Roy Ilan

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Piloting an Extracurricular Quality Improvement and Patient Safety Training Program for Interprofessional Learners

MedEdPublish, 2019

Introduction Experts recommend that health professions students acquire knowledge and skills in q... more Introduction Experts recommend that health professions students acquire knowledge and skills in quality improvement and patient safety. Educational initiatives exist, but involve minimal interprofessional contact and experiential learning. We piloted an extracurricular program combining didactic elements and projects to address these issues. Methods We collected demographic information and administered a post-program survey to assess the pilot's reach and impact. We analyzed responses using simple descriptive statistics and thematically analyzed unstructured feedback. Results Fifty-one students participated, including twenty-one (41%) undergraduate students, sixteen (31%) graduate students, and fourteen (27%) medical students. Nineteen (37%) participants responded to the survey. Qualitatively, themes around workshop effectiveness, program administration, project-student mismatch, and engagement and accountability emerged. Discussion Despite limited response rates, our training program appeared to be well received. However, key issues of engagement and impact remain. Future efforts will focus on improvement in these areas and more rigorous evaluation of learning outcomes.

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Multidisciplinary Approach to Critical Care Design

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care

The goal of this project is to improve clinical decision-making in the intensive care unit (ICU) ... more The goal of this project is to improve clinical decision-making in the intensive care unit (ICU) environment. Making the optimal decisions depends on the quality and timeliness of the information available to the clinician. We believe that healthcare professionals will make better clinical decisions when the relevant information is collected and organized in a manner appropriate to support in situ decision-making. This is especially important in complex situations such those commonly encountered in the ICU environment. Currently there is no single integrated source of information that presents relevant information to clinicians. This project is developing methods to identify the core information required to engineer the information exchange among medical devices, and the information presentation layer, to support clinical decision-making in the ICU.

Information Display in the Intensive Care Unit – Considerations for System Design and Implementation

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care

Healthcare working environments are complex, and intensive care units (ICUs) are particularly com... more Healthcare working environments are complex, and intensive care units (ICUs) are particularly complex due to the influx of data to the healthcare professionals who are providing continuous care to the most critically ill patients. Systems that are designed to work in these environments should take into consideration varied patient conditions, the clinical professionals who use these systems, and the features and performance requirements that will support their efforts to provide care to their patients. We suggest that developing systems that will meet these challenges requires customized design approach, including cognitive system engineering. Until recently, this work domain has been largely ignored by manufacturers of patient monitoring systems. This panel brought together two separate teams who have been using such an approach independently to design new systems for information integration and display in ICU settings. The goals of this panel discussion were to take a close look a...

Engineering the Integrated Clinical Environment Organizing Information in the Intensive Care Unit (ICU)

Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care

Non-essential blood tests in the intensive care unit: a prospective observational study

Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2017

Non-essential blood testing in the acute care setting can be a prominent source of morbidity, pat... more Non-essential blood testing in the acute care setting can be a prominent source of morbidity, patient discomfort, increased workload for the healthcare provider, and wasteful spending. The magnitude of such non-essential blood testing has not been well described. We aimed to measure the extent of unnecessary blood testing in a 33-bed intensive care unit (ICU) at a tertiary-care teaching hospital in Ontario, Canada. Over a period of four weeks, all ICU attending physicians were asked to select, from a comprehensive list, blood tests that they deemed essential to the appropriate care for each of their patients on the following day. The actual tests processed on the following day were recorded. Descriptive statistics were used to determine what proportion of all processed tests were deemed essential blood tests. The association between patient characteristics and the total cost of unnecessary tests was assessed using the Wilcoxon rank-sum test and the Spearman correlation coefficient, ...

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Essential and Nonessential Blood Testing in the Clinical Teaching Unit

Journal of patient safety, Jan 22, 2017

The aim of the study was to evaluate the essential and nonessential blood tests ordered on the in... more The aim of the study was to evaluate the essential and nonessential blood tests ordered on the internal medicine clinical teaching units (CTUs) at Kingston General Hospital. Our aim was to establish a baseline performance measure identifying appropriate use of laboratory tests that could be used to inform improvement over time. For an 8-week period, 14 CTU attending physicians at Kingston General Hospital were surveyed. They were asked for each of their patients, "What blood tests do you consider to be essential for tomorrow morning to maintain appropriate care for this patient?" The following day, blood tests that were ordered were compared with the "essential" list previously given by the attending physicians. Of 291 processed blood tests, 148 (51%) had not been considered essential by attending physicians; of the 203 tests considered essential, 60 (30%) were not ordered. Total agreement between "essential" and processed tests was poor (κ = 0.51; conf...

Coordinating Flexible Performance During Everyday Work: An Ethnomethodological Study of Handoff Routines

Organization Science, 2016

O ur paper examines the challenge of coordinating flexible performance during everyday work. We d... more O ur paper examines the challenge of coordinating flexible performance during everyday work. We draw on routine dynamics and ethnomethodology to examine how intensive care unit (ICU) physicians coordinate their actions-flexibly yet intelligibly-as they handoff patients at change of shift. Through our analysis of interview and video data, we demonstrate how physicians use the sequential features of the handoff routine-i.e., the expected moves and their expected sequence-to adapt each performance of the routine to the unique needs of each patient. We show the need for ongoing coordinating despite a strongly shared ostensive pattern and we illustrate how participants use the sequential nature of the ostensive pattern of the routine as a resource for flexible performance, to manage sequential variation and the sufficiency of moves at transitions. Our findings contribute to the routine dynamics and coordination literatures by providing a more nuanced understanding of how mutual intelligibility is achieved through coordinating, whereby participants create the conditions to move forward with a common project.

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Évaluation De Cathéters Veineux Centraux Inutiles Chez Des Patients Gravement Malades: Une Étude Observationnelle Prospective

Can J Anaesth, 2010

Introduction Central venous catheters are used commonly in critical care. Evidence-based practic... more Introduction Central venous catheters are used commonly in critical care. Evidence-based practices to prevent catheter-related bloodstream infections have been widely promoted. One such practice includes assessing the need for central venous catheters on a daily basis and removing those found to be unnecessary. However, little is known about the adherence to this recommendation. Our objective was to examine the prevalence of

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study

BMJ quality & safety, Sep 9, 2015

In the hospital setting, inadequate engagement between healthcare professionals and seriously ill... more In the hospital setting, inadequate engagement between healthcare professionals and seriously ill patients and their families regarding end-of-life decisions is common. This problem may lead to medical orders for life-sustaining treatments that are inconsistent with patient preferences. The prevalence of this patient safety problem has not been previously described. Using data from a multi-institutional audit, we quantified the mismatch between patients' and family members' expressed preferences for care and orders for life-sustaining treatments. We recruited seriously ill, elderly medical patients and/or their family members to participate in this audit. We considered it a medical error if a patient preferred not to be resuscitated and there were orders to undergo resuscitation (overtreatment), or if a patient preferred resuscitation (cardiopulmonary resuscitation, CPR) and there were orders not to be resuscitated (undertreatment). From 16 hospitals in Canada, 808 patients ...

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Effective handover communication: Do we need more evidence?

Canadian respiratory journal : journal of the Canadian Thoracic Society

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Creating patient safety capacity in a nation's health system: A comparison between Israel and Canada

Israel journal of health policy research, Jan 23, 2012

Injuries to patients by the healthcare system (i.e., adverse events) are common and their impact ... more Injuries to patients by the healthcare system (i.e., adverse events) are common and their impact on individuals and systems is considerable. Over the last decade, extensive efforts have been made worldwide to improve patient safety. Given the complexity and extent of the activities required to address the issue, coordinating and organizing them at a national level is likely beneficial. Whereas some capacity and expertise already exist in Israel, there is a considerable gap that needs to be filled. In this paper two countries, Canada and Israel, are examined and some of the essential steps for any country are considered. Possible immediate next steps for Israel are suggested.

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Barriers to Goals of Care Discussions With Seriously Ill Hospitalized Patients and Their Families: A Multicenter Survey of Clinicians

JAMA internal medicine, Jan 2, 2015

Seriously ill hospitalized patients have identified communication and decision making about goals... more Seriously ill hospitalized patients have identified communication and decision making about goals of care as high priorities for quality improvement in end-of-life care. Interventions to improve care are more likely to succeed if tailored to existing barriers. To determine, from the perspective of hospital-based clinicians, (1) barriers impeding communication and decision making about goals of care with seriously ill hospitalized patients and their families and (2) their own willingness and the acceptability for other clinicians to engage in this process. Multicenter survey of medical teaching units of nurses, internal medicine residents, and staff physicians from participating units at 13 university-based hospitals from 5 Canadian provinces. Importance of 21 barriers to goals of care discussions rated on a 7-point scale (1 = extremely unimportant; 7 = extremely important). Between September 2012 and March 2013, questionnaires were returned by 1256 of 1617 eligible clinicians, for a...

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End-of-round time compression in physician handoff sessions

JAMA internal medicine, Jan 10, 2013

Evidence of Airborne Transmission of SARS

New England Journal of Medicine, 2004

To laypeople, the computational fluid-dynamics analysis described in the article is not readily c... more

Brief history of patient safety culture and science

Journal of Critical Care, 2005

The science of safety is well established in such disciplines as the automotive and aviation indu... more The science of safety is well established in such disciplines as the automotive and aviation industry. In this brief history of safety science as it pertains to patient care, we review remote and recent publications that have guided the maturation of this field that has particular relevance to the complex structure of systems, personnel, and therapies involved in caring for the critically ill.

Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study

Journal of Critical Care, 2011

The aims of this study were to increase the reporting of patient safety events and to enhance rep... more The aims of this study were to increase the reporting of patient safety events and to enhance report analysis and responsive action. A prospective, interventional study in 2 adult intensive care units (ICUs) in an academic center was used. A paper-based reporting system, adapted from a previously reported intervention, was introduced. A multifaceted approach, including education, reminders, regular updates, personal and group feedback, and weekly leadership rounds, was led by a patient safety committee. Committee members reviewed the reports and initiated solutions as required. During the first year, a total of 332 safety events were reported using the new system, reflecting a significant increase in total reporting (10.3/1000 patient days preintervention to 34.5/1000 patient days postintervention; rate ratio, 3.35; 95% confidence interval, 2.23-5.04). Most reports were submitted by nurses (nurses, 75.3%; physicians, 10.5%; other workers, 7.8%). Overall reported events per 1000 patient days differed by unit (level 3 ICU, 44.1; level 2 ICU, 24.9; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Several system-based interventions were initiated in the ICUs to address reported safety hazards. After the introduction of this new approach, reporting rates have increased significantly throughout the first year. Differences in reporting rates among workers and units may reveal priorities and barriers to reporting. The integrated approach facilitated prompt response to selected reports.

Knowledge translation in critical care: Factors associated with prescription of commonly recommended best practices for critically ill patients*

Critical Care Medicine, 2007

To describe prescription rates of commonly recommended best practices (clinical interventions wit... more To describe prescription rates of commonly recommended best practices (clinical interventions with a strong base of evidence supporting their implementation) for critically ill patients and determine factors associated with increased rates of prescription. A retrospective observational study. A university-affiliated medical-surgical-trauma intensive care unit over a 1-yr period. One hundred randomly selected critically ill patients. None. Among the best practices studied, there was great variability in the proportion of patients eligible (median 36.5%, range 10% to 100%) and the proportion without contraindication (32.5%, range 10% to 86%) for each practice. The median rate of prescription of best practices for eligible patients was 56.5%, with a range from 8% to 95%. There was greater prescription of best practices when standard admission orders included an option to prescribe them (p = .048). Among those practices with standard admission orders, there was greatest prescription for practices additionally having a specialty consultation service (p = .004). There was an inverse association between severity of illness and prescription of best practices (p = .001): Sicker patients were less likely to be prescribed best practices. There may be substantial variability in the acceptance and prescription of commonly recommended best practices for critically ill patients. Standard order sets and focused specialty consultation may improve knowledge translation and prescription of best practice.

Should we use albumin or saline for fluid resuscitation of critically ill patients?

Canadian Medical Association Journal, 2004

Background: It is uncertain whether the choice of resuscitation fluid affects the survival of cri... more Background: It is uncertain whether the choice of resuscitation fluid affects the survival of critically ill patients. Metaanalyses of clinical trials using colloid (albumin) administration have delivered conflicting results. 1,2 Design: This prospective, multicentre, double-blind controlled trial randomly allocated critically ill adults who required intravascular fluid resuscitation to receive either 4% albumin or normal saline. The duration of intervention was 28 days from the time of admission to the intensive care unit. Other therapies and maintenance fluids were administered at the discretion of the treating clinician. Patients with severe burns or those who had undergone cardiac or liver transplantation were excluded from the study. The primary outcome measure was the all-cause 28-day mortality; secondary outcome measures included duration of survival, occurrence of organ failure, and the durations of mechanical ventilation, renal replacement therapy, intensive care and hospital stay. Results: Of the 6997 patients who were enrolled in the study, 3497

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Removing nonessential central venous catheters: evaluation of a quality improvement intervention

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2012

Introduction Nonessential central venous catheters (CVCs) should be removed promptly to prevent a... more Introduction Nonessential central venous catheters (CVCs) should be removed promptly to prevent adverse events. Little is known about effective strategies to achieve this goal. The present study evaluates the effectiveness of a quality improvement (QI) initiative to remove nonessential CVCs in the intensive care unit (ICU).

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Evaluation of unnecessary central venous catheters in critically ill patients: a prospective observational study

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2010

Introduction Central venous catheters are used commonly in critical care. Evidence-based practice... more Introduction Central venous catheters are used commonly in critical care. Evidence-based practices to prevent catheter-related bloodstream infections have been widely promoted. One such practice includes assessing the need for central venous catheters on a daily basis and removing those found to be unnecessary. However, little is known about the adherence to this recommendation. Our objective was to examine the prevalence of unnecessary central venous catheters in our intensive care units. Methods We performed a prospective observational study during 28 consecutive days in two adult intensive care units at an academic medical centre. The principal investigator screened patients daily for the presence of non-tunnelled central venous catheters and assessed

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