversity

BackgroundReviewsofinterventionstoreducephysician’simage-orderingforlowbackpain(LBP)indicatethatdecision-supportandtargetedreminderscouldhaveasmalleffect.Thereviewsdescribedinterventioncontentbutnotthespecifictechniquesusedtochangebehaviour.Therefore,weaimtobuildonexistingliteraturebysynthesizingwhatbehaviourchangetechniques(BCTs)havebeenusedtochangephysician’simage-orderingbehaviourforLBP.Methods:3Electronicdatabasesweresearched.TworeviewersassessedeligibilityandcodedinterventionsusingtheBCTtaxonomy;whichcontains93BCTsorganizedinto16categories.Interventionsweresynthesizedbythosetargetingphysicians(reportedhere),health-systemsorpatients.

Results14interventionswereidentified.Elevenofthe16BCTcategorieswereused:4.0-Shaping-knowledge(10interventions),2.0-Feedback-and-monitoring(7interventions),7.0-Associations(7interventions),8.0-Repetition/substitution(6interventions),6.0-Comparison-of-behavior(5interventions),12.0-Antecedents(5interventions),9.0-Comparison-of-outcomes(4interventions),1.0-Goals-and-planning(4interventions),3.0-socialsupport(3interventions),5.0-Natural-consequence(3interventions)and10.Reward-and-threat(1intervention).Intotal,29ofthe93BTCswereused.ThemostcommonBCTswere4.1-instructiononhowtoperformthebehavior(i.e.redflagassessment)in10interventions,7.1-Prompts-and-cues(i.e.genericpostersaboutwhentouseimaging,reminderstouseinterventionmaterials,orpersonalelectronicmessageswithalternativesforinappropriateimagingorders)in7interventions,and2.2-Feedback-on-Behaviour(i.e.numberofimagesorderedinthepreviousmonths/year)in6interventions.ThenumberofBCTsusedrangedfrom1to17withmoststudiesusing>/=5.

ConclusionMostinterventionsfocusedonknowledge/remindersofwhentouseimagingandpersonalperformancereports.Fewinterventionstargetwell-knownbarriersofsocialinfluence(e.g.patientexpectations),skills(communicatingsatisfactorydiagnosiswithoutimaging)andresources(lackoftimetodiscussdiagnosis,imagingneedsandtreatmentrecommendations),limitingthepotentialforeffect.

Measuring Benzodiazepine use Among Seniors with In-Hospital DeliriumBrandonWagar,JayO’DonnellandJamesHutchinsonIslandHealth

ChoosingWiselyCanada(CWC)recommendationsforHospitalMedicineandGeriatricsbothincludeDon’tusebenzodiazepinesandothersedative-hypnoticsinolderadultsasfirstchoiceforinsomnia,agitationordelirium.AtVancouverIslandHealthAuthority,in-hospitaldeliriumhasbeenidentifiedasapriorityforQualityandPatientSafety.Itisimportanttotrytopreventdeliriumbyaddressingmodifiableriskfactors.Itisalsoimportantthat,oncedeliriumisestablished,itstreatmentshouldfollowbestpractice.ConsistentwithCWCrecommendations,recommendedbestpracticesfortreatingdeliriumemphasisenon-pharmacologicalstrategies.Pharmacologicalinterventionsmayaugmenttheseapproaches;however,theevidencetosupportthisislimitedandtheiruseiscontroversialbecauseofthelackofevidenceoftheireffectivenessandpotentialforharm.ClinicalordersdatafromIslandHealth’selectronichealthrecordwerelinkedwithCIHI’sDischargeAbstractDatabasetoevaluatebenzodiazepineuseamongseniorswithin-hospitaldelirium.Nearlytwothirds(64%)ofin-hospitaldeliriumcasesatIslandhealthweresurgicalcases.Amongseniors(65+)whoacquiredin-hospitaldeliriumatIslandHealthhospitals,53%ofsurgicalpatientsand44%ofmedicalpatientsweregivenbenzodiazepines.Bothratesarehighgiventherecommendations,andtherateamongsurgicalpatientswassignificantlyhigherthantherateamongmedicalpatients(?2=3.8,p<0.05).

Assessing the Risk of Intracranial Bleeding in Emergency Department Seniors who have FallenKerstindeWit,McMasterUniversity

BackgroundFallingisthemostcommoncauseofintracranialinjuryamongtheelderly,accountingforalmost80%ofbraininjury.Thenumberofemergencydepartmentvisitsforfallsinseniorsisrising.Ouraimwasto1).determinetheproportionofelderlywhopresenttotheemergencydepartmentafterafall,whoarediagnosedwithintracranialbleedingand2).reportemergencyphysicianuseofheadCTtodiagnoseintracranialbleedinginthispatientgroup.

MethodsWeconductedaprospectivecohortstudyattwoemergencydepartmentswithanannualvolumeof100,000patients.Werecruitedemergencydepartmentpatientsage>65whohadfallenonlevelgroundordown1-2stepswithintheprevious48hours.Wefollowedthepatientbychartreviewandtelephonecallforthenextsixweeks.

ResultsWerecruited890patientsovera10-monthperiod.Overall,34/890(3.8%,95%CI2.7-5.3%)patientswerediagnosedwithanintracranialbleedwithin6weeksofpresentation.469/890(52.9%,49.4-56.0%)hadaheadCToninitialassessmentintheemergencydepartmentofwhich28/469(6%)werepositiveforintracranialbleeding.3/440(0.7%)whohadaCTand3/421(0.7%)whodidnothaveaCTwerediagnosedwithintracranialbleedingduringfollowup.

ConclusionsIntracranialbleedingisnotacommonoccurrenceafterafall.TheheadCTyieldwaslow.Withbetterevidenceonwhomtoscan,emergencyphysicianscouldreducetheiruseofheadCTinthispopulation.

The Prevalence of Intracranial Bleeding in Elderly who have FallenKerstindeWit,McMasterUniversity

BackgroundTheemergencydepartmentcanbeanuncomfortableandunpleasantplaceforseniors.Elderlyfrequentlypresentwithafall.ThereispracticevariationaroundorderingaheadCTtodiagnoseintracranialbleedingafterafallintheemergencydepartment.CTscansarecostlyandleadtodelayswhichincreasetheriskofacutedeliriumintheelderly.Weaimedtodeterminetoincidenceofintracranialbleedingamongthispopulation.

MethodsWesystematicallysearchedMedline,EMBASEandGooglescholarforpublicationsreportingtheincidenceofintracranialbleedingamongpatients>65yearswhopresentedtotheemergencydepartmentafterafallonlevelground.Twoauthorsreviewedalltitlesusingpredefinedinclusionandexclusioncriteria.Authorswerecontactedwheredatawasmissing.Twoauthorsperformedriskofbiasassessmentandextractedthedata.Therandomeffectsmodelwasusedtoreportapointestimateofintracranialbleedingincidence.

ResultsFromaninitial6036citationsonMedlineandEMBASE,6studieswereincluded.Anadditional2studieswereidentified.Riskofbiaswaslowforonly2studies.Therewere5961patientsincludedinthemeta-analysis.Thepooledestimatefortheincidenceofintracranialbleedingwas5.2%(95%CI2.8-9.2%).

ConclusionsOnly1in20elderlyemergencydepartmentpatientswhohavefallenonlevelgrounddevelopintracranialbleeding.ResearchisneededtodeterminewhichpatientsshouldhaveheadCT.

Serum Protein Electrophoresis Testing in Northern Alberta: An Audit and Intervention to Curtail OveruseAlbertTsui,AlbertaHealthServicesKarinaRodriguez-Capote,LaboratoryMedicineandPathology,UniversityofAlbertaDylanThomas,DynaLIFEMedicalLabsMathewEstey,DynaLIFEMedicalLabsTreforHiggins,AlbertaHealthServicesDonZhang,DynaLIFEMEDICALLABSIrwindeepSandhu,UniversityofAlberta

GoalDynaLIFEperformsserumproteinelectrophoresisforacatchmentareaof2millionpeopleinNorthernAlberta,Canada.Theprimaryreasonforrequestingserumproteinelectrophoresis(SPE)isintheinvestigationofpatientsinwhomplasmacelldisorderssuspected.Concernsregardingtheperceivedover-utilizationofSPEpromptedustoauditphysicianorderingpatternstoassessandpromoteappropriatetesting.

ImplementationTwofamilyphysiciansresponsibleforthemostSPEordersin2014weredirectlycontactedbyanoncologisttoreduceSPEorders.Additionally,orderingpatternsweretrackedinfamilyphysicianswhoattendedtwolecturesonSPEutilization.Wecomparedtheeffectsbetweendirectpeereducationandsymposiumeducationthroughalecture.

MeasuresAuditofSPEsperformedatDynaLIFEMedicalLabsin2014revealedatotalof40930SPEtestswereperformedin2014,with566SPEsperformedinpatientsyoungerthan19yearsold.90%ofrepeattestingwasrelatedtodiseasemonitoringbyoncologistsand20%oftheseorderswerewithin26days.Directphysicianeducationresultedina90%dropinmonthlySPEordersfromthetwofamilyphysicians.Incontrast,physicianeducationviasymposiumdidnotleadtoasignificantreductionintestorders.Forphysicianswhoattendedbotheducationsessions,SPEordersweregenerallyincreasedfollowingthefirstsessionandSPEorderswerelowerorremainedstablefollowingthesecondsession.

ChallengesHowtosuccessfullydeliverphysicianeducationtobestpromotepracticechange.

Lessons LearnedTest-specificeducationwithcomparisonbyoncologistismosteffectivethandidacticlecture.

Allergy Testing in Northern Alberta: An Audit and Intervention to Curtail OveruseKarinaRodriguez-Capote,LaboratoryMedicineandPathology,UniversityofAlbertaDylanThomas,TamaraStock,MathewEstey,DonZhang,NormaPage,TerenceAgbor,FayeChambersandKayNgDynaLIFEMEDICALLABS

BackgroundDynaLIFEMedicalLabsisthesolelaboratoryperformingallergytestingforacatchmentareaof2millionpeopleinNorthernAlberta,Canada.InvitroallergenspecificIgEtesting(sIgE)isincreasinginprimarycarewheretheskinprick/puncturetestisimpracticalandwaitingtimesfrompatientreferraltospecialistconsultationareoftenlengthy.However,broadscreeningforallergensmayhaveanegativeimpactonpatientoutcome.Guidelinesrequireselectionofindividualallergensbasedonpatienthistory.

GoalToassessphysicianorderingpatternsandpromoteappropriateuseofdiagnostictesting.Todevelopastrategytoimproveallergytestingutilization.

ImplementationAmultimodalprocesswasimplementedin2015thatincluded:Modifyreflextestingofferedforpositiveinhalantandfoodscreensaccordingtoprevalenceandseason.ProvidingphysicianeducationthroughsymposiaandCMEsessions.DistributingeducationalfaxestophysiciansrequestinganunwarrantednumberofsIgEtestsorundefinedrequests(RAST,allergytesting).

MeasuresThe2013auditrevealedthat168,038sIgEtestswereperformedfor28,464patientswith83%oftherequestsorderedasfoodorinhalantscreens.Modificationstothereflextestingallowedareductionof55,952tests.Prevalenceofexposureandpositivityratesweretakenintoconsiderationinthedecisiontoremovetestsfromtheinhalantscreenreflexpanel.

ChallengesChallengesincludeencouragingpracticechangeandmanualreviewofrequisitions.

Lessons LearnedThereisaneedintheprovinceforelectronictestrequestsystem.Thereisaneedforabettersystemtoprovidephysicianeducationandmonitoringcompliance.

Curtailing the Inappropriate Urine Hcg Qualitative Testing in a Community Lab SettingKarinaRodriguez-CapoteandAsifaAmin,DepartmentofLaboratoryMedicine&PathologyUniversityofAlbertaDylanThomas,MathewEstey,DebHolmes,TerenceAgbor,DonZhangandMarkMalickDynaLIFEMEDICALLABS

BackgroundTeststodetecthumanchorionicgonadotropin(HCG)orpregnancytests,canbeperformedonurine(uHCG)orserum(sHCG).Selectionoftheoptimaltestisinfluencedbyanalyticalperformance,convenience,andturnaroundtime.WhilesHCGismoresensitive,samplecollectionforuHCGislessinvasiveandresultsmaybeavailablesooner.Inthecommunitysettinghowever,physiciansoftenrequestuHCGconcurrentlywithsHCGand/orotherbloodwork.Inaddition,turnaroundtimeisnotsignificantlydifferentbetweenthetwotestswhensampletransporttimetothelaboratoryisconsidered.ThisstudyaimstodissectthecommunityorderingpatternsforHCGtoassessifordersubstitutionscanbeimplementedtoimprovepatientcare.

Methodsallphysician-orderedqualitativeurineHCGtestsperformedatDynaLIFEin2017werereviewedtodeterminewhetherothertestswererequestedsimultaneously.

Results9031physician-orderedqualitativeuHCGtestswereperformedduringthestudyperiod.Themajorityofpatientswereofreproductiveage,howeversomeuHCGwererequestedinpostmenopausalfemales.Bloodwassimultaneouslydrawnfrom20469(71%)ofthesepatients,5218ofwhichalsohadserumHCGrequested.

ConclusionsAlargeproportionofofuHCGrequestswereperformedinadditiontosHCGorotherbloodwork.Insuchinstances,theuHCGtestoffersnoadvantageoversHCGasabloodspecimenhasalreadybeencollectedandturnaroundtimesaresimilarwhenanalyzedinacommunitylaboratory.SubstitutionofuHCGforsHCGincommunitypatientswouldprovidemoreaccurateresultsanddecreaseunnecessarytesting.

Stewardship with a Handshake: Impact of Collaborative, Prospective Audit and Feedback Antimicrobial Stewardship Rounds in an Adult, Medical-Surgical Intensive Care Unit in Saskatoon, SaskatchewanShaqilPeermohamed,SaskatchewanHealthAuthorityJustinKosar,SaskatchewanHealthAuthority

Background: Approximately30%ofantimicrobialuseinICUshasbeenshowntobeinappropriate,particularlyduetoprescribingtherapytoobroadinspectrumofactivity.Prospectiveauditandfeedbackisacorestrategyofantimicrobialstewardshipprograms(ASP)withrelevanceinICUs,whichrepresenthigh-acuitycareenvironmentswherehigherproportionsofbroad-spectrumantimicrobialsareoftenprescribed.

Methods: Aquasi-experimentalstudywasperformedtoevaluatetheimpactofcollaborative,prospectiveauditandfeedbackroundsinanadult,medical-surgicalICU.In-personASProundswereperformedthreetimesperweekbyapharmacist-physicianteaminaseventeen-bed,medical-surgicalICU,beginninginmid-November2016.Aseparatefifteen-bed,medical-surgicalICUservedasacontrol.ASPrecommendationswererecordedprospectivelyinthemedcategoriesandacceptanceratesweretracked.Monthlyantimicrobialutilizationdata,collectedforbothICUs,wasmeasuredusingATC/DDDmethodologyduringpre-implementation(November2015toOctober2016)andpost-implementation(December2016toNovember2017)periods.

Results: ASPprovided270recommendationsamongst327patients,withanoverallacceptancerateof91.1%.Themostcommonrecommendationsincludeddurationoptimization(26.3%),de-escalationoftherapy(21.9%)anddiscontinuationoftherapy(21.5%).A19.6%reductionintheuseofantimicrobialswithbroad-spectrumactivityandcoverageofmulti-drugresistantorganismswasobserved(p=0.03).Significantdecreasesinuseofanti-pseudomonalantimicrobials(21.4%,p=0.04)werealsoobserved.Nosignificantdifferencesinantimicrobialusagewereobservedinthenon-interventionICU.

Conclusions: Implementationofcollaborative,prospectiveauditandfeedbackroundsinanadult,medical-surgicalICUiseffectiveinreducinguseofbroad-spectrumantimicrobials,likelyreflectingearlierde-escalationofantimicrobialtherapy.

Appropriateness of CT and X-ray Ordering by Physicians for Low Back Pain: A Systematic ReviewGabrielleLogan,MemorialUniversityAmandaHall,MemorialUniversity

Background. ChoosingWiselyrecommendsappropriateuseofdiagnosticimagingforlowbackpaintodecreaseunnecessarytesting.Severalstudieshaveinvestigatedtheappropriatenessofimagingwhencomparedtotheguidelines,yetnosynthesishasbeenconductedtodate.ThissystematicreviewsynthesizeswhatisknownregardingtheappropriatenessofCTandx-rayimagingforlowbackpain.

Methods. PubmedandEmbaseweresearchedforderivativetermsof“lowbackpain”,“guidelines”,and“adherence”.Titles,abstractsandfulltextswerereviewedforinclusionbyreviewers.Referencelistsofincludedstudieswerealsoscannedforeligiblestudies.NationalInstituteofHealth’sQualityAssessmentToolforObservationalCohortandCross-SectionalStudieswasusedonincludedstudies.Datawasextractedanddescriptivelysynthesized.

Results. 671publicationswereidentifiedintheelectronicsearchand131underwentfulltextreview.TwostudiesreportedappropriatenessofCTscans,threereportedappropriatenessofx-rays,andeightstudiesreportedcombinedappropriatenessforatotalof13includedstudies.StudieswereconductedinCanada,UnitedStates,Ireland,France,Australia,&Finland.ComparisonguidelinescamefromtheEuropeanCommissionrecommendations,AgencyforHealthcareResearch&Quality,AgencyforHealthCarePolicy&Research,NationalInstituteforHealth&CareExcellence,AmericanCollegeofRadiology,RoyalCollegeofRadiologists,orNationalAgencyforAccreditation&HealthEvaluation.Ratesofappropriatenessrangedfrom2%to96%.

Conclusion. Widevariationintheratesofappropriatenessexistswhichmaybeduetothedifferentguidelinesusedtogenerateappropriatenesscriteria.Thisareawouldbenefitfromfurthercollaborationamongexpertstogenerateastandardizedsetofcriteriawithwhichtojudgeimagingappropriateness.

MEDICAL EDUCATION - PAGE 99

MEDICAL EDUCATION

Incorporating Resource Stewardship into Undergraduate Medical Education at McMaster University BushraKhan,CatherineFriedman,SonjaWakeling,JasmineLiu,andIfrahShahMcMasterUniversity

BackgroundMedicalstudentsreceivelimitedformaleducationinresourcestewardship(RS);withincreasinghealthcarecostsandwait-times,studentsmustbetrainedtomakechoicesthatminimizeunnecessarytestsandtreatmentstodecreasepotentialharmandspending.ChoosingWiselyCanada(CWC)createdStudentsandTraineesAdvocatingforResourceStewardship(STARS)toaddressthisneed.TwoSTARScohortsatMcMasterhaveinitiatedcurricularchange,conferences,interestgroupsandadvocatedforRStobeapriorityoftheirprovincialstudentorganization.

Case StudySTARSmetwithMcMaster’sUndergraduateMedicalEducation(UGME)DeanandthroughhisguidanceformedateamtoidentifyareastoimplementRSinthecurriculum.

Aneedsassessmentwasconductedthroughasurvey,focusingonstudents’exposureto,attitudestowards,andconfidenceapplyingresourcestewardshipprinciples.ApilotstudyincorporatingtheCWCrecommendationsinfivecasesandassessingstudents’confidenceinapplyingresourcestewardshipprinciplesbeforeandaftertheinterventionwasconducted.LearnerswerealsointroducedtoCWClistsforspecialtiesandformedicalstudentsattheirclerkshiporientation.

STARSconnectedwithphysicianchampionsofRSinHamiltonandorganizedanannualconferencetohighlighthowRStranslatedtopractice.Additionally,aninterestgroupwascreatedtofostercontinuedengagementwithlike-mindedpeers.STARSfurtherassistedinestablishingapartnershipbetweenCWCandtheOntarioMedicalStudents’AssociationtoadvocateforRStraininginUGMEacrossOntario.McMasterSTARS’experienceinincorporatingRSintheirUGMEoffersaprimeopportunityforeducatorsacrossCanadatolearnhowtofosterleadershipandengagementinRSintheirownlearners.

Choosing Wisely Canada STARS: Training the Next Generation of Medical Professionals at UBCMelissaWanandDhruvPandeyUniversityofBritishColumbia

BackgroundUnnecessarytesting,treatments,andproceduresaresrootedinphysicianhabits.Toencouragequalityandcostconscioushabits,wemustactupstreamtointroducetraineestoresourcestewardshipprinciplesearlyintheireducation.Currently,inBC,resourcestewardshipisnotreadilyintegratedintothemedicalschoolcurriculum.

GoalOurgoalistofosteraculturethatallowstraineestoengageinconversationsaboutmedicaltestingandqualityofcare,byeducatingtraineesabouttheimportanceofresourcestewardshipandequipthemwithnecessarytoolstoadvocateforappropriatecare.

InterventionAspartofthestudent-ledcampaign,theUBCSTARShavelaunchedaBC-widecampaign.Thisinvolvesadvocatingforpre-clerkshipcurriculumchangestoincluderesourcestewardshipprinciplesandthecreationofaninterestgroup.Herewewillpresentasummaryofthecurrentknowledgelevelofpre-clerkshipstudents,changesmadetotheUBCcurriculum,andtheactivitiesoftheinterestgroupthusfar.

Challenges/ Lessons LearnedChallengesincludedidentifyingopportunitiestointegrateresourcestewardshipprinciplesintoapacked,clinicalpresentationbased,curriculum.Asaresult,ourLessonsLearnedinclude:distillingdownourambitionstofocusourefforts;recommendingsmall,realistic,andpracticalchanges;andensuringthatwebuildastrongfoundationtoensurethesustainabilityofthecampaign.

ImpactWeanticipatethatthesecurriculumchangesmakealastingimpactontrainees,staff,andpatientsbyincreasingawarenessaboutresourcestewardshiptoimprovethequalityofpatientcare.

Incorporating Resource Stewardship into the University of Manitoba Undergraduate Medical Education ProgramAndreaKulyk,UniversityofManitobaMing-KaChan,UniversityofManitobaEricBohm,UniversityofManitobaSarahKirby,GeorgeandFayYeeCentreforHealthcareInnovationYounTaeChung,UniversityofManitoba

GoalThemaingoalswere1)enhancetraininginresourcestewardshipprinciplesandintegrateChoosingWiselyCanada(CWC)recommendationsintotheUniversityofManitobaUndergraduateMedicalEducation(UGME)pre-clerkshipcurriculumand2)studytheimpactofthesechangesonstudentattitudesandknowledge.

ImplementationPartoneincludedreviewingtheUGMEPCC,identifyingopportunitiesforenhancedresourcestewardshiptraining.Wedevelopednovellearningmaterials(lecturesandteam-basedsessions)andsuggestedareastointegrateCWCrecommendationsthroughoutthepre-existingcurriculum.Inparttwoweanalyzedtheimpactofthesechangesonstudents’attitudeandknowledge.

MeasuresTheadaptedcurriculumwasreviewedtodetermine1)uptakeofoursuggestionsintoexistinglectures,and2)implementationofnewcontent.Onlinesurveysassessedstudents’attitudeandknowledgetowardsresourcestewardshippreandpostimplementation(September2016,April2017).

ChallengesTwolectureswereaddedforfirstyearandoneintosecondyear.AlthoughauthorshadsupportofthePre-ClerkshipCommittee,overalluptakeofCWCrecommendationswaslessthan20%.Therewasstatisticallysignificantimprovementinstudents’knowledgescores(p

Lessons LearnedStudentsexhibitedpositiveattitudestowardsresourcestewardship.Resourcestewardshiptrainingatthepre-clerkshiplevelshouldfocusonresourcestewardshipprinciples,asopposedtospecificCWCrecommendations,givingstudentstheabilitytodevelopacorefoundation,whichcanfurtherevolveastheybecomeimmersedintheclinicalsetting.Furtherstudiesplantoexaminethechallengesofincorporatingtheaforementionedmaterials,andhowtocontinueintegratingresourcestewardshiptraininginundergraduateyears.

Time to Forget About DRE? LeenNajiandJasonProfettoMcMasterUniversity

PurposeCurrentrecommendationsregardingprostatecancerscreeningmadebyvariousCanadianguidelinesareconflicting.Surveyshavealsoshownthatwhileover80%ofCanadianfamilyphysiciansofferthedigitalrectalexam(DRE)asascreeningtoolforprostatecancer,onlyaminoritybelievesithasbenefit.Giventheconflictingguidelinesandlackofstandardizedpractice,weaimedtoevaluatethediagnosticaccuracyoftheDREinscreeningforprostatecancerintheprimarycaresetting.

MethodsSixdatabasesweresearchedfrominceptiontoJune2016.Allcitationswereindependentlyscreenedforeligibilitybythreepairsofreviewers.Thepooledsensitivity,specificity,positivepredictivevalue(PPV)andnegativepredictivevalue(NPV)oftheDREinscreeningforprostatecancerintheprimarycaresettingwerecalculatedusingmeta-analysesweightedbyinversevariance.TheGRADEframeworkwasemployedtoassessthequalityofourpooledanalyses.

ResultsOursearchyielded8,217studies,andsevenwereeligibleforinclusion(n=9,241men).AllparticipantsanalyzedreceivedbothaDREandbiopsy.Pooledsensitivitywas0.51(95%confidenceinterval[CI]0.36,0.67;I2=98.4%)andpooledspecificitywas0.59(95%CI0.41,0.76;I2=99.4%).PooledPPVwas0.41(95%CI0.31,0.52;I2=97.2%),andpooledNPVwas0.64(95%CI0.58,0.70;I2=95.0%).Thequalityofevidencewas‘verylow’inaccordancewithGRADE.

ConclusionGiventhelackofevidencesupportingitsefficacy,andtheharmsassociatedwithover-investigationandover-treatment,werecommendagainstroutineperformanceoftheDREasascreeningtoolforprostatecancerinprimarycare.

Resource Stewardship in Undergraduate Medical Education (UME)SahilSharmaandMatthewRoweSchulichSchoolofMedicine

NewresearchsuggestsCanadianphysiciansordermorethan1,000,000potentiallyunnecessarytestsandtreatmentseachyear.StrategiestoeducatemedicalstudentsabouttheCanMEDsResourceStewardshipdirectiveandjudicioustestingpracticescanhelpthehealthcaresystemmanagefiscalstressandimprovehealthcareexperiencesforpatients.ThispaperoutlinesseveralstrategiesthatcanbeimplementedattheundergraduatemedicaleducationlevelthroughChoosingWiselyCanada’sStudentsandTraineesAdvocatingforResourceStewardship(STARS)program.Theeducationalstrategiesfeaturegroup-basedlearning,lectureintegration,andsupportiveonlinemodules.Educatingmedicalstudentsacrossthecountryaboutjudicioustestingcanproducethegenerationofresource-conscientiousdoctorsthathealthcare’sincreasinglytightbudgetdemands.

Evaluating Canadian Medical Students’ Interest in and Readiness for Learning and Practicing High-Value Care: Preparing for ChangeAhmadSidiqi,NorenKhamisandGeoffreyBlairUniversityofBritishColumbia

IntroductionTheCanMEDSframeworkwasrecentlyupdatedtoincludehigh-valuecareandresourcestewardshipasacorecompetency.Thisprinciple,whichencouragesappropriateandjudicioususeofdiagnosticandtherapeuticactions,promotespatientsafetyandfostersfinancialsustainability.Whethercurrentundergraduateandresidencytrainingprogramseffectivelyeducatetraineesonhigh-valuecareremainsunknown.Weaimtotest:1)medicalstudents’currentknowledgearoundresourcestewardship;2)theimportancestudentsplaceonhigh-valuecareeducation;3)theidealformattotrainstudentsonthissubject.Resultswillguideappropriatecurriculumadjustments.

MethodsAvalidatedandresearchethics-approved21-itemonlinesurveywaspilotedon43medicalstudentsandsubsequentlydistributedtoallmedicalstudentsattheUniversityofBritishColumbiaviaanelectronicmailinglist.Thesurveywasvoluntary.Studentperspectiveswereanalyzedusingdescriptivestatistics.

ResultsTherewere88surveyresponses.Themajorityofstudents(93%)agreedorstronglyagreedontheimportanceofresourcestewardshipinclinicaldecision-making,howeverallrespondentsfeltthattheirtraininghasinadequatelypreparedthemonthistopicandonly28%feelcomfortablediscussingcostsofcareandovertreatmentwithpatients.Discussinghigh-valuecarewithresidentandstaffsupervisorswasreportedby86%ofclinicalclerkstobeaneffectiveandpreferredteachingstrategy.

ConclusionsParticipantsvalueresourcestewardshipeducation,butlackadequatetrainingonthesubject.Voluntaryresponsebiasmayhaveconfoundedtheseresults.Formallytrainingresidentsinhigh-valuecaremayenablethemtotransferthisknowledgetoclinicalclerks,andrequiresfurtherinvestigation.

PATIENT ENGAGEMENT - PAGE 106

PATIENT ENGAGEMENT

Engaging Patients as Partners in CWNL: Low Back Imaging Case StudyAmandaHall,MemorialUniversityKristaMahoney,ChoosingWiselyNLandQualityofCareNLRobertWilson,TPMI/MUNPatrickParfrey,TPMI/MemorialUniversityHollyEtchegary,ClinicalEpidemiologyandNLSUPPORT,FacultyofMedicine,MemorialUniversity

BackgroundCWNLisunderpinnedbyCIHR’sStrategyforPatientOrientedResearch(SPOR)andIntegratedKnowledgeTranslation(iKT).Thus,engagingpatients/stakeholdersaspartnersiscorecomponentinprojectplanning.Projectsareapprovedbyasteeringcommitteeofpatients,physicians,researchers,anddecision-makers.Approvedprojectsconveneateamincludingpatients/keystakeholdersaspartnerswithresource-assistancefromtheNLSupportUnit.Wepresentanexampleofourstakeholderengagement-processusingtheCWNLproject:reducingunnecessaryimagingforlowbackpain.

MethodsKnowledge-brokering(KB)andknowledge-exchange(KE)wereusedtoinitiateengagement.First,relevantknowledgeusers/stakeholderswereidentifiedandcontactedtoset-upinformalKBdiscussionsto(i)heartheirexperiencetreating/havingLBP,(ii)understandrelevanttacitknowledge,(iii)sharetheCWNL-LBPproject.Second,allstakeholderswereinvitedtoamulti-disciplinaryKEsessionto(i)introducetheprojectaim/researchteam,(ii)shareLessonsLearnedfromKB,(iii)documenttheproblemfromtheirperspective,and(iv)confirmdesiredengagementlevel.

ResultsTelephoneandface-to-faceKBsessionswithover12stakeholdergroups(i.e.patients/communitygroups,radiologists,physicians/specialists,alliedhealth,anddecisionmakers)wereconducted.33participants(organisedinto4groupswithrepresentationfromdifferentperspectives)attendedtheKEsession.AllagreedLBPmanagementneedsimprovementincludingreducingunnecessaryimaging.Desiredengagementlevelsincluded“inform”(n=23),“consult”(n=10)and“collaborate”inprojectplanning(n=16)anddisseminatingresults(n=14).

ConclusionThisprocessallowedustoconfirmthatunnecessaryimagingforLBPisapriorityissueforstakeholders.ItprovidedavenueforopenKEbetweenresearchersandknowledgeusersandwassuccessfulfordevelopingmeaningfulpartnerships.

Regional Media Strategies: Choosing Wisely in Former Cypress Health RegionKevinWasko,SaskatchewanHealthAuthority

Asalocalphysiciancommunity,theCypressRegionalMedicalAssociationrecognizedthatthesuccessfulimplementationofChoosingWiselydependedonengagementandeducationofpatients.Themedicalassociationapproachedthelocalhealthauthorityleadershiptopartneronanadvertisingcampaigntargetingpatients.

AfterreachingouttoChoosingWiselyCanada,themedicalassociationandthehealthauthoritycreatedalocalmediaandadvertisingstrategy.ThecampaignwaslaunchedwiththecreationofavideofeaturinglocalphysiciansespousingtheprinciplesofChoosingWisely.Itwasdirectedatthelocalpatientpopulationintheareaandcirculatedonsocialmedia.Itwasthoughtthatfeaturinglocalphysicianswouldresonatemorewithpatientsthansimplypromotinggenericmaterials.Thisvideowasaverysuccessfulcommunicationvehicle,withover32,000viewsaroundtheworldand265sharesonFacebook.IthasbeenpostedtotheChoosingWiselyCanadaandCollegeofPhysiciansandSurgeonsofCanadawebsites.Thevideowasfollowedupwithprintadsinthelocalpapers,disseminationofchoosingwiselymaterialsandanothervideofeaturingalocalphysician.Thesecondvideofocusedontheannualphysical.Ithasbeenviewed12,000timesandagainwasfeaturednationally.

Thiscampaignisstillongoingbuthasbeenasuccessfulwaytointroducethemovementamongstthegeneralpopulationandhasallowedforconversationsbetweenphysiciansandpatientsthatwouldhaveotherwisebeendifficulttoinitiate.Wefeelthatthelessonswehavelearnedcouldhelpinformsimilarcampaigns.

Changing the Way we Understand and Label Behaviour will Reduce the use of Antipsychotics in Dementia CareSusanMacaulay,MyAlzheimersStory.com

BackgroundInthemid-1980s,researcherDr.JiskaCohen-Mansfielddevelopedatooltomeasureagitationinpeoplelivingwithdementia(PLWD)inlong-termcarefacilities(LTCFs).CalledtheCohen-MansfieldAgitationInventory(CMAI),thetoolcomprises29behaviours.Inthelate1990s,theInternationalPsychogeriatricAssociation(IPA)tooktheCMAIandsimilarscalesand“renamed”thebehavioursonthelisttheBehaviouralandPsychologicalSymptomsofDementia(BPSD).TheIPA’snewconstructbecameawayoflabelingnormalbehaviourasaberrantinPLWD.

ObjectivesShowthatBPSDaregenerallynottheresultofdementia,butrathernormalhumanresponsestoparticularsetsofcircumstances,andthatPLWDshouldnotbeinappropriatelymedicatedfornormalbehaviour.

MethodsPersonalobservation,one-on-oneinteractionwithaPLWD(6,850hoursoverfiveyears)hundredsofhoursofaudiovisualdocumentation;reviewandanalysisofnurses’notes;onlinesurveywith1,300+responses.

ResultsAssessingandreportingthebehaviourofPLWDthroughthelensofBPSDisproblematic.UsingBPSDasanassessmenttoolleadsPLWDtobeinappropriatelyprescribedantipsychoticmedications.

ConclusionsWemustreframebehaviouralexpressionsinPLWDinwaysthatenableustoidentifytheirrootcausesand,inturn,informimprovedeffortstoimplementhumane,personalized,andeffectiveapproachesforthecareofPLWD.Betterunderstandingofwhatcausesbehavioursthatdementiacarepartnersandcarestaffexperienceaschallengingwillreducesuchbehavioursandthustheratesatwhichantipsychoticsareprescribedtoaddressthem.

Deepening Patient Engagement: Sharing the patient voice at all levels of an organization and beyondMelissaGiguere(Presenter),HealthSciencesNorthRosieGraffi,HealthSciencesNorth

Background Onourjourneytoimprovethepatientexperience,HealthSciencesNorthimplementedaframeworktodeepenthelevelofpatientengagementbyimplementingaPatientandFamilyAdvisoryProgram.ItbeganwiththeformationoftheCEOPatientandFamilyAdvisoryCouncilin2012with12members,andhasgrowntoanadditionalpoolof28PatientAdvisors(PA).PAonboardingincludesIntroductiontoLeanManagementasadvisorsparticipateinimprovementwork(36projectsoutofthetotal116theywereinvolvedin2017)acrossthesystem.PatientswhohavegonethroughthepatientrelationsprocessarereferredtoapplytobecomeaPAandtosharetheirpatientstory,furtherdeepeningtheirlevelofengagementwiththeorganization.Fourpatientstoriesarecollectedeachmonth(video,audio,written,speakingengagements)andanalyzedforsharingwiththeBoard,QualityCommitteeoftheBoard,ProgramCouncils,MedicalAdvisoryCommittee,LeadershipDevelopmentSessions,NorthernOntarioMedicalSchooleventsandwithstaffthroughanelectronicpatientstorylibrary.Patientstoriesarealsoprofiledonasocialmediablogcalled“HumansofHSN”,includingtheexperienceofpatientswhohavebeenaffectedbyacriticalincident.

Case Study: Participantsgivenacriticalincident.Usingapatientstoriescollectionguide,participantsaretaskedwithroleplayingtocollectandrecordthepatientstory,toanalyzethepatientstorywiththeanalysisguidewhichincludes:qualitydimensions,learnings,andproblem/improvement/countermeasure/measurement/results.

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