Katrina F. Hurley

Ontology Engineering to Model Clinical Pathways: Towards the Computerization and Execution of Clinical Pathways

Clinical pathways translate evidence-based recommendations into locally practicable, process-specific algorithms that reduce practice variations and optimize quality of care. Our objective was to abstract practice-oriented knowledge from a cohort of real clinical pathways and represent this knowledge as a clinical pathway ontology. We employed a four step methodology: (1) knowledge source identification and classification of clinical pathways according to variations in setting, stage of care, patient type, outcome and specialty; (2) iterative knowledge abstraction using grounded theory; (3) ontology engineering as adapted from the Model-based Incremental Knowledge Engineering approach; and, (4) ontology evaluation through encoding a sample of real clinical pathways. We present our clinical pathway ontology that offers a detailed ontological model describing the structure and function of clinical pathways. Our ontology can potentially integrate with a healthcare semantic web, and ontologies for clinical practice guidelines, patients and institutions to form the foundational knowledge for generating patient-specific CarePlans.

Evaluating a clinical practice intervention to promote delivery of salbutamol by metered-dose inhalers with holding chambers in a pediatric emergency department

OBJECTIVE The primary objective of this study was to quantify the impact of a clinical practice intervention to promote the delivery of salbutamol by metered-dose inhaler (MDI) in a pediatric emergency department (PED). A secondary objective was to retrospectively document the components of the intervention. METHODS PED inventory data for salbutamol inhalation solution (nebules), MDIs, and holding chambers were obtained from the pharmacy department. Patient data were obtained from the hospitals decision support unit. Interrupted time series analysis was used to evaluate trends in salbutamol inventory data, patient triage acuity, and hospital admissions from January 1, 2003, to May 31, 2010. Interviews and administrative documents were used to identify components of the intervention, which began in 2006. RESULTS There was a 1,215% increase in the proportion of salbutamol delivered as MDIs compared to total inhaled salbutamol (MDI plus nebulization solution) following the intervention (95% CI 1,032% to 1,396%, p < 0.001). Increases in salbutamol MDI use were associated with the implementation of an institution-specific asthma care map. A relative decrease of 32% in the hospital admission rate (absolute -7.25%: 95% CI -8.31 to -6.19, p < 0.001) was associated with the change in salbutamol MDI use and the use of the asthma care map. CONCLUSIONS A multifaceted intervention, designed and implemented by local PED clinical leaders, resulted in a pronounced change in salbutamol inhalation practice, with an associated decrease in admission rates. This intervention demonstrated many of the criteria for successful health system change. Findings from this research may be contextualized to inform change elsewhere.

Advocacy and activism in emergency medicine

Advocacy can be defined as speaking forth in order to compel positive change at a personal, institutional or governmental level. Advocacy is a central part of medical professionalism and of the growing movement of preventative medicine, which extends from the bedside to the global community. Although the subjects and means of advocacy vary, several fundamental elements are common to successful endeavours. These include knowledge, passion, skilled communication, vigilance and perseverance. Residency presents an opportunity to learn and practise advocacy, a skill that can be carried forward into our careers as emergency physicians. Some consider an advocate to be an intercessor — one who supports, pleads or speaks forth on behalf of another. Activism, on the other hand, is defined as vigorous actions to achieve political or other goals. It is not clear when advocacy becomes activism, but the 2 are part of a continuum designed to reach similar ends. We may engage in advocacy with or on behalf of individual patients, local communities or broader communities, such as those at a state, provincial, national or global level. We act as bedside advocates when we counsel patients to quit smoking, wear bicycle helmets and use seatbelts. Community advocates might lobby for improved street lighting at a dangerous intersection or a needle exchange for drug addicts. Advocacy for improved traffic legislation and disaster preparedness, for example, affect the larger community. We can embark on these activities as individuals, as members of a physician organization such as the Canadian Association of Emergency Physicians (CAEP), or as members of community organizations such as Families for Seismic School Safety.

Probing the effect of OSCE checklist length on inter-observer reliability and observer accuracy

Purpose The Objective Structured Clinical Examination (OSCE) is a widely employed tool for measuring clinical competence. In the drive toward comprehensive assessment, OSCE stations and checklists may become increasingly complex. The objective of this study was to probe inter-observer reliability and observer accuracy as a function of OSCE checklist length. Method Study participants included emergency physicians and senior residents in Emergency Medicine at Dalhousie University. Participants watched an identical series of four, scripted, standardized videos enacting 10-min OSCE stations and completed corresponding assessment checklists. Each participating observer was provided with a random combination of two 40-item and two 20-item checklists. A panel of physicians scored the scenarios through repeated video review to determine the ‘gold standard’ checklist scores. Results Fifty-seven observers completed 228 assessment checklists. Mean observer accuracy ranged from 73 to 93% (14.6–18.7/20), with an overall accuracy of 86% (17.2/20), and inter-rater reliability range of 58–78%. After controlling for station and individual variation, no effect was observed regarding the number of checklist items on overall accuracy (p=0.2305). Consistency in ratings was calculated using intraclass correlation coefficient and demonstrated no significant difference in consistency between the 20- and 40-item checklists (ranged from 0.432 to 0.781, p-values from 0.56 to 0.73). Conclusions The addition of 20 checklist items to a core list of 20 items in an OSCE assessment checklist does not appear to impact observer accuracy or inter-rater reliability.Purpose The Objective Structured Clinical Examination (OSCE) is a widely employed tool for measuring clinical competence. In the drive toward comprehensive assessment, OSCE stations and checklists may become increasingly complex. The objective of this study was to probe inter-observer reliability and observer accuracy as a function of OSCE checklist length. Method Study participants included emergency physicians and senior residents in Emergency Medicine at Dalhousie University. Participants watched an identical series of four, scripted, standardized videos enacting 10-min OSCE stations and completed corresponding assessment checklists. Each participating observer was provided with a random combination of two 40-item and two 20-item checklists. A panel of physicians scored the scenarios through repeated video review to determine the ‘gold standard’ checklist scores. Results Fifty-seven observers completed 228 assessment checklists. Mean observer accuracy ranged from 73 to 93% (14.6–18.7/20), with an overall accuracy of 86% (17.2/20), and inter-rater reliability range of 58–78%. After controlling for station and individual variation, no effect was observed regarding the number of checklist items on overall accuracy (p=0.2305). Consistency in ratings was calculated using intraclass correlation coefficient and demonstrated no significant difference in consistency between the 20- and 40-item checklists (ranged from 0.432 to 0.781, p-values from 0.56 to 0.73). Conclusions The addition of 20 checklist items to a core list of 20 items in an OSCE assessment checklist does not appear to impact observer accuracy or inter-rater reliability.

Infant strangulation from an amber teething necklace

Amber teething necklaces supposedly provide analgesia for teething infants. Their use is becoming more widespread, despite lack of peer-reviewed evidence and warnings from Health Canada that they pose a strangulation and aspiration risk. To date, there have been no published reports of strangulation secondary to amber teething necklaces. In this report we present a case of non-fatal infant strangulation from the first time use of an amber teething necklace. We will also discuss the role of physicians as advocates in reporting similar cases and educating families. Finally, we will comment on the responsibility of all professionals and professional organizations that work with infants and toddlers to advocate for children by raising concerns and counselling parents.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia.

BACKGROUND Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data. METHODS Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used. RESULTS Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of

Testing usability and measuring task-completion time in hospital-based health information systems: A systematic review

24/patient in the PED and

The utility of multiple imaging modalities to diagnose acute aortic dissection

180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs. CONCLUSIONS Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.

Examining Medical Student Specialty Choice Through a Gender Lens: An Orientational Qualitative Study

Usability testing is often performed on health information systems in hospital settings. Task-completion time is a frequently used measure of efficiency and a marker of successful systems. This paper presents a systematic review of the literature to determine if usability testing during the implementation of health information systems in hospitals is associated with reductions in the time necessary to complete tasks. Multiple databases were searched for combinations of search term variants. Search results were reviewed by two independent reviewers. Three studies met inclusion criteria. Although the studies report reductions in task-completion time on systems that have been modified after usability testing, rigorous original research that supports this theory is sparse.

Summer Camp Health Initiative: An Overview of Injury and Illness in Two Canadian Summer Camps

A 21-year-old man with Marfan syndrome and known aortic root aneurysm presented to our emergency department with symptoms suggestive of acute aortic dissection. The patient was hemodynamically stable and bilateral upper extremity blood pressures were similar. There was no mediastinal widening on portable chest radiograph. Both contrast CT and retrograde angiography of the aorta failed to identify dissection. Subsequent transesophageal echocardiography demonstrated a Stanford classification type A dissection. This case demonstrates the utility of multiple imaging modalities for identifying aortic dissection in high-risk patients.