[Making a safe transition home after a meningioma resection: The impact of nursing care]

INTRODUCTION

This study originated from patients' demands that they be better informed and that their meningioma diagnosis be considered serious. Meningioma are brain tumours that represent about 30% of all primary brain tumours. In 90% of the cases, they are non-cancerous. The objective was to identify whether educational intervention by nurses would have a positive impact on transition.

METHOD

The study lasted 12 months and included two groups: intervention and control. Intervention involved the verbal and written delivery of answers to frequently asked questions, as well as patient follow-up for six weeks post-surgery. Nurses were available during the preparation for discharge, as well as the follow-up call 48-72 hours later.

RESULTS

Educational nursing care had no demonstrable effect.

DISCUSSION

Differences between the groups might have influenced the effect of educational intervention. Our results suggest certain lines of thought as to the doses of information that should be given based on stages of care and individual particularities.

Information Challenges in Patient Transition

The aim of this workshop is to address challenges in access to accurate and relevant information for both patients and their clinicians during patient transitions. Successful exchange of information across transitions relies on clinicians' use of the electronic health record, information systems that support workflow and communication and access to actionable information to facilitate information exchange. In this workshop the speakers will illustrate the above mentioned challenges. The chairman will initially make a short statement of the purpose and the organization of the workshops.

Attributes common to programs that successfully treat high-need, high-cost individuals

Using literature review and interviews, we have identified 8 attributes of programs, such as accountable care organizations, readmission initiatives, special needs plans, care transition programs, and patient-centered medical homes, that successfully treat high-need, high-cost patients. These 8 attributes--illustrated here with specific examples--are specific ways to target these types of individuals, promote leadership at various levels, emphasize interaction with the care coordinator, use data strategically to refine the program, update the program periodically, allow physicians to spend more time with patients, and promote interaction among clinicians and high-need, high cost patients and their families.

The Institutional Costs and Resource Profile of Transfer Patients Into an Arthroplasty Service

The decision point with inter-hospital arthroplasty patient transfers and its financial implications have not been well studied. Factors outside of complexity of medical and surgical care are believed to drive the transfer of orthopaedic patients to tertiary care centers. We compared our institutional cost and resource utilization between transfer and elective patients in need of arthroplasty care. We hypothesized that transfer patients will incur a higher direct cost and resource utilization compared to elective patients, and that socioeconomic factors will play a role in the decision of transfer. After analysis of key metrics, transfer patients at our institution did not have any significant differences in insurance types. However, they did incur a longer length of stay (p<0.0001) and incurred greater direct costs (p<0.0001) to the hospital. After analysis of key parameters, transfer patients were more complex and costly to care for compared to our in-system patients.

Addressing Needs of Long-Term Care Facility Residents During Acute Hospitalization

Patients who reside in long-term care facilities for extended periods of time offer many health care challenges. Recognition of early signs of illness, care transitions, and underutilization of community resources are common concerns.

Successes and Challenges in Patient Care Transition Programming: One Hospital's Journey

The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions. Data are emerging from the additional Care Transition Measures and benchmarks have been developed. This article briefly describes the context of care transition. We describe the journey of Indiana University Health North Hospital to overcome patient care transition obstacles, ultimately achieving designation as a top performer. We will discuss our efforts to personalize patient outcomes and transition through activation and improve transitions for vulnerable populations, specifically in the bariatric and orthopedic patient populations. The article concludes with discussion of overcoming obstacles and future directions with continued focus on collaboration and improvement.

Insurance status influences emergent designation in surgical transfers

BACKGROUND

There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs.

MATERIALS AND METHODS

A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only.

RESULTS

There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77).

CONCLUSIONS

The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.

Patient Selection for Drip and Ship Thrombolysis in Acute Ischemic Stroke

OBJECTIVES

The drip and ship model is a method used to deliver thrombolysis to acute stroke patients in facilities lacking onsite neurology coverage. We sought to determine whether our drip and ship population differs from patients treated directly at our stroke center (direct presenters).

METHODS

We retrospectively reviewed consecutive patients who received thrombolysis at an outside facility with subsequent transfer to our center between 2009 and 2011. Patients received thrombolysis after telephone consultation with a stroke specialist. We examined demographics, vascular risk factors, laboratory values, and stroke severity in drip and ship patients compared with direct presenters.

RESULTS

Ninety-six patients were identified who received thrombolysis by drip and ship compared with 212 direct presenters. The two groups did not differ with respect to sex, ethnicity, vascular risk factors, or admission glucose. The odds ratio (OR) of arriving at our hospital as a drip and ship for someone 80 years or older was 0.31 (95% confidence interval [CI] 0.15-0.61, P < 0.001). Only 21% of drip and ship patients were black versus 38% of direct presenters (OR 0.434, 95% CI 0.25-0.76, P = 0.004). Even after stratifying by age (<80 vs ≥80), a smaller proportion of drip and ship patients were black (OR 0.44, 95% CI 0.24-0.81, P = 0.008). Furthermore, we found that fewer black patients with severe strokes arrived by drip and ship (OR 0.33, 95% CI 0.11-0.98, P = 0.0028).

CONCLUSIONS

Our study showed that a smaller proportion of blacks and older adults arrived at our center by the drip and ship model. This may reflect differences in how patients are selected for thrombolysis and transfer to a higher level of care.

Interfacility Transports Utilizing the 9-1-1 Emergency Medical Services System

BACKGROUND

With the increasing development of regional specialty centers, emergency physicians are often confronted with patients needing definitive care unavailable at their hospital. Interfacility transports (IFTs) may be a useful option to ensure timely, definitive patient care. However, since traditional IFT can be a challenging and time-consuming process, some EMS agencies that have previously limited their service to 9-1-1 emergency responses are now performing emergency IFTs.

OBJECTIVE

We sought to determine the frequency and nature of transfers provided by a local fire-based 9-1-1 EMS agency that recently began to provide limited IFT for time-critical emergencies.

METHODS

A retrospective review of paramedic reports for all IFTs between April 2007 and March 2014 in the City of Los Angeles, California. All IFTs initiated by 9-1-1 call from an emergency department (ED) and performed by Los Angeles Fire Department paramedics were included. Reason for transfer, patient demographics, and key time metrics were captured.

RESULTS

There were 919 IFTs during the study period, out of approximately 1,160,000 total ambulance transports (0.1%). The most frequent reason for IFT request was for transport of patients with ST segment elevation MI (STEMI) to a STEMI receiving center, followed by major trauma to a trauma center, and intracranial hemorrhage to a center with neurosurgical capability. Less common reasons included vascular emergencies, acute stroke, obstetric emergencies, and transfers to pediatric critical care facilities. Median transport time was 8 minutes (IQR 6-13 minutes) and median total time for IFT was 51 minutes (IQR 39-69 minutes). All IFTs involved a potentially life-threatening condition requiring a higher level of care than was available at the referring hospital.

CONCLUSIONS

Emergent ED-to-ED interfacility transport can provide access to time critical definitive care. EMS agencies that have limited the scope of their response to community 9-1-1 emergencies should have policies in place to assure timely response for emergent IFT requests.

Predicting patients that require care at a trauma center: analysis of injuries and other factors

INTRODUCTION

The detection of occult or unpredictable injuries in motor vehicle crashes (MVCs) is crucial in correctly triaging patients and thus reducing fatalities. The purpose of the study was to develop a metric that indicates the likelihood that an injury sustained in a MVC would require management at a Level I/II trauma centre (TC) versus a non-trauma centre (non-TC).

METHODS

Transfer Scores (TSs) were computed for 240 injuries that comprise the top 95% most frequently occurring injuries in the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) with an Abbreviated Injury Scale (AIS) severity of 2 or greater. A TS for each injury was computed using the proportions of patients involved in a MVC from the National Inpatient Sample (NIS) that were transferred to a TC or managed at a non-TC. Similarly, a TSMAIS that excludes patients with higher severity co-injuries was calculated using the proportion of patients with a maximum AIS (MAIS) equal to the AIS severity of a given injury.

RESULTS

The results indicated for injuries of a given AIS severity, body region, and injury type, there were large variations in the TSMAIS. Overall results demonstrated higher TSMAIS values when injuries were internal, haemorrhagic, intracranial or of moderate severity (AIS 3-5). Specifically, injuries to the head possessed a TSMAIS that ranged from 0.000 to 0.889, with head injuries of AIS 3-5 severities being the most likely to be transferred.

DISCUSSION AND CONCLUSIONS

The analysis indicated that the TSMAIS is not solely correlated with AIS severity and therefore it captures other important aspects of injury such as predictability and trauma system capabilities. The TS and TSMAIS can be useful in advanced automatic crash notification (AACN) research for the detection of highly unpredictable injuries in MVCs that require direct transport to a TC.

Staffing and training issues in critical care hyperbaric medicine

The integrated chain of treatment of the most severe clinical cases that require hyperbaric oxygen therapy (HBOT) assumes that intensive care is continued while inside the hyperbaric chamber. Such an approach needs to take into account all the risks associated with transportation of the critically ill patient from the ICU to the chamber and back, changing of ventilator circuits and intravascular lines, using different medical devices in a hyperbaric environment, advanced invasive physiological monitoring as well as medical procedures (infusions, drainage, etc) during long or frequently repeated HBOT sessions. Any medical staff who take care of critically ill patients during HBOT should be certified and trained according to both emergency/intensive care and hyperbaric requirements. For any HBOT session, the number of staff needed for any HBOT session depends on both the type of chamber and the patient's status--stable, demanding or critically ill. For a critically ill patient, the standard procedure is a one-to-one patient-staff ratio inside the chamber; however, the final decision whether this is enough is taken after careful risk assessment based on the patient's condition, clinical indication for HBOT, experience of the personnel involved in that treatment and the available equipment.

EHR System MojTermin: Implementation and Initial Data Analysis

Healthcare informatics has gained importance over the last several years. E-health systems on a national level have already been implemented in most European countries. Data generated by these systems are used to improve healthcare policies as well as health services. In this paper we present the system MojTermin (MyAppointment), as it evolves from a healthcare appointment engine to a complete national e-health system. We also present preliminary results from data gathered during the implementation of this system. In our analysis, we show how the system aided in the discovery of several specific socio-cultural phenomena, which led to governance changes in order to optimize resourses and raise the quality of the entire national healthcare system.

Experiences as input to eHealth design - a hip surgery patient journey case

The objective of the study is to describe the planned hip-surgery care process as experienced by patients and healthcare professionals, as well as a qualitative analysis of problems. Data was collected through 3 focus group meetings with patients and healthcare professionals. We present the results in form of a patient journey model, examples of problems as expressed by patients and examples of proposed eHealth services by both patients and care professionals. The results indicate that although the patient journey is similar for most patients, their experiences are highly individual and designing eHealth to improve the patient journey will require flexibility and adaptability to the individual's needs.

Using business intelligence for efficient inter-facility patient transfer

In the context of inter-facility patient transfer, a transfer operator must be able to objectively identify a destination which meets the needs of a patient, while keeping in mind each facility's limitations. We propose a solution which uses Business Intelligence (BI) techniques to analyze data related to healthcare infrastructure and services, and provides a web based system to identify optimal destination(s). The proposed inter-facility transfer system uses a single data warehouse with an Online Analytical Processing (OLAP) cube built on top that supplies analytical data to multiple reports embedded in web pages. The data visualization tool includes map based navigation of the health authority as well as an interactive filtering mechanism which finds facilities meeting the selected criteria. The data visualization is backed by an intuitive data entry web form which safely constrains the data, ensuring consistency and a single version of truth. The overall time required to identify the destination for inter-facility transfers is reduced from hours to a few minutes with this interactive solution.

Teaching patients to protect themselves during care transitions: a patient safety campaign

Patient safety can be compromised at any time, but a disproportionate number of problems occur when patients are transitioning between care settings and care providers. Therefore, those trying to improve patient safety need to focus particular attention on times of transition. This article describes a public education campaign to change patients' behaviors during those periods.

Supporting residents moving into long-term care: multiple layers shape residents' experiences

This interpretive grounded theory study explores 10 residents' retrospective accounts of the relocation process, including the decision to move into a long-term care home, the pre-move preparations, the moving day circumstances, and the initial adjustment period following the move. Analysis of the data revealed a complex intersection of conditions at multiple layers that shaped residents' experiences of the transitional process. Recommendations to enhance circumstances at individual, interpersonal, and systemic layers, for each temporal stage of the relocation process are proposed. Implications for social work practice across the continuum of care are also discussed.

Patient Reporting of Safety experiences in Organisational Care Transfers (PRoSOCT): a feasibility study of a patient reporting tool as a proactive approach to identifying latent conditions within healthcare systems

BACKGROUND

It is increasingly recognised that patients can play a role in reporting safety incidents. Studies have tended to focus on patients within hospital settings, and on the reporting of patient safety incidents as defined within a medical model of safety. This study aims to determine the feasibility of collecting and using patient experiences of safety as a proactive approach to identifying latent conditions of safety as patients undergo organisational care transfers.

METHODS AND ANALYSIS

The study comprises three components: (1) patients' experiences of safety relating to a care transfer, (2) patients' receptiveness to reporting experiences of safety, (3) quality improvement using patient experiences of safety. (1) A safety survey and evaluation form will be distributed to patients discharged from 15 wards across four clinical areas (cardiac, care of older people, orthopaedics and stroke) over 1 year. Healthcare professionals involved in the care transfer will be provided with a regular summary of patient feedback. (2) Patients (n=36) who return an evaluation form will be sampled representatively based on the four clinical areas and interviewed about their experiences of healthcare and safety and completing the survey. (3) Healthcare professionals (n=75) will be invited to participate in semistructured interviews and focus groups to discuss their experiences with and perceptions of receiving and using patient feedback. Data analysis will explore the relationship between patient experiences of safety and other indicators and measures of quality and safety. Interview and focus group data will be thematically analysed and triangulated with all other data sources using a convergence coding matrix.

ETHICS AND DISSEMINATION

The study has been granted National Health Service (NHS) Research Ethics Committee approval. Patient experiences of safety will be disseminated to healthcare teams for the purpose of organisational development and quality improvement. Results will be disseminated to study participants as well as through peer-reviewed outputs.

Quality of care and interhospital collaboration: a study of patient transfers in Italy

OBJECTIVES

We examine the dynamics of patient-sharing relations within an Italian regional community of 35 hospitals serving approximately 1,300,000 people. We test whether interorganizational relations provide individual patients access to higher quality providers of care.

RESEARCH DESIGN AND METHODS

We reconstruct the complete temporal sequence of the 3461 consecutive interhospital patient-sharing events observed between each pair of hospitals in the community during 2005-2008. We distinguish between transfers occurring between and within different medical specialties. We estimate newly derived models for relational event sequences that allow us to control for the most common forms of network-like dependencies that are known to characterize collaborative relations between hospitals. We use 45-day risk-adjusted readmission rate as a proxy for hospital quality.

RESULTS

After controls (eg, geographical distance, size, and the existence of prior collaborative relations), we find that patients flow from less to more capable hospitals. We show that this result holds for patient being shared both between as well as within medical specialties. Nonetheless there are strong and persistent other organizational and relational effects driving transfers.

CONCLUSIONS

Decentralized patient-sharing decisions taken by the 35 hospitals give rise to a system of collaborative interorganizational arrangements that allow the patient to access hospitals delivering a higher quality of care. This result is relevant for health care policy because it suggests that collaborative relations between hospitals may produce desirable outcomes both for individual patients, and for regional health care systems.