Background: Few studies of hospital-based implementation assess sustainability or collect formal implementation outcomes, in part because the emphasis is often on initial adoption and rapid cycles of improvement. The purpose of this process evaluation was to assess the implementation of a pharmacy-led, hospital-wide program and contribute to the literature by collecting formal implementation outcomes, including sustainability.Methods: This was a qualitative process evaluation of a program that delivers discharge medications and related education to hospitalized patients' bedside prior to discharge. Semi-structured interviews were conducted with the program's key stakeholders to assess the program's implementation barriers and facilitators as well as its potential for sustainability. An interview guide was created based on the RE-AIM constructs of Reach, Adoption, Implementation, and Maintenance. Effectiveness was not assessed due to an ongoing effectiveness evaluation by another team. Each interview was coded by two independent coders and any discrepancy was adjudicated by a third, independent coder.Results: Twelve stakeholders were approached and all agreed to be interviewed. Related to providers' decisions to adopt the program, key themes emerged around the different priorities of nurses and physicians, which has implications for how program leadership promoted the program to these different stakeholder groups. Key implementation barriers included the nature of hospital provider rotations and turnover, which led to confusion on who could use the program and to whom providers should direct program-related questions. Key implementation facilitators included the enthusiasm of program staff and identified champions on the units. Themes related to maintenance or sustainability included the need to continually generate buy-in and educate providers about the program and allowing program staff and leadership to remain nimble and adapt their operations to meet evolving needs.Conclusions: The results suggest that in an environment in which rapidly achieving improvement is often the focus more than maintaining that improvement, strategies to achieve successful implementation may not be sufficient to achieve successful sustainment. New strategies are likely needed to address the unique barriers to sustaining a program once initial adoption and implementation is complete. Bedside medication delivery programs, commonly referred to as “meds to beds” or “meds in hand,” involves delivering discharge medications to hospitalized patients' bedside prior to discharge and often includes a medication education component , 2. ThisThese programs have been shown to significantly reduce 30-day hospital readmissions (in one study the reduction was greater among older adult patients)  and emerTo our knowledge, there has been no study of the implementation of these programs. A recent systematic review of the barriers and facilitators to the implementation of hospital-based interventions by Geerligs and colleagues found that the barriers and facilitators fell into three domains: system-, staff-, and intervention-level . System-However, the authors also noted a number of areas in which the included studies fell short. First, few studies addressed sustainability thus it was unclear how the barriers and facilitators to initial implementation impacted long-term sustainability . SimilarThe current study addresses these limitations by evaluating the implementation of a pharmacy-led, hospital-wide intervention 3 years after implementation and using RE-AIM  to guideThis study was conducted at Vanderbilt University Medical Center. Vanderbilt University Hospital (VUH) has 834 beds, 36 nursing units, and provides a variety of services including medical, surgical, and specialty care. The hospital-affiliated, on-site outpatient pharmacy serves the adult hospital for discharge prescriptions, as well as all outpatient clinics at the medical center.The Meds to Beds program, launched in March of 2016, fills the patients' discharge medications and delivers them to their hospital bedside, where education about their medications is also provided. Through the program, the pharmacy processes patients' insurance (just as a third-party pharmacy would) and, if the patient cannot pay for their medications, utilizes appropriate discount or charity programs to assist patients in covering the costs. Ideally, the inpatient providers (physicians or nurses) send patients' discharge medication prescriptions to the pharmacy as soon as those orders are written, and the pharmacy processes those orders and delivers the medications to the patients' bedsides as soon as possible. On average, it takes the pharmacy approximately 2 h from the time they receive the orders to process them and deliver the medications. However, as we will discuss below, this ideal process is not always feasible.The program was initially provided to only a few units on a few services  but within 6 months expanded to the entire hospital. The program has designated full-time staff including pharmacy technicians and pharmacists. In the beginning pharmacists delivered the medications and provided the education, but as the program expanded the increased demand caused program leadership to adapt the program. With this adaptation, pharmacy technicians now deliver the medications and use a tablet computer to facilitate a two-way video call between the patient in the hospital room and a program pharmacist in the pharmacy to provide education. The program is “opt-out,” where patients are able to choose not to use the program or the hospital pharmacy if they prefer to use an outside pharmacy.We used the RE-AIM framework to guide our evaluation. RE-AIM stands for Reach, Effectiveness or Efficacy, Adoption, Implementation, and Maintenance  RE-AIM wWe conducted brief, semi-structured interviews with various program stakeholders and hospital providers. We structured our interview guide around Reach, Adoption, Implementation, and Maintenance. A separate effectiveness study was being conducted at the same time as this implementation evaluation; therefore, we chose not to measure program effectiveness in the current study.We worked with program leadership to identify key stakeholders in the implementation of the program to approach for interviews. These included pharmacy and nursing leadership, program staff, physicians, and nurses. We also utilized snowball sampling techniques, asking interviewees for the names and information of others they thought we should speak to. All identified stakeholders were employees of Vanderbilt University Medical Center. This project was reviewed by the Institutional Review Board at Vanderbilt University Medical Center and was deemed a quality improvement project evaluation and not human subjects research thus informed consent was not obtained from the providers.The program was adopted  in March 2016 and was fully implemented hospital-wide by October 2016. Data collection for this evaluation took place over a 5-month period from November 2017 to March 2018, beginning approximately 21 months after adoption and 13 months after implementation was complete. Semi-structured interviews were conducted by a single interviewer (author BP). A structured interview guide based on the RE-AIM framework was used and is available see . For theA codebook was created based on RE-AIM. This codebook was created by author BP and sent to authors ASM and SK for input. Clarifications and additional detail was added to the codebook based on their input. The purpose of this codebook was to define the constructs of the RE-AIM framework and to guide coders in assigning text to one of the four constructs .BP and AM then independently coded each interview to identify blocks of text that represented one of the four constructs. The results of this first round were reviewed and any discrepancy was adjudicated by SK. Then BP and AM conducted a more detailed second round of coding to identify specific themes within these blocks of text. The results of this second round were discussed by BP, AM, and SK, and consensus was reached on the emergent themes.A total of 12 interviews were conducted. The two program leaders who assisted in identifying stakeholders were interviewed in addition to one representative from pharmacy operational leadership, one representative from nursing operational leadership, one pharmacy supervisor, one program supervisor, one program pharmacist, one inpatient unit pharmacist (not affiliated with the program), two attending physicians (one of whom was a champion of the program when it began), and two nurses. These nurses were specifically “patient flow nurses” which is a type of nurse at the hospital tasked with facilitating timely and quality discharges.reach of the program was the program being “opt-out,” meaning only when patients expressed wishes to not use the program did they actually not receive it.A key facilitator to the The opt-out model is extremely important. The patient is sick, the caregiver is in the room tapping their foot, and everyone just wants to go home.” – Pharmacy Administrator“In turn, stakeholders noted that the main reason patients declined to use the program was when they had a strong, personal relationship with their hometown pharmacy.If they want to go to their local pharmacy that's fine but if the default is they get the medications here, at least they have it in their hand when they leave and they don't ultimately come back.” – Pharmacy Administrator“Patients who have a local, independent pharmacy are “ride or die” with their pharmacy because the pharmacist there knows their history and knows their families so they will often decline (the program).”– Inpatient Unit Pharmacist (not affiliated with the program)“A common theme discussed related to providers decision to adopt the program was that stakeholders have not just different priorities but competing priorities. This was apparent when interviewees discussed how the program was “pitched” to them or how they pitched it to others. Depending on what the actual or perceived priorities were of a stakeholder group, the pitch changed and in some cases these priorities were mutually exclusive. For example, priorities for attending physicians were related to the comprehensiveness of the program and the services—medication education and assistance with payment—it provides to their patients.It was described that patients would get pharmacy education around their medications and previously I think it was an assumption on the nursing staff part that physicians did counseling and the physicians thought the nurse or pharmacy did the counseling so it didn't happen. With Meds to Beds it was actually guaranteed that the pharmacist would do it.” – Attending 1“These additional services may be priorities for physicians because they recognize their potential effect on reducing readmissions, which was also stated as a priority for physicians.For physicians it is all about readmissions and why readmissions occur—patients not getting prescriptions filled, reasons why they don't get prescriptions filled. And how we help with those things.” – Program Pharmacy Supervisor“However, the provision of these additional services takes additional time, which was in conflict with the priorities of nurses. A key quality metric on which nursing units are monitored is what time patients actually leave the hospital.[I tell the nurses] it will help decrease your work[load] and make your discharges quicker.” – Patient Flow Nurse 1, describing how she sells the program to other nurses“Likewise, if nurses prioritize expedient discharges but patients leave too quickly without receiving appropriate arrangements and counseling, this could conflict with best practices for reducing readmissions.Another instance where competing priorities related to the timing of discharge presented was during the implementation of the program. One of the most frequently cited barriers to implementation was the amount of time it took to deliver the medications. Physicians and nurses reported that the medications were often delivered later than they would prefer which delayed discharge.I think some people didn't buy into it because they thought it would delay discharge. What do we do if their [the patient] ride is there but they don't have their meds? Do we reprint the prescriptions and let them go? Or spend extra time to call pharmacy and see when the meds will be there? Even now I still think about timing.” – Attending“The program staff and leadership were made aware of this complaint from providers early during implementation and attempted to address the barrier by requesting that providers order their discharge medications as early as possible. The program often received patients' medication orders in the morning  for a same-day, afternoon discharge. The pharmacy, on average, takes 2 h after receiving the prescription orders to process and deliver the medications. In order to get the medications delivered sooner, the program asked that providers send the orders to the pharmacy as soon as possible.If there's a way to just start sending prescriptions down sooner that would be helpful. Sometimes they send them down the day before but it's at the end of the day at 6:29 p.m. And I mean, did you just now decide that patient was going home tomorrow? So if they could send the prescriptions down in real time that would help.” – Program Supervisor“However, providers expressed concern about sending the orders sooner.There was a fear in the beginning that if you sent the prescriptions down a day early, is the patient going to get them? Will they actually appear the next day?” – Attending 1“And this will just be impossible on different services. On a teaching services the intern isn't going to prescribe until they've rounded with the attending. It's just not going to happen. So that won't ever happen early.” – Attending 2“This tension—providers wanting the medications sooner but not always being able to follow the proposed solution of sending the orders sooner—is another example of not just different stakeholder' priorities but of conflicting priorities in which no “silver-bullet” solution exists.Another recurring theme across the interviews was the challenge of implementing a program in an environment with complicated care structures and frequent planned and unplanned staff changes. VUH does not have geographic localization for most medical services, where physicians on a given rotation see all of their patients in the same hospital unit or location (exceptions include contained units like the Intensive Care Unit or Geriatrics). Instead, the hospital has a structure where physicians admit patients across different units and floors. The nursing staff is unit-based, however.In addition to this unique structure, attendings, residents, and interns commonly rotate on and off teaching services at 2-week intervals. Attendings on non-teaching services rotate more frequently, usually every 5 days or so. Also, not unique to VUH is the typical, unanticipated staff turnover that all hospitals experience across all staff members.The unique structure of VUH, the typical physician rotation schedule, and turnover of providers and staff were reported to have significant impact on the implementation of the program. First, program leaders and staff said the structure made the decision about where to begin rolling out the program difficult. If they decided to go with a physician-based rollout around specific medical or surgical teams, then it became challenging for the nurses, who were unit-based. Because the nurses on a single unit cared for the patients of numerous physicians, they had to remember which physicians were assigned the program and therefore which patients could receive the program. The alternative—a service- or unit-based rollout—would be challenging to physicians because they would have to remember which units were assigned the program and therefore which patients on their service they could enroll in the program based on what unit the patient was on.Every unit has a different process for discharge. We went live on 7 North [service] because they had some familiarity with the Meds to Beds process then we went to the Riven [Hospitalist] Services. But Riven is everywhere with certain beds on certain units. So we had to pull back and rethink.” – Program Leader“There was a big decision about which service to approach first. Do we go floor by floor? We started with one service spread across all these floors. Then communication and education with providers were really difficult.”– Program Pharmacy Supervisor“The program leaders reported that they quickly learned their initial plan to start with one hospital service and slowly rollout the program sequentially to others was not feasible due to the reasons mentioned above (physicians had to remember which units and therefore which patients were eligible for the program).They tried to roll out the program too quickly when they didn't have the staff. And then it was taking too long to get scripts and if the nurses have one bad experience or don't know who to contact they will write off the program as not useful. They don't have time to try things more than once.” – Patient Flow Nurse 1“These challenges led the program to scale-up hospital-wide shortly after starting.So we decided to roll out to everywhere and then go around and educate everyone. Because not being live on all floors was causing problems.” – Program Leadership“It was this next phase of implementation—educating providers about the program—where providers' rotations and staff turnover caused challenges, according to multiple interviewees. Education about the program to providers included in-person instruction delivered by program staff to providers and reminder materials such as posters and flyers posted around the unit.The hospital has high turnover, residents come through, and suddenly no one knows about us.” – Program pharmacist“I would like to go to each unit and find the person who is going to—just someone who I can explain the program to and clear up any misconceptions. Because some people think they can't start the process until the patient is ready to discharge and I want them to know they can start it much earlier. But you know you have new residents coming in and out and they are hearing about the program from someone else and it's not the full story.”– Program Supervisor“Residents need formal, in-depth education on the program from their attendings. If it's someone from the program delivering it, then it just seems like is a vendor wanting the residents to use their service.”– Patient Flow Nurse 1“These comments highlight the challenges that presents to a program that is implemented hospital-wide.Despite these significant barriers to implementation, interviewees also noted two major facilitators: patient flow nurses and the positive attitudes of the program staff.Patient flow nurses are nurses hired for the specific purpose of facilitating patients' discharges, including ensuring the patients' hospitalizations and discharges are timely and high quality. While the hospital did not begin employing patient flow nurses because of the Meds-to-Beds program, their hiring did coincide with the program's rollout, with patient flow nurses starting only a few months after the program began. Multiple program staff commented on the importance of patient flow nurses in the program's implementation and future sustainability.We got patient flow nurses about a year in and that made a huge difference. One of their chief goals is to get fast discharge. The hospital implementing them was a lucky break for the program. “– Program Pharmacy Supervisor“The PFNs [Patient flow nurses] are great. They have our backs and they have similar barriers in their jobs. The perception is that Meds to Beds is taking too long but Pharmacy doesn't know when the physician wants the patient to go home. The PFN helps with that and gets the prescriptions sent the night before.”– Program Leadership“The relationships between the (program) coordinator and the PFN [are] critical.”– Program Supervisor“Likewise, many interviewees who did not work directly for the program cited the positive attitudes of the pharmacy program staff as an important facilitator to successful implementation.The enthusiasm from staff stuck out to me. I'm sure they had a lot of challenges on their end but my impression was that it was a lot of work but I never got the impression they didn't have time for me or my patient. There was always someone to answer the phone. It never rang and rang and rang. They never appeared overwhelmed. It would have been a big barrier if there was a ‘you're in the queue’ attitude or a ‘we're just trying to get through the day.’ But they always had a positive attitude.”– Attending“I also liked that they were pretty available from the get-go. They started with very reasonable hours. It was impressive. They weren't just available during business hours. I just liked that it was comprehensive to start. It was a complete package. A lot of pilot programs start small and build up and it takes a long time. (The Program) bit off a big chunk and they delivered. It was also great the speed at which they expanded. It was rapid. They expanded very quickly.”– Attending“The two (program) pharmacists at the beginning were extremely helpful. We knew that they would do what was right for the patients and they could trust them them…The pharmacists were super responsive, helpful, and would work hard for our patients.”– Attending“The (program) pharmacy was really good about listening to each PFN and listening to what works and what doesn't work and adapting.”– Patient Flow Nurse“Each stakeholder was asked if they believed the program was sustainable and what needed to happen to bolster its sustainability. Numerous stakeholders cited the need to continually educate hospital providers about the program in order for it to be sustained.I think you always have to change to sustain. You can't take your finger off the pulse. You always have to keep reselling and re-educating and keep the communication lines open. I think they've done a good job in the pharmacy doing this but it has to continue—getting input from stakeholders, listen to them, and give feedback.”– Nursing Administration.“We can't have sustainability without progress. We must continue to actively market the program, keep constant communication and education going. Still need to ‘make a presence’ though.  has high turnover, residents come through, and suddenly no one knows about us.”– Program pharmacist.“The education is on autopilot for people who are already using the program but for new residents, thorough education needs to take place.” – Patient Flow Nurse.“In addition to the need for recurring education and outreach, stakeholders cited the need for more resources such as staff and physical space to support the program long-term.With more volume, more demand for staff, new staff means training, training is hard in a busy pharmacy location so training sometimes fall to wayside, which can cause staff issues. It's helpful that we hired pharmacist manager and tech coordinator to oversee staff. I don't know if we needed them in the beginning. They may not have been necessary. It was when more staff were hired that the need for oversight was needed.” – Program Pharmacist“Training takes a lot of time, too. We've had major staffing changes. We have to be prepared for those changes, though, and make a comprehensive training plan. But even that means having staff available to do that.” – Program Leadership“The physical space of the pharmacy is important. It's very challenging to get a physical workflow in order. “Everything has to be like McDonald's. Everything moves in a certain order.” We have that now but if they change our space that will be a problem. We're constantly trying to improve things and find ways to make things better. We have no bureaucratic red tape to go through in terms of changing our physical space. We have good autonomy. But to hire more staff and get more space, we need approval. It's not sustainable if administration doesn't listen to the issues we're bringing up. When your team is asking for certain things…”– Program Pharmacist“We have to find space dedicated to Meds to Beds. We have reworked, and reworked, and triple worked our space over time to make it more streamlined and efficient.” – Program Leadership“The results thus far represent common themes across the interviews and key points are summarized in Pharmacy operational leadership noted that when adaptations needed to be made to the program, even though they were in a position to authorize such adaptations, the implementation of those adaptations was dependent upon others. In reference to a decision to start using the tablet computers to deliver the education to patients rather than in-person:We want to do education. We have to do it. But we have people running all over the hospital. So [program leadership] asked, ‘Why can't we use an iPad?’ I thought it was a great idea. What took a long time, though, was getting the device compliant with HIPAA and PHI. We approved the idea quickly and then it took a long time to actually implement it.”– Pharmacy Administrator“In reference to a request from program leadership for more physical office space:[Program leadership] brought me the idea about how they were running out of space but could remodel the store room in the pharmacy relatively easily. And that was a quick decision because I just said ‘Go do it’.” – Pharmacy Administrator“Certain classes of medications also presented unique challenges that were unanticipated.The controlled substances were an issue before [the new EMR] because they required a paper prescription and there were issues with printing, because the printers were tied to the units but I may be printing a prescription on one unit for a patient on another unit and then I have to get that paper prescription from the other unit, sign it, then find a tube [the pneumatic tube system that physically sends a paper prescription that had to be hand-signed to the pharmacy].”– Attending“Patients who get prescriptions [from the hospital] for narcotics must fill those prescriptions in Tennessee so for out-of-state patients, they can't get it filled at home. So [the program] helps get them filled in Tennessee.”– Patient Flow Nurse“There have been issues with narcotics and blood thinners in the past so the medications were being delivered to the nursing station but that caused downstream problems because the patients have to be notified that their meds have arrived and have to be educated and some patients were then getting upset that they weren't allowed to leave or have their medications. In other instances the patients were going to jail after discharge and telling them where their meds were was causing problems because the [police] officers didn't want them to know they were going to be discharged and then going to jail.”– Unit-Based Clinical Pharmacist“Every interviewee was asked what advice they had for others who are planning to implement a program hospital-wide.I think they have to get stakeholders early so they understand their perspectives. They need to know who the stakeholders are even. The pharmacy didn't know who to get, who to bring in. So finding someone who can match up the right stakeholders with the project, know who does what roles and who they should talk to. Because you have to have the ability to pitch to key institutional stakeholders. It makes a huge difference.”– Attending“In future roll-outs, just rip the band-aid off and realize that you're going to experience some kickback but have enough staff—too many staff is not a bad thing—to handle that. ” – Unit-Based Clinical Pharmacist“You have to set clear expectations with nurses and physicians. Because if they think something is going to take 30 minutes and you don't tell them otherwise then when it takes longer you look like you failed.” – Program Supervisor“In the future, if we're rolling out a new initiative my advice would be to get a champion in administration, sell them on it, then have that trickle down effect. It has to be a top-down approach. Sure, there will be growing pains but it's going to take a lot of selling and talking to the same people over and over again. We need to be a permanent fixture on the floors.” – Program Pharmacy Supervisor“We found considerable interaction between the different levels of implementation barriers and facilitators, consistent with the findings of Geerligs and colleagues . The tenAnother example of the interaction between system-, staff-, and intervention-level barriers and facilitators is the challenge of rolling out the program hospital-wide. The hospital structure and staff fluctuations represented structural barriers to implementation which conflicted with the intervention-level barrier of needing to provide detailed education to providers so they understood the program. The intervention required that program staff provide thorough instructions and education to providers who would be using the program, but the structure of the hospital nursing units and medical services made this difficult. This need to provide detailed education on a continual basis for implementation and sustainability purposes is especially pertinent within the context of continuing medical education (CME). In its most recent strategic plan, the Accreditation Council for Continuing Medical Education noted its plan to evolve CME to include not just clinicians but other members of the healthcare team as well the healthcare institution as a whole . Given tThis study is also significant because of the inclusion of sustainability data, something Geerling and colleagues noted many hospital-based implementation studies did not examine. At the time of data collection, the program had been operating hospital-wide for more than 2 years, which provided a unique opportunity to study the sustainability of a program in a hospital, where a version of a program may generally be more short-lived due to the use of rapid-cycle quality improvement methods . We collected sustainability data with the Maintenance construct of the RE-AIM framework. In the interviews we found that the points interviewees believed were most critical to the sustainability of the program were to address or mitigate the cited implementation barriers and continue or bolster the implementation facilitators. For example, the timing of medication delivery was the most commonly cited barrier to implementation and was cited as an ongoing issue. When asked about what the program needs to do in order to be sustained, not surprisingly many interviewees said the timing issue needed to be resolved. Likewise, when asked what the program “had going for it” in terms of sustainability many interviewees said the positive attitudes of the program staff and the effective communication between providers and the program staff. These were also cited as facilitators to implementation.This relationship between barriers and facilitators and sustainability has multiple implications. First, it suggests that how programs address barriers is important not just for implementation but also sustainability, which is consistent with other findings . This alThe last important finding we will discuss is how counterintuitive the program's rollout was. Existing guidance found in the quality improvement and implementation science literature suggests that programs should be rolled out in phases, starting with small-scale change working up to system-wide rollout . While tThis study is not without limitations. First, this was part of a small-scale evaluation project which placed certain restrictions on the data collection procedures including what data were collected, how they were collected, and the number of interviews conducted. However, we believe our close relationship with the two program leaders in identifying key stakeholders to interview and our rigorous data analysis process help to mitigate this limitation. Second, given the important adaptation to the program that had to be made involving pharmacy technicians, it is a limitation that a pharmacy technician was not interviewed. Because we were not aware of this important adaptation until the data analysis phase, we could not go back to collect more data from this important stakeholder group.This study begins to fill two gaps in the implementation literature: it includes assessment of sustainability in hospital settings and sheds light on the implementation of pharmacy-led, bedside medication delivery interventions which are growing in popularity. Results indicate that there are unique challenges both to implementation in a hospital setting and that barriers and facilitators present during early implementation phases may not be resolved and yet the program can still continue for an extended period of time. However, it is unknown how long the program can sustain with unaddressed barriers and facilitators. More work is needed to better understand the relationship between implementation and sustainability and the results of this study can serve as guidance for this future work.The datasets generated and analyzed during the current study are not publicly available due concerns about confidentiality with the limited number of participants but are available from the corresponding author on reasonable request.This project was reviewed by the Institutional Review Board at Vanderbilt University Medical Center  and was determined not to be human subjects research  thus informed consent was not required.BP and SK conceptualized the study. BP collected all data. BP, AM, and SK analyzed the data, interpreted the results, and contributed to the writing of the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program.During the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding.This analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention  relative to the first week . Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time.The nurse-mentoring program appears to have built providers’ capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally. Globally, an estimated 275,000 maternal deaths and 2.7 million neonatal deaths occur annually, a quarter of which occurs in India , 2. HemoA critical step towards preventing maternal and neonatal mortality is timely diagnosis and management of postpartum hemorrhage (PPH) and intrapartum asphyxia, which remains largely underdiagnosed in primary care facilities in India , 9. SkilThe Government of India initiated a program in 2005 to increase institutional deliveries with the expectation that skilled attendants are better able to identify and manage maternal and neonatal complications, thereby saving lives . HoweverA nurse-mentoring program including integrated simulation training targeting individual and team performance was implemented in Bihar with the overall aim of improving the quality of facility-based care . PreviouApatkaleen Matritva evam Navjat Tatparta (AMANAT), meaning ‘emergency obstetrical and neonatal readiness’ in Hindi. AMANAT was a multi-faceted quality improvement nurse-mentoring program to reduce maternal and neonatal mortality by improving provider skills in normal and complicated deliveries. Other key components included support for positive changes in infrastructure and management, infection control, hazardous waste disposal, and creating and maintaining a newborn care corner in public health facilities.In 2011, CARE India, a non-governmental organization, collaborated with the Government of Bihar to implement a pilot program in eight districts . PromisiThe AMANAT program was implemented in four phases between May 2015 and January 2017 at 320 high volume, BEmONC facilities at the primary care level (80 facilities per phase (P), P1 –May to October 2015, P2 –September 2015 to May 2016, P3 –Nov 2015 to June 2016 and P4 –June 2016 to Jan 2017). Due to administrative limitations, only facilities with adequate readiness in terms of infrastructure and management were included. In Bihar, BEmONC facilities serve twice as many people than federally mandated, often with limited resources to effectively diagnose and manage obstetric and neonatal emergencies . Only vaIn each phase, a pair of nurses (mentors) were assigned four facilities to conduct on-site mentoring of labor room nurse mentees . Mentor http://prontointernational.org) simulation and team training. The simulation and team training curriculum was tailored to address local contextual needs and incorporated in the AMANAT program since the outset. The three components of the PRONTO curriculum were: (1) realistic human-centered in-situ simulation scenarios of normal and complicated deliveries, including scenarios with simultaneously occurring emergencies, to promote use of EBPs, (2) efficient teamwork and communication (T&C) among providers and (3) increasing provider awareness around person-centered maternity care  . The aveIn the between-facility comparisons across phases, diagnosis was always higher in the final week of intervention  relative to the first week , which tended to be significant, except in a few cases . In geneThe final longitudinal models had 52,099 deliveries with 1,239 PPH cases, after excluding deliveries with dates inconsistent with arrival and discharge dates and those that occurred outside the days of mentoring . The witAmong all PPH cases, 96% and 84% received IV fluids or uterotonics, respectively. From week 1 through 7, these proportions changed little and in the adjusted models changes per week were not significant .The diagnosis of intrapartum asphyxia among all livebirths increased from 2.5% in week 1 to 4.8% in week 5, after which it reduced to 4.0% through week 7 . When a Seventy-eight percent of the asphyxiated newborns were taken to a radiant warmer, 92% were dried or stimulated, 81% were suctioned and 41% received PPV. From week 1 through 7 of mentoring, asphyxia management improved and adjusted models showed a 5–9 percentage-points increase in radiant warmer use, drying/stimulation and PPV with each additional week of mentoring , Table 4This investigation identified some improvement in the diagnosis of PPH and intrapartum asphyxia in both between- and within-facility comparisons. Comparison between facilities within similar geographies and time generally suggests improvement in diagnosis. Within-facilities over time, diagnosis of PPH and intrapartum asphyxia among all deliveries increased up to week 5, after which it began trending downward. Despite the overall increase in proportions of PPH and intrapartum asphyxia, these were still not on par with levels observed in Southeast Asia and globally, suggesting some complicated deliveries remain undiagnosed –34. For Studies from the United States and Canada showed temporal increase in PPH incidence, driven by an increase in uterine atony, changes in demography, maternal comorbidities, or delivery mode , 36. OurOverall proportions of PPH in this study are consistent with another report on Helping Mothers Survive (HMS) Bleeding after Birth . That stAmong the strengths are the large statewide coverage powering the investigation and lending limited external validity to facilities in similar low-resource settings and readiness. The longitudinal comparison within-facilities enabled examination of trends over time, which a pre-post design would have missed. The analytical strategy minimizes the possibility of residual confounding and strengthens causal inference because several models and a range of covariate adjustment yielded robust results.Given the operational limits in Bihar we were unable to use objective measures for the diagnosis of PPH (blood loss) and intrapartum asphyxia . We tried using a calibrated obstetric drape to quantify blood loss; however, we could not support universal use, as there were concerns about cleaning, re-use and infections. To establish intrapartum causation of asphyxia more accurately, postnatal neuroimaging or blood gas analysis are needed, which were not available in Bihar, and we acknowledge this as a limitation.Additionally, we did not have true control facilities and addressed this limitation by using both between- and within-facility comparisons. Another challenge we had was related to measurement of time, which is critical for an asphyxiated infant. Simply noting a specific step to resuscitate an infant was performed with no reference to time portrays an incomplete picture of case management. A related study identified several barriers to clinical urgency among mentees, including poor understanding of the indications  . There iDuring the AMANAT program there was an increase in the diagnosis of PPH, which decreased somewhat during the last two weeks. At baseline, the majority of the PPH cases were managed using selected EBPs, which remained largely unchanged throughout the program. Diagnosis and management of intrapartum asphyxia using selected EBPs improved with duration of mentoring. Diagnosis of PPH and intrapartum asphyxia in public facilities in Bihar is still not on par with regional or international levels. Thus, continued efforts to improve providers’ ability to recognize and act on these important causes of maternal and newborn mortality are needed. In order to sustain the gains achieved through this program, in the next phase of intervention, champion mentees were identified from facilities, then trained to serve as mentors and continue these activities in their respective facilities. This study also provides empirical evidence that, following identification, providers demonstrated the capacity to appropriately manage PPH and intrapartum asphyxia.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 TableThe results are for weeks 1 through 9 of mentoring without any exclusion.(DOCX)Click here for additional data file.S4 TableA comparison between facilities across phases.(DOCX)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.


BCR-ABL1 transcripts, beside the most common e1a2, e13a2 and e14a2, have been described, mainly in patients with CML. However, ALL and de novo AML may also carry BCR-ABL1 atypical transcripts which will confer a poor prognosis.Philadelphia (Ph) chromosome results from the reciprocal translocation t and is diagnostic for chronic myeloid leukemia (CML). However, this translocation is also found in acute lymphoid leukemia (ALL), as well as in rare cases of acute myeloid leukemias (AML). Most patients with CML harbor either the e13a2 or the e14a2 BCR-ABL fusion product, while a small subset of the cases expresses e1a2 or e19a2 transcripts. Moreover, several atypical A 78-years old male was admitted at our hospital with clinical and laboratory features allowing to make the diagnosis of AML. No evidence of a preceding CML  was found. The karyotype on G-banded metaphases was 46,XY, t. While the molecular analysis was ongoing, the patient started treatment based on hydroxyurea followed by 5-aza-2′-deoxycytidine. The molecular biology analysis revealed the simultaneous presence of the common p190 e1a2 and the rare e6a2 isoforms. Because of persistent pancytopenia and presence of blasts, according to the molecular data, he was then switched to tyrosine kinase inhibitors (TKIs) treatment. Nevertheless, after 2 months, the patient was still refractory to second line treatment dying because of a pulmonary infection.BCR-ABL1 transcripts may help to establish optimal treatment approaches on these aggressive BCR-ABL1 phenotypes in different setting of patients.The atypical p190 e6a2 transcript seems to be associated in AML with aggressive disease. TKI therapy alone does not seem to control the disease. Prompt observations on these patients carrying rare  The t9;22) chromosome translocation originating the BCR-ABL1 fusion oncoprotein is detected in more than 95% of patients with CML representing the hallmark of the disease [2 chromosBCR gene, consisting of 23 exons, thus resulting in several distinct fusion genes. Generally, the breakpoints location on BCR gene occur between b1-b5 exons, within a central region called major breakpoint cluster region (M-bcr), whereas rare cases occur within two other breakpoint cluster regions: minor (m-bcr), with the breakpoint between e1-e2 exons, and micro (μ-bcr) with rupture point between e19-e20 exons. Depending on the breakpoint of the ABL1 gene, the fusion protein has different molecular weight: p190, p210 and p230 proteins for m-bcr, M-bcr and μ-bcr, respectively [BCR breakpoints outside the cluster regions have been described, involving splicing between whole exons, insertion of small sequences or genomic breakpoints within exons. For example, e8a2, e15a2 and e6a2 have been also described and their clinical significance is under investigation [BCR-ABL1 transcript produces a rare fusion protein of 185 kDa conferring a poor prognosis in CML due to its association with aggressive phenotype and early transformation, perhaps due to the lack of an important regulatory BCR sequence within the fusion proteins [BCR-ABL1 transcript e6a2.The breakpoint on chromosome 9 is localized between exons 1a, 1b and a2. In contrast, breakpoints on chromosome 22 occur within the tigation , 5. The A 78-years old male was admitted to the Hematology of the University Hospital Sant’Andrea-Sapienza, because of worsening fatigue and abdominal pain. Written informed consent was obtained from the patient and the study was approved by our institutional review board.9/L), anemia (hemoglobin 8.6 g/dl) and mild thrombocytopenia (98 × 109/L), with no associated splenomegaly. Peripheral blood smear showed hypercellularity with 90% blast cells.The peripheral blood count showed hyperleucocytosis  aspirate showed 90% agranular blast cells of medium and large size Fig.  and the 9/L.A diagnosis of AML (M2) was established and the patient started cytoreduction with hydroxyurea obtaining after seven days of treatment a WBC count of 39 × 10BCR-ABL1 fusion gene.Conventional karyotyping was performed on the BM diagnostic aspirate after short-term culture and analyzed after G-banding. The description of the karyotype was made according to the International System for Human Cytogenetic Nomenclature. The cytogenetic analysis on G-banded metaphases disclosed a 46,XY,t karyotype. Then, interphase FISH experiments were carried out using BCR-ABL1 probes (Vysis) and demonstrated the presence of 2 for 5 days) for a total of two cycles. Subsequently, nested RT-PCR revealed the simultaneous presence of the common p190 e1a2 and the rare e6a2 isoforms , the reverse primer ENR561 and the ENP541 probe reported elsewhere [ABL1 transcripts and expressed as the number of p190 e6a2 copies every 104 copies of ABL1. To assess molecular response after treatment, a real-time quantitative RT-PCR assay (RQ-PCR) for p190 e6a2 was designed by which we observed significant different kinetics through the e1a2 and e6a2 transcripts with consistent persistence of e6a2 [At the resolution of a pulmonary aspergillus infection treated with voriconazole, while the cytogenetic and molecular analyses were ongoing, the patient started treatment with 5-aza-2′-deoxycytidine  as a provisional entity of myeloid neoplasm and acute leukemia [The AML with leukemia . The 201leukemia . In factleukemia . A recenleukemia ; howeverleukemia . Table 1leukemia , 16. HerBCR-ABL1 [Data reported so far indicate that the course of disease associated with e6a2a is particularly aggressive both in chronic and acute leukemias. In fact, within CML cases harboring this transcript, 6/17 developed an accelerated or blastic phase , 17–20. BCR-ABL1 . He was Despite the clinical heterogeneity, all previously reported cases and the one here reported indicate that the atypical e6a2 transcript is associated with aggressive disease and underline the potential advantage of TKIs and allo-SCT in improving prognosis of these patients –20, 25. BCR-ABL1 fusion transcripts. Furthermore, the different clearance of the e1a2 and e6a2 transcripts underlines the importance to design specific molecular assays for the evaluation of minimal residual disease and to choose the best therapeutic options.The case here described presents a diagnostic and therapeutic challenge since it shows the importance of combining conventional karyotype/FISH and appropriate genetic assays to detect rare In conclusion, hematological malignancies with the atypical e6a2 show an aggressive phenotype with an higher capacity of transformation to blast crisis in CML. Ph + AML is more rare, but with the same worse prognosis . TherapeBCR-ABL1 and poor physical condition [For patients not eligible to transplantation, the prognosis is even more unfavourable and a different approach should be considered. There is no standard of care and treatment of patients affected by Ph + AML, especially elderly, remains an area of unmet need. Notably, Shao et al. recently reported that dasatinib single agent may be an effective and tolerable induction therapy for AML patients with ondition . Hovewerondition . Moreoveondition  that inhBCR-ABL1 transcripts associated with unfavourable prognosis remain mandatory to include these patients in more aggressive treatment strategies. In vitro studies are necessary to clarify the transforming property and the mechanisms of resistance of e6a2 transcript and to design novel target therapeutic agents.Prompt observations of patients carrying rare


The University of Utah’s Gerontology Interdisciplinary Program (UUGIP), a fully online program recently aligned all courses to meet the 2014 Academy of Gerontology in Higher Education (AGHE) “Gerontology Competencies for Undergraduate and Graduate Education” and to meet best practices in online teaching. These efforts led to the GIP Masters of Science program being recognized in 2017 by AGHE as a Program of Merit as well as a publication in the AGHE Journal of Gerontology & Geriatrics Education . In an effort to further this work, we analyzed student evaluations in core Master of Science program courses prior to and following these program revisions, assessed by qualitative and quantitative evaluation data from two semesters immediately prior and two semesters immediately following revisions. This presentation will discuss results, implications, and future applications of this analysis.


The Balancing Incentive Program (BIP) was an optional Medicaid program within the Affordable Care Act. States spending less than 50% of Medicaid long-term services and supports on home and community-based services (HCBS) were eligible for the program and could participate from 2011 to 2015. Participating states received an enhanced federal match in exchange for rebalancing LTSS spending and adopting structural changes to their long-term services and supports system. The purpose of this study is to understand the barriers and facilitators to implementing the BIP in two states. Data was collected through semi-structured interviews with individuals involved in HCBS policy nationally and in Maryland and Texas, including government bureaucrats, consumer advocates, and provider representatives. Findings indicate that factors that facilitated Maryland and Texas’ implementation of the BIP were regular communication with the Centers for Medicare and Medicaid Services and their consultants, Mission Analytics Group, merging the BIP with existing HCBS programs, and the substantial amount of funding associated with the program. On the other hand, the short duration of the BIP presented a challenge for states because they needed to enact multiple changes within a limited period of time. In addition, state procurement and contracting processes impeded the speed with which BIP requirements could be met. Key stakeholders, including consumer advocacy and provider organizations, often felt as though their state implemented the BIP with minimal input from interested groups. The findings indicate that the structure of the Balancing Incentive Program as well as internal state factors influenced the program’s implementation.


Family Physicians with Enhanced Surgical Skills (FPESS) have sustained rural operative care, including local access to caesarean section, in many communities across rural Canada and internationally. The contemporary role of FPESS within the health system, however, has not been without challenges. The 12-month Prince Albert Enhanced Surgical Skills (ESS) program intakes two learners a year and is one of only two accredited programs in Canada offering a scope of surgical practice beyond operative delivery.This paper highlights the results of an evaluation of graduates’ experiences of training and the post-training environment. Graduates were practicing in Western and Northern Canada after completing the ESS training program, specifically in British Columbia, Alberta, Manitoba, and the Northwest Territories.Findings suggest the overall success of the program in meeting learners’ needs. There was a close match between the training curriculum and post-training practice.The findings from the post training experience suggest that sustainability of ESS is linked to 1) creating pathways to privileges between the ESS community and the Health Authorities, 2) building functional and trusting relationships with surgical specialists, and 3) creating a web of accessible effective rurally appropriate surgical Continuing Professional Development (CDP). Ongoing CPD is identified as essential in increasing the comfort of FPESS. This is often addressed through rotating practice in high-volume regional or tertiary centres or through overseas work and addressed locally through on-going interprofessional Continuing Professional Development (CPD). Recent innovations in British Columbia have led to the introduction of real presence technology, which enables virtual linkages between rural surgical services with regional referral sites for virtual procedural learning and urgent consult if necessary. These strategies may mitigate the practice challenges in low volume centres; however, careful attention to local process for Continuous Quality Improvement and process evaluation are essential for system accountability.Both Canadian and International scholars have noted the diversity of conditions cared for within a low volume generalist model .Where specialist practice exists, it is often supported by a family physician with Enhanced Surgical Skills (FPESS) to reduce the burden of continuous on call. In rural communities in Western and Northern Canada, many of the surgical needs are met by FPESS in partnership with general practitioner (GP) anesthetists. This model of generalism plays well in settings that may not have the volume to support a full-time proceduralist but still have the need for some local care.10Support for Enhanced Surgical Skills for Canada’s rural family physicians is driven by the evidence based policy framework to sustain rural maternity care programs close to home. The recent recognition of the critical role played by robust local surgical programs in rural maternity care, as well as the importance of local surgical first responders, has been endorsed in the Joint Position Paper on Rural Surgery and Operative Delivery.11 These challenges are well-known among the Enhanced Surgical Skills (ESS) community. Understanding program participants’ experiences during training and post-program can lead to responsive adjustments to the program and awareness of ways pentagram partners  can increase their support of rural surgical care.The contemporary role of FPESS within the health system, however, has not been without challenges due to the lack of 1) national training standards supported by Canada’s two licensing Colleges, 2) on-going continuing medical education, and 3) supportive interprofessional relationships with specialist colleagues.The University of Saskatchewan (U of S) convened an Enhanced Surgical Skills Retreat in Prince Albert in September 2017 with the purpose of examining the first 10 years of its ESS program. Attending were graduates, faculty, researchers, postgraduate education, and representatives from specialty societies, Canada’s two licensing Colleges, and Health Authorities. The ESS program invited the University of British Columbia Centre for Rural Health Research to interview the graduates on their training and post-training experienceThe history of training for rural FPESS identifies two pathways: 1) informal, in-person mentorship, most often as a one off effort that consists of only one interaction; and 2) a formal 12-month postgraduate accredited program. The University of Alberta had a 12-month training program based in Grande Prairie between 1990 and 2000. From 2007 to 2017, the University of Saskatchewan in Prince Albert was the only Canadian ESS program offering surgical training across a broad scope of obstetrical and general surgery procedures. Specialists worked to develop the skills of ESS residents through a curriculum of practical experience in the operating room (OR). The program was structured around six months of general surgical training and six months of obstetrical and gynecological training. Residents often spent time in other specialty areas  as per individual and community interests and needs. There are three other 3-6 month ESS programs in Canada that offer a skill set restricted to operative delivery. A full scope ESS program has recently been started in Fort McMurray, Alberta through the University of Alberta.12 rural-specific competencies14 and education-based mechanisms for meeting rural surgical need,15 most of the literature focuses on the specialist surgical workforce. There is scant research on the training of FPESS, and no program evaluations of the efficacy of training curricula. The research that does exist focuses on experiences of less formal training11 and experiences of practice.7 The former found significant issues around the lack of collegial and health authority support for the practice, the lack of recognized and respected credentials, the lack of formal training avenues, and the lack of effective accessible CPD.Although there is a growing body of research evidence on the importance of a rural surgical workforce,16 The authors suggested that the call for a core curriculum of defined competencies will lead to a generic and portable skill set which will be one step towards the stability of FPESS. It is encouraging that at the time of writing the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) were collaborating to translate the curriculum into the core competencies and national training standards for ESS.A 2015 Canadian consensus effort proposed a curriculum leading to core competencies selected from “historical skill sets in which ESS physicians have provided services, the skill sets for which there is good research evidence on the outcomes and safety of appropriately trained ESS physicians performing these procedures… and the present University of Saskatchewan R3 ESS training program.”17 and found short-course training improved confidence levels for practitioners who had already completed training. The authors noted the difficulty for rural GPs who want to increase or maintain their surgical skills, namely the difficulty in leaving the community due to scarce locum coverage. Despite the availability of surgical training in Australia, however, and the qualifications offered by the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM), the training programs are not recognized by the Royal Australian College of Surgeons. The authors of a 2014 study note that due to this situation, the qualifications “provide little or no benefit in granting surgical privileges in rural hospitals.”18 Concomitantly, the authors suggested that any training pathway for this group “needs to be developed in collaboration with the relevant colleges and credentialing bodies,” reflecting similar challenges and pathways as those faced in Canada.Research from Australia examined the effect of a surgical skills course on confidence levels of rural general practitionersFPESS play an important role in meeting the surgical needs of rural communities in Western and Northern Canada. This is the first evaluation of the Prince Albert ESS program, the only formal 12-month graduate accredited program for ESS in Canada from 2007 to 2017. The goals of this study were to evaluate the ESS training program from the perspective of graduates and to explore the post-training experiences of graduates, including the facilitators and barriers to practicing and maintaining ESS.We administered a structured survey with some open-ended questions  by telep19 The lead investigator and a research coordinator read all transcripts and jointly developed a codebook. The research coordinator applied this codebook to the transcripts using NVivo  software and then grouped codes under broader themes; these themes ended up matching a priori survey sections. We summarized themes and sub-themes. We selected for inclusion in the report quotations most representative of a thematic response.We analyzed the qualitative data from the interviews for recurring themes using basic principles of thematic analysis: immersion in the transcripts, development of a codebook, coding of transcripts, and identification of themes.The sample was homogenous and almost everyone who went through the ESS training program at Prince Albert participated in this study. Thus, theoretical saturation was reached. The study was approved by the Behavioural Research Ethics Board, University of British Columbia.Eleven FPESS graduates participated in the study out of 13. They were all in rural practice in British Columbia (BC), Alberta, Saskatchewan, Manitoba, or the Northwest Territories . Six parOne study participant worked as a solo FPESS in the community; six had one other ESS colleague, three had three other colleagues. No graduate practiced alongside local specialists. However, four were supported through Obstetrical outreach from a regional centre and three were supported by General Surgery outreach. Other outreach included Ear, Nose, Throat (ENT), and Orthopedics. The respondent who worked in the solo model noted that another ESS practitioner was highly desired and two others noted additional ESS support in the community would be of benefit.Survey results, including thematic summaries of participant comments, are presented below by survey topic. Almost all of the graduates interviewed noted that the scope and volume of their training was adequate preparation for independent practice. As one participant noted, “I knew exactly what I needed and got the training I needed.”Participants reported their surgical volumes within the past year (after completing the ESS training program). The most common procedures performed in community practice were upper GI endoscopy , colonoscopy , and caesarean section . For the remainder of the major procedures , the volumes were low. The average annual volume of appendectomies and hernias were 3 and 8 respectively with a range of 1-5 for appendectomies and 3-17 for hernia repair.There was a close match between the training curriculum and post-training practice . DiscrepMost participants suggested that although there may be other procedures useful in a rural setting , the program was already broad enough and it would be difficult to adequately train for more within the 12-month period.When asked about local OR availability, five of the respondents reported having one operating room in their local hospital and six noted they had two. Five participants reported their ORs running two days a week , one three days/week and one five days/week.Most participants felt that the volume in their surgical program was sufficient to maintain skills, although as one participant suggested, this volume was “just barely [sufficient].” Another noted, “I think we’d always want more volume and more cases.” One participant who did not think there was enough volume in her/his community to maintain surgical competence noted there would likely be “pushback” from colleagues if they left the community for a locum to increase surgical exposure. Likewise, although the majority of respondents felt their surgical program was sustainable, two respondents expressed concern regarding adequate volume for anesthesia and nursing to remain current.All physicians with ESS providing procedural care must be privileged  by their local hospital. The majority of participants entered the ESS program with a designated community in mind for rural practice and most noted that they had an understanding with the health authority on anticipated privileges and scope of practice post-training. Concomitantly, the majority of participants did not have difficulties with the privileging process. Challenges that did arise in the privileging process were due primarily to the novelty of ESS locally and the lack of any interprofessional understanding of the letter from the U of S that attests to completion of training . In some jurisdictions, this was compounded by on-going changes in provincial privileging processes or other administrative guidelines. One participant described requiring a letter from regional department heads attesting to competency in addition to the letter of competency issued from the University of Saskatchewan, which created delays to practice.For the majority of participants who were able to receive privileges, familiarity with FPESS by others was seen as a significant facilitator This familiarity was due to either practicing in the health authority where training was received or practicing in a community familiar with ESS practice. As one participant said, “I’ve been very lucky. Because [our community] has had a history of doing this….” For others, strong community need for local surgical services was also a facilitator to privileging.One of the key enablers of effective post-training CPD was supportive relationships with mentors through contact “on a daily basis” to affirm learning and acquire new skills. Participants in BC noted the efficacy of a newly instituted Clinical Coaching program which links rural FPESS with regional specialists in a formalized coaching relationship with both virtual linkages and face-to-face practice experience in the rural and regional sites. Only two of the participants in the study reported having experience in regional or tertiary ORs.Seven participants noted they had incorporated new procedural skills since graduating. Skills acquired included vasectomies, laparoscopic appendectomy, carpal tunnel release, endoscopic polypectomy, induction of labour with oral misoprostol, and minor trauma. For those participants who had incorporated new techniques or procedures since graduating from the PA program, common mechanisms of acquisition included overseas work, Alberta Society for Endoscopic Practice CPD conference, peer-to-peer mentoring and the bi-annual Enhanced Surgical Skills conference in Banff. The only barrier to CPD reported was the inability to leave the community due to clinical  responsibilities.When prompted, almost all participants felt that a remote presence platform, in which technology  is available to connect teams separated by distance including for training and consultation, would be useful in linking their rural OR with regional specialists. As one participant noted, “I would really like it. I would really like the surgeon to be in the operating room with me if I needed it.”not to do the procedure”) and opportunities for high volume practice. Others noted the value of specific venues such as the Alberta Society for Endoscopic Practice yearly conference, the Comprehensive Approach to Rural Emergencies course and “Really Rural Surgery” podcasts. Almost half of the respondents noted the value of overseas high-volume experience; several who did not have this opportunity appreciated its potential value but found it infeasible, mainly due to family reasons. One participant noted the lack of facilitation of CPD by her/his health authority to address concerns with competencies due to low volume; this lead to increased stress and negatively affected this her/his overall quality of life. As the participant noted:Recommendations for ESS CPD included system-level suggestions such as the use of remote technology, increased theory in practice . There was more variation in perception regarding the supportiveness of the U of S Department of Surgery with three participants responding they were not supportive due to lack of contact.Outside of the Clinical Coaching program in BC, graduates of the PA program were not successful in establishing mentoring relationships with their regional referral centres. Participants reported that barriers to establishing supportive mentoring relationships outside of the program were rooted in distrust and misunderstanding. As one participant noted, “Lack of understanding for ESS breeds a sense of threat or mistrust.”flexibility and, as noted above, support by faculty being the most important attributes. Flexibility was seen as that which allowed learning to be tailored to the needs of the individual learner and community to which they would return (a heightened sense of flexibility was noted by those who went through the program earlier). This flexibility was linked by some to a sense of openness: “The General Surgeons didn’t understand my role at the end, but they were welcoming and motivated to teach even though they didn’t understand fully.” Faculty support was also manifest through the responsibility the trainees felt they were given and “the enthusiasm of the Obstetricians and General Surgeons for training us.” In a representative summary, one participant said:Participant feedback about their experiences in the PA program was overwhelmingly positive with Cannot say anything bad about [the program] – cherished it. The immersion in it was really great, the fact there’s only two ESS residents in the whole hospital, everyone quickly figures out who you are. Therefore, the opportunities to get involved are more. The volume was good. Appropriate patient selection.Additional comments included “I had such a good experience that year, and even exceeded my expectations” and “Best department that I worked in. They just wanted me to learn new things all the time. The endoscopy training was fantastic; the volume amount was the great way to make sure I succeeded.”Suggestions for improvement focused on increased volume of procedures and expanded educational modalities. Several participants specifically noted the desire for increased volume for endoscopy training and others noted the value of moving to a competency-based program:  and have the confidence.”). Another participant noted the need for prioritization of ESS learners for OR time: “I understand [specialist residents] need experience and tissue time, but they have five years to acquire this and we have one year.”Participants suggested several ways to augment the core curriculum including a structured reading program, seminars with practicing ESS physicians to understand to a larger practice context, surgical office time , training in rural communities by shadowing physicians with variation in scope of practice, simulation training outside of the OR and a set plan for post-training CME. A further suggestion was increased program organization (“It’s a little bit chaotic”). The final more substantive suggestion regarded the perceived need for a stronger political voice for the Prince Albert Surgical Department in academic and provincial discussions around workforce training.When asked for their assessment of the future of enhanced surgical skills in Canada, participant responses included concern over costs in a climate of fiscal constraint, the impact of the low numbers of FPESS working on call and consequently on sustainability, and difficulties recruiting and maintaining the limited number of proceduralists that currently practice. Several participants believed the future of ESS will depend on the quality of their reputation: “It will be a struggle, but as long as the ESS student keeps performing high quality work, they will gradually build their reputation.”The total potential participant cohort for this study was 13 and we reached 11, close to the population, allowing us to capture enough variation in response to represent experiences of the program adequately. The consistency of the responses across participants allows some tentative conclusions to be drawn, namely that overall, the Prince Albert ESS training program, through the lens of its graduates, was successful in meeting the training needs of learners and preparing them for rural practice. Beyond experiences with the program, however, further reflections of participants regarding 1) post-training privileging for practice, 2) on-going relationships with specialists, and 3) the lack of formalized continuing medical education suggest larger systemic issues, centered in the post training reality of the ESS graduates.20 This would also help to address the significant challenge of privileging of FPESS, not only inter-provincially but also intra-provincially, that is, a physician who has permission to perform a set of clinical activities in one health authority may not be able to obtain this same permission if they move to another health authority.Graduates of the ESS program do not receive official accreditation or designation after completing the program. They receive a letter of completion from the program as evidence of the demonstration of individual competence in a high-quality training program. The comparison would be the Category 1 programs in Emergency Medicine and Family Practice Anesthesia, each with their own Certificate of Added Competence (CAC) from the College of Family Physicians of Canada (CFPC). The present collaborative process between the Royal College of Physicians and Surgeons of Canada (RCPSC) and the CFPC to elevate ESS programs to Category 1 status promises to unlock the postgraduate privileging process and build support for ESS among specialist colleagues.21 The new Clinical Coaching programs, proposed in the Rural Surgery and Obstetric Networks in BC, offer an evidence based model within which to grow these relationships.If the recommendations for networked rural surgical care from the Joint Position Paper are to be realized, the historical frequently dysfunctional relationships between specialist and FPESS will need to grow into the relationships of trust and collaboration described as the foundation for successful network.The small cohort of ESS participants, the heterogeneity of its practice scope, the barriers to leaving the community even for a short time, the current lack of support and understanding within the specialist surgical societies, together pose large challenges to CPD for ESS. While volumes in training were considered to be sufficient for competency, the low volume nature of a rural generalist surgical practice was clearly a threat to sustaining currency amongst the graduates. We imagine that Clinical Coaching programs, remote presence, and CQI programs will mitigate the challenges posed by low volume. The global surgical experiences sought by many FPESS graduates offer CPD experiences that pose disruptive challenges to traditional CPD programming and introduce new ethical challenges.23 The sustainability of rural FPESS will require, in addition to the improved CPD needs already highlighted, robust Continuous Quality Improvement programs. In a low volume generalist environment, measuring quality might require the documentation and examination of outcomes for 100% of all surgical procedures. It is promising that the new Rural Surgical and Obstetrical Networks program in BC proposes to do just that – reporting and examining all outcomes using a thoughtful reflective privatized self corrective methodology.Outside of endoscopy, colonoscopy, and caesarean section, the procedural volumes were low. These findings are a step towards updating existing literature on surgical procedural volumes in rural Canadian jurisdictions.There is broad satisfaction among the graduates of the PA program with the scope and quality of the 12-month program. They developed, and continue to hold, strong mentoring relationships with the faculty. The concordance between the curriculum and their scope of practice attests to the suitability of the program to future practice. Their post training challenges with obtaining permission to conduct procedures and with forming collaborative relationships with specialist surgeons might be resolved, at least partly, with the present collaborative efforts between the two licensing Colleges to elevate ESS to Category 1 and to award a Certificate of Added Competency to its graduates. Concomitantly, this may lead to greater awareness and understanding of ESS practice by the specialties and foster stronger and more collaborative relationships between providers. This leaves the urgent need for effective rurally appropriate post-training CPD opportunities as the outstanding challenge to the sustainability of FPESS.


Despite high quality evidence supporting multiple physical and cognitive benefits of community-based exercise for people after stroke, there is little understanding on how to facilitate uptake of these research findings to real-world programs. A common barrier is a lack of standardised training for community fitness instructors, which hampers the ability to train more instructors to deliver the program as it was designed. Scaling up program delivery, while maintaining program fidelity, is complex. The objective of this research is to explore novel use of the Template for Intervention Description and Replication (TIDier) framework to evaluate and support implementation fidelity of a community exercise program.We embedded intervention fidelity evaluation into an inaugural training program for fitness instructors who were to deliver the Fitness and Mobility Exercise Program for stroke, which has established efficacy. The training program consisted of a face-to-face workshop followed by 3 worksite ‘audit and feedback coaching cycles’ provided over 3 iterations of the 12-week program offered over 1 year. A modified TIDIER checklist  was used within the training workshop to clarify the key ‘active ingredients’ that were required for program fidelity, and secondly as a basis for the audit and feedback process enabling the quantitative measurement of fidelity. Data were collected from audits of observed classes and from a survey provided by fitness instructors who implemented the program.We demonstrated the feasibility of the TIDier checklist to capture 14 essential items for implementation evaluation of a complex exercise intervention for people with chronic health conditions over 3 iterations of the program. Based on the audit tool, program fidelity was high and improved over time. Three content areas for workplace coaching  were identified from the audit tool and were addressed.Training of staff to deliver exercises to high need populations utilising workshops and workplace coaching that used the TIDier framework for training, onsite audit and feedback resulted in a high level of fidelity to the program principles. A novel checklist based on the TIDier framework was useful for embedding implementation fidelity in complex community-based interventions. While there is good quality evidence and guidelines supporting community-based exercise to improve physical and cognitive functioning in people with stroke , there iThe lack of ability to standardise the delivery and evaluation of complex health interventions can arise in barriers to implementation  and jeopImplementing community-based exercise programs remains challenging , with a The objective of this research is to evaluate implementation fidelity of a complex multi-component community-based exercise program using a framework adapted from the Template for Intervention Description and Replication (TIDier) checklist that we embedded in a training program built on the TIDier framework when we ran it for the first time. The intervention implemented was the Fitness and Mobility Exercise (FAME) for people after stroke which has a high level of effectiveness that had been demonstrated in multiple randomised controlled clinical trials –13.This project took place in a recreation community centre in a suburb of a large metropolitan city. The staff to deliver the program were fitness instructors employed at this centre who had experience in delivery of group classes to older adults but had no experience with stroke. Training consisted of a one-day workshop, four workplace audits and four sessions of workplace coaching 1 week after each audit over three iterations of the program over 1 year , intensity monitoring charts and images of all exercises. These tools included an outline of the essential elements (described here as program principles) and fitness instructors were informed that they would receive feedback after auditing based on 7 principles: Progression, Repetition, Intensity, Normal movement, Core components, Encouragement and education (PRINCE) . All teaching resources and manuals are available from All fitness instructors who regularly delivered the FAME program over the first year participated in the workplace audit and coaching process. The workplace coaching was facilitated by one of the physical therapy instructors who had delivered the day-long workshop. The content of each coaching session was determined by the workplace audit which took place a week before each of the coaching sessions.The audit tool was based on the format of the TIDier framework checklist  and inclAfter 12 months and three rounds of the FAME program, the fitness instructors were invited to complete a closed online survey to indicate how they had used the training in their practice and what other training needs there were. The survey used open-ended questions to ask about the fidelity to the program content and delivery, challenges and future training needs. The survey also included a series of open-ended Likert scale questions to determine the impact of the workplace coaching. The survey was administered online using a Qualtrics platform through an anonymous email link. The survey was open between 24.04.2018 and 24.06.2018. Instructors were able to go back and change responses. The survey collected IP address data so that multiple entries could be monitored. All instructors received a $CAD25 gift card after the survey was completed. The CHERRIES checklist was used in designing the online survey . A copy An inductive form of content analysis was used explicitly to categorise open-ended survey responses on training and implementation fidelity . The datTwelve fitness instructors undertook the initial workshop  who were delivering exercise with the community centre. All 12 instructors had a provincial designation as a registered fitness instructor. Ten of these instructors also had a bachelor’s degree; three of these in kinesiology and in addition two of these instructors had master’s level qualification in exercise science or exercise physiology.The FAME program ran for 1 hour on 2 days a week led by two trained instructors at each session. Four instructors taught regularly and were present for the workplace coaching. Two other instructors were available for relief and taught in the program as needed.Program fidelity was generally high based on our TIDier audit checklist, but three of the 14 items had some non-adherence. The three items identified as not meeting audit criteria were; Item 4.2: intensity monitoring, item 3.7: discussing educational tips  and Item 7: adequate space. Potential solutions were discussed with the fitness instructors to rectify these problems. Program fidelity improved over the course of the audits. Difficulties in using personal carers in class was identified as a challenge at the second audit, although this was not on the original checklist.The TIDier checklist audit results informed the subsequent workplace coaching session in terms of learning objectives, content and preferred format for delivery. This was done in collaboration between the fitness instructors and the auditor. Multiple educational strategies were used in the workplace coaching, which included development of new written and equipment-based resources and practical components. The written material was subsequently included in the workshop manual for future delivery of training to the next cohorts of fitness instructors.The first workplace coaching session addressed Item 4.2 and included intensity monitoring information  and use of heart rate monitors. To meet the criteria of providing educational tips (Item 3.7), a more detailed script for the educational tips was used, with coaching on their use in the class.The second workplace coaching session included demonstrations of how to instruct carers to assist with management of their client in the class (Item 11). This included where to stand for balance activities and how and where to hold their client in the class. With the high turnover of carers attending with the people with stroke, a handout was requested by the fitness instructors to give to the carers about how to support their person in the class. This was developed by the research team and included in the manual in the subsequent versions.The third workplace coaching session addressed TIDier audit checklist item 3.7 and included a discussion of why the educational tips were still not being used. The fitness instructors commented that it was difficult to include the information and exercises in the same session and suggested the provision of handouts for the class participants.The fourth workplace coaching session included a visit to negotiate with management to move the program to a larger space to meet the TIDier checklist audit criteria 7.Six of the 12 instructors that attended the workshop had opportunity to teach the FAME program over the first year. All these six instructors completed a survey at 1 year to provide feedback on the FAME program implementation. While the other 6 instructors applied their FAME knowledge to other programs they delivered, they were not specifically evaluated. Three themes relating to the program fidelity emerged from the open-ended survey data. These themes are ‘program delivery – highlights and challenges’, ‘active ingredients’, and ‘confidence from coaching’.In general, the instructors found that the program was well received and could describe gains made for the participants with stroke, a chronic disease population that has more physical and cognitive needs than typically seen by fitness instructors: “I see such an improvement with the participants. They all have complemented us on the class and how they are enjoying it.” (P1) and “seeing the improvements in the people in their balance and stamina was gratifying.” (P6) Five people commented on the small exercise space when asked about challenges in delivering the program. Another person described the challenge of delivering a program to people of different abilities, especially as some people needed a caregiver to support them to participate. Five of the six respondents indicated that they had made changes to the program, although only two provided details which within the scope of the program . Neither of these changes altered program fidelity.The explicit identification of 7 essential “active ingredients” which was part of the Tidier audit was helpful to maintain fidelity and it appeared that respondents were delivering the program in line with the program principles as intended; they identified several components of the program itself that were working well, including the program plan, and the actual exercise components. The resources provided in the training workshop were “helpful to keep all of the instructors on the same direction.” (P5). One respondent stated that the high level of evidence of the program was a major reason why they had not changed the program delivery. Ongoing commitment to program delivery was noted by one respondent; “I see the importance of this program in the community and would like to be more involved teaching [it] in the future.” (P2).All six respondents agreed or strongly agreed that they were confident to deliver the program and that their confidence had improved over the year since initial training. Five out of six respondents agreed or strongly agreed that they understood common impairments for people with stroke, with one neutral response. All respondents agreed or strongly agree that they understood the exercise benefits for people after stroke. Responses related to program principles of repetition and progression were positive (agreed or strongly agreed), with only one neutral response. Five out of six respondents also agreed or strongly agreed that their confidence in physically supporting people within the class had improved, with one neutral response.Complex interventions are hard to reproduce  and idenThe application of the TIDier framework required us to identify and describe the ‘active ingredients’ in sufficient detail to facilitate the implementation of the intervention as intended, as well as to enable evaluation of program fidelity. The future use of this tool in supporting and evaluating fidelity during wider scale replication warrants further exploration.The high levels of implementation fidelity for the delivery of an exercise program for people after stroke was supported by the use of a checklist at multiple points within this project. Initially, the checklist was used within the training workshop to clarify the key ‘active ingredients’ that were required for program fidelity to the instructors. Second, the checklist was used as a basis for the audit and feedback process within the workplace visits, enabled the quantitative measurement of fidelity and supported demonstrable improvements in fidelity over time. Assessing Implementation fidelity is vital for determining effectiveness, feasibility and variation in the intervention delivery .This is the first time that the TIDier checklist  has beenWhile audit and feedback is effective in changing health professional behaviour in health settings , this isIt is a strength of this study that there were multiple iterations of audit and workplace coaching using the TIDier audit checklist to improve fidelity of the program over a year. Transferability may be limited because data was only collected at one site with a small number of participants.Implementing complex community-based exercise requires the people delivering exercise be trained to ensure that all the active ingredients of the program are addressed. Through defining, describing and embedding the ‘active ingredients’ (program principles) in training and then using an audit and feedback process to measure fidelity and inform ongoing learning, we have demonstrated that evidence-based exercise can be delivered with fidelity within a community centre. A novel checklist based on the TIDier framework supported program implementation and fidelity evaluation. Other program deliverers may find this TIDier adapted checklist useful to measure their own program fidelity.Additional file 1. Survey for Exercise Instructors.Additional files 2: Table S1. TIDier adapted checklist with examples.


Phomopsis sp. FJBR-11, based on phylogenetic analysis, led to the identification of six compounds, including dothiorelones A–C, and H, and cytosporones C and U. Among these compounds, cytosporone U exhibited potent inhibitory activity against Tobacco mosaic virus (TMV). Moreover, the crude and a purified exopolysaccharide were proved to possess strong inhibitory effects against the virus infection.The fermentation and isolation of metabolites produced by an endophytic fungus, which was identified as  Tobacco mosaic virus (TMV) is a prevalent plant pathogen which brings about dramatic losses to modern agriculture. Over 885 plant species in 65 families could be infected by TMV, and up to U.S. $100 million is lost each year globally due to plant diseases caused by TMV. However, no effective chemical treatments appear capable, so far, of inhibiting virus replication once plants are infected ) × 100%, where C is the average number of local lesions of the control, while T is the average number of local lesions of the treatment.A mixture of test solution with TMV  was made 30 min before inoculation. The mixture was inoculated on the left side of the leaves of N. tabacum cv. K326 were mechanically inoculated with TMV (30 μg/mL in 0.01 M PBS). After 6 h, leaf discs (1 cm diameter) were punched and floated on solutions for testing. Discs of healthy and inoculated leaves floated on a solution of 0.01 M PBS with 2% DMSO were used as mock and negative controls, respectively. Three replicates were carried out for each sample. After incubating for 48 h at 25 °C in a culture chamber, the leaf discs were ground in 0.01 M carbonate coating buffer (pH 9.6) and OD405 values were measured using the TAS-ELISA method. TAS-ELISA was performed as described in the literature [405 values of purified TMV at concentrations of 1.0, 0.5, 0.25, 0.125, and 0.0625 μg/mL. The inhibition of test solutions on TMV was calculated as follows: Inhibition rate = (1 − (virus concentration of treatment)/(virus concentration of negative control)) × 100%.Growing leaves of terature . Virus cPhomopsis sp. FJBR-11 isolated from the stem of B. javanica. All the compounds, except cytosporone U, showed only weak or no inhibitory activity against TMV under test using the local lesion and leaf-disc methods. However, the crude and a purified polysaccharide produced by Phomopsis sp. FJBR-11 showed strong inhibitory effects against the virus infection as determined by using the local lesion assay.Six compounds, including dothiorelones A–C and H, and cytosporones C and U, were identified from the metabolites of an endophytic