Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

'Patients come with two garbage bags full of problems and we have to sort them.' A qualitative study of the experiences of healthcare professionals on patients admitted to short-term residential care in the Netherlands

BACKGROUND

Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing.

OBJECTIVE

To obtain perspectives of STRC professionals on the patient journey from admission to discharge.

DESIGN

Qualitative study.

SETTING

Eight nursing homes and three hospitals.

SUBJECTS

A total of 28 healthcare professionals.

METHODS

A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically.

RESULTS

Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important.

CONCLUSIONS

STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.

Review of electronic discharge summaries from the general medicine, general surgery and mental health streams at a tertiary hospital: retrospective analysis of timeliness, brevity and completeness

Objective This retrospective study identified and compared the performance of electronic discharge summaries (EDSs) from three hospital in-patient streams (surgical, medical and mental health) with Australian standards. Methods An audit was performed of 120 EDSs extracted from a tertiary hospital. Auditors evaluated each EDS using an adaptation of the Australian Commission on Safety and Quality in Health Care's EDS toolkit. Results EDSs from all in-patient streams were lengthy and most did not include information regarding discharge destination, patient education or recommendations. General Medicine EDSs were most timely, averaging within 1 day of discharge. Conclusions Key areas of improvement remain for improving the timeliness, brevity and completeness of EDSs. Key areas identified for improvement include page length, discharge destination, alerts, patient education and recommendations. Variability in audit results between streams suggests the need for speciality-specific templates, standards and medical officer training. What is known about the topic? The literature suggests that an EDS is timely if it is completed within 2 days of discharge. A complete and brief EDS should also include key details of the care in two (or fewer) pages. What does this paper add? This paper evaluated 120 EDSs, compared them against a standard and stratified the EDSs according to three core clinical in-patient streams that produced them (surgical, medical and mental health). What are the implications for practitioners? Although broad guidelines for timeliness, brevity and completeness have been established for EDSs, each in-patient stream will require different standards. A hospital or health service should have established standards relevant to each in-patient stream. Before commencing a term in any of the three in-patient streams, medical officers who are to generate EDSs should be trained in the required standard. Training should highlight critical elements of a speciality stream to ensure EDS authors are aware of the nuances of the stream in which they are rotating. In addition, general practitioners should liaise with local hospitals to ensure ongoing dialogue and improvement of clinical handover documents.

A retrospective analysis of discharge summaries from a tertiary care hospital medical oncology unit: To assess compliance with documentation of recommended discharge summary components

Background

Discharge summaries are essential for health transition between inpatient hospital teams and outpatient general practices. The patient's outcome is dependent on the quality and timeliness of discharge summaries.

Aim

A retrospective analysis was carried out to assess the compliance with recommended documentation of 697 electronic discharge summaries (eDSs) of oncology inpatients discharged in 2018 from the Canberra Hospital according to the National Guidelines of On‐Screen Presentation of Discharge Summaries.

Methods and results

Individual medical records were identified and screened for the recommended eDS components according to the National Guidelines. Out of the 17 recommended components, nine components were included in all discharge summaries, two components in more than 99% and two components in 95–96% of discharge summaries. The most frequently omitted components include “information provided to the patient,” “ceased medicine” and “procedures,” and these were omitted in 8, 38 and 82% of discharge summaries, respectively.

Conclusion

Overall, most discharge summaries adhered to the national guidelines quite well by including most of the recommended components. However, the discharge summary quality is still inadequate in some domains.

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BACKGROUND

Minimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.

OBJECTIVE

We assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.

METHODS

In this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).

RESULTS

After the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.

CONCLUSIONS

The implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.

Analysis of discharge documentation for older adults living with dementia: A cohort study

BACKGROUND

Older adults living with dementia frequently transition between healthcare settings. Care transitions increase vulnerability and risk of iatrogenic harm.

AIM AND OBJECTIVE

To examine the quality of transitional care arrangements within discharge documentation for older people living with dementia.

DESIGN

Secondary analysis of cohort study data.

METHOD

A secondary analysis of the IDEAL Study [ACTRN12612001164886] discharge documents, following the STROBE guidelines. Participants had a confirmed diagnosis of dementia and were discharged from hospital to a nursing home. An audit tool was used to extract the data. This was developed through a synthesis of existing tools and finalised by an expert panel. The analysis assessed the quality of discharge documentation, in the context of transitional care needs, and presented results using descriptive statistics. Functional ability; physical health; cognition and mental health; medications; and socio environmental factors were assessed.

RESULTS

Sixty participants were included in analyses, and half were male (52%), with a total participant mean age of 83 (SD 8.7) years. There was wide variability in the quality of core discharge information, ranging from excellent (37%), adequate (43%) to poor (20%). A sub-group of these core discharge documentation elements that detailed the participants transitional care needs were rated as follows: excellent (17%), adequate (46%) and poor (37%).

CONCLUSION

Discharge documentation fails to meet needs of people living with dementia. Improving the quality of discharge documentation for people living with dementia transitioning from hospital to nursing home is critical to provide safe and quality care.

RELEVANCE TO CLINICAL PRACTICE

There is a need for safe, timely, accurate and comprehensive discharge information to ensure the safety of people living with dementia and prevent adverse harm.

Development and implementation of a transmural palliative care consultation service: a multiple case study in the Netherlands

Background

In the Netherlands, healthcare professionals attending patients in the last phase of life, can consult an expert palliative care team (PCT) in case of complex problems. There are two types of PCTs: regional PCTs, which are mainly consulted by general practitioners, and hospital PCTs, which are mainly consulted by healthcare professionals in the hospital. Integration of these PCTs is expected to facilitate continuity of care for patients receiving care in different settings. We studied facilitators and barriers in the process of developing and implementing an integrated transmural palliative care consultation service.

Methods

A multiple case study was performed in four palliative care networks in the southwest Netherlands. We aimed to develop an integrated transmural palliative care consultation service. Researchers were closely observing the process and participated in project team meetings. A within-case analysis was conducted for each network, using the Consolidated Framework for Implementation Research (CFIR). Subsequently, all findings were pooled.

Results

In each network, project team members thought that the core goal of a transmural consultation service is improvement of continuity of palliative care for patients throughout their illness trajectory. It was nevertheless a challenge for hospital and non-hospital healthcare professionals to arrive at a shared view on goals, activities and working procedures of the transmural consultation service. All project teams experienced the lack of evidence-based guidance on how to organise the service as a barrier. The role of the management of the involved care organisations was sometimes perceived as unsupportive, and different financial reimbursement systems for hospital and out-of-hospital care made implementation of a transmural consultation service complex. Three networks managed to develop and implement a transmural service at some level, one network did not manage to do so.

Conclusions

Healthcare professionals are motivated to collaborate in a transmural palliative care consultation service, because they believe it can contribute to high-quality palliative care. However, they need more shared views on goals and activities of a transmural consultation service, more guidance on organisational issues and appropriate financing. Further research is needed to provide evidence on benefits and costs of different models of integrated transmural palliative care consultation services.

Patient-Reported Continuity of Care and Functional Safety Concerns After Inpatient Cancer Rehabilitation

BACKGROUND

Patients with cancer have been noted to have inadequate continuity of care after discharge from hospital. We sought to assess patient-reported continuity of care and functional safety concerns after acute inpatient rehabilitation.

METHODS

This was a prospective study that used cross-sectional surveys at a National Cancer Institute Comprehensive Cancer Center. All patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, met the inclusion criteria, and completed two surveys (assessing continuity of care and functional safety concerns) upon discharge and 1 month after discharge were included in the study.

RESULTS

A total of 198 patients completed the study, and no major concerns were reported by the patients. The greatest concern was a lack of adequate communication management among different providers, reported by only 10 (5.0%) patients. The combined fall and near-fall rate within 1 month after discharge was (25/198) 13%. Brain metastasis, a comorbidity of depression, and a history of falls were significantly associated with a higher risk of falls or near falls within 1 month after discharge.

CONCLUSION

Although overall patients with cancer reported adequate continuity of care and feeling safe to function at home after acute inpatient rehabilitation, it is important to be aware that fall or near-fall events within 1 month after acute inpatient rehabilitation are associated with brain metastasis, comorbidity of depression, and a history of falls. Thus, patients with these risk factors may benefit from including more focused fall prevention education and interventions.

IMPLICATIONS FOR PRACTICE

Patients with cancer often have extensive problems that require care from multiple health care providers simultaneously, and a high level of coordination is needed for adequate transition of care from the inpatient to the outpatient setting. This transition of care period is prone to inadequate continuity of care and, for older adults, a particular risk for falls. Assessment for risk of fall is also an important factor to consider when evaluating patients to continue oncology treatments. There is a gap in knowledge regarding patient-reported continuity of care and functional safety concerns after acute inpatient cancer rehabilitation.

Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

Stress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.

Barriers to postpartum diabetes screening: a qualitative synthesis of clinicians' views

BACKGROUND

Gestational diabetes mellitus (GDM) is an important risk factor for developing type 2 diabetes mellitus (T2DM) later in life. Postpartum screening provides an opportunity for early detection and management of T2DM, but uptake is poor.

AIM

To explore barriers to screening from clinicians' perspectives to guide future interventions to increase uptake of postpartum screening.

DESIGN AND SETTING

Systematic review and qualitative synthesis.

METHOD

Qualitative studies included in a previous review were assessed, and then five electronic databases were searched from January 2013 to May 2019 for qualitative studies reporting clinicians' perspectives on postpartum glucose screening after GDM. Study quality was assessed against the Critical Appraisal Skills Programmes checklist. Qualitative data from the studies were analysed using thematic synthesis.

RESULTS

Nine studies were included, containing views from 187 clinicians from both community and hospital care. Three main themes were identified: difficulties in handover between primary and secondary care (ambiguous roles and communication difficulties); short-term focus in clinical consultations (underplaying risk so as not to overwhelm patients and competing priorities); and patient-centric barriers such as time pressures.

CONCLUSION

Barriers to diabetes screening were identified at both system and individual levels. At the system level, clarification of responsibility for testing among healthcare professionals and better systems for recall are needed. These could be achieved through registers, improved clinical protocols, and automatic flagging and prompts within electronic medical records. At the individual level, clinicians should be supported to prioritise the importance of screening within consultations and better educational resources made available for women. Making it more convenient for women to attend may also facilitate screening.

What's in a Summary? Laying the Groundwork for Advances in Hospital-Course Summarization

Summarization of clinical narratives is a long-standing research problem. Here, we introduce the task of hospital-course summarization. Given the documentation authored throughout a patient's hospitalization, generate a paragraph that tells the story of the patient admission. We construct an English, text-to-text dataset of 109,000 hospitalizations (2M source notes) and their corresponding summary proxy: the clinician-authored "Brief Hospital Course" paragraph written as part of a discharge note. Exploratory analyses reveal that the BHC paragraphs are highly abstractive with some long extracted fragments; are concise yet comprehensive; differ in style and content organization from the source notes; exhibit minimal lexical cohesion; and represent silver-standard references. Our analysis identifies multiple implications for modeling this complex, multi-document summarization task.

Effect of a Real-Time Risk Score on 30-day Readmission Reduction in Singapore

OBJECTIVE

To develop a risk score for the real-time prediction of readmissions for patients using patient specific information captured in electronic medical records (EMR) in Singapore to enable the prospective identification of high-risk patients for enrolment in timely interventions.

METHODS

Machine-learning models were built to estimate the probability of a patient being readmitted within 30 days of discharge. EMR of 25,472 patients discharged from the medicine department at Ng Teng Fong General Hospital between January 2016 and December 2016 were extracted retrospectively for training and internal validation of the models. We developed and implemented a real-time 30-day readmission risk score generation in the EMR system, which enabled the flagging of high-risk patients to care providers in the hospital. Based on the daily high-risk patient list, the various interfaces and flow sheets in the EMR were configured according to the information needs of the various stakeholders such as the inpatient medical, nursing, case management, emergency department, and postdischarge care teams.

RESULTS

Overall, the machine-learning models achieved good performance with area under the receiver operating characteristic ranging from 0.77 to 0.81. The models were used to proactively identify and attend to patients who are at risk of readmission before an actual readmission occurs. This approach successfully reduced the 30-day readmission rate for patients admitted to the medicine department from 11.7% in 2017 to 10.1% in 2019 (p < 0.01) after risk adjustment.

CONCLUSION

Machine-learning models can be deployed in the EMR system to provide real-time forecasts for a more comprehensive outlook in the aspects of decision-making and care provision.

Rural family physician perspectives on communication with urban specialists: a qualitative study

OBJECTIVE

Communication is a key competency for medical education and comprehensive patient care. In rural environments, communication between rural family physicians and urban specialists is an essential pathway for clinical decision making. The aim of this study was to explore rural physicians' perspectives on communication with urban specialists during consultations and referrals.

SETTING

Newfoundland and Labrador, Canada.

PARTICIPANTS

This qualitative study involved semistructured, one-on-one interviews with rural family physicians (n=11) with varied career stages, geographical regions, and community sizes.

RESULTS

Four themes specific to communication in rural practice were identified. The themes included: (1) understanding the contexts of rural care; (2) geographical isolation and patient transfer; and (3) respectful discourse; and (4) overcoming communication challenges in referrals and consultations.

CONCLUSIONS

Communication between rural family physicians and urban specialists is a critical task in providing care for rural patients. Rural physicians see value in conveying unique aspects of rural clinical practice during communication with urban specialists, including context and the complexities of patient transfers.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention

INTRODUCTION

Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.

METHODS AND ANALYSIS

Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.

TRIAL REGISTRATION NUMBER

NCT03442426;Pre-results.

Standardization of the Discharge Process for Inpatient Hematology and Oncology Using Plan-Do-Study-Act Methodology Improves Follow-Up and Patient Hand-Off

Background

Hematology and oncology patients represent a complex population that requires timely follow-up to prevent clinical decompensation and delays in treatment. Previous reports have demonstrated that follow-up within 14 days is associated with decreased 30-day readmissions, and the magnitude of this effect is greater for higher-risk patients. This project was designed to standardize the discharge process with the primary goal of reducing average time to hematology and oncology follow-up to < 14 days.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a multidisciplinary team of hematology and oncology staff developed and implemented a standardized discharge process. Rotating resident physicians were trained through online and in-person education. Additional interventions included the development of a discharge checklist handout, and a clinical decision support tool including a note template and embedded order set. All patients discharged during the 2-month period before and after the implementation of the standardized process were evaluated. Follow-up appointment scheduling data and communication between inpatient and outpatient providers were reviewed.

Results

A total of 142 consecutive patients were reviewed. The primary endpoint of time to hematology and oncology follow-up appointment improved from a mean 17 days prior to intervention to 13 days in PDSA cycles 1 and 2 and 10 days in PDSA cycle 3. The target of 14-day average time to follow-up was achieved. Furthermore, the upper control limit decreased from 58 days at baseline to 21 days in PDSA cycle 3, demonstrating a decrease in variation. Electronic alerting of outpatient hematology and oncology providers to discharge summary increased from 20% before the intervention to 62% after the intervention (P = .01).

Conclusions

This quality initiative to standardize the discharge process for the hematology and oncology service decreased time to hematology and oncology follow-up appointments, improved communication between inpatient and outpatient teams, and decreased process variation. Timelier follow-up for this complex patient population will prevent clinical decompensation and delays in treatment.

Teaching and Learning Core Values in General Practice/Family Medicine: A Narrative Review

General Practice/Family Medicine (GP/FM) is a key discipline within primary health care and so by extension for the whole health care system. An essential condition for effective GP/FM care is a work force that is highly qualified. As society is changing rapidly, a revision of the GP/FM definition is ongoing, in addition to a recent movement of identifying related core values. In this paper, we want to give an overview on how these new paths and perspectives are currently reflected in GP/FM teaching and training. We selected four core values that fit in with possible future visions: person-centered care, continuity of care, cooperation in care, and community-oriented care. By a narrative review, we observed that GP/FM education toward core values is often built around overarching topics. Teaching and learning take place in specific contexts, most of all through placements within communities, primary care settings, or hospital wards. Mixed teaching- and training methods are used combining knowledge, skills, and attitude. Furthermore, collaboration with other health professionals and peers is stressed, in addition to the importance of role models, a holistic focus and the involvement of patients. Since these core values are important within GP/FM and rather few studies on the educational aspects and learning tools were found we advocate encouraging each other more to share good practices, certainly the innovative ones specifically related to GP/FM.

Discharge Summary Completion Timeliness and the Association of 30-Day Readmission

OBJECTIVE

This study aimed to review the association between timeliness to completion of a discharge summary to 30-day readmission to the hospital.

METHODS

This was a retrospective chart review of 109 patients discharged from Mayo Clinic Hospital.

RESULTS

Twenty-four of these patients were readmitted within 30 days. The time to completion of discharge summary was categorized for these readmissions to <72 hours: 15 (20%), between 72 hours and 7 days: 2 (11.1%), and >7 days: 7 (43.7%). There was no statistical significance for readmission for discharge summaries completed between 72 hours and 7 days compared with <72 hours (P = 0.44). There was statistical significance correlating readmission within 30 days to the discharge summary completed >7 days compared with <72 hours (P = 0.04).

CONCLUSIONS

This study found that discharge summaries completed >7 days have an increased association with 30-day readmission rate.

Non-systematic review: Correspondence quality and interoperability between family physicians and hospital clinicians

BACKGROUND

Medical correspondence between physicians working in the community and in hospital is paramount to provide continuity of care, but there is no agreement on what constitutes a good quality letter, not even interest by some clinicians on this interface. Information flow could be faster electronically rather than in paper, but is content improving? What defines a good letter?

AIM

(a) To assess what information should be shared between family doctors and hospital physicians and could it be shared better. (b) To assess the possibility of linking the sections of the letter to SNOMED-CT codes to improve interoperability.

RESULTS

Authors vary regarding what is to be included in communications, and as they also have different needs among services, it creates a very long list of possible items to consider. Standardised templates with their corresponding SNOMED-CT codes are presented.

CONCLUSION

Standardised correspondence could improve continuity of care. Appropriately coded it could facilitate the information sharing and the data manipulation required to provide an adequate provision of services among primary care or family physicians and hospitals or secondary care organisations. It could also serve as a tool to assess clinicians' performance.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action

BACKGROUND

Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care.

METHODS

We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility.

FINDINGS

Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences.

CONCLUSIONS

The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives

BACKGROUND

Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship.

OBJECTIVE

To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home.

DESIGN

Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone.

PARTICIPANTS

A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers.

MAIN MEASURES

A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition.

KEY RESULTS

The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home.

CONCLUSIONS

Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.

Factors Associated With Discharge Planning Practices for Patients Receiving Inpatient Psychiatric Care

OBJECTIVE

This study examined associations of patient, hospital, and service system factors with provision of discharge planning to individuals treated in hospital psychiatric units.

METHODS

This retrospective cohort analysis used 2012-2013 New York State Medicaid claims data of 18,185 patients ages <65 years who were treated in hospital psychiatric units and discharged to the community. The claims data were linked to data from managed behavioral health care organizations indicating whether inpatient staff scheduled a follow-up outpatient appointment with a mental health provider. Additional data regarding hospital and service system characteristics were obtained from the American Hospital Association Annual Survey, the Area Health Resource File, and other state administrative databases. Rates and adjusted odds ratios were assessed for the likelihood of inpatient staff scheduling a follow-up appointment.

RESULTS

Inpatient staff scheduled outpatient appointments for 79.8% of discharges. The adjusted odds of not having an outpatient appointment scheduled as part of the patient's discharge plan were significantly associated with several factors, including being homeless on admission, having a diagnosis of a co-occurring substance use disorder, having high levels of medical comorbid conditions, and not being engaged in psychiatric outpatient services in the month prior to admission.

CONCLUSIONS

Patient characteristics were more strongly associated with failure to receive discharge planning than were hospital and service system characteristics.

Impacts of Post-Hospitalization Accessible Health Technology and Caregiver Support on 90-Day Acute Care Use and Self-Care Assistance: A Randomized Clinical Trial

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Health care providers' experiences with delivering person centred care in an Integrated Care Program for thoracic surgery patients in Ontario, Canada

Purpose

The purpose of this study is to understand health care providers' experiences with delivering a novel Integrated Care (IC) Program that co-ordinates hospital-based clinical services and home care for thoracic surgery patients, including perceptions on the provision of person-centred care and quality of work life.

Design/methodology/approach

The authors conducted a process evaluation using qualitative methods to understand provider experiences in the Integrated Care (IC) Program and to identify areas for programme improvement. Study data were collected using a focus group with thoracic surgeons, open-ended survey with home care providers, and semi-structured interviews with lead thoracic surgeons and IC leads, who are nurses serving as the primary point of contact for one consistent care team. Data were analysed using thematic analysis.

Findings

The IC Program was successful in supporting a partnership between health care providers and patients and caregivers to deliver a comprehensive and person-centred care experience. Informational continuity between providers was facilitated by IC leads and improved over time with greater professional integration and adaptation to the new care delivery processes. Differential impacts were found on quality of work life for providers in the IC Program.

Originality/value

This study describes provider experiences with delivering integrated and person-centred care across the hospital to home continuum, which can inform future integrated care initiatives.

Health care transitions for persons living with dementia and their caregivers

BACKGROUND

Persons with dementia are likely to require care from various health care providers in multiple care settings, necessitating navigation through an often-fragmented care system. This study aimed to create a better understanding of care transition experiences from the perspectives of persons living with dementia and their caregivers in Ontario, Canada, through the development of a theoretical framework.

METHODS

Constructivist grounded theory guided the study. Seventeen individual caregiver interviews, and 12 dyad interviews including persons with dementia and their caregivers, were recorded and transcribed verbatim. The data were coded using NVivo 10 software; analysis occurred iteratively until saturation was reached.

RESULTS

A theoretical framework outlining the context, processes, and influencing factors of care transitions was developed and refined. Gaining an in-depth understanding of the complex care transitions of individuals with dementia and their caregivers is an important step in improving the quality of care and life for this population.

CONCLUSION

The framework developed in this study provides a focal point for efforts to improve the health care transitions of persons living with dementia.

Prioritising the mobilisation of emergency medical services: patient making at the healthcare gateway

Purpose

The purpose of this paper is to analyse the socio-material practices through which organisational understanding of patients is accomplished in order to prioritise calls and mobilise emergency medical services at the gateway of the healthcare system.

Design/methodology/approach

The methodology of this paper is an ethnographic study of the co-ordination of collective action in an emergency services control room in the Welsh NHS, with data generation and analysis informed by Translational Mobilisation Theory.

Findings

Mobilisation of emergency medical services entails the translation of callers' undifferentiated problems into response priority categories, which are used by dispatch operators to mobilise crews. A central actor in these processes is the computerised Medical Priority Dispatch System. While designed to enable non-clinically qualified call handlers to triage calls in a standardised way, the system constrains caller–call handler interaction, which negatively impacts the categorisation process. Analysis of these interactional difficulties and associated mitigation strategies highlights opportunities for intervening to support co-ordination at this healthcare boundary.

Originality/value

Orthodox approaches to improving interface management are founded on a conceptualisation of “patients” as immutable actors in care transfer processes. Translational Mobilisation Theory brings into view the multiple versions of the “patient” produced by healthcare systems and offers a framework for analysing the mechanisms of action necessary to create organisational understandings of patients at boundary crossings. While the ambulance control centre is a singular case, the paper illustrates the value of attending to these processes in interface organisation.

Measuring Processes of Integrated Care for Hospital to Home Transitions

Background:

Integrated care is a promising approach to improve transitions from hospital for older adults. Measures of integrated care tend to be survey-based or outcomes focused. This study determined the feasibility of using hospital chart data to measure integrated processes of care.

Methods:

This paper reports on two objectives: 1) the development of an integrated care transition framework and associated features of care; 2) a pilot study to test if the features could be applied to 214 hospital patient charts.

Results:

Twenty-four features were tested, and fifteen features could be reliably measured using chart review. Of these, the percent of patients classified as receiving integrated care varied widely across the items, from 0.05% to 84.1%.

Discussion:

The framework presented in this paper can guide measurement of system and clinical delivery of integrated care transitions. In combination with other tools, chart review can provide perspective on day-to-day care delivery not otherwise accessible, and highlight areas requiring practice change.

Conclusion:

Multiple measurement perspectives are needed to improve our understanding of how integrated care is being implemented. While chart review cannot address the full breadth of integrated care, it can help understand how processes of care are being implemented in routine daily care.

Patient handover in a European border region: Cross-sectional survey study among healthcare workers to explore the status quo, potential risks, and solutions

Introduction

While the popularity of international care is rising, the complexity of international care compromises patient safety. To identify risks and propose solutions to improve international care, this study explores experiences of healthcare workers with international handovers in a European border region.

Methods

A cross-sectional survey design was used to reach out to 3000 healthcare workers, working for hospitals or emergency services in three neighboring countries in the Meuse-Rhine Euregion. In total, 846 healthcare workers completed the survey with 35 closed- and open-ended questions about experiences with international patient handover.

Results

One-third of respondents had been involved in international handover in the previous month. The handovers occurred in planned and acute care settings and were supported by numerous, yet varying standardized procedures. Healthcare workers were trained for this in some, but not all settings. Respondents mentioned 408 risks and proposed 373 solutions, which were inductively analyzed. Six identified themes classify the level on which risks and accompanying solutions can be found: awareness, professional competencies, communication between professionals, loss of information, facilities and support, and organizational structure.

Discussion

This study gives insight in international patient handovers in a European border region. Among the biggest risks experienced are procedural differences, sharing patient information, unfamiliarity with foreign healthcare systems, and not knowing roles and responsibilities of peers working across the border. Standardization of procedures, harmonization of systems, and the possibility for healthcare workers to get to know each other will contribute to reach common ground and move towards optimized and patient-safer cross-border care.

What makes a "successful" or "unsuccessful" discharge letter? Hospital clinician and General Practitioner assessments of the quality of discharge letters

BACKGROUND

Sharing information about hospital care with primary care in the form of a discharge summary is essential to patient safety. In the United Kingdom, although discharge summary targets on timeliness have been achieved, the quality of discharge summaries' content remains variable.

METHODS

Mixed methods study in West Midlands, England with three parts: 1. General Practitioners (GPs) sampling discharge summaries they assessed to be "successful" or "unsuccessful" exemplars, 2. GPs commenting on the reasons for their letter assessment, and 3. surveying the hospital clinicians who wrote the sampled letters for their views. Letters were examined using content analysis; we coded 15 features (e.g. "diagnosis", "GP plan") based on relevant guidelines and standards. Free text comments were analysed using corpus linguistics, and survey data were analysed using descriptive statistics.

RESULTS

Fifty-three GPs participated in selecting discharge letters; 46 clinicians responded to the hospital survey. There were statistically significant differences between "successful" and "unsuccessful" inpatient letters (n = 375) in relation to inclusion of the following elements: reason for admission (99.1% vs 86.5%); diagnosis (97.4% vs 74.5%), medication changes (61.5% vs 48.9%); reasons for medication changes (32.1% vs 18.4%); hospital plan/actions (70.5% vs 50.4%); GP plan (69.7% vs 53.2%); information to patient (38.5% vs 24.8%); tests/procedures performed (97.0% vs 74.5%), and test/examination results (96.2% vs 77.3%). Unexplained acronyms and jargon were identified in the majority of the sample (≥70% of letters). Analysis of GP comments highlighted that the overall clarity of discharge letters is important for effective and safe care transitions and that they should be relevant, concise, and comprehensible. Hospital clinicians identified several barriers to producing "successful" letters, including: juniors writing letters, time limitations, writing letters retrospectively from patient notes, and template restrictions.

CONCLUSIONS

The failure to uniformly implement national discharge letter guidance into practice is continuing to contribute to unsuccessful communication between hospital and general practice. While the study highlighted barriers to producing high quality discharge summaries which may be addressed through training and organisational initiatives, it also indicates a need for ongoing audit to ensure the quality of letters and so reduce patient risk at the point of hospital discharge.

The role of personalised professional relations across care sectors in achieving high continuity of care

Background

High continuity of care has a positive impact on health outcomes, but insight into the mechanisms underlying this impact is limited. Information continuity, on which our study focuses, is especially important when relational continuity is not given, which is often the case at hospital admission or hospital discharge. The aim of this study is to provide insight into the information flows between general practices and hospitals in Germany, and to identify factors associated with these flows of information.

Methods

This is a qualitative interview study in a purposeful sample of staff from hospitals and general practices (general practitioners, care assistants in general practice, hospital management, hospital physicians, and nursing staff). Interviews were conducted via telephone or face-to-face using a self-developed semi-structured interview guide. Stepwise systematic content analysis was used to structure collected material into themes and sub-themes that related to the study aim. Data was analysed by two researchers in several cycles, alternating between inductive and deductive approaches.

Results

A total of 49 interviews were conducted. Duration of the interviews varies between 21 and 78 min (mean duration 43 min). Across all groups, more than two thirds of participants were female (n = 34, 69%). The analysis highlighted six interdependent main themes regarding factors that affect information flows between hospitals and general practices: organisational, legal, financial, patient factors, individual characteristics, and emotional & social factors. The latter theme emerged as particularly rich and was therefore divided into four subthemes: appreciation and understanding of the respective other, (intrinsic) motivation, socialisation, and relationships. Organised meetings and events were mentioned as strategies to address emotional and social factors.

Conclusions

Digitalisation can facilitate information flows between care providers. However, knowing each other and good personal relations remain important for effective collaboration. Cooperation between all stakeholders is needed to aim to achieve continuity of care.

Trial registration: DRKS00015183 on DRKS/ Universal Trial Number (UTN): U1111-1218–0992. Date of registration 23/08/2018.

Multidisciplinary telephone conferences about medication therapy after discharge of older inpatients: a feasibility study

Background Studies have shown poor post-discharge implementation by the general practitioner of changes made to patients' medication during admission. Objective To assess the feasibility of conducting telephone conferences delivering information about changes in older patients' medications from hospital to general practitioners. Setting Two departments of geriatric medicine in a Danish routine healthcare setting. Method Older polypharmacy patients (≥ 65 years and ≥ 5 prescriptions) consecutively admitted were eligible for inclusion. Telephone conferences based on a review of these patient's medication therapy during hospital stay were arranged between a pharmacist and a geriatrician from the hospital, and a general practitioner. Interviews were conducted with pharmacists, geriatricians, and general practitioners about their perspectives on the feasibility of telephone conferences. Interviews were analyzed using systematic text condensation. Main outcome measure The proportion of telephone conferences conducted and perspectives on the feasibility of the study. Results A total of 113 patients were included and 82 patients (75%) were eligible for telephone conferences. A total of 40 (49%) telephone conferences were conducted. The main reasons for conferences not being conducted were general practitioners not wanting to participate or not returning the calls from the pharmacists. Three themes emerged from the qualitative analysis: considerations on planning and running the project, Barriers, facilitators, and implications of the telephone conference, and Actual and desirable cross-sectorial communication. Conclusion Telephone conferences were only possible for half of the patients. The participating general practitioners, pharmacists and geriatricians expressed varied benefit and agreed that telephone conferences were mainly relevant for complex patients.

Impact of the COVID-19 pandemic on acute surgical patients’ discharge summaries – Experience of Wales worst-hit COVID-19 hospital

Background

The emergence of the COVID-19 pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units. The subsequent redistribution of surgical house officers to accommodate this in a single-centre NHS hospital has possibly negatively impacted on the effective discharge notification of acute surgical patients.

Methods

Discharge summaries of all patients directly discharged from a Surgical Assessment Unit were collected on the day of discharge and analysed to identify the date of completion and staff grade of the responsible clinician. Data collection was carried out before the initiation of lockdown measures and continued for a further three weeks during the peak of the COVID-19 pandemic with an interventional period in between. A poster was created and displayed in areas where discharge software could be accessed.

Results

In the initial audit, 36.2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete. On re-evaluation, 45.3% of the 223 patients had delayed discharge summaries, taking an average of 12 days to complete. A survey conducted post-re-audit identified that the most common reason for delayed discharge summaries was due to time constraints associated with the increased workload.

Conclusion

The reallocation of surgical staff in response to the COVID-19 pandemic has affected communication between primary and secondary care, with a rise in delayed discharge letters of acute surgical patients. Given the potential repercussions of these delays, healthcare systems should be aware of this consequence of the pandemic, especially in preparation for any resurgences.

Perspectives on team communication challenges in caring for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care.

METHODS

This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis.

RESULTS

Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care).

CONCLUSION

Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.

Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial

Importance

Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce.

Objective

To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care.

Design, Setting, and Participants

The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020.

Interventions

Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist.

Main Outcomes and Measures

The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care.

Results

Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes.

Conclusions and Relevance

In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT02986425.

Improving community-based care for children with a rare condition: The example of long-segment congenital tracheal stenosis and perceptions of health professionals, parents and teachers

BACKGROUND

Long segment congenital tracheal stenosis (LSCTS) is a rare, complex condition which is often poorly understood by community-based health professionals (HPs). Anecdotally, such HPs often lack confidence providing care for children, resulting in children being brought to the tertiary centre more frequently than necessary. We wanted to identify the information and support needs of HPs in primary and secondary care looking after a child with LSCTS, the views of those providing education to these children, and elicit parents' perceptions about community-based services, to improve overall care for children and families.

METHOD

Questionnaires were sent to 175 community-based HPs and 34 teachers involved in the care of children with LSCTS. Face-to-face or telephone interviews were conducted with 12 parents of patients with LSCTS to establish their perceptions of community-based services.

RESULTS

Ninety (51%) completed questionnaires were returned from HPs and 18 (53%) from teachers. Responses indicated low levels of knowledge of LSCTS. Physical, practical and communication information needs were identified by all respondent groups, together with general and condition-specific concerns. Interviews with parents indicated that they thought the level of knowledge about LSCTS in the community was low, which had a negative impact on their willingness to consult local services. Better information provision for HPs, teachers and parents was identified as a means of improving outcomes.

CONCLUSION

Professionals caring for children with LSCTS in the community and in schools have unmet information and support needs, with consequences for children, families, HCPs in both the community and tertiary hospital, and teachers.

Team interventions in acute hospital contexts: protocol for the evaluation of an initial programme theory using realist methods

Introduction: Literature on multi-disciplinary healthcare team interventions to improve quality and safety of care in acute hospital contexts tends to focus on evaluating the success of the intervention by assessing patient outcomes. In contrast, there is little focus on the team who delivered the intervention, how the team worked to deliver the intervention or the context in which it was delivered. In practice, there is therefore a poor understanding of why some interventions work and are sustained and why others fail. There is little emphasis in the literature on how the team delivering the intervention might impact success or failure.

Given that team is the vehicle through which these interventions are introduced, it is important to understand interventions from their perspectives.

This research seeks to deepen understanding of enablers and barriers for effective team interventions. Using two case studies, we will evaluate previously developed initial programme theories to understand, what worked for whom, in what conditions, why, to what extent and how?

Methods and analysis: A realist evaluation approach will be employed to test the previously formed set of initial programme theories. Two multi-disciplinary acute hospital team interventions in two different geographical and organisational contexts will be identified. In case study 1, a theory based approach to interviewing will be used. In case study 2, interview transcripts obtained using a semi- structured approach for primary research purposes will undergo secondary analysis.

This will enable a more sensitive look at patterns and variations in patterns of multi-disciplinary team interventions. Researchers will first iteratively interrogate each respective dataset to identify the characteristics or resources present within the specific context that influenced how the team intervention worked to produce particular outcomes. Data will then be synthesised across contexts in order to produce middle range theories and thereby more generalisable insights.

Development, testing and generalizability of a standardized evaluation form for the assessment of patient-directed reports in the new final medical licensing examination in Germany

Background: As doctors often fail to explain diagnoses and therapies to patients in an understandable and appropriate way, the improvement of doctor-patient communication is essential. The current medical training and examinations are focused on verbal rather than on written communication. Following the premise of "assessment drives learning", the final medical licensing examination in Germany has been further developed by the German National Institute for state examinations in Medicine, Pharmacy and Psychotherapy (IMPP). As part of the discharge management the candidates have to prepare a report for the patient that is understandable and provides them with all important information about their stay in hospital. Aim: A standardized evaluation form for formative and summative feedback has been developed and tested with regard to applicability and the assurance of test quality criteria, especially the reliability to assess the written communication skills of the students. Methodology: In an expert consensus procedure, a draft for a standardized evaluation form was developed. This form was revised after an initial trial run on patient-directed reports written by students in their last year of medical studies. Afterwards twenty-one patient-directed reports were evaluated by fourteen different examiners. The reliability was tested by calculating the generalizability-coefficient and by analysing the inter-rater reliability. Results: The first test on the evaluation of the patient-directed reports indicated the practicability of the application and the usefulness of the evaluation form as an instrument for assessing the written communication skills of students. The analyses of the inter-rater reliability showed that the degree of agreement in the evaluations was partly different between two groups of examiners. The calculated G-coefficient indicates a high reliability. The content validity of the evaluation form was given through the comprehensive medical expertise in the development process. Conclusion: Assessing written patient-directed communication is a benefit of the newly developed last part of the medical licensing examination in Germany. Continuous formative assessment and feedback based on the evaluation form is intended to improve the written communication skills of future doctors. Furthermore, a better understanding of their diagnosis and treatment as well as a trusting relationship with their doctor may empower patients in the medical decision process and lead to fewer dismissal errors in the future. For consistent use of the evaluation form a standardized training of examiners should be implemented.

AGREEMENT BETWEEN CLINICAL AND ANATOMOPATHOLOGICAL DIAGNOSES IN PEDIATRIC INTENSIVE CARE

Objective:

Although autopsy is deemed the gold standard for diagnosis, its performance has been decreasing while adverse events have been increasing, of which 17% consist in diagnostic errors. The purpose of this study was to estimate the prevalence of diagnostic errors based on anatomopathological diagnosis in a Pediatric Intensive Care Unit (PICU).

Methods:

This is a cross-sectional, retrospective study on 31 patients who died between 2004 and 2014. Diagnoses were compared in order to assess whether there was agreement between clinical major diagnosis (CMD) and the cause of death as described in the autopsy record (CDAR), which were classified according to the Goldman Criteria.

Results:

Of 3,117 patients, 263 died (8.4%). Autopsy was conducted in 38 cases (14.4%), and 31 were included in the study. There was a 67% decrease in the number of autopsies over the last 10 years. Absolute agreement between the diagnoses (class V) was observed in 18 cases (58.0%), and disagreement (class I), in 11 (35.4%). There was greater difficulty in diagnosing acute diseases and diseases of rapid fatal evolution such as myocarditis. Seven patients were admitted in critical health conditions and died within the first 24 hours of hospitalization.

Conclusions:

Autopsy not only enables to identify diagnostic errors, but also provides the opportunity to learn from mistakes. The results emphasize the relevance of the autopsy examination for diagnostic elucidation and the creation of an information database concerning the main diagnoses of patients who rapidly progress to death in PICU, increasing the index of clinical suspicion of the team working at this unit.

Effectiveness of person- and family-centred care transition interventions on patient- oriented outcomes: A systematic review

AIM

The aim was to critically analyse the body of evidence regarding the effectiveness of PFCC transition interventions on the quality of care and the experience of patients.

DESIGN

We conducted a systematic review using the Cochrane Handbook's guidelines and adhered to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

METHODS

Four databases and grey literature were searched. Following a two-step screening process, data from the eligible studies were extracted. Risk of bias and quality of the studies were also assessed. Narrative synthesis and vote counting were used for the data analysis.

RESULTS

A total of 28 articles met our inclusion criteria. Interventions varied in regards to the extent of the PFCC focus and the comprehensiveness of the transition of care. Educating patients to promote self-management was the most commonly included component and it was described in all 28 interventions.

How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol

INTRODUCTION

Older adults may experience challenges during the hospital to home transitions that could be mitigated by digital health solutions. However, to promote adoption in practice and realise benefits, there is a need to specify how digital health solutions contribute to hospital to home transitions, particularly pertinent in this era of social distancing. This rapid review will: (1) elucidate the various roles and functions that have been developed to support hospital to home transitions of care, (2) identify existing digital health solutions that support hospital to home transitions of care, (3) identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions for older adults (eg, the pre-trial results of the Digital Bridge intervention; ClinicalTrials.gov Identifier: NCT04287192).

METHODS AND ANALYSIS

A two-phase rapid review will be conducted to meet identified aims. In phase 1, a selective literature review will be used to generate a conceptual map of the roles and functions of individuals that support hospital to home transitions for older adults. In phase 2, a search on MEDLINE, EMBASE and CINAHL will identify literature on digital health solutions that support hospital to home transitions. The ways in which digital health solutions can support the roles and functions that facilitate these transitions will then be mapped in the analysis and generation of findings.

ETHICS AND DISSEMINATION

This protocol is a review of the literature and does not involve human subjects, and therefore, does not require ethics approval. This review will permit the identification of gaps and new opportunities for digital processes and platforms that enable care transitions and can help inform the design and implementation of future digital health interventions. Review findings will be disseminated through publications and presentations to key stakeholders.

Understanding Gaps Between Daily Living and Clinical Settings in Chronic Disease Management: Qualitative Study

BACKGROUND

Management of chronic conditions entails numerous activities in both clinical and daily living settings. Activities across these settings interact, creating a high potential for a gap to occur if there is an inconsistency or disconnect between controlled clinical settings and complex daily living environments.

OBJECTIVE

The aim of this study is to characterize gaps (from the patient's perspective) between health-related activities across home-based and clinical settings using anticoagulation treatment as an example. The causes, consequences, and mitigation strategies (reported by patients) were identified to understand these gaps. We conceptualized gaps as latent phenomena (ie, a break in continuity).

METHODS

Patients (n=39) and providers (n=4) from the anticoagulation clinic of an urban, western mountain health care system were recruited. Data were collected through primary interviews with patients, patient journaling with tablet computers, exit interviews with patients, and provider interviews. Data were analyzed qualitatively using a theory-driven approach and framework method of analysis.

RESULTS

The causes of gaps included clinician recommendations not fitting into patients' daily routines, recommendations not fitting into patients' living contexts, and information not transferred across settings. The consequences of these gaps included increased cognitive and physical workload on the patient, poor patient satisfaction, and compromised adherence to the therapy plan. We identified resources and strategies used to overcome these consequences as patient-generated strategies, routines, collaborative management, social environment, and tools and technologies.

CONCLUSIONS

Understanding gaps, their consequences, and mitigating strategies can lead to the development of interventions that help narrow these gaps. Such interventions could take the form of collaborative health information technologies, novel patient and clinician education initiatives, and programs that strongly integrate health systems and community resources. Current technologies are insufficient to narrow the gaps between clinical and daily living settings due to the limited number and types of routines that are tracked.

Methods and Effectiveness of Communication Between Hospital Allied Health and Primary Care Practitioners: A Systematic Narrative Review

Background

There is a compelling rationale that effective communication between hospital allied health and primary care practitioners may improve the quality and continuity of patient care. It is not known which methods of communication to use, nor how effectively they facilitate the transition of care when a patient is discharged home from hospital. Our systematic review aims to investigate the methods and effectiveness of communication between hospital allied health and primary care practitioners.

Methods

Systematic review of quantitative and qualitative studies with narrative synthesis. Medline, CINAHL, EMBASE, PsycInfo and Proquest Nursing and Allied Health Sources were searched from January 2003 until January 2020 for studies that examined hospital-based allied health professionals communicating with community-based primary care practitioners. Risk of bias in the different study designs was appraised using recognized tools and a content analysis conducted of the methodologies used.

Results

From the located 12,281 papers (duplicates removed), 24 studies met the inclusion criteria with hospital allied health communicating in some form with primary care practitioners. While none of the included studies specifically investigated the methods or effectiveness of communication between hospital allied health and primary care practitioners, 12 of the 24 studies described processes that addressed components of their discharge communication. Four enablers to effective communication between hospital allied health and primary care practitioners were identified: multidisciplinary care plans, patient and caregiver involvement, health information technology and a designated person for follow up/care management.

Conclusion

There is currently no “gold standard” method or measure of communication between hospital allied health and primary care practitioners. There is an urgent need to develop and evaluate multidisciplinary communication with enhanced information technologies to improve collaboration across care settings and facilitate the continuity of integrated people-centered care.

Challenges Faced by Health Professionals in Obtaining Correct Medication Information in the Absence of a Shared Digital Medication List

Information about patient medication use is usually registered and stored in different digital systems, making it difficult to share information across health care organisations. The lack of digital systems able to share medication information poses a threat to patient safety and quality of care. We explored the experiences of health professionals with obtaining and exchanging information on patient medication lists in Norwegian primary health care within the context of current digital and non-digital solutions. We used a qualitative research design with semi-structured interviews, including general practitioners (n = 6), pharmacists (n = 3), nurses (n = 17) and medical doctors (n = 6) from six municipalities in Norway. Our findings revealed the following five challenges characterised by being cut off from information on patient medication lists in the current digital and non-digital solutions: ‘fragmentation of information systems’, ‘perceived risk of errors’, ‘excessive time use’, ‘dependency on others’ and ‘uncertainty’. The challenges were particularly related to patient transitions between levels of care. Our study shows an urgent need for digital solutions to ensure seamless, up-to-date information about patient medication lists in order to prevent medication-related problems. Future digital solutions for a shared medication list should address these challenges directly to ensure patient safety and quality of care.

The Cardiac Care Bridge randomized trial in high-risk older cardiac patients: A mixed-methods process evaluation

Aim

To evaluate healthcare professionals' performance and treatment fidelity in the Cardiac Care Bridge (CCB) nurse‐coordinated transitional care intervention in older cardiac patients to understand and interpret the study results.

Design

A mixed‐methods process evaluation based on the Medical Research Council Process Evaluation framework.

Methods

Quantitative data on intervention key elements were collected from 153 logbooks of all intervention patients. Qualitative data were collected using semi‐structured interviews with 19 CCB professionals (cardiac nurses, community nurses and primary care physical therapists), from June 2017 until October 2018. Qualitative data‐analysis is based on thematic analysis and integrated with quantitative key element outcomes. The analysis was blinded to trial outcomes. Fidelity was defined as the level of intervention adherence.

Results

The overall intervention fidelity was 67%, ranging from severely low fidelity in the consultation of in‐hospital geriatric teams (17%) to maximum fidelity in the comprehensive geriatric assessment (100%). Main themes of influence in the intervention performance that emerged from the interviews are interdisciplinary collaboration, organizational preconditions, confidence in the programme, time management and patient characteristics. In addition to practical issues, the patient's frailty status and limited motivation were barriers to the intervention.

Conclusion

Although involved healthcare professionals expressed their confidence in the intervention, the fidelity rate was suboptimal. This could have influenced the non‐significant effect of the CCB intervention on the primary composite outcome of readmission and mortality 6 months after randomization. Feasibility of intervention key elements should be reconsidered in relation to experienced barriers and the population.

Impact

In addition to insight in effectiveness, insight in intervention fidelity and performance is necessary to understand the mechanism of impact. This study demonstrates that the suboptimal fidelity was subject to a complex interplay of organizational, professionals' and patients' issues. The results support intervention redesign and inform future development of transitional care interventions in older cardiac patients.

Family medicine practitioners' stress during the COVID-19 pandemic: a cross-sectional survey

BACKGROUND

The COVID-19 pandemic has shaken the world in early 2020. In France, General Practitioners (GPs) were not involved in the care organization's decision-making process before and during the first wave of the COVID-19 pandemic. This omission could have generated stress for GPs. We aimed first to estimate the self-perception of stress as defined by the 10-item Perceived Stress Score (PSS-10), at the beginning of the pandemic in France, among GPs from the Auvergne-Rhône-Alpes, a french administrative area severely impacted by COVID-19. Second, we aimed to identify factors associated with a self-perceived stress (PSS-10 ≥ 27) among socio-demographic characteristics of GPs, their access to reliable information and to personal protective equipment during the pandemic, and their exposure to well established psychosocial risk at work.

METHODS

We conducted an online cross-sectional survey between 8th April and 10th May 2020. The self-perception of stress was evaluated using the PSS-10, so to see the proportion of "not stressed" (≤20), "borderline" (21 ≤ PSS-10 ≤ 26), and "stressed" (≥27) GPs. The agreement to 31 positive assertions related to possible sources of stress identified by the scientific study committee was measured using a 10-point numeric scale. In complete cases, factors associated with stress (PSS-10 ≥ 27) were investigated using logistic regression, adjusted on gender, age and practice location. A supplementary analysis of the verbatims was made.

RESULTS

Overall, 898 individual answers were collected, of which 879 were complete. A total of 437 GPs (49%) were stressed (PSS-10 ≥ 27), and 283 GPs (32%) had a very high level of stress (PSS-10 ≥ 30). Self-perceived stress was associated with multiple components, and involved classic psychosocial risk factors such as emotional requirements. However, in this context of health crisis, the primary source of stress was the diversity and quantity of information from diverse sources (614 GPs (69%, OR = 2.21, 95%CI [1.40-3.50], p < 0.001). Analysis of verbatims revealed that GPs felt isolated in a hospital-based model.

CONCLUSION

The first wave of the pandemic was a source of stress for GPs. The diversity and quantity of information received from the health authorities were among the main sources of stress.

Healthcare professionals' experiences of inter-professional collaboration during patient's transfers between care settings in palliative care: A focus group study

BACKGROUND

Continuity of care is challenging when transferring patients across palliative care settings. These transfers are common due to the complexity of palliative care, which has increased significantly since the advent of palliative care services. It is unclear how palliative care services and professionals currently collaborate and communicate to ensure the continuity of care across settings, and how patient and family members are involved.

AIM

To explore healthcare professionals' experiences regarding the communicative aspects of inter-professional collaboration and the involvement of patient and family members.

DESIGN

Qualitative design, including focus group discussions.

SETTING/PARTICIPANTS

The study focused on one palliative care network in Belgium and involved all palliative care settings: hospital, hospital's palliative care unit, home care, nursing home. Nine group discussions were conducted, with diverse professionals (n = 53) from different care settings.

RESULTS

Timely and effective inter-professional information exchange was considered fundamental. A perceived barrier for interprofessional collaboration was the lack of a shared electronic health record. Efficiency regarding multidisciplinary team meetings and inter-professional communication were subject to improvement.A striking study finding was the perceived insufficient open communication of specialists towards patients and the lack of shared decision making. This not only hampered advance care planning discussions and early integration of palliative home care, but also the functioning of other professionals.

CONCLUSION

From the perspective of the integrated care framework, several areas of improvement on different levels of care and collaboration are identified. Support from policymakers and researchers is required to achieve integrated palliative care in regional networks.

ECHO-CT: An Interdisciplinary Videoconference Model for Identifying Potential Postdischarge Transition-of-Care Events

BACKGROUND

Discharge from the hospital to a post-acute care setting can be complex and potentially dangerous, with opportunities for errors and lapses in communication between providers. Data collected through the Extension for Community Health Outcomes- Care Transitions (ECHO-CT) model were used to identify and classify transition-of-care events (TCEs).

METHODS

The ECHO-CT model employs multidisciplinary videoconferences between a hospital-based team and providers in post-acute care settings; during these conferences, concerns regarding the patient's care transition were identified and recorded. The videoconferences took place from January 2016 to October 2018 and included patients discharged from inpatient medical and surgical services to a total of eight participating post-acute care facilities (skilled nursing facilities or long-term acute care hospitals).

RESULTS

During the interdisciplinary videoconferences in this period, 675 patients were discussed. A total of 139 TCEs were identified; 58 (41.7%) involved discharge communication or coordination errors and 52 (37.4%) were classified as medication issues.

CONCLUSION

The TCEs identified in this study highlight areas in which providers can work to reduce issues arising during the course of discharge to post-acute care facilities. Standardized processes to identify, record, and report TCEs are necessary to provide high-quality, safe care for patients as they move across care settings.

Patients' perceptions of medicines information received at hospital discharge in Norway: a qualitative interview study

Background Insufficient transfer of medicines information is a common challenge at discharge from hospital. Following discharge, home dwelling patients are expected to manage their medicines themselves and adequate counselling is an important prerequisite for patient empowerment and self-efficacy for medicines management. Objective The aim was to identify patients' needs for medicines information after discharge from hospital, including the patients' perception and appraisal of the information they received at discharge. Setting The study enrolled patients discharged from three medical wards at a secondary care hospital in Oslo, Norway. Method Patients were included at the hospital, at or close to the day of discharge and qualitative, semi-structured interviews were performed during the first 2 weeks after discharge. Eligible patients were receiving medicines treatment on admission and after discharge, were handling the medicines themselves, and discharged to their own home. Data were collected in 2017. Interviews were analysed with thematic analysis inspired by Systematic Text Condensation. Main outcome measure Patients' perceptions of medicines information. Results In total, 12 patients were interviewed. They were discharged in equal numbers from the three wards, representing both sexes and a broad age range. Patients perceive medicines information as a continuum and not limited to specific encounters, like the discharge conversation. They gain information in several ways; by receiving information from health care professionals, through observations, and by seeking it themselves. Some thought they could have been better informed about adverse reactions and how to manage life while being a medicines user. Others felt they did not want or need more information. Patients employ various strategies for coping with their use of medicines, influencing their self-efficacy towards medicine management. Conclusion Medicines information should focus on empowering the patients throughout the hospital stay and not solely at discharge, taking into account the individual patient's needs for information, preferences and prior knowledge.

Driving Digital Transformation During a Pandemic: Case Study of Virtual Collaboration in a German Hospital

Background

The COVID-19 pandemic has not only changed the private lives of millions of people but has significantly affected the collaboration of medical specialists throughout health care systems worldwide. Hospitals are making changes to their regular operations to slow the spread of SARS-CoV-2 while ensuring the treatment of emergency patients. These substantial changes affect the typical work setting of clinicians and require the implementation of organizational arrangements.

Objective

In this study, we aim to increase our understanding of how digital transformation drives virtual collaboration among clinicians in hospitals in times of crisis, such as the COVID-19 pandemic.

Methods

We present the lessons learned from an exploratory case study in which we observed the introduction of an information technology (IT) system for enhancing collaboration among clinicians in a German hospital. The results are based on 16 semistructured interviews with physicians from various departments and disciplines; the interviews were generalized to better understand and interpret the meaning of the statements.

Results

Three key lessons and recommendations explain how digital transformation ensures goal-driven collaboration among clinicians. First, we found that implementing a disruptive change requires alignment of the mindsets of the stakeholders. Second, IT-enabled collaboration presupposes behavioral rules that must be followed. Third, transforming antiquated processes demands a suitable technological infrastructure.

Conclusions

Digital transformation is being driven by the COVID-19 pandemic. However, the rapid introduction of IT-enabled collaboration reveals grievances concerning the digital dissemination of medical information along the patient treatment path. To avoid being caught unprepared by future crises, digital transformation must be further driven to ensure collaboration, and the diagnostic and therapeutic process must be opened to disruptive strategies.

Engineering care transitions: Clinician perceptions of barriers to safe medication management during transitions of patient care

Medication safety during care transitions is a significant challenge, especially for older adults prescribed multiple medications. Using a systems approach to understand barriers to and strategies for safe medication management throughout high-risk periods of hospital-to-home transition is one important step in designing effective interventions. Framing the care transition as a collaboration between healthcare and patient "work systems," we conducted semi-structured interviews with 37 clinical team members, representing 10 different professional roles involved in providing transitional care for patients. Thematic analyses identified key strategies used by clinical team members in preparing patients to self-manage medications safely in the home environment: (1) streamlining and coordinating clinical management of medication reconciliation across care settings; (2) building patient capacity and engagement in self-management of medications; and (3) redesigning the transitional process. Our research highlights the value in aligning professionals' care transition goals with patients and caregiver(s) to better prepare them to self-manage medications upon discharge.

Constructing an Adapted Cascade of Diabetes Care Using Inpatient Admissions Data (Preprint)

Background

The diabetes mellitus cascade of care has been constructed to evaluate diabetes care at a population level by determining the percentage of individuals diagnosed and linked to care as well as their reported glycemic control.

Objective

We sought to adapt the cascade of care to an inpatient-only setting using the electronic health record (EHR) data of 81,633 patients with type 2 diabetes.

Methods

In this adaptation, linkage to care was defined as prescription of diabetes medications within 3 months of discharge, and control was defined as hemoglobin A_1c (HbA_1c) below individual target levels, as these are the most reliably captured items in the inpatient setting. We applied the cascade model to assess differences in demographics and percent loss at each stage of the cascade; we then conducted two-sample chi-square equality of proportions tests for each demographic. Based on findings in the previous literature, we hypothesized that women, Black patients, younger patients (<45 years old), uninsured patients, and patients living in an economically deprived area called the Promise Zone would be disproportionately unlinked and uncontrolled. We also predicted that patients who received inpatient glycemic care would be more likely to reach glycemic control.

Results

We found that out of 81,633 patients, 28,716 (35.2%) were linked to care via medication prescription. Women and younger patients were slightly less likely to be linked to care than their male and older counterparts, while Black patients (n=19,141, 23.4% of diagnosed population vs n=6741, 23.5% of the linked population) were as proportionately part of the linked population as White patients (n=58,291, 71.4% of diagnosed population vs n=20,402, 71.0% of the linked population). Those living in underserved communities (ie, the Promise Zone) and uninsured patients were slightly overrepresented (n=6789, 8.3% of diagnosed population vs n=2773, 9.7% of the linked population) in the linked population as compared to patients living in wealthier zip codes and those who were insured. Similar patterns were observed among those more likely to reach glycemic control via HbA_1c. However, conclusions are limited by the relatively large amount of missing glycemic data.

Conclusions

We conclude that inpatient EHR data do not adequately capture the care cascade as defined in the outpatient setting. In particular, missing data in this setting may preclude assessment of glycemic control. Future work should integrate inpatient and outpatient data sources to complete the picture of diabetes care.

Medication adherence in community-dwelling older people exposed to chronic polypharmacy

BACKGROUND

To evaluate medication adherence and associated factors of seven of the most common drug classes prescribed to community-dwelling older people.

METHODS

This is a retrospective cohort study on medication adherence in community-dwelling older people (65-94 years old) on chronic polypharmacy and recorded from 2013 to 2015 in the administrative database of the Lombardy region (Northern Italy). Adherence was assessed for diabetic drugs, antithrombotic agents, drugs acting on the renin-angiotensin system, statins, bisphosphonates, antidepressants and drugs for obstructive airway diseases by calculating the medication possession ratio (MPR). Patients were then divided in fully (MPR ≥80%), partially (40%≤MPR<80%) and poorly adherent (10%<MPR<40%).

RESULTS

Among 140 537 patients included in the study, only 19.3% was fully adherent to all the therapies considered. Almost 40% of them were poorly adherent to at least one drug class, becoming 50% when patients exposed to four or more drug classes were considered. In adjusted regression model, being women (OR=1.14, 95% CI 1.13 to 1.16) and aged ≥80 years old (OR=1.22, 95% CI 1.20 to 1.24) were associated with an overall lower adherence. Instead, the participation to an experimental healthcare programme was associated with higher adherence (OR=0.92, 95% CI 0.87 to 0.96). Furthermore, being coprescribed with ≥10 drugs was associated with lower adherence to all the drug classes, with different effects (ORs from 0.42 to 0.73).

CONCLUSION

This study overall shows a low medication adherence in community-dwelling older people on chronic polypharmacy, especially in women and oldest old. The implementation and promotion of healthcare programmes for these patients could help improve overall adherence to chronic drug therapies.