To improve the detection of delirium amongst patients aged over 65 in Queen's Hospital, and then incorporate a clearer management pathway for these patients to be treated safely with more appropriate intervention and better follow up care. As part of the management pathway, the aim was to increase the delirium referrals made to the local Dementia and Delirium Team for quicker implementation and education regarding non-pharmacological interventions in treating delirium, whilst ensuring that Psychiatric Liaison Service (PLS) referrals for delirium were also appropriate.

A multi-phase approach to quality improvement and service development for patients with delirium has been adopted, and the first step is to improve the screening of patients over 65 years old with delirium and then to refer to appropriate teams accordingly. Our first intervention was changing the PLS referral form. It has been simplified with less input data required, and now includes a mandatory 4AT screening score for delirium, as well as a mandatory referral to the Dementia and Delirium Team for any patient with positive screening for delirium. The intervention was implemented in November 2023, with pre and post intervention data collected in October and December 2023 respectively. Data was collected prospectively and retrospectively using medical notes.

Queen's Hospital PLS received a total of 60 older adult referrals in October 2023 and 49 referrals in December 2023, of which the total proportion of referrals diagnosed with delirium was 47% and 35% respectively (12% absolute reduction). The proportion of patients referred to the PLS team with delirium, who did not require further intervention after initial assessment, had reduced by 29% (87% to 58%). The proportion of patients with delirium referred to PLS, who had also been appropriately screened and referred to the Dementia and Delirium Team prior to PLS assessment, has also increased by 4%. There has been a marked increase in total delirium referrals to the Dementia and Delirium team after intervention, from 31 referrals in October to 85 referrals in December (174% increase).

There is an improvement in screening for delirium, with marked increase in referrals made to the Dementia and Delirium team. There is a decrease in uncomplicated delirium referrals who do not require further PLS intervention and can be appropriately managed with the Dementia and Delirium team input.

Ambulances are where patient care is often initiated or maintained, but this setting poses safety risks for paramedics. Paramedics have found that in order to optimize patient care, they must compromise their own safety by standing unsecured in a moving ambulance.

This study sought to compare the quality of chest compressions in the two positions they can be delivered within an ambulance.

A randomized, counterbalanced study was carried out with 24 paramedic students. Simulated chest compressions were performed in a stationary ambulance on a cardiopulmonary resuscitation (CPR) manikin for two minutes from either: (A) an unsecured standing position, or (B) a seated secured position. Participants’ attitudes toward the effectiveness of the two positions were evaluated.

The mean total number of chest compressions was not significantly different standing unsecured (220; SD = 12) as compared to seated and secured (224; SD = 21). There was no significant difference in mean compression rate standing unsecured (110 compressions per minute; SD = 6) as compared to seated and secured (113 compressions per minute; SD = 10). Chest compressions performed in the unsecured standing position yielded a significantly greater mean depth (52 mm; SD = 6) than did seated secured (26 mm; SD = 7; P < .001). Additionally, the standing unsecured position produced a significantly higher percentage (83%; SD = 21) for the number of correct compressions, as compared to the seated secured position (8%; SD = 17; P < .001). Participants also believed that chest compressions delivered when standing were more effective than those delivered when seated.

The quality of chest compressions delivered from a seated and secured position is inferior to those delivered from an unsecured standing position. There is a need to consider how training, technologies, and ambulance design can impact the quality of chest compressions.

To summarize the evidence for neurologic uses of immunoglobulin, intravenous (IGIV) in light of present-day clinical usage. This summary guided the development of practice recommendations for the effective and efficient use of IGIV in Neurology.

MEDLINE was searched to identify pertinent English-language review articles and original reports (n = 231) on the use of IGIV in neurology (excluding editorials, letters, and comments) published before March 1998. Evidence on alternative therapies was only included as compared to IGIV. The relevant original reports and review articles and older classic studies (n = 92) were synthesized into an information foundation. Extracted data included laboratory and clinical findings, objective measures, and clinical impressions. Clinical recommendations were based on evidence quality, graded by study design, clinical experiences of IGIV in Neurology Advisory Board members, and the conditions of IGIV use in therapy.

In neurology, many disorders are poorly understood, and the mechanisms behind beneficial regimens even less so. As a result, it is fairly common for best-practice decisions to rest on weaker evidence. The usefulness of IGIV in neurology can be described by a “combined score” based on evidence quality and strength of impact. Combined scores ranged from A+ (strongly recommended) to C (recommended as a last resort). The following clinical recommendations are made: IGIV is: strongly recommended for the treatment of Guillain-Barré syndrome (A+); favorably recommended for the treatment of chronic inflammatory demyelinating polyradiculoneuropathy, dermatomyositis, and multifocal motor neuropathy (A); recommended as a second resort for the treatment of multiple scerosis and myasthenia gravis (B); and recommended as a last resort for the treatment of polymyositis, inclusion-body myositis, intractable epilepsies, and stiff-man syndrome (C).

Access to multiple sclerosis (MS) diagnosis in Canada has never been assessed. This study was designed to examine the pattern of MS diagnosis in Canada, including neurologists' diagnostic approach and waiting times for investigations.

A mail survey was forwarded to every registered neurologist in Canada (n = 479) in late 1996. Questions included their diagnostic approach to MS including perceived waiting times for various investigations including MRI. Actual MRI waiting periods were separately obtained from booking clerks or neuroradiologists from every MRI unit in Canada.

153 responses were received. Neurological assessment is obtained, on average, 1 month after referral. MRI is routinely ordered by 92% of neurologists for suspected MS followed by evoked potentials (EP) (36%) and lumbar puncture (LP) (17%). The perceived waiting period for EP and LP is less than one month but 3 months for MRI. This is very similar to the actual waiting periods obtained from the MRI units surveyed (mean of 101 days). There is a trend for longer waiting periods as one moved east to west (Eastern provinces — mean of 62 days, Ontario — 95 days, Quebec — 102 days and 122 days in the Western provinces). Private MRI units have appeared in the Western provinces and have the shortest waiting periods (2 weeks maximum). The current MRI/million population ratio in Canada is 1.8, far below the ratios of other developed nations.

Canadian neurologists prefer MRI of the brain to confirm an MS diagnosis and desire greater access to it. Access to neurological assessment, EP and LP is probably adequate but the average wait for MRI of 3 months is relatively long. The perceived average waiting period for MRI is similar to the actual waiting times of 3 months, with the Western provinces of Canada having the longest waits. Canada continues to have one of the lowest MRI/population ratios in the developed world.

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.

A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.

Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).

Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.

This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.

During the study period, 632 clients were served. Rates of goal achievement ranged from 25%–87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.

The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.

Intravenous methylprednisolone (IVMP) is the treatment of choice for multiple sclerosis (MS) patients undergoing acute exacerbation of disease symptoms and yet its cost has not been accurately determined. Determination of this cost in different settings is also pertinent to consideration of cost-saving alternatives to in-patient treatment.

Cost analysis from the point of view of the health care system of IVMP treatment of MS patients receiving treatment in association with a selected Toronto teaching hospital in fiscal year 1994/95 was carried out. Costs of any concurrent treatments were excluded.

Total cost for 92 patients, based on a 4 dose regime, was estimated to be $78,527. The the cost per patient was $1,1181.84 for in-patients (IP), $714.64 for out-patients of the MS Clinic (OP) and $774.21 for patients whose treatment was initiated in the Clinic, but completed in the home (HC). Sensitivity analyses indicated: 1) IP treatment was in all cases more expensive than that of OP or HC; 2) the cost savings of OP vs. HC was sensitive to assumptions made regarding Clinic overhead, Clinic nursing costs and Home Care Program overhead.

Alternatives to in-patient care must be considered carefully. In this study, both out-patient and in-home treatment were cost-saving alternatives to in-patient treatment, but large differences in the cost of hospital out-patient vs. in-home care could not be demonstrated.

Natalizumab is indicated for the treatment of relapsing multiple sclerosis (MS) with insufficient response to first-line disease-modifying therapy (DMT). We studied the efficacy of natalizumab for treatment of MS in a single centre observational design.

A retrospective observational study of 146 patients [66% female; mean age 37.4; 72% relapsing remitting MS (RRMS), 28% secondary progressive MS (SPMS)] referred for natalizumab treatment at St. Michael's Hospital MS Clinic between 2007 and August 2009. Data included demographic, clinical (Expanded Disability Status Scale (EDSS) and annualized relapse rate (ARR)) and patient self-report measures.

The mean duration of treatment was 20 months in those treated with natalizumab and 97% had received prior DMTs. Eighty-three patients (57%) received at least 12 months of natalizumab treatment. In those who received at least 12 months of treatment, baseline ARR and EDSS were 1.6 and 2.7 in RRMS patients versus 1.0 and 5.4 in SPMS with relapses. The ARR decreased with natalizumab treatment to 0.38 (76% reduction, p<0.001) in RRMS versus 0.32 in SPMS patients (68% reduction, p=0.01). There was a treatment associated 11% reduction in EDSS to 2.4 (p=0.04) in RRMS, but no significant change in SPMS. Eighty-five percent of patients reported improved overall quality of life (QOL) and 62% indicated improved energy.

There was a major reduction in relapse rate, stabilization in EDSS and improvement in QOL and energy in some patients on natalizumab, all similar to treatment effects in the pivotal trial.