Purpose -The purpose of ths paper is to report that timely interventions to facilitate medical patient flow and reduce medical outliers may be associated with a reduction in hospital mortality. Design/methodology/approach -Interventions to improve the flow of medical patients were used to unblock and facilitate the discharge process allowing a reduction in medical outliers. SPC run charts of mortality were used to quality control the changes. Findings -Timeliness in daily senior medical review and discharge planning, a level 1 medical ward, and outreach including ALERT training and early warning scoring allowed a rationalisation in medical beds and a reduction in mortality for emergency medical admissions, reflected in a lower hospital standarised mortality rate (HSMR). Practical implications -Interventions to improve flow can also lead to a reduction in mortality. Originality/value -This paper emphasises how quantitative flow improvements can also generate qualitative improvements.

ObjectiveAlcohol-related admissions are increasing. A significant number of these admissions are attributable to a small number of complex patients with other comorbidities who do not engage well with mainstream services. Assertive outreach teams have been used in the field of psychiatry to engage patients who are poorly compliant. This study examines whether an alcohol assertive outreach team (AAOT) can engage with this group and reduce hospital admissions.DesignThe AAOT is a multidisciplinary team with medical, psychiatric, substance misuse, psychology, nursing and social work specialists. The team worked with patients with the highest number of alcohol-related admissions and case managed in a community setting for 6 months. The admission and emergency department attendances of the cohort were compared for the 3-month period before and after the intervention. Christo inventory for substance misuse services (CISS) scores were determined pre and post the intervention period.Results54 patients were case managed. The total number of admissions in 3 months fell from 151 prior to the intervention period to 50 following the intervention. Emergency department attendances also fell from 360 in 3 months to 146 following the intervention period. CISS scores fell from 11 preintervention to eight postintervention.ConclusionsAn AAOT model appears to reduce hospital admissions and emergency department attendances in a complex group of patients that display high alcohol-related admissions.

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Background Early learning and childcare centers (ELCCs) can offer young children critical opportunities for quality outdoor play. There are multiple actual and perceived barriers to outdoor play at ELCCs, ranging from safety fears and lack of familiarity with supporting play outdoors to challenges around diverse perspectives on outdoor play among early childhood educators (ECEs), administrators, licensing officers, and parents. Objective Our study objective is to develop and evaluate a web-based intervention that influences ECEs’ and ELCC administrators’ perceptions and practices in support of children’s outdoor play at ELCCs. Methods The development of the fully automated, open-access, web-based intervention was guided by the intervention mapping process. We first completed a needs assessment through focus groups of ECEs, ELCC administrators, and licensing officers. We identified key issues, needs, and challenges; opportunities to influence behavior change; and intervention outcomes and objectives. This enabled us to develop design objectives and identify features of the OutsidePlay web-based intervention that are central to addressing the issues, needs, and challenges of ECEs and ELCC administrators. We used social cognitive theory and behavior change techniques to select methods, applications, and technology to deliver the intervention. We will use a two-parallel-group randomized controlled trial (RCT) design to evaluate the efficacy of the intervention. We will recruit 324 ECEs and ELCC administrators through a variety of web-based means, including Facebook advertisements and mass emails through our partner networks. The RCT study will be a purely web-based trial where outcomes will be self-assessed through questionnaires. The RCT participants will be randomized into the intervention group or the control group. The control group participants will read the Position Statement on Active Outdoor Play. Results The primary outcome is increased tolerance of risk in children’s play, as measured by the Teacher Tolerance of Risk in Play Scale. The secondary outcome is self-reported attainment of a self-developed behavior change goal. We will use mixed effects models to test the hypothesis that there will be a difference between the intervention and control groups with respect to tolerance of risk in children’s play. Differences in goal attainment will be tested using logistic regression analysis. Conclusions The OutsidePlay web-based intervention guides users through a personalized journey that is split into 3 chapters. An effective intervention that addresses the barriers to outdoor play in ELCC settings has the potential to improve children’s access to outdoor play and support high-quality early childhood education. Trial Registration ClinicalTrials.gov NCT04624932; https://clinicaltrials.gov/ct2/show/NCT04624932 International Registered Report Identifier (IRRID) DERR1-10.2196/31041

Background Outdoor play is critical to children’s healthy development and well-being. Early learning and childcare centers (ELCCs) are important venues for increasing children’s outdoor play opportunities, and early childhood educators’ (ECE) perception of outdoor play can be a major barrier to outdoor play. The OutsidePlay-ECE risk-reframing intervention is a fully automated and open access web-based intervention to reframe ECEs’ perceptions of the importance of outdoor play and risk in play and to promote a change in their practice in supporting it in ELCC settings. We grounded the intervention in social cognitive theory and behavior change techniques. Objective The aim of this study is to evaluate the effectiveness of the OutsidePlay-ECE web-based risk-reframing intervention. Methods We conducted a single-blind randomized controlled trial in Canada between December 2020 and June 2021 to test the OutsidePlay-ECE risk-reframing intervention for ECEs. We recruited participants using social media and mass emails through our partner and professional networks. We invited ECEs and administrators working in an ELCC, who can speak, read, and understand English. We randomized consented participants to the intervention or control condition. The participants allocated to the intervention condition received a link to the OutsidePlay-ECE intervention. Participants allocated to the control condition read the Position Statement on Active Outdoor Play, a 4-page document on research and recommendations for action in addressing barriers to outdoor play. The primary outcome was a change in tolerance of risk in play. The secondary outcome was goal attainment. We collected data on the web via REDCap (Vanderbilt University) at baseline and 1 week and 3 months after intervention. Results A total of 563 participants completed the baseline survey, which assessed their demographics and tolerance of risk in play. They were then randomized: 281 (49.9%) to the intervention and 282 (50.1%) to the control condition. Of these, 136 (48.4%) and 220 (78%) participants completed the baseline requirements for the intervention and control conditions, respectively. At 1 week after intervention, 126 (44.8%) and 209 (74.1%) participants completed follow-up assessments, respectively, and at 3 months after intervention, 119 (42.3%) and 195 (69.1%) participants completed the assessments, respectively. Compared with participants in the control condition, participants in the intervention group had significantly higher tolerance of risk in play at 1 week (β=.320; P=.001) and 3 months after intervention (β=.251; P=.009). Intention-to-treat analyses replicated these findings (β=.335; P<.001 and β=.271; P=.004, respectively). No significant intervention effect was found for goal attainment outcomes (odds ratio 1.124, 95% CI 0.335-3.774; P=.85). Conclusions The results of this randomized controlled trial demonstrated that the OutsidePlay-ECE intervention was effective and had a sustained effect in increasing ECEs’ and administrators’ tolerance of risk in play. It was not effective in increasing goal attainment. Trial Registration ClinicalTrials.gov NCT04624932; https://clinicaltrials.gov/ct2/show/NCT04624932 International Registered Report Identifier (IRRID) RR2-10.2196/31041

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BACKGROUND Outdoor play is critical to children’s healthy physical, social, emotional and intellectual development and well-being; yet children’s opportunities for outdoor play have steadily decreased across generations in many developed countries. Early learning and childcare centers are an important venue for increasing children’s outdoor play opportunities because many children spend most of their waking hours in these facilities. Early childhood educators’ perception of outdoor play and its inherent physical risks can be a major barrier to outdoor play. The OutsidePlay-ECE risk-reframing intervention is a fully-automated and open access web-based intervention to reframe early childhood educators’ perception of the importance of outdoor play and risk in play, and to promote a change in their practice in supporting for children’s outdoor play in early learning and childcare center settings. We grounded the intervention in social cognitive theory and behavior change techniques. OBJECTIVE To evaluate the efficacy of the OutsidePlay-ECE web-based risk-reframing intervention. METHODS We conducted a single-blinded randomized controlled trial in Canada between December 2020 to June 2021 to test the OutsidePlay-ECE risk-reframing intervention for early learning and childcare center educators. We conducted recruitment primarily through social media and mass emails through our partner and professional networks. We invited those interested in participating to self-assess their eligibility: working as an early childhood educator and/or administrator in an early learning and childcare center in Canada, and able to speak, read and understand English. We randomized consented participants to the intervention condition or the control condition. Participants allocated to the intervention condition received a link to the OutsidePlay-ECE intervention. The OutsidePlay-ECE intervention guided participants through three chapters, consisting of: 1) an introduction to outdoor play, and reflections on their own childhood experiences of play and the experiences of children in their center, 2) a series of interactive video scenarios about outdoor play, and 3) setting a personalized goal for change in their centre. Participants allocated to the control condition read the Position Statement on Active Outdoor Play, a 4-page document on research and recommendations for action in addressing barriers to outdoor play. The primary outcome was increase in tolerance of risk in play. The secondary outcome was goal attainment. We collected data online via the REDCap at baseline, 1-week, and 3-month post-intervention. We conducted randomization using sealedenvelope.com. We concealed allocations from researchers at assignment and during data analysis. RESULTS A total of 563 participants completed baseline survey consisting of sociodemographic questions and a questionnaire that assessed participant tolerance for risk in play, self-efficacy, and stage of change. These participants were then randomized: 281 in the intervention, and 282 in the control condition. Of 281 participants who were allocated to the intervention condition, 199 completed the baseline requirement (i.e., completion of the baseline survey and the intervention, and setting-up their goal). Respectively, of 282 participants who were allocated to the control condition, 221 completed the baseline requirement. At 1-week post intervention 126 and 209 participants completed assessments for each condition, respectively, and at 3-month post intervention, 119 and 195 completed the assessments, respectively. Compared to participants in the control condition, participants in the intervention had significantly higher tolerance of risk in play at 1-week (β=0.323, P= 0.001) and 3-month post-intervention (β=0.342, P= 0.001), after controlling for sociodemographic covariates. Intention-to-treat analysis replicated these findings (β=0.348, P= 0.001 and β=0.35, P= 0.001, respectively). No significant intervention effect was found for the goal attainment outcome. CONCLUSIONS The results of this randomized controlled trial demonstrate that the OutsidePlay-ECE intervention was effective and had sustained effect in increasing early childhood educators’ and administrators’ tolerance of risk in play. It was not effective at increasing goal attainment. CLINICALTRIAL ClinicalTrials.gov, NCT04624932. Retrospectively registered on April 26, 2021. INTERNATIONAL REGISTERED REPORT RR2-10.2196/31041