Can hospitalists improve COVID-19 vaccination rates?

Three years after the start of the SARS-CoV-2 virus (COVID-19) pandemic, its effects continue to affect society and COVID-19 vaccination campaigns continue to be a topic of controversy and inconsistent practice. After experiencing spikes in COVID-19 cases, our University of California Davis Health Division of Hospital Medicine sought to understand the reasons underlying the low COVID-19 vaccination rates in our county and find approaches to improve the number of vaccinations among adults admitted to the inpatient setting. This quality improvement project aimed to increase COVID-19 primary and booster vaccine efforts through a multi-pronged approach of increased collaboration with specialised staff and optimisation of use of our electronic health record system.Our key interventions focused on developing a visual reminder of COVID-19 vaccine status using the functionality of our electronic medical record (EMR), standardising documentation of COVID-19 vaccine status and enhancing team-based vaccination discussions through team huddles and partnering with inpatient care coordinators. While our grassroots approach enhanced COVID-19 vaccination rates in the inpatient setting and had additional benefits such as increased collaboration among teams, system-level efforts often made a greater impact at our healthcare centre. For other institutions interested in increasing COVID-19 vaccination rates, our top three recommendations include integrating vaccination into pre-existing workflows, optimising EMR functionality and increasing vaccine accessibility in the inpatient setting.

Bridging the gap: a resident-led transitional care clinic to improve post hospital care in a safety-net academic community hospital

The transitional period between hospital discharge and primary care follow-up is a vulnerable time for patients that can result in adverse health outcomes and preventable hospital readmissions. This is especially true for patients of safety-net hospitals (SNHs) who often struggle to secure primary care access when leaving the hospital due to social, economic and cultural barriers. In this study, we describe a resident-led postdischarge clinic that serves patients discharged from NYU Langone Hospital-Brooklyn, an urban safety-net academic hospital. In our multivariable analysis, there was no statistical difference in the readmission rate between those who completed the transitional care management and those who did not (OR 1.32 (0.75-2.36), p=0.336), but there was a statistically significant increase in primary care provider (PCP) engagement (OR 0.53 (0.45-0.62), p<0.001). Overall, this study describes a postdischarge clinic model embedded in a resident clinic in an urban SNH that is associated with increased PCP engagement, but no reduction in 30-day hospital readmissions.

"It's a stressful, trying time for the caretaker": an interpretive description qualitative study of postoperative transitions in care for older adults with frailty from the perspectives of informal caregivers

BACKGROUND

Older adults with frailty have surgery at a high rate. Informal caregivers often support the postoperative transition in care. Despite the growing need for family and caregiver support for this population, little is known about the experience of providing informal care to older adults with frailty during the postoperative transition in care. The purpose of this study was to explore what is important during a postoperative transition in care for older adults with frailty from the perspective of informal caregivers.

METHODS

This was a qualitative study using an interpretive description methodology. Seven informal caregivers to older adults [aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery] participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using reflexive thematic analysis.

RESULTS

Four themes were constructed: (1) being informed about what to expect after surgery; (2) accessible communication with care providers; (3) homecare resources are needed for the patient; and (4) a support network for the caregivers. Theme 4 included two sub-themes: (a) respite and emotional support and (b) occupational support.

CONCLUSIONS

Transitions in care present challenges for informal caregivers of older adults with frailty, who play an important role in successful transitions. Future postoperative transitional care programs should consider making targeted information, accessible communication, and support networks available for caregivers as part of facilitating successful transitions in care.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

BACKGROUND

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

OBJECTIVES

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

METHODS

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

RESULTS

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

CONCLUSION

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

"I can't imagine having to do it on your own": a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty

BACKGROUND

Adults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care.

OBJECTIVE

To explore what is important to older adults with frailty during a postoperative transition in care.

METHODS

This qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis.

RESULTS

Five themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes.

CONCLUSION

Future programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.

Telehealth-based transitional care management programme to improve access to care

BACKGROUND

The transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning.

LOCAL PROBLEM

Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission.

METHODS

This is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort.

INTERVENTIONS

Patients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey.

RESULTS

68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005).

CONCLUSIONS

Using a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.

Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study

IMPORTANCE

The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange.

OBJECTIVE

To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes.

DESIGN

Prospective interventional cohort study.

SETTING

A 792-bed tertiary care hospital.

PARTICIPANTS

All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022.

INTERVENTIONS

A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre.

MAIN OUTCOMES AND MEASURES

Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission.

RESULTS

Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality.

CONCLUSIONS AND RELEVANCE

Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.

Mixed-methods study examining family carers' perceptions of the relationship between intrahospital transitions and patient readiness for discharge

INTRODUCTION

Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals. However, carers frequently experience exclusion from care planning during IHTs, potentially decreasing their awareness of patients' clinical status, postdischarge needs and carer preparation. The purpose of this study was to explore family carers' perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.

METHODS

Sequential, explanatory mixed-methods study involving retrospective analysis of hospital inpatients from a parent study (1R01HS026248; PI Wallace) for whom patient and family carer Readiness for Hospital Discharge Scale (RHDS) score frequency of IHTs and patient and caregiver characteristics were available. Maximum variation sampling was used to recruit a subsample of carers with diverse backgrounds and experiences for the participation in semistructured interviews to understand their views of how IHTs influenced preparation for discharge.

RESULTS

Of discharged patients from July 2020 to April 2021, a total of 268 had completed the RHDS and 23 completed the semistructured interviews. Most patients experienced 0-2 IHTs and reported high levels of discharge readiness. During quantitative analysis, no association was found between IHTs and patients' RHDS scores. However, carers' perceptions of patient discharge readiness were negatively associated with increased IHTs. Moreover, non-spouse carers reported lower RHDS scores than spousal carers. During interviews, carers shared barriers experienced during IHTs and discussed the importance of inclusion during discharge care planning.

CONCLUSIONS

IHTs often represent disruptive events that may influence carers' understanding of patient readiness for discharge to home and, thus, their own preparation for discharge. Further consideration is needed regarding how to support carers during IHT to facilitate high-quality discharge planning.

Improving hand therapy delivery during care transitions in multisystem trauma patients

High-quality hand therapy is critical to maximising functional capacity and optimising overall outcomes following hand injuries. Therapy delivery requires clear communication between surgeons and occupational therapists. At Sunnybrook Health Sciences Centre (SHSC), Canada's largest tertiary care centre, suboptimal communication is a significant barrier to efficient hand therapy delivery in acute multisystem trauma patients. A baseline audit at SHSC found that 41% of hand therapy orders required clarification and 35% of patients waited over 24 hours before their order was fulfilled. In many cases, communication errors created unacceptably long delays that were suspected by surgeon stakeholders to impede patient outcomes. This highlighted an opportunity for investigation and system improvement.Using process mapping methodology, we outlined standard process involved in patient care and identified barriers to successful communication. We collaborated with key stakeholders to codesign a standardised template for care orders. We aimed to improve order clarity and consistency with the goal of reducing the incidence of clarification and delays.Postimplementation, the percentage of hand therapy orders requiring clarification was decreased to 24%. The number of patients waiting over 24 hours for therapy was also reduced; however, further investigation is required to verify this finding. In addition, essential order components were more consistently and comprehensively included. Next steps of this work include expanding the use of the order template outside of the multisystem trauma population and improving the communication of hand therapy at discharge from hospital.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BACKGROUND

Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.

METHODS

Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.

RESULTS

The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).

CONCLUSION

The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.

TRIAL REGISTRATION

NCT03695081.

Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: a multicentre study

There is potential for many medication errors to occur due to the complex medication use process. The medication reconciliation process can significantly lower the incidence of medication errors that may arise from an incomplete or inaccurate medication history as well as reductions in length of hospital stay, patients' readmissions and lower healthcare costs.The quality improvement collaborative project was conducted as a pilot study in two hospitals, then implemented on a broader scale in 18 hospitals in Saudi Arabia. The goal of the project was to reduce the percentage of patients with at least one outstanding unintentional discrepancy at admission by 50%, over 16-month period (July 2020-November 2021). Our interventions were based on the High 5's project medication reconciliation WHO, and Medications at Transitions and Clinical Handoffs toolkit for medication reconciliation by Agency for Healthcare Research and Quality. Improvement teams used the Institute of Healthcare Improvement's (IHI's) Model for improvement as a tool for testing and implementing changes. Collaboration and learning between hospitals were facilitated by conducting learning sessions using the IHI's Collaborative Model for Achieving Breakthrough Improvement. The improvement teams underwent three cycles.By the end of the project significant improvements were observed. The percentage of patients with at least one outstanding unintentional discrepancy at admission showed a 20% reduction (27% before, 7% after; p value <0.05) (Relative Risk (RR) 0.74) with a mean reduction in the number of discrepancies per patient by 0.74. The percentage of patients with at least one outstanding unintentional discrepancy at discharge showed 12% reduction (17% before, 5% after; p value <0.05) (RR 0.71) with a mean reduction in the number of discrepancies per patient by 0.34.Compliance to medication reconciliation documentation within 24 hours of admission and discharge showed significant improvement by an average of 17% and 24%, respectively. Additionally, the implementation of medication reconciliation had a negative correlation with the percentage of patients with at least one outstanding unintentional discrepancy at admission and discharge.

Feasibility of a multidisciplinary Transitional Pain Service in spine surgery patients to minimise opioid use and improve perioperative outcomes: a quality improvement study

INTRODUCTION

Spine surgery patients have high rates of perioperative opioid consumption, with a chronic opioid use prevalence of 20%. A proposed solution is the implementation of a Transitional Pain Service (TPS), which provides patient-tailored multidisciplinary care. Its feasibility has not been demonstrated in spine surgery. The main objective of this study was to evaluate the feasibility of a TPS programme in patients undergoing spine surgery.

METHODS

Patients were recruited between July 2020 and November 2021 at a single, tertiary care academic centre. Success of our study was defined as: (1) enrolment: ability to enrol ≥80% of eligible patients, (2) data collection: ability to collect data for ≥80% of participants, including effectiveness measures (oral morphine equivalent (OME) and Visual Analogue Scale (VAS)-perceived analgesic management and overall health) and programme resource requirements measures (appointment attendance, 60-day return to emergency and length of stay), and (3) efficacy: estimate potential programme effectiveness defined as ≥80% of patients weaned back to their intake OME requirements at programme discharge.

RESULTS

Thirty out of 36 (83.3%) eligible patients were enrolled and 26 completed the TPS programme. The main programme outcomes and resource measures were successfully tracked for >80% of patients. All 26 patients had the same or lower OME at programme discharge than at intake (intake 38.75 mg vs discharge 12.50 mg; p<0.001). At TPS discharge, patients reported similar overall health VAS (pre 60.0 vs post 70.0; p=0.14), improved scores for VAS-perceived analgesic management (pre 47.6 vs post 75.6; p<0.001) and improved Brief Pain Inventory pain intensity (pre 39.1 vs post 25.0; p=0.02).

CONCLUSION

Our feasibility study successfully met or exceeded our three main objectives. Based on this success and the defined clinical need for a TPS programme, we plan to expand our TPS care model to include other surgical procedures at our centre.

Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators

INTRODUCTION

Transitional-aged youth (TAY) with mental health and/or addictions (MHA) concerns and their families experience significant challenges finding, accessing, and transitioning through needed MHA care. To develop appropriate supports that assist TAY and their families in navigating MHA care, their experiences of transitions in the MHA care system must be better understood. This scoping review identifies and explores the needs, barriers, and facilitators for TAY and their families when transitioning through MHA care.

METHODS

This scoping review commenced with a search of five relevant databases. Three research team members were involved in title, abstract, and full-text scanning and data extraction. Sources focusing on TAY anywhere between the ages of 12-29 years and meeting the study objectives were included. Extractions compiled background and narrative information about the nature and extent of the data. Analysis and synthesis of findings involved numerical description of the general information extracted (e.g., numbers of sources by country) and thematic analysis of narrative information extracted (e.g., family involvement in TAY help-seeking).

RESULTS

A total of 5894 sources were identified. Following title and abstract scanning, 1037 sources remained for full-text review. A total of 66 sources were extracted. Findings include background information about extracted sources, in addition to five themes that emerged pertaining to barriers and facilitators to access and transitions through care and the needs and roles of TAY and families in supporting help-seeking and care transitions: holistic supports, proactive preparation, empowering TAY and families, collaborative relationships, and systemic considerations. These five themes demonstrate approaches to care that can ensure TAY and families' needs are met, barriers are mitigated, and facilitators are enhanced.

CONCLUSION

This review provides essential contextual information regarding TAY with MHA concerns and their families' needs when seeking care. Such findings lend to an enhanced understanding of how MHA programs can support this population's needs, involve family members as appropriate, reduce the barriers experienced, and work to build upon existing facilitators.

Transitions in care between hospital and community settings for individuals with a substance use disorder: A systematic review

BACKGROUND AND AIMS

Individuals with a substance use disorder (SUD) have high rates of hospital service utilization including emergency department (ED) presentations and hospital admissions. Acute care settings offer a critical opportunity to engage individuals in addiction care and improve health outcomes especially given that the period of transition from hospital to community is challenging. This review summarizes literature on interventions for optimizing transitions in care from hospital to community for individuals with a SUD.

METHODS

The literature search focused on key terms associated with transitions in care and SUD. The search was conducted on three databases: MEDLINE, CINAHL, and PsychInfo. Eligible studies evaluated interventions acting prior to or during transitions in care from hospital to community and reported post-discharge engagement in specialized addiction care and/or return to hospital and were published since 2010.

RESULTS

Title and abstract screening were conducted for 2337 records. Overall, 31 studies met inclusion criteria, including 7 randomized controlled trials and 24 quasi-experimental designs which focused on opioid use (n = 8), alcohol use (n = 5), or polysubstance use (n = 18). Interventions included pharmacotherapy initiation (n = 7), addiction consult services (n = 9), protocol implementation (n = 3), screening, brief intervention, and referral to treatment (n = 2), patient navigation (n = 4), case management (n = 1), and recovery coaching (n = 3).

CONCLUSIONS

Both pharmacologic and psychosocial interventions implemented around transitions from acute to community care settings can improve engagement in care and reduce hospital readmission and ED presentations. Future research should focus on long-term health and social outcomes to improve quality of care for individuals with a SUD.

Perceived discharge quality and associations with hospital readmissions and emergency department use: a prospective cohort study

Background

At hospital discharge, care is handed over from providers to patients. Discharge encounters must prepare patients to self-manage their health, but have been found to be suboptimal. Our study objectives were to describe and determine the correlates of perceived discharge quality and to explore the association between perceived discharge quality and postdischarge outcomes.

Methods

We conducted a prospective cohort study in medical inpatients admitted to a tertiary care hospital in Calgary, Canada. Perceived discharge quality was measured by the Care Transitions Measure (CTM). Linkage to administrative databases provided data for the composite outcome—90-day hospital readmission or emergency department visit. Logistic regression modelling was used to determine the association between global CTM scores, and the individual CTM components, and the composite outcome.

Results

A total of 316 patients were included in the analysis. The median CTM score was 80.0 (IQR 66.6–100.0). The distribution of CTM scores were significantly different based on comorbidity burden, with the median and maximum CTM scores being lower and the IQR being narrower, for those with six or more comorbidities compared with those with fewer comorbidities. CTM scores were not associated with the composite outcome, though a single CTM item—not understanding warning signs and symptoms—was (adjusted OR 3.46 (95% CI 1.02 to 11.73)).

Conclusion

Perceived quality of discharge varies based on patient burden of comorbidities. While global perceived discharge quality was not associated with postdischarge outcomes, lack of patient understanding of warning symptoms was. Discharging healthcare teams should pay special attention to these priority patient groups and specific discharge process components.

Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

BACKGROUND

Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.

AIM

To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.

METHODS

Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients’ specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.

RESULTS

Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient’s health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was “not reasonable” in their daily clinical workflow due to “time constraint”.

CONCLUSION

The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.

Feasibility, acceptability, and preliminary effects of PATH FOR timely transfer of geriatric HIP fracture patients from hospital to rehabilitation to home (PATH4HIP): a protocol for a mixed method study

BACKGROUND

Hip fractures in older adults are significant contributors to severe functional decline and disability as well as hospitalization and increased health care costs. Research shows that timely referral to geriatric rehabilitation leads to better patient outcomes. Currently, a wide variability in the timing, the frequency, and the choice of appropriate setting for rehabilitation of hip fracture patients exists.

AIM

Evaluate the feasibility, acceptability, and preliminary effectiveness of PATH4HIP, a pathway intervention for timely transfer of post-operative geriatric hip fracture patients from hospital to rehabilitation to home.

METHODS

This is a single-arm, pragmatic feasibility study to measure reach, effectiveness, adoption, implementation, and maintenance of PATH4HIP, a pathway for post-operative hip fracture patients from a large academic health science center to a geriatric rehabilitation service in Ottawa, Canada. During a 6-month period, all hip fracture patients, 65 years of age or older who have undergone surgery and have met the eligibility criteria (n = 96), will be transferred to the geriatric rehabilitation service no later than post-operative day 6. Patients (n = 10-12) and clinicians who are working on the orthopedic team (n = 10-12) and on the geriatric rehabilitation service (n = 10-12) will be invited to participate in an interview to share their feedback on the intervention's feasibility and acceptability and to provide suggestions to improve PATH4HIP. Descriptive statistics will be used to summarize results of the quantitative data and content analysis will be used to analyze the qualitative data. The study will be open for recruitment from January to July 2022.

DISCUSSION

If feasible, PATH4HIP will result in the reduction of the post-operative acute care length of stay to less than or equal to 6 days, while having no detrimental effect on rehabilitation outcomes such as functional gains, or discharge destination.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol

BACKGROUND

This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal.  METHODS: Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation.

DISCUSSION

As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor's recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

A pragmatic approach for implementation of value-based healthcare in Amsterdam UMC, the Netherlands

Background

The emphasis on implementation of value-based healthcare (VBHC) has increased in the Dutch healthcare system. Yet, the translation of the theoretical principles of VBHC towards actual implementation in daily practice has been rarely described. Our aim is to present a pragmatic step-by-step approach for VBHC implementation, developed and applied in Amsterdam UMC, to share our key elements. The approach may inspire others and can be used as a template for implementing VBHC principles in other hospitals.

Methods

The local approach is developed in a major academic hospital in the Netherlands, based at two locations with 15,000 employees in total. Experience-based co-design is used, building on our learning experiences from implementing VBHC for 14 specific patient groups. The described steps and activities devolved from iterative and participative co-design sessions with various experienced stakeholders involved in the implementation of one or more VBHC pathways.

Results

The approach includes five phases; preparation, design (team introduction, outcome selection, action agenda), building (outcome set integration in daily practice), implementation (training, outcome registration and implementation) and the continuous improvement cycle. We described two cases for illustration of the approach; the Cleft Lip and Palate and the Chronic Kidney Disease patient groups. For a good start, involvement of a clinical leader as driving force, ensuring participation of patient representatives and sufficient resources are needed.

Conclusion

We have experienced that several defining features of the development and implementation of this approach may have contributed to its completeness and applicability. Key elements for success have been organisational readiness and clinical leadership. In conclusion, the approach has provided a first step towards VBHC in our hospital. Further research is needed for evaluation of its effectiveness including impact on value for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07919-1.

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada

Background

Older adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture.

Methods

This descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically.

Results

A total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings.

Conclusions

Our findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting

Background

Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community).

Methods

We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle.

Results

Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants’ AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle.

Conclusions

Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07392-2.

Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care

BACKGROUND

Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU?

METHODS

This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process.

RESULTS

We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge.

CONCLUSIONS

Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.

Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation

Background

Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process.

Methods

Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations.

Results

Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant.

Conclusions

This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06374-8.

Cancer survivor's perspectives on the major challenge in the transition to survivorship

OBJECTIVES

To understand cancer survivors' perspectives regarding the major challenge in transitioning from cancer treatment to follow-up care. Identification of major issues should inform survivorship care and help reduce suffering.

METHODS

A national survey was conducted to identify experiences with follow-up for cancer survivors one to three years post-treatment. The survey included open-ended questions for respondents to add topics of importance and details that offer deeper insight into their experiences. This publication presents analysis of the open-ended question about the major challenge faced by adult cancer population.

RESULTS

Of 13,534 unique adult survey respondents, 8706 respondents identified major challenges. Of those reporting challenges, 4727 (54.3 %) named a single challenge but 3979 (45.7 %) identified more than one. In total, 15,351 challenges were identified. Responses to open-ended questions are summarized under significant themes: major concerns are often more than singular issues; recovery and fear of recurrence; and information needs.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Results indicate significant numbers of adult survivors have multiple concerns about physical, emotional, and practical issues but are not receiving assistance and/or appropriate information to help manage these concerns. It is important to determine how health care can be proactive in identifying and addressing needs of survivors.

Evaluation of Intraoperative Hand-Off Frequency, Duration, and Context: A Mixed Methods Analysis

BACKGROUND

Hand-offs in the operating room contribute to poor communication, reduced team function, and may be poorly coordinated with other activities. Conversely, they may represent a missed opportunity for improved communication. We sought to better understand the coordination and impact of intraoperative hand-offs.

METHODS

We prospectively audio-video (AV) recorded 10 operations and evaluated intraoperative hand-offs. Data collected included percentage of time team members were absent due to breaks, relationships between hand-offs and intraoperative events (incision, surgical counts), and occurrences of simultaneous hand-offs. We also identified announcement that a hand-off had occurred and anchoring, in which team members not involved in the hand-off participated and provided information.

RESULTS

Spanning 2919 min of audio-video data, there were 74 hand-offs (range, 4-14 per case) totaling 225.2 min, representing 7.7% of time recorded. Thirty-two (45.1%) hand-offs were interrupted or delayed because of competing activities; eight hand-offs occurred during an instrument or laparotomy pad count. Six cases had simultaneous hand-offs; two cases had two episodes of simultaneous hand-offs. Eight hand-offs included an announcement. Seven included anchoring. Evaluating both temporary and permanent hand-offs, one or more original team members was absent for 40.7% of time recorded and >one team member was absent for 20.5% of time recorded.

CONCLUSIONS

Intraoperative hand-offs are frequent and not well coordinated with intraoperative events including counts and other hand-offs. Anchoring and announced hand-offs occurred in a small proportion of cases. Future work must focus on optimizing timing, content, and participation in intraoperative hand-offs.

Improving transitions in care for children with complex and medically fragile needs: a mixed methods study

Background

Children with medical complexity are a small yet resource intensive population in the Canadian health care system. The process for discharging these children from hospital to home is not yet optimal. The overall goal of this project was to develop recommendations to be included in a provincial strategy to support transitions in care for children with complex and medically fragile needs.

Methods

A wide assortment of stakeholders participated in this mixed method, multiphase project. During Phase 1, data was gathered from a range of sources to document families’ experiences transitioning from an inpatient hospital stay back to their home communities. In Phase 2, pediatricians, nurses, and health administrators participated in key stakeholder interviews to identify barriers and facilitators to a successful transition in care for children and families with complex care needs. A multi-sector consensus meeting was held during Phase 3 to discuss study findings and refine key recommendations for inclusion in a provincial strategy.

Results

Six case studies were developed involving children and families discharged home with a variety of complex care needs. Children ranged in age from 15 days to 9 years old. Nine telephone interviews were conducted in Phase 2 with pediatricians, nurses, and administrators from across the province. A variety of inter-institutional communication challenges were described as a major barrier to the transition process. A consistent message across all interviews was the need for improved coordination to facilitate transitions in care. The consensus meeting to review study findings included physicians, nurses, paramedics, senior administrators, and policy analysts from different health and government sectors and resulted in six recommendations for inclusion in a provincial strategy.

Conclusions

This project identified policy and practice gaps that currently exist related to transitions in care for children with complex and medically fragile needs and their families. Our collaborative patient-centred approach to understanding how children and families currently navigate transitions in care provided a foundation for developing recommendations for a provincial wide strategy.

A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to community: A mixed-methods study

BACKGROUND

People transitioning from hospital- to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation.

METHODS

PROMPT was implemented for 14 weeks (January-April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient's community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists.

RESULTS

The intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists' difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources.

CONCLUSION

Improving intraprofessional collaboration, through interventions such as PROMPT, positions pharmacists as leaders of medication management services across care settings and has the potential to improve patient care; however, more co-design work is needed to enhance the intervention and its fidelity.

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation

BACKGROUND

The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.

METHODS

MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.

DISCUSSION

A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Moving Along: Team Training for Emergency Room Trauma Transfers (T2ERT2)

OBJECTIVES

To determine whether high fidelity simulation-based training (SBT) of interprofessional teams involving trauma transfers has an immediate impact on participants' team-based attitudes and behaviors.

DESIGN

A quasi-experimental, pre-/postintervention comparison design examined high fidelity SBT of inter-professional teams using a 2 scenario format with immediate after action structured debriefing. Pre-/postsession Readiness for Inter-Professional Learning Scale (RIPLS, 19 items, Likert-type) surveys as well as Interprofessional Teamwork (IPT, 15 items, Likert-type) questionnaires, and postscenario participant- and observer-rated Teamwork Assessment Scales (TAS, 3 subscales, 11 items, Likert-type) were completed during each training session. Mean RIPLS, IPT, and TAS scores were calculated and matched pre-/postscore differences compared using paired t-test or analysis of variance with Bonferroni adjustment.

SETTING

A large, urban, academic, state health sciences institution in the Southeastern United States during the 2014 to 2015 academic year.

PARTICIPANTS

General surgery residents, emergency medicine residents, and senior undergraduate nursing students comprising ten interprofessional teams.

RESULTS

From approximately 48 participants, matched pre-/postsession IPT surveys were available for 42 individuals; 45 had an observer TAS evaluation for both scenarios; and 40 completed TAS peer evaluations for both scenarios. 47 participants had matched RIPLS surveys. Statistically significant improvements in matched pre-/postscore differences occurred for all 15 IPT items. Observer TAS scores significantly improved on 2 of the 3 subscales comparing the second to the first scenario. Peer evaluations statistically improved comparing the second to the first scenario. Two of the 19 RIPLS items demonstrated statistically significant improvement.

CONCLUSIONS

Interprofessional trauma team transfer training using SBT changes attitudes toward key team-based competencies and leads to learning them in the simulated environment. Such improvement in team-based skill and attitudes is an important first step in adopting team-based behaviors in the actual clinical environment and improving transfer care.

Experiences of adult cancer survivors in transitions

Purpose

To understand the experiences of adult cancer survivors as they transition from the end of cancer treatment to follow-up care as a basis for developing actionable recommendations to integrate cancer care delivery and survivorship care.

Methods

A national survey was conducted in collaboration with ten Canadian provinces to identify unmet needs and experiences with follow-up for cancer survivors between 1 and 3 years post-treatment. Surveys were available in English and French and completed either on paper or on-line. Samples were drawn from provincial cancer registries and packages distributed by mail.

Results

A total of 40,790 survey packages were mailed out across the ten provinces and 12,929 surveys were completed by adults (age 30+ years), and 329 surveys were completed by adolescents and young adults (age 18 to 29 years) giving an overall response rate of 33.3%. For the purposes of this publication, the focus will be on the adult sample. In the adult cohort (age 30+ years), 51% of the sample were females, 60% were 65 years of age or older, and 77% had not experienced metastatic spread. Three-quarters reported their health as good/very good and 82% that their quality of life was good/very good. Overall, 87% experienced at least one physical concern, 78% experienced at least one emotional concern, and 44% experienced at least one practical concern. The average number of concerns reported for each domain ranged from 2.0 to 3.8. For those who sought help, a third experienced difficulty obtaining assistance or did not receive it. The most frequently cited reasons for not seeking help was that someone had told them what they were experiencing was normal.

Conclusions

The results indicate that many adult survivors have concerns about physical, emotional, and practical issues but are not receiving help to reduce their suffering. It is imperative we take action to correct this current reality.

Transitions in care from pediatric to adult general surgery: Evaluating an unmet need for patients with anorectal malformation and Hirschsprung disease

BACKGROUND

The provision of timely and comprehensive transition of care from pediatric to adult surgical providers for patients who have undergone childhood operations remains a challenge. Understanding the barriers to transition from a patient and family perspective may improve this process.

METHODS

A cross-sectional survey was conducted of patients with a history of anorectal malformation (ARM) or Hirschsprung Disease (HD) and their families. The web-based survey was administered through two support groups dedicated to the needs of individuals born with these congenital abnormalities. Categorical variables were compared using Chi-squared and Fisher's exact test with Student's t test and ANOVA for continuous variables.

RESULTS

A total of 118 surveys were completed (approximately 26.2% response). The average age of patients at time of survey was 12.3years (SD 11.6) with 64.5% less than 15years old. The primary diagnosis was reported for 78.8% patients and included HD (29.0%), ARM (61.3%), and cloaca (9.7%). The average distance traveled for ongoing care was 186.6miles (SD 278.3) with 40.9% of patients traveling ≥30miles; the distance was statistically significantly greater for patients with ARM (p<0.001). With regards to ongoing symptoms, 44.1% experience constipation, 40.9% experience diarrhea, and approximately 40.9% require chronic medication for management of bowel symptoms; only 3 respondents (3.2%) reported fecal incontinence. The majority of patients, 52.7% reported being seen by a provider at least twice per year and the majority continued to be followed by a pediatric provider, consistent with the majority of the cohort being less than 18years of age. Conversations with providers regarding transitioning to an adult physician had occurred in fewer than 13% of patients. The most commonly cited barrier to transition was the perception that adult providers would be ill-equipped to manage the persistent bowel symptoms.

CONCLUSION

Patients undergoing childhood procedures for ARM or HD have a high prevalence of ongoing symptoms related to bowel function but very few have had conversations regarding transitions in care. Early implementation of transitional care plans and engagement of adult providers are imperative to transitions and may confer long-term health benefits in this patient population.

LEVEL OF EVIDENCE

Level IV, case series with no comparison group.

The experiences of older caregivers of cancer patients following hospital discharge

PURPOSE

This study addressed the experiences of older caregivers of cancer patients in the 2 weeks following a hospital discharge. It sought to understand the challenges they face in providing supportive care to patients at home.

METHODS

Qualitative descriptive interviews with a narrative approach were conducted with each caregiver at 1 and 2 weeks following the patient's discharge from the hospital. A thematic analysis approach was used to identify the themes that emerged from the caregiver interviews.

RESULTS

Caregivers were primarily Caucasian (77%), were mostly 68 years of age or older (62%), and were primarily caring for a spouse (69%). Three key themes emerged from the qualitative analysis: caregiver and patient wellness are connected, caregivers' struggle with control issues, and challenges in communication with health professionals.

CONCLUSIONS

These findings highlight psychosocial changes that caregivers experience over the 2-week time period following hospital discharge. Implications include the need to identify interventions to better prepare caregivers for the post-discharge period.

Simplification of the HOSPITAL score for predicting 30-day readmissions

OBJECTIVE

The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

DESIGN AND SETTING

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.

PARTICIPANTS

We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.

MEASUREMENTS

The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.

RESULTS

Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.

CONCLUSIONS

The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Large-scale implementation of the I-PASS handover system at an academic medical centre

BACKGROUND

Healthcare has become increasingly complex and care delivery models have changed dramatically (eg, team-based care, duty-hour restrictions). However, approaches to critical communications among providers have not evolved to meet these new challenges. Evidence from safety culture surveys, academic studies and malpractice claims suggests that healthcare handover quality is problematic, leading to preventable errors and adverse outcomes. To address this concern, from 2013 to 2016 Massachusetts General Hospital completed phase I of a multifaceted programme to implement standardised, structured handovers across all departments, units and direct care providers.

METHODS

A multidisciplinary Handovers Committee selected the I-PASS handover system. Phase I implementation focused on large-scale training and shift-to-shift handovers. Important features included administrative and clinical leadership support; EHR templates for I-PASS; hospital handover policy revision; varied educational modalities, venues and durations; concomitant TeamSTEPPS training; unit-level I-PASS champions; handover observations; and solicitation of caregiver feedback and suggestions.

RESULTS

More than 6000 doctors, nurses and therapists have been trained. Trended observation scores demonstrate progressive but non-uniform adoption of I-PASS, with significant improvements in the correct sequencing and percentage of I-PASS elements included in handovers. Adoption of Synthesis (readback) has been challenging, with lower scores.

CONCLUSIONS

Comprehensive I-PASS implementation in a large academic medical centre necessitated major cultural change. I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows. EHR I-PASS templates facilitated caregiver acceptance. Initial phase I results are encouraging and the lessons learned should be helpful to other programmes planning handover initiatives. Phase II is ongoing, focusing on more uniform and consistent adoption, spread and sustainability.

Socioeconomic status influences the toll paediatric hospitalisations take on families: a qualitative study

BACKGROUND

Stress caused by hospitalisations and transition periods can place patients at a heightened risk for adverse health outcomes. Additionally, hospitalisations and transitions to home may be experienced in different ways by families with different resources and support systems. Such differences may perpetuate postdischarge disparities.

OBJECTIVE

We sought to determine, qualitatively, how the hospitalisation and transition experiences differed among families of varying socioeconomic status (SES).

METHODS

Focus groups and individual interviews were held with caregivers of children recently discharged from a children's hospital. Sessions were stratified based on SES, determined by the percentage of individuals living below the federal poverty level in the census tract or neighbourhood in which the family lived. An open-ended, semistructured question guide was developed to assess the family's experience. Responses were systematically compared across two SES strata (tract poverty rate of <15% or ≥15%).

RESULTS

A total of 61 caregivers who were 87% female and 46% non-white participated; 56% resided in census tracts with ≥15% of residents living in poverty (ie, low SES). Interrelated logistical (eg, disruption in-home life, ability to adhere to discharge instructions), emotional (eg, overwhelming and exhausting nature of the experience) and financial (eg, cost of transportation and meals, missed work) themes were identified. These themes, which were seen as key to the hospitalisation and transition experiences, were emphasised and described in qualitatively different ways across SES strata.

CONCLUSIONS

Families of lower SES may experience challenges and stress from hospitalisations and transitions in different ways than those of higher SES. Care delivery models and discharge planning that account for such challenges could facilitate smoother transitions that prevent adverse events and reduce disparities in the postdischarge period.

TRIAL REGISTRATION NUMBER

NCT02081846; Pre-results.

Conceptualizing smartphone use in outpatient wound assessment: patients' and caregivers' willingness to use technology

BACKGROUND

Information technology is transforming health care communication. Using smartphones to remotely monitor incisional wounds via digital photos as well as collect postoperative symptom information has the potential to improve patient outcomes and transitional care. We surveyed a vulnerable patient population to evaluate smartphone capability and willingness to adopt this technology.

METHODS

We surveyed 53 patients over a 9-mo period on the vascular surgery service at a tertiary care institution. Descriptive statistics were calculated to describe survey item response.

RESULTS

A total of 94% of recruited patients (50 of 53) participated. The cohort was 50% female, and the mean age was age 70 y (range: 41-87). The majority of patients owned cell phones (80%) and 23% of these cell phones were smartphones. Ninety percent of patients had a friend or family member that could help take and send photos with a smartphone. Ninety-two percent of patients reported they would be willing to take a digital photo of their wound via a smartphone (68% daily, 22% every other day, 2% less than every other day, and 8% not at all). All patients reported they would be willing to answer questions related to their health via a smartphone. Patients identified several potential difficulties with regard to adopting a smartphone wound-monitoring protocol including logistics related to taking photos, health-related questions, and coordination with caretakers.

CONCLUSIONS

Our survey demonstrates that an older patient cohort with significant comorbidity is able and willing to adopt a smartphone-based postoperative monitoring program. Patient training and caregiver participation will be essential to the success of this intervention.

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs

BACKGROUND

Shift change handoffs are known to be a point of vulnerability in the quality, safety and outcomes of healthcare. Despite numerous efforts to improve handoff reliability, few interventions have produced lasting change. Although the opportunity to ask questions during patient handoff has been required by some regulatory bodies, the function of questions during handoff has been less well explored and understood.

OBJECTIVE

To investigate questions and the functions they serve in nursing and medicine handoffs.

RESEARCH DESIGN

Qualitative thematic analysis based on audio recordings of nurse-to-nurse, medical resident-to-resident and surgical intern-to-intern handoffs.

SUBJECTS

Twenty-seven nurse handoff dyads and 18 medical resident and surgical intern handoff dyads at one VA Medical Center.

RESULTS

Our analysis revealed that the vast majority of questions were asked by the Incoming Providers. Although topics varied widely, the bulk of Incoming Provider questions requested information that would best help them understand individual patient conditions and plan accordingly. Other question types sought consensus on clinical reasoning or framing and alignment between the two professionals.

CONCLUSIONS

Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations

BACKGROUND

Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.

METHODS

We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.

RESULTS

Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.

CONCLUSIONS

Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

BACKGROUND

We investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing.

METHODS

Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years.

FINDINGS

Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann-Whitney U p<0.05; PACT median -1, IQR -3.75 to 0; standard care median +1, IQR -1 to +6).

CONCLUSIONS

PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.

Defining quality outcomes for complex-care patients transitioning across the continuum using a structured panel process

BACKGROUND

No standardised set of quality measures associated with transitioning complex-care patients across the various healthcare settings and home exists. In this context, a structured panel process was used to define quality measures for care transitions involving complex-care patients across healthcare settings.

METHODS

A modified Delphi consensus technique based on the RAND method was used to develop measures of quality care transitions across the continuum of care. Specific stages included a literature review, individual rating of each measure by each of the panelists (n=11), a face-to-face consensus meeting, and final ranking by the panelists.

RESULTS

The literature review produced an initial set of 119 measures. To advance to rounds 1 and 2, an aggregate rating of >75% of the measure was required. This analysis yielded 30/119 measures in round 1 and 11/30 measures in round 2. The final round of scoring yielded the following top five measures: (1) readmission rates within 30 days, (2) primary care visit within 7 days postdischarge for high-risk patients, (3) medication reconciliation completed at admission and prior to discharge, (4) readmission rates within 72 h and (5) time from discharge to homecare nursing visit for high-risk patients.

CONCLUSIONS

The five measures identified through this research may be useful as indicators of overall care quality related to care transitions involving complex-care patients across different healthcare settings. Further research efforts are called for to explore the applicability and feasibility of using the quality measures to drive quality improvement across the healthcare system.

Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study

OBJECTIVE

To explore implementation of the modified early obstetric warning system (MEOWS) in practice to further understanding about the influence of contextual factors.

METHODS

An ethnographic study using observations (>120 h), semi-structured interviews (n=45) and documentary review was performed in the maternity services in two UK hospitals over a 7-month period. Doctors, midwives and managers participated in the study and data were analysed thematically.

RESULTS

For women admitted to hospital in the antenatal and postnatal period with an established risk of morbidity, the MEOWS enabled communication about vital signs from junior to senior midwives and obstetricians. The trigger prompts helped shape shared understandings of maternal complications. However, midwifery and obstetric staff questioned the added value of an extra chart in the postnatal period given the low incidence of maternal complications and the resulting increase in workload. In an effort to prioritise workload demands and respond to the immediate needs of both women and their babies, midwives exercised professional discretion regarding its use. However, discretionary use of MEOWS meant the loss of a potential universal safety net for detection of deterioration.

CONCLUSIONS

Despite a decade of use in acute settings, research into the effectiveness of early warning systems still yields conflicting results. Widespread policy support for the MEOWS is based on its intuitive appeal and no validated system for use in the maternity population currently exists. Our findings suggest that, while the MEOWS has value in structuring the surveillance of hospitalised women with an established risk of morbidity, the complexities of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation currently call into question its role for routine use.