Not Virtual Enough: A Virtual Library’s Challenges During the COVID-19 Pandemic

As part of the University of Manitoba Libraries Outreach Services, the Winnipeg Regional Health Authority (WRHA) Virtual Library provides library services to hospitals, health centres, community health agencies, and personal care homes throughout the city of Winnipeg, Manitoba. All services of the WRHA Virtual Library, including the collection, are entirely virtual, though staff are physically located in the University’s health library. In March 2020, shortly after the World Health Organization declared the novel coronavirus disease (COVID-19) pandemic, libraries around the world started closing their doors and staff were required to work from home. The virtual infrastructure of our services and collections required no changes in how our patrons accessed the Virtual Library and a smooth transition was expected, but the sudden shift to working from home revealed gaps. This article discusses the unique experience of the WRHA Virtual Library transitioning to a completely virtual environment, the previous reliance on the University’s physical infrastructure, and the inequities identified between librarians and library technicians.

Beyond traditional library spaces: the practicalities of closing hospital libraries and opening a virtual library

The formation of the University of Manitoba Health Sciences Libraries (UMHSL) was the result of signing consecutive agreements over a period of 24 years between the University of Manitoba (UM) and Winnipeg area hospitals, now collectively known as the Winnipeg Regional Health Authority (WRHA). In 2017, the UMHSL included the UM's Neil John Maclean Health Sciences Library (NJMHSL) and eight hospital and health centre libraries located in the city of Winnipeg. In 2018, all the hospital and health centre libraries closed and the UML opened the rebranded WRHA Virtual Library. This article describes the complications and lessons learned while closing the hospital libraries and opening a virtual library service to a distributed health care system with diverse clinical and educational needs.

Review of icatibant use in the Winnipeg Regional Health Authority

Background This is a retrospective review of the Winnipeg Regional Health Authority’s (WRHA) angioedema patients who were dispensed icatibant in hospital. Icatibant is a bradykinin B2 receptor antagonist indicated for Hereditary Angioedema (HAE) types I and II and is used off-label for HAE with normal C1INH (HAE-nC1INH) and ACE-inhibitor induced angioedema (ACEIIAE). The WRHA’s use of icatibant is regulated by the Allergist on call. We characterized icatibant's use and the timeline from patient presentation, compared the real-world experience with the FAST-3 trial and hypothesized the factors which may affect response to icatibant. Methods Background data were collected on patients. Angioedema attack-related data included administered medications, performed investigations and the timeline to endpoints such as onset of symptom relief. Data was analyzed in R with the package “survival.” Time-to-event data was analyzed using the Peto–Peto Prentice method or Mann–Whitney U-test. Data was also compared with published clinical trial data using the Sign Test. Fisher’s Exact Test was used to produce descriptive statistics. Results Overall, 21 patients accounted for 23 angioedema attacks treated with icatibant. Approximately half the patients had a diagnosis of HAE-nC1IHN and half of ACEIIAE. Of those presenting with angioedema, 65% were first treated with conventional medication. Patients without a prior angioedema diagnosis were evaluated only 40–50% of the time for C4 levels or C1INH function or level. The median time from patients’ arrival to the emergency department until the Allergy consultant’s response was 1.77 h. Patients with HAE-nC1IHN had median times to onset of symptom relief and final clinical outcome (1.13 h, p = 0.34; 3.50 h, p = 0.11) similar to those reported in FAST-3 for HAE I/II. Patients with ACEIIAE had longer median times to onset of symptom relief (4.86 h, p = 0.01) than predicted. Conclusions HAE-nC1INH may be an appropriate indication for treatment with icatibant. Conversely, the results of this study do not support the use of icatibant for the treatment of ACEIIAE, concordant with a growing body of literature. Patients should be stratified into groups of more- or less-likely icatibant-responders through history and laboratory investigations in order to prevent potential delays.

P0820EMERGENCY DEPARTMENT UTILIZATION BY PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE AND DIALYSIS: A POPULATION BASED STUDY

Background and Aims Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and Those on dialysis when compared to a non-renal population. Method We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-renal population. Results Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-renal population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. Admission to hospital was higher in CKD and dialysis populations than in the non-renal population (29.56%, 26.07% vs 10.61%, respectively). Conclusion Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population.

P123: Emergency department utilization by patients with advanced chronic kidney disease and dialysis: A population based study

Introduction: Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and those on dialysis when compared to a non-CKD population. Methods: We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-CKD population. Results: Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-CKD population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. . Admission to hospital was higher in CKD and dialysis populations than in the non-CKD population (29.56%, 26.07% vs 10.61%, respectively). Conclusion: Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population when compared to the general population.

Gastroenterologist Consultation Is Uncommon but Associated with Improved Care Among IBD Patients Presenting to Emergency Departments in Winnipeg Hospitals

Objective To describe the patterns of care when persons with inflammatory bowel disease (IBD) present to the Emergency Department (ED) and post-ED follow-up. Methods We linked the University of Manitoba IBD Epidemiology Database with the Emergency Department Information System of the Winnipeg Regional Health Authority from January 1, 2010 to December 31, 2012. We then generated a list of all ED attendances by persons with IBD at four of six hospitals within the City of Winnipeg (two academic and two community hospitals). The charts were reviewed by two investigators extracting data on testing, consulting and treatment undertaken in the ED as well as postdischarge follow-up. We focused on outcomes among those attending the ED but not admitted to hospital. Results Of 1275 IBD patients with a first visit to the ED, 523 (41%) were for IBD-specific complaints. Three hundred and twenty-seven (62.5%) were discharged from the ED without an in-hospital admission. Nearly 80% had an identified gastrointestinal (GI) specialist (either gastroenterologist or GI surgeon) involved in their care. A gastroenterologist was consulted in the ED 20% of the time. Follow-up post-ED with a gastroenterologist was only documented in 36%. For those who saw a gastroenterologist in the ED, there was more likely to be a change in medications and follow-up arranged with a gastroenterologist. ED consultation with a gastroenterologist was the only predictor of seeing a gastroenterologist in follow-up post-ED. Conclusions ED gastroenterology consultation is more likely to effect IBD management change. When discharged from the ED gastroenterology, follow-up should be arranged and documented.

The Cost of Use of the Emergency Department by Persons With Inflammatory Bowel Disease Living in a Canadian Health Region: A Retrospective Population-Based Study

Background We aimed to determine the costs of emergency department (ED) attendance by persons with inflammatory bowel disease (IBD) not admitted to hospital from the ED. Methods This was a population-based administrative database study linking the University of Manitoba IBD Epidemiology Database with the Winnipeg Regional Health Authority (WRHA) ED Information Service database. We identified persons with IBD who presented to the ED and were not admitted between January 1, 2009 and March 31, 2012. We then applied costs in Canadian dollars for these visits including an average ED visit cost plus 26% for overhead (total = $508), an average estimated cost of laboratory investigations ($50), and costs for each of radiographic imaging, lower endoscopy and consultation with an internist/gastroenterologist or a surgeon. We tallied the costs of each unique ED presentation. We determined average costs for visits associated with specific consultations or investigations. Results One thousand six hundred and eighty-two persons with IBD (4,853 individual visits) attended the ED and did not get hospitalized. The average cost per ED visit by a person with IBD who did not get hospitalized was $650. This resulted in a total expenditure of $3,152,227 on these persons for their ED attendance or $969,916 per year. The visits with the highest mean costs were those associated with an abdominal computerized tomography scan ($979), those associated with surgical consultation ($1019), and those associated with an internist/gastroenterologist consultation ($942). Conclusion Better strategies for management of acute issues for persons with IBD that can reduce the use of an ED are needed and can be considerably cost saving.

Impact of Pharmacists in a Community-Based Home Care Service: A Pilot Program

<p> </p><p> </p><p><strong>ABSTRACT</strong></p><p><strong>Background: </strong>Historically, pharmacists have not been included on home care teams, despite the fact that home care patients frequently experience medication errors. Literature describing Canadian models of pharmacy practice in home care settings is limited. The optimal service delivery model and distribution of clinical activities for home care pharmacists remain unclear.</p><p><strong>Objectives: </strong>The primary objective was to describe the impact of a pharmacist based at a community home care office and providing home visits, group education, and telephone consultations. The secondary objective was to determine the utility of acute care clinical pharmacy key performance indicators (cpKPIs) in guiding home care pharmacy services, in the absence of validated cpKPIs for ambulatory care.</p><p><strong>Methods: </strong>The Winnipeg Regional Health Authority hired a pharmacist to develop and implement the pilot program from May 2015 to July 2016. A referral form, consisting of consultation criteria used in primary care practices, was developed. The pharmacist also reviewed all patient intakes and all patients waiting in acute care facilities for initiation of home care services, with the goal of addressing issues before admission to the Home Care Program. A password-protected database was built for data collection and analysis, and the data are presented in aggregate.</p><p><strong>Results: </strong>A total of 197 referrals, involving 184 patients, were received during the pilot program; of these, 62 were excluded from analysis. The majority of referrals (95 [70.4%]) were for targeted medication reviews, and 271 drug therapy problems were identified. Acceptance rates for the pharmacist’s recommendations were 90.2% (74 of 82 recommendations) among home care staff and 47.0% (55 of 117 recommendations) among prescribers and patients. On average, 1.5 cpKPIs were identified for each referral.</p><p><strong>Conclusions: </strong>The pilot program demonstrated a need for enhanced access to clinical pharmacy services for home care patients, although the best model of service provision remains unclear. More research is warranted to determine the optimal pharmacy service for home care patients and the most appropriate cpKPIs to measure its effects.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte : </strong>Historiquement, les équipes de soins à domicile ne comptaient pas de pharmaciens, et ce, malgré le fait que des erreurs de medicaments sont fréquentes chez les patients bénéficiant de ces soins. Il y a peu de documentation sur les modèles canadiens de pratique de la pharmacie en soins à domicile. Le choix optimal du modèle de prestation de services et de distribution des activités cliniques pour les pharmaciens en soins à domicile reste méconnu.</p><p><strong>Objectifs : </strong>L’objectif principal était de décrire l’effet d’un pharmacien travaillant dans un centre communautaire de soins à domicile, faisant des visites à domicile, de l’éducation de groupe et des consultations téléphoniques. L’objectif secondaire était de déterminer si les indicateurs clés de rendement relatifs à la pharmacie clinique (ICRpc, c.-à-d. <em>clinical</em> <em>pharmacy key performance indicators </em>[<em>cpKPI</em>] en anglais) en soins de courte durée étaient utiles pour orienter les services de pharmacie en soins à domicile en l’absence d’ICRpc validés en soins ambulatoires.</p><p><strong>Méthodes : </strong>La Winnipeg Regional Health Authority a embauché un pharmacien pour élaborer et mettre en oeuvre un programme pilote se déroulant de mai 2015 à juillet 2016. Un formulaire de demande de consultation, constitué de critères de consultation employés dans les établissements de soins primaires, a été mis au point. Le pharmacien a aussi évalué toutes les admissions de patients au centre communautaire de soins à domicile et tous les patients attendant en établissements de soins de courte durée que débutent leurs soins à domicile dans le but de s’attaquer aux problèmes avant leur admission au programme. Une base de données protégée par un mot de passe a été créée pour y recueillir les données et les analyser. Les données étaient présentées de façon agrégée.</p><p><strong>Résultats : </strong>Au total, 197 demandes de consultation visant 184 patients ont été reçues pendant le programme pilote; parmi celles-ci, 62 ont été exclues de l’analyse. La plupart (95 [70,4 %]) étaient des demandes d’évaluation ciblée de médicaments et 271 problèmes pharmacothérapeutiques ont été repérés. Les taux d’acceptation des recommandations du pharmacien étaient de 90 % (74 des 82 recommandations) chez le personnel de soins à domicile et de 47 % (55 des 117 recommandations) chez les prescripteurs et les patients. En moyenne, 1,5 ICRpc a été identifié pour chaque demande de consultation.</p><strong>Conclusions : </strong>Le projet pilote a montré la nécessité d’améliorer l’accès aux services de pharmacie clinique pour les patients en soins à domicile, mais l’on ignore toujours quel serait le meilleur modèle de prestation de services. De plus amples recherches seraient donc justifiées afin de déterminer quels services de pharmacie sont optimaux pour les patients bénéficiant de soins à domicile et quels ICRpc sont les plus adéquats pour en mesurer les effets.

Practice and Documentation of Performance of Colonoscopy in a Central Canadian health Region

OBJECTIVE: To evaluate the reporting and performance of colonoscopy in a large urban centre.METHODS: Colonoscopies performed between January and April 2008 in community hospitals and academic centres in the Winnipeg Regional Health Authority (Manitoba) were identified from hospital discharge databases and retrospective review of a random sample of identified charts. Information regarding reporting of colonoscopies (including bowel preparation, photodocumentation of cecum/ileum, size, site, characteristics and method of polyp removal), colonoscopy completion rates and follow-up recommendations was extracted. Colonoscopy completion rates were compared among different groups of physicians.RESULTS: A total of 797 colonoscopies were evaluated. Several deficiencies in reporting were identified. For example, bowel preparation quality was reported in only 20%, the agent used for bowel preparation was recorded in 50%, photodocumentation of colonoscopy completion in 6% and polyp appearance (ie, pedunculated or not) in 34%, and polyp size in 66%. Although the overall colonoscopy completion rate was 92%, there was a significant difference among physicians with varying medical specialty training and volume of procedures performed. Recommendations for follow-up procedures (barium enema, computed tomography colonography or repeat colonoscopy) were recorded for a minority of individuals with reported poor bowel preparation or incomplete colonoscopy.CONCLUSIONS: The present study found many deficiencies in reporting of colonoscopy in typical, city-wide clinical practices. Colonoscopy completion rates varied among different physician specialties. There is an urgent need to adopt standardized colonoscopy reporting systems in everyday practice and to provide feedback to physicians regarding deficiencies so they can be rectified.