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Holdsworth LM, Stedman M, Gustafsson ES, Han J, Asch SM, Harbert G, Lorenz KA, Lupu DE, Malcolm E, Moss AH, Nicklas A, Tamura MK. "Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers. BMC Health Serv Res 2023; 23:1384. [PMID: 38082293 PMCID: PMC10712060 DOI: 10.1186/s12913-023-10360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers. METHODS We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation. RESULTS The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores. CONCLUSIONS NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing. TRIAL REGISTRATION ClinicalTrials.gov, NCT04125537 . Registered 14 October 2019 - Retrospectively registered.
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Affiliation(s)
- Laura M Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA.
| | - Margaret Stedman
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erika Saliba Gustafsson
- Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA
- Center for Innovation to Implementation, Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Glenda Harbert
- School of Nursing, George Washington University, Washington, D.C, USA
| | - Karl A Lorenz
- Division of Primary Care and Population Health, Stanford University School of Medicine, 3180 Porter Drive, Palo Alto, CA, 94304, USA
- Center for Innovation to Implementation, Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Dale E Lupu
- School of Nursing, George Washington University, Washington, D.C, USA
| | - Elizabeth Malcolm
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, D.C, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
- Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, CA, USA
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Moss AH, Harbert G, Aldous A, Anderson E, Nicklas A, Lupu DE. Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care. Kidney360 2023; 4:1738-1751. [PMID: 37889550 PMCID: PMC10758509 DOI: 10.34067/kid.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023]
Abstract
Key Points A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices. Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance. Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers. Background Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers. Methods The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC. Results The seven key lessons are (1 ) systematically assess KSC needs; (2 ) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3 ) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4 ) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5 ) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6 ) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7 ) implement systematic approaches to support patients who choose active medical management without dialysis. Conclusions Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals. Clinical Trial registry name and registration number Pathways Project: KSC, NCT04125537 .
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Affiliation(s)
- Alvin H. Moss
- Sections of Nephrology and Palliative Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | | | - Annette Aldous
- Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | - Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
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Kurella Tamura M, Holdsworth L, Stedman M, Aldous A, Asch SM, Han J, Harbert G, Lorenz KA, Malcolm E, Nicklas A, Moss AH, Lupu DE. Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients. Clin J Am Soc Nephrol 2022; 17:1495-1505. [PMID: 36104084 PMCID: PMC9528276 DOI: 10.2215/cjn.00090122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods. RESULTS One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway. CONCLUSIONS A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Pathways Project: Kidney Supportive Care, NCT04125537.
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Affiliation(s)
- Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Laura Holdsworth
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Margaret Stedman
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Annette Aldous
- Milkin Institute School of Public Health, George Washington University, Washington, DC
| | - Steven M. Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Glenda Harbert
- School of Nursing, George Washington University, Washington, DC
| | - Karl A. Lorenz
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Elizabeth Malcolm
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | - Alvin H. Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
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Rodriguez de Sosa G, Nicklas A, Thamer M, Anderson E, Reddy N, Stevelos J, Germain MJ, Unruh ML, Lupu DE. Implementing Advance Care Planning for dialysis patients: HIGHway project. Palliat Care 2022; 21:129. [PMID: 35841019 PMCID: PMC9286956 DOI: 10.1186/s12904-022-01011-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Patients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. Methods We will train between 50–60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage. Discussion Effective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients. Trial registration The George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.
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Affiliation(s)
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC, USA
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, MD, USA
| | | | | | - JoAnn Stevelos
- School of Nursing, George Washington University, Washington, DC, USA
| | - Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Dale E Lupu
- Center of Aging, Health and Humanities, George Washington University, Washington DC, USA
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Lupu DE, Aldous A, Harbert G, Kurella Tamura M, Holdsworth LM, Nicklas A, Vinson B, Moss AH. Pathways Project: Development of a Multimodal Innovation To Improve Kidney Supportive Care in Dialysis Centers. Kidney360 2020; 2:114-128. [PMID: 35368811 PMCID: PMC8785737 DOI: 10.34067/kid.0005892020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/23/2020] [Indexed: 02/04/2023]
Abstract
Current care models for older patients with kidney failure in the United States do not incorporate supportive care approaches. The absence of supportive care contributes to poor symptom management and unwanted forms of care at the end of life. Using an Institute for Healthcare Improvement Collaborative Model for Achieving Breakthrough Improvement, we conducted a focused literature review, interviewed implementation experts, and convened a technical expert panel to distill existing evidence into an evidence-based supportive care change package. The change package consists of 14 best-practice recommendations for the care of patients seriously ill with kidney failure, emphasizing three key practices: systematic identification of patients who are seriously ill, goals-of-care conversations with identified patients, and care options to respond to patient wishes. Implementation will be supported through a collaborative consisting of three intensive learning sessions, monthly learning and collaboration calls, site data feedback, and quality-improvement technical assistance. To evaluate the change package's implementation and effectiveness, we designed a mixed-methods hybrid study involving the following: (1) effectiveness evaluation (including patient outcomes and staff perception of the effectiveness of the implementation of the change package); (2) quality-improvement monitoring via monthly tracking of a suite of quality-improvement indicators tied to the change package; and (3) implementation evaluation conducted by the external evaluator using mixed methods to assess implementation of the collaborative processes. Ten dialysis centers across the country, treating approximately 1550 patients, will participate. This article describes the process informing the intervention design, components of the intervention, evaluation design and measurements, and preliminary feasibility assessments. Clinical Trial registry name and registration number Pathways Project: Kidney Supportive Care, NCT04125537.
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Affiliation(s)
- Dale E. Lupu
- School of Nursing, George Washington University, Washington, DC
| | - Annette Aldous
- Milken Institute School of Public Health, George Washington University, Washington, DC
| | | | - Manjula Kurella Tamura
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California,Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Laura M. Holdsworth
- Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC
| | | | - Alvin H. Moss
- Sections of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, West Virginia
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Nagele U, Kugler M, Nicklas A, Merseburger AS, Walcher U, Mikuz G, Herrmann TR. Waterjet hydrodissection: first experiences and short-term outcomes of a novel approach to bladder tumor resection. World J Urol 2011; 29:423-7. [DOI: 10.1007/s00345-011-0653-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/18/2011] [Indexed: 12/28/2022] Open
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Abstract
STUDY OBJECTIVE To determine the anatomy of the left upper quadrant (LUQ) of the abdomen in women with different body mass indexes. DESIGN Review of computed tomographic (CT) scans and medical records (Canadian Task Force classification II-2). SETTING Large tertiary care medical center. PATIENTS Sixty-three women over age 18 years who had scans performed for any indication. Nine women were excluded because of contraindication to LUQ laparoscopic cannula insertion and five because of incomplete records. Intervention. None. MEASUREMENTS AND MAIN RESULTS The closest organs to the LUQ insertion site were the liver and stomach. There was significantly more subcutaneous fat at the umbilicus than at the insertion site. A positive correlation was found between body mass index and distance between structures and the site. CONCLUSION Cannulas should not be inserted in the LUQ in women with hepatomegaly or splenomegaly. Because the stomach is so close to the insertion site, gastric drainage should be performed before cannula insertion. The site is likely safe in obese women whose abdominal organs are far away from it, and who have less subcutaneous fat there than at the umbilicus.
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Affiliation(s)
- P K Tulikangas
- Department of Minimally Invasive Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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