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Aims: We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing., Design: A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019., Methods: Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020., Discussion: To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events., (© 2020 John Wiley & Sons Ltd.)

Objective: Errors in community medication histories increase the risk of adverse events. The objectives of this study were to estimate the extent to which access to community-based pharmacy records provided more information about prescription drug use than conventional medication histories., Materials and Methods: A prospective cohort of patients with public drug insurance who visited the emergency departments (ED) in two teaching hospitals in Montreal, Quebec was recruited. Drug lists recorded in the patients' ED charts were compared with pharmacy records of dispensed medications retrieved from the public drug insurer. Patient and drug-related predictors of discrepancies were estimated using general estimating equation multivariate logistic regression., Results: 613 patients participated in the study (mean age 63.1 years, 59.2% women). Pharmacy records identified 41.5% more prescribed medications than were noted in the ED chart. Concordance was highest for anticoagulants, cardiovascular drugs and diuretics. Omissions in the ED chart were more common for drugs that may be taken episodically. Patients with more than 12 medications (OR 2.92, 95% CI 1.71 to 4.97) and more than one pharmacy (OR 3.85, 95% CI 1.80 to 6.59) were more likely to have omissions in the ED chart., Discussion: The development of health information exchanges could improve the efficiency and accuracy of information about community medication histories if they enable automated access to dispensed medication records from community pharmacies, particularly for the most vulnerable populations with multiple morbidities., Conclusions: Pharmacy records identified a substantial number of medications that were not in the ED chart. There is potential for greater safety and efficiency with automated access to pharmacy records.

Background: Thiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices., Methods: A comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data., Results: We identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach., Conclusions: Physicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.

Background: : Health care transformations often involve the development of networks to ensure smooth and safe patient flows throughout the care continuum. However, more empirical information is needed on the workings of health networks and on how their structures, processes, and systems influence access to high-quality patient care., Purpose: : Using Miller's concept of configuration, we describe the workings of a health network specialized in the provision of neonatal-perinatal care, a specialty where accessibility issues are quite problematic. We aimed to generate evidence that will assist policy makers, network managers, and clinicians in facilitating access to high-quality neonatal-perinatal care., Methodology/approach: : From late 2007 to early 2008, we conducted a case study of all (N = 7) neonatal intensive care units (NICUs) in the province of Quebec (Canada). We performed field work into two purposefully selected NICUs. This involved 450 hours of nonparticipant observation and 56 semistructured interviews with various actors. Data from these sources were triangulated with data collected during informal interviews with key actors from the other five NICUs in the province and from administrative databases., Findings: : We found that the elements of this health network are pulled together by a core orchestrating theme: "Forcing the system." Indeed, in attempting to fulfill the network mission of providing access to high-quality neonatal-perinatal care, clinicians and managers must implement various strategies to compensate for the misfit of the configuration. Although these strategies are successful in providing access to neonatal-perinatal care, they, however, have adverse effects that are paradoxically in contradiction with the network's core mission., Practice Implications: : This configuration analysis enabled us to identify a set of modifiable elements that contribute to the misfit of the configuration and its suboptimal functioning. The comprehensiveness of the configuration approach was proven useful for the analysis of such a complex organizational form.

Aim: This paper is a report of a study of the relationship between work environment characteristics and neonatal intensive care unit nurses' perceptions of care rationing, job outcomes, and quality of care., Background: International evidence suggests that attention to work environments might improve nurse recruitment and retention, and the quality of care. However, comparatively little attention has been given to neonatal care, a specialty where patient and nurse outcomes are potentially quite sensitive to problems with staffing and work environments., Methods: Over a 6-month period in 2007-2008, a questionnaire containing measures of work environment characteristics, nursing care rationing, job satisfaction, burnout and quality of care was distributed to 553 nurses in all neonatal intensive care units in the province of Quebec (Canada)., Results: A total of 339 nurses (61.3%) completed questionnaires. Overall, 18.6% were dissatisfied with their job, 35.7% showed high emotional exhaustion, and 19.2% rated the quality of care on their unit as fair or poor. Care activities most frequently rationed because of insufficient time were discharge planning, parental support and teaching, and comfort care. In multivariate analyses, higher work environment ratings were related to lower likelihood of reporting rationing and burnout, and better ratings of quality of care and job satisfaction., Conclusion: Additional research on the determinants of nurse outcomes, the quality of patient care, and the impact of rationing of nursing care on patient outcomes in neonatal intensive care units is required. The Neonatal Extent of Work Rationing Instrument appears to be a useful tool for monitoring the extent of rationing of nursing care in neonatal units., (© 2010 Blackwell Publishing Ltd.)