Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver

Development and Validation of a Fall Prevention Efficiency Scale

OBJECTIVES

Fall TIPS (Tailoring Interventions for Patient Safety) is an evidence-based fall prevention program that led to a 25% reduction in falls in hospitalized adults. Because it would be helpful to assess nurses' perceptions of burdens imposed on them by using Fall TIPS or other fall prevention program, we conducted a study to learn benefits and burdens.

METHODS

A 3-phase mixed-method study was conducted at 3 hospitals in Massachusetts and 3 in New York: (1) initial qualitative, elicited and categorized nurses' views of time spent implementing Fall TIPS; (2) second qualitative, used nurses' quotes to develop items, research team inputs for refinement and organization, and clinical nurses' evaluation and suggestions to develop the prototype scale; and (3) quantitative, evaluated psychometric properties.

RESULTS

Four "time" themes emerged: (1) efficiency, (2) inefficiency, (3) balances out, and (4) valued. A 20-item prototype Fall Prevention Efficiency Scale was developed, administered to 383 clinical nurses, and reduced to 13 items. Individual items demonstrated robust stability with Pearson correlations of 0.349 to 0.550 and paired t tests of 0.155 to 1.636. Four factors explained 74.3% variance and provided empirical support for the scale's conceptual basis. The scale achieved excellent internal consistency values (0.82-0.92) when examined with the test, validation, and paired (both test and retest) samples.

CONCLUSIONS

This new scale assess nurses' perceptions of how a fall prevention program affects their efficiency, which impacts the likelihood of use. Learning nurses' beliefs about time wasted when implementing new programs allows hospitals to correct problems that squander time.

Engaging Patients in the Use of Real-Time Electronic Clinical Data to Improve the Safety and Reliability of Their Own Care

OBJECTIVES

There is considerable evidence that providing patients with access to their health information is beneficial, but there is limited evidence regarding the effect of providing real-time patient safety-related information on health outcomes. The aim of this study was to evaluate the association between use of an electronic patient safety dashboard (Safety Advisor) and health outcomes.

METHODS

The Safety Advisor was implemented in 6 adult medicine units at one hospital in the United States. Study participants were asked to use the Safety Advisor, which provides real-time patient safety-related information through a Web-based portal. The primary outcome was the association between the application usage and health outcomes (readmission rate and mortality rate) per 3 different usage groups, and the secondary outcome was the association of Patient Activation Measure (PAM) scores with use.

RESULTS

One hundred eighty-one participants were included for the data analysis. Approximately 90% of users accessed the application during the first 4 days of enrollment: 51.6% of users only accessed it on 1 day, whereas 5.8% used it more than 3 days. Patients who used the application more had lower 30-day readmission rates (P = 0.01) compared with the lower-usage group. The PAM scores for users of Safety Advisor (71.8) were higher than the nonpatient portal users (60.8, P < 0.0001).

CONCLUSIONS

We found an association between the use of Safety Advisor and health outcomes. Differences in PAM scores between groups were statistically significant. A larger-scale randomized control trial is warranted to evaluate the impact on patient outcomes among a high-risk patient population.

Unique Patient-Reported Hospital Safety Concerns With Online Tool: MySafeCare

BACKGROUND

Hospitalized patients and their care partners have valuable and unique perspectives of the medical care they receive. Direct and real-time reporting of patients' safety concerns, though limited in the acute care setting, could provide opportunities to improve patient care.

METHODS

We implemented the MySafeCare (MSC) application on six acute care units for 18 months as part of a patient-centered health information technology intervention to promote engagement and safety in the acute care setting. The web-based application allowed hospitalized patients to submit safety concerns anonymously and in real time. We describe characteristics of patient submissions including their categorizations. We evaluated rates of submissions to MSC and compared them with rates of submissions to the Patient Family Relations department at the hospital. In addition, we performed thematic analysis of narrative concerns submitted to the application.

RESULTS

We received 46 submissions to MSC and 33% of concerns received were anonymous. The overall rate of submissions was 0.6 submissions per 1000 patient-days and was considerably lower than the rate of submissions to the Patient Family Relations during the same period (4.1 per 1000 patient-days). Identified themes of narrative concerns included unmet care needs and preferences, inadequate communication, and concerns about safety of care.

CONCLUSIONS

Although the submission rate to the application was low, MSC captured important content directly from hospitalized patients or their care partners. A web-based patient safety reporting tool for patients should be studied further to understand patient and care partner use and willingness to engage, as well as potential effects on patient safety outcomes.

Use of a perceived efficacy tool to evaluate the FallTIPS program

BACKGROUND/OBJECTIVES

To assess nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program.

DESIGN

Survey research.

SETTING

Seven adult acute-care hospitals in 2 hospital centers located in Boston and NYC.

PARTICIPANTS

A total of 298 medical-surgical nurses on 14 randomly selected units.

INTERVENTION

Three-step FallTIPS fall prevention program that had been in use as a clinical program for a minimum of 2 years in each hospital.

MEASUREMENTS

Fall Prevention Efficiency Scale (FPES), range 13-52; four-factorilly derived subscales: valued, efficiency, balances out and inefficiency; and 13 psychometrically validated individual items.

RESULTS

Nurses perceived the FallTIPS fall prevention program to be efficacious. The FPES mean score of 38.55 (SD = 5.05) and median of 39 were well above the lowest possible score of 13 and scale midpoint of 32.5. Most nurses (N = 270, 90.6%) scored above 33. There were no differences in FPES scores between nurses who had only used FallTIPS and nurses who had previously used a different fall prevention program.

CONCLUSION

The nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program and findings confirmed the importance of patient and family engagement with staff in the fall prevention process. Regardless of the fall prevention program used, organizations should examine staff perceptions of their fall prevention program because programs that are not perceived as being useful, efficient, and valuable will lead to nonadherence over time and then will not reduce falls and injuries. The recently developed FPES used in this study is a brief tool available for organizations to assess nurses' perceptions of the efficacy of their fall prevention program. Additional FPES research is needed with larger and more diverse samples.

Use and impact of an online community for hospital patients

OBJECTIVE

Although patient-peer support technologies have demonstrated effectiveness in a variety of health contexts-including diabetes, weight loss, and cancer-less is known about how hospitalized patients can benefit from this support. We investigated the nature of peer support in the hospital and the impact this support had on patients' hospital stays.

MATERIALS AND METHODS

We created a technology, resembling an online health community, in which patients could exchange advice about their hospitalization. We deployed it at 1 pediatric hospital and 1 adult hospital. With 30 participants, we conducted bedside interviews, observed how they used the technology during their hospitalization, and completed follow-up phone interviews.

RESULTS

Participants shared advice about several topics, including adjusting to the hospital and building relationships with providers. Contrary to concerns that such a system would primarily serve as a place for patients to "complain," sentiment analysis showed that 23 of 36 (64%) of the shared advice reflected positive sentiment. Patients also reported positive impacts to their quality, safety, and hospital experience due to the inpatient peer support community.

DISCUSSION

Participants benefited from peer support that transcended diagnoses and individual health conditions. The shared experience of being in the hospital was sufficient to yield valuable and practical peer support. Participants who did not contribute their own advice still experienced benefits from reading their peers' advice.

CONCLUSIONS

Our study demonstrated the positive nature of peer advice exchanged, and the benefits of this advice on patients' hospital stays. Inpatient peer support technologies could be an additional resource for patients to engage in their care.

Informatics opportunities to involve patients in hospital safety: a conceptual model

Objective

Inpatients could play an important role in identifying, preventing, and reporting problems in the quality and safety of their care. To support them effectively in that role, informatics solutions must align with their experiences. Thus, we set out to understand how inpatients experience undesirable events (UEs) and to surface opportunities for those informatics solutions.

Materials and Methods

We conducted a survey with 242 patients and caregivers during their hospital stay, asking open-ended questions about their experiences with UEs. Based on our qualitative analysis, we developed a conceptual model representing their experiences and identified informatics opportunities to support patients.

Results

Our 4-stage conceptual model illustrates inpatient experiences, from when they first encounter UEs, when they could intervene, when harms emerge, what types of harms they experience, and what they do in response to harms.

Discussion

Existing informatics solutions address the first stage of inpatients’ experiences by increasing their awareness of potential UEs. However, future researchers can explore new opportunities to fill gaps in support that patients experience in subsequent stages, especially at critical decision points such as intervening in UEs and responding to harms that occur.

Conclusions

Our conceptual model reveals the complex inpatient experiences with UEs, and opportunities for new informatics solutions to support them at all stages of their experience. Investigating these new opportunities could promote inpatients’ participation and engagement in the quality and safety of their care, help healthcare systems learn from inpatients’ experience, and reduce these harmful events.

Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study

BACKGROUND

Poor discharge preparation during hospitalization may lead to adverse events after discharge. Checklists and videos that systematically engage patients in preparing for discharge have the potential to improve safety, especially when integrated into clinician workflow via the electronic health record (EHR).

OBJECTIVE

This study aims to evaluate the implementation of a suite of digital health tools integrated with the EHR to engage hospitalized patients, caregivers, and their care team in preparing for discharge.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify pertinent research questions related to implementation. We iteratively refined patient and clinician-facing intervention components using a participatory process involving end users and institutional stakeholders. The intervention was implemented at a large academic medical center from December 2017 to July 2018. Patients who agreed to participate were coached to watch a discharge video, complete a checklist assessing discharge readiness, and request postdischarge text messaging with a physician 24 to 48 hours before their expected discharge date, which was displayed via a patient portal and bedside display. Clinicians could view concerns reported by patients based on their checklist responses in real time via a safety dashboard integrated with the EHR and choose to open a secure messaging thread with the patient for up to 7 days after discharge. We used mixed methods to evaluate our implementation experience.

RESULTS

Of 752 patient admissions, 510 (67.8%) patients or caregivers participated: 416 (55.3%) watched the video and completed the checklist, and 94 (12.5%) completed the checklist alone. On average, 4.24 concerns were reported per each of the 510 checklist submissions, most commonly about medications (664/2164, 30.7%) and follow-up (656/2164, 30.3%). Of the 510 completed checklists, a member of the care team accessed the safety dashboard to view 210 (41.2%) patient-reported concerns. For 422 patient admissions where postdischarge messaging was available, 141 (33.4%) patients requested this service; of these, a physician initiated secure messaging for 3 (2.1%) discharges. Most patient survey participants perceived that the intervention promoted self-management and communication with their care team. Patient interview participants endorsed gaps in communication with their care team and thought that the video and checklist would be useful closer toward discharge. Clinicians participating in focus groups perceived the value for patients but suggested that low awareness and variable workflow regarding the intervention, lack of technical optimization, and inconsistent clinician leadership limited the use of clinician-facing components.

CONCLUSIONS

A suite of EHR-integrated digital health tools to engage patients, caregivers, and clinicians in discharge preparation during hospitalization was feasible, acceptable, and valuable; however, important challenges were identified during implementation. We offer strategies to address implementation barriers and promote adoption of these tools.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03116074; https://clinicaltrials.gov/ct2/show/NCT03116074.

Acute Care Patient Portal Intervention: Portal Use and Patient Activation

Background

Patient-facing health information technology (HIT) tools, such as patient portals, are recognized as a potential mechanism to facilitate patient engagement and patient-centered care, yet the use of these tools remains limited in the hospital setting. Although research in this area is growing, it is unclear how the use of acute care patient portals might affect outcomes, such as patient activation.

Objective

The aim of this study was to describe the use of an acute care patient portal and investigate its association with patient and care partner activation in the hospital setting.

Methods

We implemented an acute care patient portal on 6 acute care units over an 18-month period. We investigated the characteristics of the users (patients and their care partners) of the patient portal, as well as their use of the portal. This included the number of visits to each page, the number of days used, the length of the user’s access period, and the average percent of days used during the access period. Patient and care partner activation was assessed using the short form of the patient activation measure (PAM-13) and the caregiver patient activation measure (CG-PAM). Comparisons of the activation scores were performed using propensity weighting and robust weighted linear regression.

Results

Of the 2974 randomly sampled patients, 59.01% (1755/2974) agreed to use the acute care patient portal. Acute care patient portal enrollees were younger, less sick, less likely to have Medicare as their insurer, and more likely to use the Partners Healthcare enterprise ambulatory patient portal (Patient Gateway). The most used features of the acute care patient portal were the laboratory test results, care team information, and medication list. Most users accessed the portal between 1 to 4 days during their hospitalization, and the average number of days used (logged in at least once per day) was 1.8 days. On average, users accessed the portal 42.69% of the hospital days during which it was available. There was significant association with patient activation on the neurology service (P<.001) and medicine service (P=.01), after the introduction of HIT tools and the acute care patient portal, but not on the oncology service.

Conclusions

Portal users most often accessed the portal to view their clinical information, though portal usage was limited to only the first few days of enrollment. We found an association between the use of the portal and HIT tools with improved levels of patient activation. These tools may help facilitate patient engagement and improve outcomes when fully utilized by patients and care partners. Future study should leverage usage metrics to describe portal use and assess the impact of HIT tools on specific outcome measures in the hospital setting.

Building patient capacity to participate in care during hospitalisation: a scoping review

OBJECTIVES

To map the existing literature and describe interventions aimed at building the capacity of patients to participate in care during hospitalisation by: (1) describing and categorising the aspects of care targeted by these interventions and (2) identifying the behaviour change techniques (BCTs) used in these interventions. A patient representative participated in all aspects of this project.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, Embase and CINAHL (Inception -2017).

STUDY SELECTION

Studies reporting primary research studies on building the capacity of hospitalised adult patients to participate in care which described or included one or more structured or systematic interventions and described the outcomes for at least the key stakeholder group were included.

DATA EXTRACTION

Title and abstract screening and full text screening were conducted by pairs of trained reviewers. One reviewer extracted data, which were verified by a second reviewer. Interventions were classified according to seven aspects of care relevant to hospital settings. BCTs identified in the articles were assigned through consensus of three reviewers.

RESULTS

Database searches yielded a total 9899 articles, resulting in 87 articles that met the inclusion criteria. Interventions directed at building patient capacity to participate in care while hospitalised were categorised as those related to improving: patient safety (20.9%); care coordination (5.7%); effective treatment (5.7%) and/or patient-centred care using: bedside nursing handovers (5.7%); communication (29.1%); care planning (14%) or the care environment (19.8%). The majority of studies reported one or more positive outcomes from the defined intervention. Adding new elements (objects) to the environment and restructuring the social and/or physical environment were the most frequently identified BCTs.

CONCLUSIONS

The majority of studies to build capacity for participation in care report one or more positive outcomes, although a more comprehensive analysis is warranted.

Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall Prevention Toolkit: An Implementation Science Study

Background

Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the 3-step fall prevention process—(1) conduct fall risk assessments; (2) develop tailored fall prevention plans with the evidence-based interventions; and (3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all 3 steps of the fall prevention process. Over the past decade, our team developed 3 Fall TIPS modalities—the original electronic health record (EHR) version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patients’ fall prevention plan based on the clinical documentation in the EHR. However, the relative effectiveness of each Fall TIPS modality for engaging patients and family in the 3-step fall prevention process remains unknown.

Objective

This study aims to examine if the Fall TIPS modality impacts patient engagement in the 3-step fall prevention process and thus Fall TIPS efficacy.

Methods

To assess patient engagement in the 3-step fall prevention process, we conducted random audits with the question, “Does the patient/family member know their fall prevention plan?” In addition, audits were conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from 3 hospitals reported data from April to June 2017 on 6 neurology and 7 medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection.

Results

Overall, 1209 audits were submitted for the patient engagement measure and 1401 for the presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. While some units maintained high levels of patient engagement and adherence with the poster protocol, others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection.

Conclusions

Each Fall TIPS modality effectively facilitates patient engagement in the 3-step fall prevention process, suggesting all 3 can be used to integrate evidence-based fall prevention practices into the clinical workflow. The 3 Fall TIPS modalities may prove an effective strategy for the spread, allowing diverse institutions to choose the modality that fits with the organizational culture and health information technology infrastructure.

Must We Bust the Trust?: Understanding How the Clinician-Patient Relationship Influences Patient Engagement in Safety

Although patients desire safe care, they are reluctant to perform safety-related behaviors when they worry it could harm the relationships they have with clinicians. This influence of the clinician-patient relationship on patient engagement in safety is poorly understood, and most patient-facing safety interventions ignore its influence, focusing instead on helping patients access information about their care and report errors. We conducted semi-structured interviews with hospitalized patients to uncover their needs for patient-facing information systems that could help them prevent medical errors. We found that the clinician-patient relationship could either encourage or discourage patients and caregivers from engaging in patient safety actions. We describe our findings and discuss the implications for the design of patient-facing interventions to promote patient engagement in safety. Our findings shed light on how patient-facing safety interventions can be designed to effectively engage patients and caregivers.