Implementation, mechanisms of change and contextual factors of a complex intervention to improve interprofessional collaboration and the quality of medical care for nursing home residents: study protocol of the process evaluation of the interprof ACT intervention package

BACKGROUND

To improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs' nursing home visits) that can be locally adapted. The cluster-randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse-physician collaboration as well as preconditions and prospects for successive implementation into routine care.

METHODS

This study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper-based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick-off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non-participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models.

DISCUSSION

By integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426475 . Registered on 07/02/2018.

Measuring care coordination in German primary care - adaptation and psychometric properties of the Medical Home Care Coordination Survey

Background

Continuity of care is associated with many benefits for patients and health care systems. Therefore measuring care coordination - the deliberate organization of patient care activities between two or more participants - is especially needed to identify entries for improvement. The aim of this study was the translation and cultural adaptation of the Medical Home Care Coordination Survey (MHCCS) into German, and the examination of the psychometric properties of the resulting German versions of the MHCCS-P (patient version) and MHCCS-H (healthcare team version).

Methods

We conducted a paper-based, cross-sectional survey in primary care practices in three German federal states (Schleswig-Holstein, Hamburg, Baden-Württemberg) with patients and health care team members from May 2018 to April 2019. Descriptive item analysis, factor analysis, internal consistency and convergent, discriminant and predictive validity of the German instrument versions were calculated by using SPSS 25.0 (Inc., IBM).

Results

Response rates were 43% (n = 350) for patients and 34% (n = 141) for healthcare team members. In total, 300 patient questionnaires and 140 team member questionnaires could be included into further analysis. Exploratory factor analyses resulted in three domains in the MHCCS-D-P and seven domains in the MHCCS-D-H: “link to community resources”, “communication”, “care transitions”, and additionally “self-management”, “accountability”, “information technology for quality assurance”, and “information technology supporting patient care” for the MHCCS-D-H. The domains showed acceptable and good internal consistency (α = 0.838 to α = 0.936 for the MHCCS-D-P and α = 0.680 to α = 0.819 for the MHCCS-D-H).

As 77% of patients (n = 232) and 63% of health care team members denied to have or make written care plans, items regarding the “plan of care” of the original MHCCS have been removed from the MHCCS-D.

Conclusions

The German versions of the Medical Home Care Coordination Survey for patients and healthcare team members are reliable instruments in measuring the care coordination in German primary care practices. Practicability is high since the total number of items is low (9 for patients and 27 for team members).

Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial

BACKGROUND

In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.

METHODS

This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.

DISCUSSION

This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.

Interprofessional collaboration in nursing homes (interprof): development and piloting of measures to improve interprofessional collaboration and communication: a qualitative multicentre study

BACKGROUND

Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124).

METHODS

The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 "exploration of the situation", interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 "development of measures to improve collaboration", ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses.

RESULTS

Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a "main contact person" was not considered as an improvement.

CONCLUSIONS

Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research.

TRIAL REGISTRATION

Not applicable.

Interprofessional collaboration in nursing homes (interprof): a grounded theory study of general practitioner experiences and strategies to perform nursing home visits

Background

Interprofessionalism, considered as collaboration between medical professionals, has gained prominence over recent decades and evidence for its impact has grown. The steadily increasing number of residents in nursing homes will challenge medical care and the interaction across professions, especially nurses and general practitioners (GPs). The nursing home visit, a key element of medical care, has been underrepresented in research. This study explores GP perspectives on interprofessional collaboration with a focus on their visits to nursing homes in order to understand their experiences and expectations. This research represents an aspect of the interprof study, which explores medical care needs as well as the perceived collaboration and communication by nursing home residents, their families, GPs and nurses. This paper focusses on GPs’ views, investigating in particular their visits to nursing homes in order to understand their experiences.

Methods

Open guideline-interviews covering interprofessional collaboration and the visit process were conducted with 30 GPs in three study centers and analyzed with grounded theory methodology. GPs were recruited via postal request and existing networks of the research partners.

Results

Four different types of nursing home visits were found: visits on demand, periodical visits, nursing home rounds and ad-hoc-decision based visits. We identified the core category “productive performance” of home visits in nursing homes which stands for the balance of GPs´ individual efforts and rewards. GPs used different strategies to perform a productive home visit: preparing strategies, on-site strategies and investing strategies.

Conclusion

We compiled a theory of GPs home visits in nursing homes in Germany. The findings will be useful for research, and scientific and management purposes to generate a deeper understanding of GP perspectives and thereby improve interprofessional collaboration to ensure a high quality of care.

Intelligent monitoring networks--transformation of data into information for water management

The EU-WFD requires certain monitoring tasks, which yet cannot be fulfilled by automated monitoring devices. Nevertheless, the technical progress of recent years allows monitoring station designs, which enable long-term field application under reasonable maintenance demand. State-of-the-art monitoring stations allow the setup and operation of intelligent monitoring networks, which deliver quality proved and utilisable information to the end-user as opposed to a collection of time-series. Based on a full-scale example monitoring station design, long-term observations and possible ways of (automated) data interpretation are discussed.

Investigative monitoring in the context of detecting anthropogenic impact on an epipotamal river

In the context of an investigative monitoring programme a monitoring system comprising of a water quality monitoring station and a camera station has been installed and operated for more than one year. The monitoring target was to investigate changes of water quality which can be related to a repeated occurrence of foam, observed at a river stretch downstream the monitoring station. The extent and frequency of foam buildup was recorded by means of the camera station. The analysis of the online data clearly showed that some of the measured parameters can be used as indicators for specific discharges, which from additional targeted investigations could be identified as contributors to the foaming problems. The continuous ammonium measurement could be used to detect nitrification problems of WWTPs discharging upstream of the monitoring station. By combining different data sources (emission data, operative and investigative monitoring data) additional information can be gained, which can be used for a comprehensive data assessment as well as a detailed system analysis.

Time-resolved delta spectrometry: a method to define alarm parameters from spectral data

Alarm parameters are in many ways different from measurements of well defined chemical substances. Being confronted with an increasing number of potentially harmful compounds as well as financial and logistic constraints, new variables (such as alarm parameters) that allow for an integrated assessment or for a first screening can be a solution. To monitor for surrogate or aggregate variables can be a useful strategy to overcome some of the constraints. It must be conceived that this can go along with losses in terms of comparability of results and even in tailor-made variables. Spectral data and their evolution over time are rich in information and compensate for losses due to aggregation and generalisation. Therefore it can be expected that alarm parameters developed from spectral data are transferable, accurate and selective to an extent which is beyond the state-of-the-art. The paper introduces time-resolved delta spectrometry, a method that was developed to generate alarm parameters from spectral data.

Spectral in-situ analysis of NO2, NO3, COD, DOC and TSS in the effluent of a WWTP

An in-situ UV spectrometer was applied to the effluent of a WWTP in Switzerland and calibrated using a multivariate calibration algorithm based on PLS regression. Except for nitrite, the calibration was based on comparative measurements of the effluent in the plant laboratory. Samples made of stock solution added to three different matrices prepared in the EAWAG laboratory were used for the nitrite calibration because the effluent concentrations were always in the range of 0.06-0.26 mg/l. The results show very good precision for nitrite and nitrate. The measuring range for COD and DOC was not completely covered by the measurements, so the meaningfulness of the results is limited. Nevertheless the precision obtained for soluble COD is high enough for most applications at WWTPs. The accuracy of the TSS measurement is unsatisfactory as regards effluent limits since the spectrometer used does not cover the wavelength region up to 700 nm, which gives better signals for TSS calibration due to its strong correlation with turbidity.

Monitoring of a paper mill wastewater treatment plant using UV/VIS spectroscopy

A submersible UV/VIS spectrometer was used to monitor a paper mill wastewater treatment plant. It utilises the UV/VIS range (200-750 nm) for simultaneous measurement of COD, filtered COD, TSS and nitrate with just a single instrument. The instrument measures in-situ, directly in the process. Paper mill wastewater shows typical and reproducible spectra at various process measuring points. There is a relative maximum at 280 mm due to the absorbance by dissolved organic substances, mainly ligninic acids. Comparison of absorbance spectra distinctly shows the decrease of this peak, indicating biological degradation throughout the treatment process. Summarising, one can say that paper mill wastewater cannot be monitored by a simple UV probe measuring only the absorbance at a single wavelength. The required information can only be gained from the whole spectra. Regarding plant control it is suggested that only the overall spectral information is used. Calibrations to conventional parameters are now merely carried out for purposes of reference-checking.

On-line monitoring for control of a pilot-scale sequencing batch reactor using a submersible UV/VIS spectrometer

A submersible UV/VIS spectrometer was used to monitor a pilot-scale sequencing batch reactor (SBR). The instrument utilises the whole UV/VIS range between 200 and 750 nm. With just one single instrument nitrate, organic matter and suspended solids can be measured simultaneously. The spectrometer is installed directly in the reactor, measures in real-time, and is equipped with an auto-cleaning system using pressured air. The paper shows the calibration results for measurements in the SBR tank, time series for typical SBR cycles, and proposes possible ways for optimisation of the operation by using these measurements.

In situ sensing of volatile organic compounds in groundwater: first field tests of a mid-infrared fiber-optic sensing system

A prototype mid-infrared sensor system for the determination of volatile organic pollutants in groundwater was developed and tested under real-world conditions. The sensor comprises a portable Fourier transform infrared spectrometer, coupled to the sensor head via mid-infrared transparent silver halide fiber-optic cables. A 10 cm unclad middle section of the 6-m-long fiber is coated with ethylene propylene copolymer in order to enrich the analytes within the penetration depth of the evanescent field protruding from the fiber sensor head. A mixture of tetrachloroethylene, dichlorobenzene, diethyl phthalate, and xylene isomers at concentrations in the low ppm region was investigated qualitatively and quantitatively in an artificial aquifer system filled with Munich gravel. This simulated real-world site at a pilot scale enables in situ studies of the sensor response and spreading of the pollutants injected into the system with controlled groundwater flow. The sensor head was immersed into a monitoring well of the aquifer system at a distance of 1 m downstream of the sample inlet and at a depth of 30 cm. Within one hour, the analytes were clearly identified in the fingerprint region of the IR spectrum (1300 to 700 cm(-1)). The results have been validated by head-space gas chromatography, using samples collected during the field measurement. Five out of six analytes could be discriminated simultaneously; for two of the analytes the quantitative results are in agreement with the reference analysis.

Rapid automated detection of nitrification kinetics using respirometry

There is no doubt that respirometry is a useful measurement principle in the field of wastewater treatment. Although a large variety of methods and case studies have been published, respirometry has become neither a standard tool for control nor for assessment and optimisation of treatment plants. drawback of the conventional method for determining nitrification kinetics is the long experimental time. This disadvantage can be avoided by "turning over" the experiment. Starting with low ammonia concentrations the steep slope of the Monod curve is measured first. The low concentration branch of the Monod curve is also the part where e.g. inhibition can be detected. Therefore the proposed procedure allows us to speed up the measurement of nitrification kinetics and to measure nitrification inhibition on-line.

Online sensing of volatile organic compounds in groundwater using mid-infrared fibre optic evanescent wave spectroscopy: a pilot scale test

A prototype sensing system for in-situ monitoring of volatile organic compounds in contaminated groundwater was tested at a pilot scale plant. The sensor consists of a commercially available Fourier transform infrared spectrometer, connected to a 6 m long infrared transparent silver halide fibre optic cable. A 10 cm long core-only section at the centre of the fibre is mounted on a sensor head and coated with a hydrophobic polymer layer, while the remaining fibre is protected by Teflon tubing and thus not in contact with the surrounding media. The sensor head was immersed into the monitoring wells of the pilot plant testing the sensor system under circumstances close to field conditions and typical for in-situ measurements. The pilot plant consists of a 1 m3 cubic tank filled with gravel. A pump is used to circulate water horizontally through the tank, simulating a natural aquifer. The evolution of the concentration of analytes injected into the system is monitored with time using the developed prototype sensing system. The results are validated by corresponding sampling and analysis with headspace gas chromatography.

A multivariate calibration procedure for UV/VIS spectrometric quantification of organic matter and nitrate in wastewater

A submersible UV/VIS spectrometer for in-situ real-time measurements is presented. It utilises the UV/VIS range (200-750 nm) for simultaneous measurement of COD, filtered COD, TSS and nitrate with just a single instrument. A global calibration is provided that is valid for typical municipal wastewater compositions. Usually high correlation coefficients can be achieved using this standard setting. By running a local calibration improvements concerning trueness, precision and long term stability of the results can be achieved. The calibration model is built by means of PLS, various validation procedures and outlier tests to reach both high correlation quality and robustness. This paper describes the UV/VIS spectrometer and the calibration procedure.

Management of sensible water uses with real-time measurements

For the protection of bankside wells and a groundwater recharge an early warning system had to be developed. The monitoring network design is based on sensor measurements only. For this purpose a new submersible spectrometer has been successfully tested for multi-parameter measurements directly in the medium. The developed system can easily be upgraded with other new sensors. Only calibration and validation data are supplied by conventional grab sampling and laboratory analysis.. A conventional testfilter improved by on-line monitoring at 5 sampling sites serves as a reference system. The whole system is equipped with remote control and the internet serves as the control centre of the network. All measurement data from all 9 sites are available in real time on the internet.

Type A behavior and coronary atherosclerosis

OBJECTIVES

To evaluate whether the pathogenesis of type A behavior may involve the premature development of coronary atherosclerosis.

BACKGROUND

Type A or coronary-prone behavior is considered a possible risk factor for the development of coronary heart disease. Premature development of coronary atherosclerosis is suspected to play a role. Utilizing electron beam computed tomography, one can accurately determine the degree of coronary artery calcification, which is reflective of coronary atherosclerosis.

METHODS

We performed a study of 35 men who had no clinical evidence of coronary heart disease. Twenty exhibited severe type A behavior and 15 exhibited type B behavior. All subjects were given an Electron Beam Computed Tomography scan of their coronary arteries and a treadmill electrocardiogram.

RESULTS

Eight of the 20 (40%) type A subjects were found to have coronary calcification compared to none of the type B subjects (P=0.005). The correlation coefficient between type A score and coronary calcium score was 0.39 (P=0.09).

CONCLUSIONS

The pathophysiology by which type A behavior increases the risk for coronary heart disease may involve the premature development of coronary atherosclerosis.

Effect of type A behavioral counseling on frequency of episodes of silent myocardial ischemia in coronary patients

Thirteen of 32 patients with coronary heart disease who also exhibited symptoms and signs of severe time urgency and hostility (the two overt components of type A behavior [TAB]) were found to exhibit multiple episodes of silent myocardial ischemia over a 48-hour period of Holter monitoring as indicated by electrocardiogram ST depressions. Ten of these 13 patients were given 14 months of TAB counseling in an attempt to diminish the intensity of their time urgency and hostility. The remaining three patients served as controls. After counseling, the intensity of the time urgency and hostility of the 10 counseled patients diminished 53% and 59%, respectively, as measured by the videotaped clinical examination. The time urgency and hostility of the three uncounseled control patients did not significantly change. The mean frequency of ischemic episodes in the 10 patients who received TAB counseling significantly declined from an initial 6.6 to 3.1 ischemic episodes per 24 hours. However, the mean frequency of ischemic episodes did not significantly decline in 2 of the 3 uncounseled patients. The third uncounseled patient developed a conduction defect in the 14-month interlude, making an analysis of his repeat 48-hour electrocardiogram for episodes of ST depression impossible.

Relation between insecurity and Type A behavior

This article presents a new Type A Videotaped Clinical Examination scale that measures insecurity. This scale was validated against an existing insecurity measure in a sample of 204 individuals. The results indicated that this new scale is a valid measure of insecurity. The relation between insecurity and type A behavior was examined in a sample of 3013 people. In this large population insecurity showed a strong positive correlation to type A behavior and to each of the two overt behavioral components, time urgency and free-floating hostility.

Causal attributions and coronary heart disease in women

The relationship between coronary heart-disease endpoints and attributional style in women has been previously unexamined. This study examined the attributions of 73 postmyocardial infarction (MI) women about their heart disease and explored the relationship between attributions and nonfatal coronary recurrence. Women's primary causal attributions included personal behavior (9.6%), blaming others (19.3%), stress (28.8%), luck (12.3%), and family history (13.7%). The largest proportion of recurrences occurred in women attributing their infarcts to marital problems. Of the attributional ratings, ascriptions involving spouses were the only attributions that met entry criteria for logistic regression (p = .019) after controlling for severity of first infarction.

[Differential anesthetic block]

The concept of differential action of local anaesthetics on nerve fibers of different size is falsified by experiment. The temporal succession of alteration in perception is to be explained by changes at higher levels of integration.