Impact of specialized training for emergency department nurses screening or undetected HIV infection: the "Urgències VIHgila" project experience

OBJECTIVES

To evaluate the impact of specialized training for nurses on selective screening for undetected HIV infection in the emergency department.

MATERIAL AND METHODS

The intervention group was comprised of 6 emergency departments that had been participating in a screening program (the "Urgències VIHgila" project) for at least 3 months. Nurses on all shifts attended training sessions that emphasized understanding the circumstances that should lead to suspicion of unidentified HIV infection and the need to order serology. Two studies were carried out: 1) a quasi-experimental pre-post study to compare the number of orders for HIV serology in each time period and measures of sensitivity, and 2) a case-control study to compare the changes made in the 6 hospitals where specialized training was provided (cases) vs 6 control hospitals in the HIV screening program where no training was given.

RESULTS

A total of 280 HIV serologies were ordered for the 81015 patients (0.3%) attended during the period before training; 331 serologies were ordered for the 79620 patients in the period after training (0.4%). The relative increase in serologies was 20.3% (95% CI, 2.9% to 34.5%; P = .022). The relative increase in measures of sensitivity ranged between 19% and 39%, consistent with the main comparison. Serologies in the control group decreased between periods, from 0.9% to 0.8%, indicating a relative decrease of 15.7% (95% CI, -25.1% to -6.2%; P = .001). The absolute number of patients tested in the training group was 0.2% higher in the training hospitals (95% CI, 0.11% to 0.31%; P .001) than in the control hospitals.

CONCLUSION

Training nurses to screen for undetected HIV infection in the emergency department increased the number of patients tested, according to the pre-post and case-control comparisons.

[Effectiveness of the clinical assistant in the control of hypertensive and diabetic patients in primary care]

OBJECTIVE

To evaluate the effectiveness of the incorporation of the clinical assistant in improving the control of type 2 diabetes mellitus and hypertension in a primary care center.

DESIGN

Quasi-experimental study (pre-post), with a control group, with a 1-year follow-up.

SETTING

Primary care center.

PARTICIPANTS

Patients between the ages of 18 and 85 with a diagnosis of diabetes type 2 and/or hypertension were selected.

INTERVENTION

Incorporation of the figure of the clinical assistant, previously trained. The latter contacted the patient to explain their role and obtain informed consent, assessed compliance with the protocols, and when they were incomplete and/or detected warning signs, referred the patient directly to medicine and/or nursing.

RESULTS

Three thousand and sixty-four patients participated, 30.74% assigned to the intervention group. Fifty percent were women. The mean age was 68.5 years (SD 11.07). 93.59% of diabetic patients in the intervention group had at least one determination of glycosylated hemoglobin compared to 86.83% in the control group (p=0.003). Fundus and diabetic foot screening was significantly higher in the intervention group (94.31% and 85.41% vs. 83.49% and 72.38%). 88.43% of the patients in the intervention group had registered blood pressure figures compared to 62.06% of the patients in the control group (p<0.05). There were not statistically significant differences in the control of blood pressure between the patients with recorded measures (p=0.478).

CONCLUSIONS

Clinical assistants can facilitate the implementation and compliance with chronic diseases protocols, and in the long run improve the degree of control of these patients and the quality of care.

Comprehensive care programmes for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) represent a small, but growing, proportion of all children. Regardless of their underlying diagnosis, by definition, all CMC have similar functional limitations and high healthcare needs. It has been suggested that improving aspects of healthcare delivery for CMC improves health- and quality of life-related outcomes for children and their families and reduces healthcare-related expenditure. As a result, dedicated comprehensive care programmes have been established at many hospitals to meet the needs of CMC; however, it is unclear if such programmes are effective.

OBJECTIVES

Our main objective was to assess the effectiveness of comprehensive care programmes that aim to improve care coordination and other aspects of health care for CMC and to assess whether the effectiveness of such programmes differs according to the programme setting and structure. We aimed to assess their effectiveness in relation to child and parent health, functioning, and quality of life, quality of care, number of healthcare encounters, unmet healthcare needs, and total healthcare-related costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and CINAHL in May 2023. We also searched reference lists, trial registries, and the grey literature.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies, and interrupted time series studies were included. Studies that compared enrolment in a comprehensive care programme with non-enrolment in such a programme/treatment as usual were included. Participants were children that met the criteria for the definition of CMC, which is: having (i) a chronic condition, (ii) functional limitations, (iii) increased health and other service needs, and (iv) increased healthcare costs. Studies that included the following types of outcomes were included: health; quality of care; utilisation, coverage and access; resource use and costs; equity; and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed the risk of bias in each included study, and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. We were unable to undertake a meta-analysis for comparisons and outcomes, so we used a structured synthesis approach.

MAIN RESULTS

We included four studies with a total of 912 CMC as participants. All included studies were randomised controlled trials conducted in hospitals in the USA or Canada. Participants varied across the included studies; however, all four studies included children with complex and chronic illness and high healthcare needs. While the primary aim of the intervention was similar across all four studies, the components of the interventions differed: in the four studies, the intervention involved some element of care coordination; in two of the studies, it involved the child receiving care from a multidisciplinary team, while in one study, the intervention was primarily centred on access to an advanced practice nurse care coordinator and another study involved nurse a practitioner-paediatrician dyad partnering with families. The risk of bias in the four studies varied across domains, with issues primarily relating to the lack of blinding of participants, personnel, and outcome assessors, inadequate allocation concealment, and incomplete outcome data. Comprehensive care for CMC compared to usual care may make little to no difference to child health, functioning, and quality of life at 12 or 24 months (three studies with 404 participants) and we assessed the evidence for the outcomes in this category (child health-related quality of life and functional status) as being of low certainty. For CMC, comprehensive care probably makes little or no difference to parent health, functioning, and quality of life compared to usual care at 12 months (one study with 117 participants) and we assessed the evidence for this outcome as being of moderate certainty. Comprehensive care for CMC compared to usual care may slightly improve child and family satisfaction with, and perceptions of, care and service delivery at 12 months (three studies with 453 participants); however, we assessed the evidence for these outcomes as being of low certainty. For CMC, comprehensive care probably makes little or no difference to the number of healthcare encounters (emergency department visits) and the number of hospitalised days (hospital admissions) compared to usual care at 12 months (three studies with 668 participants), and we assessed the evidence for these outcomes as being of moderate certainty. Three of the included studies (668 participants) reported cost outcomes and had conflicting results, with one study reporting significantly lower healthcare costs at 12 months in the intervention group compared to the control group, one reporting no differences between groups, and the other study reporting a greater increase in total healthcare costs in the intervention group compared to the control group. Overall, comprehensive care may make little or no difference to overall healthcare costs in CMC; however, the methods used to measure total healthcare costs varied across studies and the certainty of the evidence relating to this outcome is low. No studies assessed the costs to the family.

AUTHORS' CONCLUSIONS

The findings of this review should be treated with caution due to the limited amount and quality of the published research that was available to be included. Overall, the certainty of the evidence for the effectiveness of comprehensive care for CMC ranged from low to moderate across outcomes and there is currently insufficient evidence on which to draw strong conclusions. There is a need for more high-quality randomised trials with consistency of the target population and intervention components, methods of reporting outcomes, and follow-up periods, as well as full cost analyses, taking into account both costs to the family and costs to the healthcare system.

A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study

PURPOSE

To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care.

METHODS

We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points).

RESULTS

We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC.

CONCLUSIONS

Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.

Effects of COVID-19-targeted non-pharmaceutical interventions on pediatric hospital admissions in North Italian hospitals, 2017 to 2022: a quasi-experimental study interrupted time-series analysis

Background

The use of Non-Pharmaceutical Interventions (NPIs), such as lockdowns, social distancing and school closures, against the COVID-19 epidemic is debated, particularly for the possible negative effects on vulnerable populations, including children and adolescents. This study therefore aimed to quantify the impact of NPIs on the trend of pediatric hospitalizations during 2 years of pandemic compared to the previous 3 years, also considering two pandemic phases according to the type of adopted NPIs.

Methods

This is a multicenter, quasi-experimental before-after study conducted in 12 hospitals of the Emilia-Romagna Region, Northern Italy, with NPI implementation as the intervention event. The 3 years preceding the beginning of NPI implementation (in March 2020) constituted the pre-pandemic phase. The subsequent 2 years were further subdivided into a school closure phase (up to September 2020) and a subsequent mitigation measures phase with less stringent restrictions. School closure was chosen as delimitation as it particularly concerns young people. Interrupted Time Series (ITS) regression analysis was applied to calculate Hospitalization Rate Ratios (HRR) on the diagnostic categories exhibiting the greatest variation. ITS allows the estimation of changes attributable to an intervention, both in terms of immediate (level change) and sustained (slope change) effects, while accounting for pre-intervention secular trends.

Results

Overall, in the 60 months of the study there were 84,368 cases. Compared to the pre-pandemic years, statistically significant 35 and 19% decreases in hospitalizations were observed during school closure and in the following mitigation measures phase, respectively. The greatest reduction was recorded for "Respiratory Diseases," whereas the "Mental Disorders" category exhibited a significant increase during mitigation measures. ITS analysis confirms a high reduction of level change during school closure for Respiratory Diseases (HRR 0.19, 95%CI 0.08-0.47) and a similar but smaller significant reduction when mitigation measures were enacted. Level change for Mental Disorders significantly decreased during school closure (HRR 0.50, 95%CI 0.30-0.82) but increased during mitigation measures by 28% (HRR 1.28, 95%CI 0.98-1.69).

Conclusion

Our findings provide information on the impact of COVID-19 NPIs which may inform public health policies in future health crises, plan effective control and preventative interventions and target resources where needed.

Significantly reduced duration of antibiotic prescription for erysipelas subsequent to the 2019 French guidelines on skin and soft tissue infection: A before-after study

BACKGROUND

New skin and soft tissue infections (SSTI) guidelines were published in 2019 in France, changing the recommended duration for antibiotic treatment. The objective of the present study was to assess the impact of the publication of the 2019 French guidelines on SSTIs on the duration of antibiotic prescription for erysipelas.

METHODS

In a before-after study (a year before and a year after April 1st, 2019), we included all adult patients diagnosed with erysipelas in Reims University Hospital medical wards and the emergency department. We retrospectively retrieved antibiotic prescription duration in the patients' medical files.

RESULTS

Among 50 patients in the "before" and 39 in the "after" group, the mean duration of antibiotic prescription was significantly shorter in the "after" group (9.4 ± 2.8 vs. 12.4 ± 3.8 days, p = 0.0001).

CONCLUSIONS

A 25% decrease in the duration of antibiotic prescription for erysipelas was observed following the implementation of these guidelines, providing useful information for an antibiotic stewardship policy.

A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study

OBJECTIVES

To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications.

DESIGN

A retrospective before-after study.

SETTING

A tertiary-care academic hospital.

PARTICIPANTS

Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups.

INTERVENTION

The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035).

CONCLUSIONS

Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.

Nurse-based counselling on thirst in patients with advanced chronic heart failure : Study protocol for a pilot before-after study and process evaluation

BACKGROUND

Many patients with chronic heart failure (CHF) are critically ill and experience increased thirst. Study aims are to develop and evaluate a nurse-based counselling intervention to promote self-care competencies related to thirst in hospitalised patients with advanced CHF eligible or listed for heart transplantation.

METHODS

A mixed-methods approach will be adapted with three study phases: (1) development of the nurse-based counselling intervention, (2) feasibility testing and training of nurses, and (3) implementation of the intervention and, evaluation of initial effects and process measures. In phase (1), interviews with hospitalised patients with advanced CHF listed for heart transplantation (n = 10), focus groups (n = 2) and a Germany-wide survey with nurses will be performed. In phase (2), experts experienced with caring for patients with advanced CHF and patients with advanced CHF will be consulted for content validation and pretest of the counselling intervention. The training concept for nurses will be evaluated using questionnaires. In phase (3), a pilot before-after study will be conducted (n = 60). Primary patient-related outcome for the pilot study is thirst intensity using a numeric rating scale. Furthermore, a process evaluation (interviews with patients [n = 10], survey with nurses and physicians) will be performed. Quantitative data will be analysed descriptively, and qualitative data will be analysed using content analysis. Mean values of thirst intensity of the individual measurement points will be evaluated as interrupted time-series analysis using regression analyses.

CONCLUSION

The development and implementation of a counselling intervention is influenced by various factors. Therefore, it is important to consider all factors throughout the process from development to evaluation.

A before-after study to evaluate the effect of pharmacy workflow redesign to improve pharmacy waiting time and reduce medication near misses in Malaysia

OBJECTIVES

This study aimed to evaluate the effectiveness of workflow redesign (eaST system) on pharmacy waiting time and near-missed events. We also investigated other factors that may potentially affect these study outcomes.

METHODS

A quasi-experimental (before-after) study design was adopted. Pre-intervention data were collected over 7 months (January-July 2017). Subsequently, the workflow redesign (eaST system) was implemented and the effect of the intervention (August 2017-February 2018) was evaluated. Univariate analysis was used to compare the differences between pre-intervention and post-intervention of pharmacy waiting time and near-missed events. Significant factors affecting study outcomes were analysed using linear regression analysis.

KEY FINDINGS

A total of 210,530 prescriptions were analysed. The eaST system significantly increases the percentage of prescriptions dispensed within 30 min per day (median = 68 (interquartile range (IQR) = 41) vs. median = 93 (IQR = 33), P < 0.001) and reduced the mean percentage of near-missed events (mean = 50.71 (standard deviation (SD) = 23.95) vs. mean = 27.87 (SD = 12.23), P < 0.001). However, the eaST system's effects on related outcomes were conditional on a three-way interaction effect. The eaST system's effects on pharmacy waiting time were influenced by the number of prescriptions received and the number of PhIS server disruptions. Conversely, the eaST system's effects on near-missed events were influenced by the number of pharmacy personnel and number of controlled medications.

CONCLUSIONS

Overall, the eaST system improved the pharmacy waiting time and reduced near-missed events.

Effects of clear aligners on the vertical position of the molar teeth and the vertical and sagittal relationships of the face: a preliminary retrospective before-after clinical trial

INTRODUCTION

Despite the popularity of clear aligners, their predictability has not been assessed adequately. Moreover, no study has investigated their effects on numerous dentomaxillary variables. Therefore, this study was conducted for the first time, assessing several new or controversial items. The aim of the study was to evaluate the effects of clear aligners on the vertical position of the molar teeth and the vertical and sagittal relationships of the face.

METHODS

This preliminary retrospective before-after non-randomized clinical trial was performed on 168 observations of 84 patients (33.60±9.28 years, 54 females) treated with 0.75mm Invisalign appliances. Pretreatment and posttreatment values were measured for: mandibular plane angle, occlusal plane angle, Y-Axis, ANB, facial angle, lower anterior facial height, overbite, and the distances of the molars from the palate and mandibular plane were measured. The alterations in parameters caused by treatment (delta values) were calculated for each measurement. Effects of treatment and some parameters on delta values were analyzed statistically (α=0.05).

RESULTS

Mean±SD of ΔMP-FH, ΔOP-FH, ΔY-Axis, ΔLAFH, ΔNPog-FH, ΔANB, ΔOverbite, ΔSNB, Δ6-PP, Δ7-PP, Δ6-MP, and Δ7-MP were respectively 0.11±1.61, 0.80±1.56, 0.15±1.18, 0.07±0.91, -0.22±1.25, 0.03±0.62, 0.04±1.15, -0.06±1.14, -0.36±0.94, -0.32±1.14, 0.19±0.96, 0.18±1.10. Only the alterations in OP-FH, 6-PP, and 7-PP were significant (P≤0.011). Age, sex, treatment duration, or pretreatment mandibular plane angle were not correlated with any delta values. However, the pretreatment occlusal plane angle was negatively correlated with ΔOP-FH and ΔY-Axis. Crowding was correlated negatively with ΔOP-FH and ΔY-Axis and positively with ΔNPog-FH. Overjet was negatively correlated with ΔANB and ΔOverbite (P≤0.035).

CONCLUSIONS

Invisalign intruded first/second maxillary molars and increased the occlusal plane angle. Age, sex, and treatment duration were not correlated with post-treatment anatomic alterations.

A cost-effectiveness analysis of a universal, preventative-focused, parent and infant programme

BACKGROUND

This study assessed whether a relatively newly developed Parent and Infant (PIN) parenting support programme was cost-effective when compared to services as usual (SAU).

METHODS

The cost-effectiveness of the PIN programme versus SAU was assessed from an Irish health and social care perspective over a 24-month timeframe and within the context of a non-randomised, controlled before-and-after trial. In total, 163 parent-infant dyads were included in the study (86 intervention, 77 control). The primary outcome measure for the economic evaluation was the Parenting Sense of Competence Scale (PSOC).

RESULTS

The average cost of the PIN programme was €647 per dyad. The mean (SE) cost (including programme costs) was €7,027 (SE €1,345) compared to €4,811 (SE €593) in the control arm, generating a (non-significant) mean cost difference of €2,216 (bootstrap 95% CI -€665 to €5,096; p = 0.14). The mean incremental cost-effectiveness of the PIN service was €614 per PSOC unit gained (bootstrap 95% CI €54 to €1,481). The probability that the PIN programme was cost-effective, was 87% at a willingness-to-pay of €1,000 per one unit change in the PSOC.

CONCLUSIONS

Our findings suggest that the PIN programme was cost-effective at a relatively low willingness-to-pay threshold when compared to SAU. This study addresses a significant knowledge gap in the field of early intervention by providing important real world evidence on the implementation costs and cost-effectiveness of a universal early years parenting programme. The challenges involved in assessing the cost-effectiveness of preventative interventions for very young children and their parents are also discussed.

TRIAL REGISTRATION

ISRCTN17488830 (Date of registration: 27/11/15). This trial was retrospectively registered.

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study

BACKGROUND AND IMPORTANCE

The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic.

OBJECTIVE

To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis.

DESIGN

This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios.

SETTINGS AND PARTICIPANTS

Patients attended 34 Spanish EDs.

INTERVENTION OR EXPOSURE

The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results.

OUTCOME MEASURES AND ANALYSIS

The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI).

MAIN RESULTS

HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests.

CONCLUSION

Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

Population-based interventions for preventing falls and fall-related injuries in older people

BACKGROUND

Around one-third of older adults aged 65 years or older who live in the community fall each year. Interventions to prevent falls can be designed to target the whole community, rather than selected individuals. These population-level interventions may be facilitated by different healthcare, social care, and community-level agencies. They aim to tackle the determinants that lead to risk of falling in older people, and include components such as community-wide polices for vitamin D supplementation for older adults, reducing fall hazards in the community or people's homes, or providing public health information or implementation of public health programmes that reduce fall risk (e.g. low-cost or free gym membership for older adults to encourage increased physical activity).

OBJECTIVES

To review and synthesise the current evidence on the effects of population-based interventions for preventing falls and fall-related injuries in older people. We defined population-based interventions as community-wide initiatives to change the underlying societal, cultural, or environmental conditions increasing the risk of falling.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in December 2020, and conducted a top-up search of CENTRAL, MEDLINE, and Embase in January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, trials with stepped-wedge designs, and controlled non-randomised studies evaluating population-level interventions for preventing falls and fall-related injuries in adults ≥ 60 years of age. Population-based interventions target entire communities. We excluded studies only targeting people at high risk of falling or with specific comorbidities, or residents living in institutionalised settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and used GRADE to assess the certainty of the evidence. We prioritised seven outcomes: rate of falls, number of fallers, number of people experiencing one or more fall-related injuries, number of people experiencing one or more fall-related fracture, number of people requiring hospital admission for one or more falls, adverse events, and economic analysis of interventions. Other outcomes of interest were: number of people experiencing one or more falls requiring medical attention, health-related quality of life, fall-related mortality, and concerns about falling.

MAIN RESULTS

We included nine studies: two cluster RCTs and seven non-randomised trials (of which five were controlled before-and-after studies (CBAs), and two were controlled interrupted time series (CITS)). The numbers of older adults in intervention and control regions ranged from 1200 to 137,000 older residents in seven studies. The other two studies reported only total population size rather than numbers of older adults (67,300 and 172,500 residents). Most studies used hospital record systems to collect outcome data, but three only used questionnaire data in a random sample of residents; one study used both methods of data collection. The studies lasted between 14 months and eight years. We used Prevention of Falls Network Europe (ProFaNE) taxonomy to classify the types of interventions. All studies evaluated multicomponent falls prevention interventions. One study (n = 4542) also included a medication and nutrition intervention. We did not pool data owing to lack of consistency in study designs. Medication or nutrition Older people in the intervention area were offered free-of-charge daily supplements of calcium carbonate and vitamin D3. Although female residents exposed to this falls prevention programme had fewer fall-related hospital admissions (with no evidence of a difference for male residents) compared to a control area, we were unsure of this finding because the certainty of evidence was very low. This cluster RCT included high and unclear risks of bias in several domains, and we could not determine levels of imprecision in the effect estimate reported by study authors. Because this evidence is of very low certainty, we have not included quantitative results here. This study reported none of our other review outcomes. Multicomponent interventions Types of interventions included components of exercise, environment modification (home; community; public spaces), staff training, and knowledge and education. Studies included some or all of these components in their programme design. The effectiveness of multicomponent falls prevention interventions for all reported outcomes is uncertain. The two cluster RCTs included high or unclear risk of bias, and we had no reasons to upgrade the certainty of evidence from the non-randomised trial designs (which started as low-certainty evidence). We also noted possible imprecision in some effect estimates and inconsistent findings between studies. Given the very low-certainty evidence for all outcomes, we have not reported quantitative findings here. One cluster RCT reported lower rates of falls in the intervention area than the control area, with fewer people in the intervention area having one or more falls and fall-related injuries, but with little or no difference in the number of people having one or more fall-related fractures. In another cluster RCT (a multi-arm study), study authors reported no evidence of a difference in the number of female or male residents with falls leading to hospital admission after either a multicomponent intervention ("environmental and health programme") or a combination of this programme and the calcium and vitamin D3 programme (above). One CBA reported no difference in rate of falls between intervention and control group areas, and another CBA reported no difference in rate of falls inside or outside the home. Two CBAs found no evidence of a difference in the number of fallers, and another CBA found no evidence of a difference in fall-related injuries. One CITS found no evidence of a difference in the number of people having one or more fall-related fractures. No studies reported adverse events.

AUTHORS' CONCLUSIONS

Given the very low-certainty evidence, we are unsure whether population-based multicomponent or nutrition and medication interventions are effective at reducing falls and fall-related injuries in older adults. Methodologically robust cluster RCTs with sufficiently large communities and numbers of clusters are needed. Establishing a rate of sampling for population-based studies would help in determining the size of communities to include. Interventions should be described in detail to allow investigation of effectiveness of individual components of multicomponent interventions; using the ProFaNE taxonomy for this would improve consistency between studies.

Impact of wearable wireless continuous vital sign monitoring in abdominal surgical patients: before-after study

BACKGROUND

Technological advances have enabled continuous monitoring of vital signs (CMVS) by wearable, wireless devices on general hospital wards to facilitate early detection of clinical deterioration, which could potentially improve clinical outcomes. However, evidence on the impact of these CMVS systems on patient outcomes is limited. This research aimed to explore the effect of CMVS on the clinical outcomes in major abdominal surgery patients in a general surgery ward.

METHODS

A single-centre before-after study was conducted from October 2019 to June 2022. Patients in the intervention group received CMVS in addition to conventional intermittent vital sign monitoring (standard care for control group). With CMVS, heart rate and respiratory rate were measured every 5 min by a patch sensor. Proactive vital signs trends assessments and, when necessary, subsequent nursing activities were performed every nursing shift. The primary outcome of interest was the length of hospital stay (LOS); also, 12 patient-related outcomes were analysed. In the CMVS group, follow-up nursing activities of deviating vital signs trends were described and patient acceptability was measured. Post-hoc subgroup analysis was performed for colorectal and hepatopancreatobiliary surgery.

RESULTS

A total of 908 patients were included (colorectal: n = 650; hepatopancreatobiliary: n = 257). Overall, median LOS was lower in the CMVS group (5.0 versus 5.5 days; P = 0.012), respectively. Post-hoc subgroup analysis showed this reduction in LOS was mostly observed in the colorectal group and not in the hepatopancreatobiliary group. Apart from a decrease in nurse-to-house-officer calls (from 15.3% to 7.7%; P = 0.007), all secondary clinical outcomes were similar in CMVS and control groups. However, a non-significant trend towards less-severe complications and reduced ICU LOS was observed in the CMVS group. In CMVS patients, 109 additional nursing activities were performed and 83% of patients indicated CMVS was acceptable.

CONCLUSION

CMVS was associated with a significant reduction in LOS, while other clinical outcomes were unchanged. CMVS triggered additional nursing activities such as extra patient assessments and therapeutic interventions.

The Impacts of Selling Alcohol in Grocery Stores in Ontario, Canada: A Before-After Study

OBJECTIVE

From 2015 to 2019, the Government of Ontario expanded privatized sales of alcohol, licensing 450 grocery stores to sell beer, cider, and wine. The impacts of a nearby grocery store gaining an alcohol license on adults' alcohol use in Ontario are examined, including whether impacts differed by gender.

METHOD

Data from 2015-2019 Canadian Community Health Survey participants in Ontario (age ≥ 20 years), living within 1,000 m and 1,500 m of grocery stores that gained a license to sell alcohol and propensity-matched controls were included (1,000 m n = 14,052, 1,500 m n = 30,486). Alcohol use outcomes included past-7-day number of standard drinks consumed, near-daily drinking (≥4 days/week), and heavy drinking (5+ drinks in men/4+ in women, at least once/month). Gender-specific difference-in-differences (DiD) analyses compared changes in alcohol use before and after intervention in intervention and control populations.

RESULTS

Decreases in past-7-day drinks, near-daily drinking, and heavy drinking were observed after intervention in both intervention and control populations. At the 1,000 m level, adjusted DiD analyses showed past-7-day drinking in women (risk ratio = 1.21, 95% CI [0.88, 1.60]) and heavy drinking in men (odds ratio = 1.38, 95% CI [0.92, 2.08]) had effect sizes above 1, a relative increase over controls, although confidence intervals crossed 1. Findings did not indicate significant differences in alcohol use in intervention relative to controls for other alcohol use measures and at 1,500 m.

CONCLUSIONS

Findings suggest no association between a partial alcohol deregulation initiative in Ontario and alcohol use from 2015 to 2019. It is important to monitor the impacts on alcohol use over time as further alcohol deregulation plans in Ontario and other jurisdictions are considered.

Effects of a healthcare students' prevention intervention for school children on their own substance use: a before-after study

BACKGROUND

Cognitive dissonance theory and research has suggested that engaging in prevention interventions for other students may be a means of reducing one's own problematic behaviors in order to reduce potential cognitive dissonance. This study assessed the effects of a new mandatory prevention intervention program for healthcare students in France. The aim was to measure the effects of engaging in a prevention program in schools on the usual increase in substance use in student populations.

METHODS

Healthcare students were trained in a French university to develop psychosocial competences as a health promotion means (FEPS training) or more specifically to prevent substance use in teenagers (Unplugged program training). The students (n = 314) who accepted to take part in the study from both groups completed questionnaires before their interventions in schools, and at the end of the year, measuring their representations and behaviors regarding psychoactive substances.

RESULTS

The results indicated a significant reduction in alcohol consumption in terms of quantity, but no significant reduction in tobacco and marijuana consumption.

CONCLUSIONS

This study showed that, contrary to the usual increase in substance use in students as they advance in their year, the students who took part in this study showed reduced self-reported consumption of alcohol after they had performed the prevention intervention in schools regardless of the type of training they had received (general health promotion vs. specific substance use prevention program). Limitations and future perspectives are discussed.

Medication reconciliationis it possible to speed up without compromising quality? A before-after study in the emergency department

OBJECTIVE

The aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more efficient method will enable more patients to receive MR as early as possible after admission to hospital.

METHODS

Potential key factors for improvement of the standard method of MR by clinical pharmacists were identified through an observational period. A revised method was developed, focusing on decreasing time spent on the patient interview by use of a condensed checklist and probing questions based on information from a prescription database. Non-inferior quality (proportion of patients with at least one identified medication discrepancy and number of identified medication discrepancies per patient) of the revised method was evaluated using a before-after study design with 200 individuals in each group. Non-inferiority limit was set at 10%. The Mann-Whitney U test was used for statistical evaluation of the difference in time use per patient in the MR process between the before and after group.

RESULTS

Mean age of the included patients was 78 years in both groups. The time used for MR in the after group was 34% shorter (37 min vs 56 min, p<0.0001) compared with the before group. The revised method was shown to be non-inferior compared with the original method with respect to the proportion of patients with at least one identified discrepancy (81%, 95% CI 76% to 86% vs 79%, 95% CI 73% to 84%). Also, non-inferiority was shown for the number of identified discrepancies per patient, where the average number of discrepancies per patient was 1.9 (95% CI 1.7 to 2.1) in both groups.

CONCLUSION

This study showed that it was possible to speed up the MR process without compromising its effectiveness in identifying medication discrepancies.

Audit and feedback as a tool to increase compliance with carbapenemase-producing Enterobacteriaceae (CPE) screening and decrease CPE transmission in the hospital

OBJECTIVE

To increase compliance with carbapenemase-producing Enterobacteriaceae (CPE) screening through real-time audit and feedback in our hospital and decrease CPE transmissions.

DESIGN

A before-and-after trial, using active enhanced surveillance of CPE carriers.

SETTING

A 500-bed, secondary, university-affiliated hospital that serves a population of 450,000 in a northern district in Israel.

METHODS

The study was conducted during 2016-2019 and included patients who were admitted to the hospital and fulfilled CPE screening criteria upon admission and during prolonged hospitalizations. On January 1, 2017, the infection control team implemented a new strategy of real-time feedback toward compliance with in-hospital screening guidelines. Other infection control measurements were performed without interventions. The primary outcome was compliance with appropriate CPE screening. Secondary outcomes included CPE acquisition and compliance with hand hygiene and contact precaution practices. Data were analyzed to calculate differences between compliance with CPE screening during the study period and to test the correlation between contact precautions and hand hygiene practices according to compliance with CPE screening.

RESULTS

During the study period, 3,131 patients were eligible for CPE screening. We detected a statistically significant increase in compliance to CPE screening from 74% during 2017 to 92% in 2018 and 95% in 2019 (P < .0001 for both comparisons). We detected a decrease in CPE transmission from 12% in 2017 to 2% in 2019 (P < .0001). We did not find any correlation between other infection control interventions and CPE screening and acquisition.

CONCLUSION

Audit and feedback can improve appropriate CPE screening and may reduce CPE transmission in the hospital.

Can video communication in the emergency medical communication centre improve dispatch precision? A before-after study in Norwegian helicopter emergency medical services

OBJECTIVES

Dispatching helicopter emergency medical services (HEMS) to the patients with the greatest medical or logistical benefit remains challenging. The introduction of video calls (VC) in the emergency medical communication centres (EMCC) could provide additional information for EMCC operators and HEMS physicians when assessing the need for HEMS dispatch. The aim of this study was to evaluate the impact from VC in the EMCC on HEMS dispatch precision.

DESIGN

An observational before-after study.

SETTING

The regional EMCC and one HEMS base in Mid-Norway.

PARTICIPANTS

EMCC operators and HEMS physicians at the EMCC and HEMS base in Trondheim, Norway.

INTERVENTION

In January 2022, VC became available in emergency calls in Trondheim EMCC. Data were collected from 2020 2021 (pre-intervention) and 2022 (post-intervention).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of seriously ill or injured HEMS patients, defined as a National Advisory Committee for Aeronautics (NACA) score between 4 and 7. The secondary outcome was the proportion of inappropriate dispatches, defined as missions with neither provision of additional competence nor any logistical contribution based on quality indicators for physician-staffed emergency medical services.

RESULTS

811 and 402 HEMS missions with patient contact were included in the pre- and post-intervention group, respectively. The proportion of missions with NACA 4-7 was not significantly changed after the intervention (OR 1.21, 95% CI 0.92 to 1.61, p=0.17). There was no significant change in HEMS alarm times between the pre- and post-intervention groups (7.6 min vs 6.4 min, p=0.15). The proportion of missions with neither medical nor logistical benefit was significantly lower in the post-intervention group (28.4% vs 40.3%, p=0.007).

CONCLUSION

The results from this study indicate that VC is a promising, feasible and safe tool for EMCC operators in the complex HEMS dispatch process.

Identification of microorganisms by a rapid PCR panel from positive blood cultures leads to faster optimal antimicrobial therapy - a before-after study

BACKGROUND

The BioFire® FilmArray® Blood Culture Identification Panel 1 (BF-FA-BCIP) detects microorganisms with high accuracy in positive blood cultures (BC) - a key step in the management of patients with suspected bacteraemia. We aimed to compare the time to optimal antimicrobial therapy (OAT) for the BF-FA-BCIP vs. standard culture-based identification.

METHODS

In this retrospective single-centre study with a before-after design, 386 positive BC cases with identification by BF-FA-BCIP were compared to 414 controls with culture-based identification. The primary endpoint was the time from BC sampling to OAT. Secondary endpoints were time to effective therapy, length of stay, (re-)admission to ICU, in-hospital and 30-day mortality. Outcomes were assessed using Cox proportional hazard models and logistic regressions.

RESULTS

Baseline characteristics of included adult inpatients were comparable. Main sources of bacteraemia were urinary tract and intra-abdominal infection (19.2% vs. 22.0% and 16.8% vs. 15.7%, for cases and controls, respectively). Median (95%CI) time to OAT was 25.5 (21.0-31.2) hours with BF-FA-BCIP compared to 45.7 (37.7-51.4) hours with culture-based identification. We observed no significant difference for secondary outcomes.

CONCLUSIONS

Rapid microorganism identification by BF-FA-BCIP was associated with a median 20-h earlier initiation of OAT in patients with positive BC. No impact on length of stay and mortality was noted.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04156633, registered on November 5, 2019.

Impact of filtering face pieces (FFP3) respiratory protective mask usage on the respiratory functions of informal sector carpenters in Douala: a five-month before-after study

Introduction

informal sector carpenters in Douala, Cameroon, face potential risks to their respiratory health due to daily exposure to fine particles and wood dust. The study aims to demonstrate the importance of preventing respiratory problems in this population through regular use of filtering face pieces (FFP3) respiratory masks.

Methods

the before-after study involved 37 carpenters who wore FFP3 masks during their professional activities for five months. Spirometry measurements were taken before and after the intervention to assess changes in respiratory function.

Results

significant improvements were observed in forced vital capacity (FVC) 89.6 % to 95.0 % (p<0.000), forced expiratory volume in one second (FEV1) 88.1 % to 95.0 % (p<0.000), Tiffeneau index 82.4 to 84.9 (p<0.000), and peak expiratory flow (PEF) 6.7 l/s to 7.9 l/s (p<0.000) after mask usage, indicating enhanced lung function.

Conclusion

the regular use of FFP3 masks had a positive impact on the respiratory health of informal sector carpenters in Douala, enhancing lung function and reducing airway obstruction. The study highlights the importance of preventive measures to safeguard the respiratory well-being of workers exposed to occupational hazards. Spell out Greek characters (i.e: alpha, beta).

The effect of audiovisual feedback of monitor/defibrillators on percentage of appropriate compression depth and rate during cardiopulmonary resuscitation

BACKGROUND

High quality cardiopulmonary resuscitation (CPR) is one of the key elements of the survival chain in cardiac arrest. Audiovisual feedback of chest compressions have been suggested to be beneficial by increasing the quality of CPR in the simulated cardiac arrests.

METHODS

A prospective before and after study was performed to investigate the effect of a real-time audiovisual feedback system on CPR quality during in-hospital cardiac arrest in intensive care units from November 2018 to February 2022. In the feedback period, CPR was performed with the aid of the real-time audiovisual feedback system. The primary outcome was the percentage of compressions with both adequate depth (5.0-6.0 cm) and rate (100-120/minute).

RESULTS

A total of 27,295 compressions in 30 cardiac arrests in the no-feedback period and 27,965 compressions in 30 arrests in the feedback period were analyzed. The percentage of compressions with both adequate depth and rate was 11.8% in the feedback period and 16.8% in the no-feedback period (P < 0.01). The percentage of compressions with adequate rate in the feedback period was lower than that in the no-feedback period (67.3% vs. 75.5%, P < 0.01). The percentage of beyond-target depth with the feedback was significantly higher than that without feedback (64.2% vs. 51.4%, P < 0.01).

CONCLUSION

Real-time audiovisual feedback system did not increase CPR quality and was associated with a higher percentage of compression depth deeper than the recommended 5.0-6.0 cm. It is essential to explore more effective ways of implementing feedback in real clinical settings to improve of the quality of CPR.

TRIAL REGISTRATION

NCT03902873 (study start: Nov. 2018, initial release April 2019, retrospectively registered).

Impact of the multiplex molecular FilmArray Respiratory Panel on antibiotic prescription and clinical management of immunocompromised adults with suspected acute respiratory tract infections: A retrospective before-after study

This study aimed to assess the impact of the implementation of a rapid multiplex molecular FilmArray Respiratory Panel (FRP) on the medical management of immunocompromised patients from a community general hospital. We conducted a single-center, retrospective, and before-after study. Two periods were evaluated: before the implementation of the FRP (pre-FRP) from April 2017 to May 2018 and after the implementation of the FRP (post-FRP) from January to July 2019. The inclusion criteria were immunocompromised patients over 18 years of age with suspected acute respiratory illness tested by conventional diagnostic methods (pre-FRP) or the FilmArray™ Respiratory Panel v1.7 (post-FRP). A total of 142 patients were included, 64 patients in the pre-FRP and 78 patients in the post-FRP. The positive detection rate was significantly higher in the post-FRP (63% vs. 10%, p<0.01). There were more patients receiving antimicrobial treatment in the pre-FRP compared with the post-FRP period (94% vs. 68%, p<0.01). A decrease in beta-lactam (89% vs. 61%, p<0.01) and macrolide (44% vs. 13%, p<0.01) prescriptions were observed in the post-FRP. No differences were observed in oseltamivir use (22% vs. 13%, p=0.14), changes in antimicrobial treatment, hospital admission rate, days-reduction in droplet isolation precautions, hospital length of stay (LOS), admission to intensive care unit (ICU), LOS in ICU, treatment failure and 30-day mortality. The implementation of the FRP impacted patient care by improving diagnostic yield and optimizing antimicrobial treatment in immunocompromised adult patients.

Prolonged use of intravenous administration sets on central line associated bloodstream infection, nursing workload and material use: A before-after study

OBJECTIVES

One of the interventions to reduce risk of central line associated bloodstream infection (CLABSI) is routine replacement of the intravenous administration sets. Guidelines advises a time interval that ranges between four and seven days. However many hospitals replace intravenous administration sets every four days to prevent CLABSI.

RESEARCH METHODOLOGY

In this single centre retrospective study we analysed whether the extension of the time interval from four to seven days for routine replacement of intravenous administration sets had impact on the incidence of CLABSI and colonization of the central venous catheter. Secondary outcomes were the effects on nursing workload, material use and costs.

RESULTS

In total, 1,409 patients with 1,679 central lines were included. During the pre-intervention period 2.8 CLABSI cases per 1,000 catheter days were found in comparison with 1.3 CLABSI cases per 1,000 catheter days during the post-intervention period. The rate difference between the groups was 1.52 CLABSI cases per 1,000 catheter days (95% CI: -0.50 to +4.13, p = 0.138). The intervention resulted in a saving of 345 intravenous single use plastic administration sets and 260 hours nursing time, and reduced cost with an estimate of at least 17.250 Euros.

CONCLUSION

Extension of the time interval from four to seven days for routine replacement of intravenous administration sets did not negatively affect the incidence of CLABSI.

IMPLICATIONS FOR CLINICAL PRACTICE

Additional benefits of the prolonged time interval were saving of nursing time by avoiding unnecessary routine procedures, the reducing of waste because of reducing the use of disposable materials and healthcare costs.