Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

The findings indicate clinical and operational issues, which will need careful consideration in the future planning of services. The high number of ARMS cases highlights the importance of clear treatment pathways and targeted interventions and may suggest a need to commission distinct ARMS services. The number of people who met the extended age and service acceptance criteria may suggest a need to adapt or redesign clinical services to meet the age-specific needs of over 35 year olds and those with an ARMS. It is unclear how changes to the remit of EIP services will impact upon future clinical outcomes.

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BackgroundPatients may be over-diagnosed with C. difficile infection (CDI) due to colonization, especially if laxatives are used. We had implemented an alert to prompt providers to discontinue C. diff orders in the setting of laxative use. This initially decreased orders by about 25%, but became less effective over time. Our objective was to strengthen our C. diff testing stewardship by creating a “hard stop” to require providers to think critically about C. diff testing in the presence of laxative use or the absence of documented diarrhea.MethodsOur two-hospital, >1100-bed community-based academic healthcare system performs all C. diff testing via PCR. We implemented our initial laxative alert, which notified providers but did not prohibit testing, in March 2015. In April 2017, we launched a new alert that fired >36 hours after admission, and assessed for documented diarrhea (>2 episodes/24 hours). If diarrhea was present, it would assess for any administered laxative within prior 24 hours. If neither criterion was met, the provider could only order C. diff testing by calling the laboratory and documenting the staff person’s name in the order; no further justification was required. We measured the number of C. diff tests completed per day, the number of calls made to lab, and CDI rates (using NHSN LabID definition). Balancing measures included monitoring oral vancomycin orders without C. diff testing, and delayed CDI diagnoses.ResultsAt baseline, we observed a mean of 9 (SD, 4–14) C. diff orders daily. After initiating the hard stop alert, daily testing decreased by 30% (Fig. 1). Frequency of hospital-onset CDI dropped by 45% during first month of implementation (Fig. 2), from mean 3.6/week to 2/week. To date we have not detected delayed diagnoses or empiric treatment without testing; 18 override laboratory calls have been documented.ConclusionGiven PCR’s high sensitivity for C. diff, testing stewardship is critical to minimize false-positive cases of CDI, which lead to inappropriate treatment, prolonged length of stay, and hospital penalties. Requiring a phone call to order C. diff testing in the setting of laxative use or minimal diarrhea effectively reduced testing, and was well-accepted by nurses and providers. To date, no adverse effects have been detected.Disclosures All authors: No reported disclosures.

P alliative care can be appropriate at any age and any stage of an incurable disease or of an advanced lifethreatening illness, and can be provided along with curative treatment. 1 It aims to give patients and those close to them the support they need to achieve the best possible quality of life. 2-5 Delivery of palliative care is a shared responsibility among all health care professions within all fields of medicine. However, only 25%-30% of practising physicians feel comfortable providing palliative care, 6 and there is a shortage of trained palliative care providers in the workforce. 7 In August 2013, the Canadian Medical Association adopted a resolution requesting that "all Canadian faculties of medicine create a curriculum for training in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise." 7 To meet current and projected palliative care needs of Canadians, most physicians should receive clinical training in palliative care, 8 and clinical rotations are an essential component of this. The proportion of medical undergraduate and postgraduate students completing palliative care clinical rotations in Canadian medical schools is unknown. To evaluate the status of palliative care clinical training in Canada, we aimed to estimate the proportion of Canadian medical trainees completing clinical rotations in palliative care and to determine whether changes in palliative care clinical training have recently taken place.