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Objectives: To evaluate the sustainability potential of Choosing Wisely (CW) to address unnecessary medical care at Ontario community hospitals. Data Sources/Study Setting: Ontario community hospitals and their affiliated family health teams (FHTs). Study Design: A mixed-methods study involving the administration of a validated sustainability survey to CW implementation teams followed by their participation in focus groups. Data Collection/Extraction Methods: Survey data were collected using an Excel file with an embedded, automated scoring system. We collated individual survey scores and generated aggregate team scores. We also performed descriptive statistics for quantitative data (frequencies, means). Qualitative data were triangulated with quantitative assessments to support data interpretations using the meta-matrix method. Principal Findings: Fifteen CW implementation teams across four Ontario community hospitals and six affiliated primary care FHTs participated. CW priority areas investigated were de-prescribing of proton pump inhibitors (PPIs) and reducing Pre-Op testing and BUN/Urea lab testing. Survey results showed steady improvements in sustainability scores from baseline to final follow-up among most implementation teams: 10% increase for PPI de-prescribing (six FHTs) and 2% increase (three hospital teams); 18% increase in BUN/Urea lab testing (three hospital teams). Regardless of site or CW priority area, common facilitators were fit with existing processes and workflows, leadership support, and optimized team communication; common challenges were lack of awareness and buy-in, leadership engagement or a champion, and lack of fit with existing workflow and culture. All teams identified at least one challenge for which they co-designed and implemented a plan to maximize the sustainability potential of their CW initiative. Conclusions: Evaluating the sustainability potential of an innovation such as Choosing Wisely is critical to ensuring that they have the best potential for impact. Our work highlights that implementation teams can be empowered to influence implementation efforts and to realize positive outcomes for their health care services and patients. KEYWORDS implementation, mixed-methods, sustainability What is known on this topic * Choosing Wisely is a de-implementation innovation aimed at reducing unnecessary tests and low-value care that are unlikely to benefit patients or which may even cause harm. * Evaluating the long-term sustainability of innovations, such as Choosing Wisely, is often lacking, and may lead to implementation failure, wasted resources, and poor patient outcomes. * The success of ongoing implementation of innovations is dependent on assessing their sustainability potential, which has the best potential to support sustained improvements in health care sen/ices and patient outcomes over time. What this study adds * Understanding the implementation context of target knowledge users, their environment, resources, and mechanisms of the implementation process are necessary for optimized sustainability of innovations. * Implementation teams can influence and optimize their implementation efforts through solutions-focused discussions whereby implementation challenges can be identified and addressed. * Sustainability assessments can be strengthened by using a sustainability model as a platform for change, using a repeated measurement strategy to allow for optimization of sustainability over time, and to include a maintenance strategy for long-term sustainability or until the change becomes part of routine care., 1 | BACKGROUND It is estimated that 30% of health care services, tests, treatments, and procedures are unnecessary and unlikely to benefit patients (1-3) and can also lead to patient [...]

A factor in septic (poisoning of the system by infection) complications after traumatic injury is the impaired function of T-lymphocytes. It is suggested that reduced ability for proliferation of lymphocytes is associated with activation of T-cell suppressors, as well as dysfunction of monocytes. Also, insufficient interleukin-2 (IL-2), a T-cell growth factor, production has been noted. IL-2 regulates the immune response through its high-affinity receptor (IL-2R). Alterations in IL-2R expression may result in impaired T-cell immune reactions. A form of IL-2R found in the blood is called Tac. The cellular expression of IL-2R and Tac in 20 blunt trauma patients, and in 20 burn patients was evaluated. It was found that the expression of Tac antigen was transiently reduced in 4 of 14 blunt trauma patients; blood levels of Tac were significantly elevated in 15 of 20 blunt trauma patients. All burn patients showed significant reduction in the percentage of IL-2R cells. Serum levels of IL-2R were significantly increased in burn patients. Additionally, it appears that persistently elevated IL-2R levels may indicate increased risk for sepsis. These findings suggest that major trauma, either by burns or mechanical injury, causes changes in the T-lymphocyte activation process. The degree and duration of these changes may vary with the type of injury. (Consumer Summary produced by Reliance Medical Information, Inc.)

Deposition of fibrin, a clotting element and part of the body's response to inflammation, is an important factor in wound healing. In the peritoneal cavity (the space between the membrane covering the abdominal wall and the abdominal organs) fibrin plays an important role in initially walling off bacteria within the cavity and slowing the spread of bacteria into the systemic circulation. It has been suggested that this process may also have an adverse effect, creating predisposition for abscess formation. Previously, it has been shown that tissue plasminogen activator (t-PA), used to break down fibrin within the peritoneal cavity, prevented abscess formation in rats. In colon surgery, the anastomotic site (joining point of two sections of colon) is prone to developing infection. Perianastomotic infection has been associated with impaired anastomotic healing. A study was conducted on rats to determine the effect of t-PA on wound healing. It was suggested that t-PA might prevent infection, and thus reverse the infection-induced impairment in wound healing. Ten days after colon anastomosis was performed on rats, the administration of t-PA had not adversely affected colonic healing. If the rats were infected with bacteria within the peritoneal cavity at the time of surgery, t-PA reversed the inhibition of wound healing within the first five days. This was due to the ability of t-PA to prevent abscess formation. Administration of t-PA did not adversely affect clotting factors and there was no evidence that it caused bleeding. These results suggest that use of t-PA intraperitoneally may be a safe and effective adjunct to treatment of peritonitis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Traumatic injury is a major cause of mortality, particularly among younger people, and when death occurs, it is usually due to sepsis (widespread, severe infection) or multisystem organ failure. Sepsis recurs in these patients as a result of impaired immune system functions, which fail at both the specific and nonspecific levels. Specific or humoral immune functions are involved with antibody-production; nonspecific or cellular immune functions occur in response to allergens and grafts. The humoral response is mediated by B cells, while cellular immunity is conferred by T cells; however, T cells also regulate many aspects of B cell function. To better understand the ways these two components interact in trauma patients, 18 victims of blunt trauma were studied. Blood was sampled within three days of injury, and weekly thereafter. Seven healthy individuals served as control subjects. Cells from the blood were evaluated for various functions related with immune responses. The results revealed that, beginning only a few hours after injury, trauma patients produced less IgG and IgM (immunoglobulins G and M) than the controls. These substances, part of the humoral response, act as antibodies and are present in the early phase of immune responding. Reductions in the immunoglobulin levels were not improved by treatments that often produce increases. (One technique involves removing macrophages, cells thought to suppress immunoglobulins). However, the immunoglobulin response was improved by the addition of factors produced by the T cells of healthy donors. These findings suggest that the inadequate humoral response of blunt trauma patients may be a result of impaired T cell function, and may ultimately lead to insufficient levels of antibodies for fighting infection. The consequence of this process seems to be repeated sepsis. (Consumer Summary produced by Reliance Medical Information, Inc.)

• Previous studies demonstrated that intraperitoneal fibrinolysis using tissue plasminogen activator (t-PA) prevented intra-abdominal abscess formation in a rat fibrin clot infection model when administered simultaneously with the infecting inoculum. To more closely mimic the clinical setting, the efficacy of delayed administration of t-PA on intra-abdominal abscess formation was examined. A delay of 2,6, and 18 hours had no effect on the rate of abscess formation but did reduce abscess size, indicating partial fibrinolysis. Since fibrin clots dehydrate in vivo, we hypothesized that a higher concentration of t-PA might be necessary to effect complete abscess resolution. High-dose t-PA (0.1 mg/mL) prevented abscess formation following a 6-hour delay and reduced mean weight following an 18-hour delay. Since heparin sodium may prevent new fibrin deposition and enhance t-PA activity, it was combined with t-PA to investigate potential synergistic effects. Despite adequate anticoagulation with heparin, no synergy with t-PA could be documented. In addition, the combination of antibiotics with t-PA did not affect its efficacy in vivo. We demonstrate that delayed administration of t-PA is effective in preventing abscess formation and may have implications for the clinical setting where initial surgical intervention is usually delayed.(Arch Surg. 1989;124:1406-1410)