Patient Partnership Tools to Support Medication Safety in Community-Dwelling Older Adults: Protocol for a Nonrandomized Stepped Wedge Clinical Trial

BACKGROUND

Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources.

OBJECTIVE

This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety.

METHODS

The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits.

RESULTS

The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024.

CONCLUSIONS

This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57878.

Medication Management Strategies by Community-Dwelling Older Adults: A Multisite Qualitative Analysis

OBJECTIVES

Community-dwelling older adults taking 5 or more medications are at risk for medication-related harm. Managing multiple medications is a challenging task for patients and caregivers. Community-dwelling older adults self-manage their medications with minimal healthcare professional supervision. Although organizations, such as the Food and Drug Administration, often issue guidelines to ensure medication safety, how older adults understand and mitigate the risk of harm from medication use in the home environment is poorly understood.

METHODS

We conducted semistructured interviews with community-dwelling older adults 65 years and older who took 5 or more prescription medications to explore medication safety strategies they use. We also compared 2 organizations' medication safety guidelines for areas of concordance and discordance.

RESULTS

A total of 28 older adults were interviewed. Four overarching themes of medication management strategies emerged: collaborating with prescribers, collaborating with pharmacists, learning about medications, and safe practices at home. Study findings revealed that older adults followed some of the published guidelines by the 2 government organizations, although there were some areas of discord. Some of the strategies used were unintentionally against the recommended guidelines. For example, older adults tried weaning themselves off their medications without notifying their providers.

CONCLUSIONS

Older adults and their caregivers in our study used strategies different from those recommended by government organizations in managing medications to enhance drug safety. Patient-provider collaboration and positive patient outcomes can be improved by understanding and respecting strategies older adults use at home. Future studies must effectively incorporate older adults' perspectives when developing medication safety guidelines.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19

BACKGROUND

Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge.

METHODS

Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization.

RESULTS

Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization.

CONCLUSIONS

HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Environmental cleaning and disinfection in the operating room: a systematic scoping review through a human factors and systems engineering lens

OBJECTIVE

To synthesize evidence and identify gaps in the literature on environmental cleaning and disinfection in the operating room based on a human factors and systems engineering approach guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model.

DESIGN

A systematic scoping review.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases (ie, PubMed, EMBASE, OVID, CINAHL) for empirical studies on operating-room cleaning and disinfection. Studies were categorized based on their objectives and designs and were coded using the SEIPS model. The quality of randomized controlled trials and quasi-experimental studies with a nonequivalent groups design was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials.

RESULTS

In total, 40 studies were reviewed and categorized into 3 groups: observational studies examining the effectiveness of operating-room cleaning and disinfections (11 studies), observational study assessing compliance with operating-room cleaning and disinfection (1 study), and interventional studies to improve operating-room cleaning and disinfection (28 studies). The SEIPS-based analysis only identified 3 observational studies examining individual work-system components influencing the effectiveness of operating-room cleaning and disinfection. Furthermore, most interventional studies addressed single work-system components, including tools and technologies (20 studies), tasks (3 studies), and organization (3 studies). Only 2 studies implemented interventions targeting multiple work-system components.

CONCLUSIONS

The existing literature shows suboptimal compliance and inconsistent effectiveness of operating-room cleaning and disinfection. Improvement efforts have been largely focused on cleaning and disinfection tools and technologies and staff monitoring and training. Future research is needed (1) to systematically examine work-system factors influencing operating-room cleaning and disinfection and (2) to redesign the entire work system to optimize operating-room cleaning and disinfection.

Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes

OBJECTIVE

This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related.

BACKGROUND

Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition.

METHOD

We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes.

RESULTS

Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task.

CONCLUSION

Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Implementing and validating a home-infusion central-line-associated bloodstream infection surveillance definition

OBJECTIVE

Central-line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy is necessary to track efforts to reduce infections, but a standardized, validated, and feasible definition is lacking. We tested the validity of a home-infusion CLABSI surveillance definition and the feasibility and acceptability of its implementation.

DESIGN

Mixed-methods study including validation of CLABSI cases and semistructured interviews with staff applying these approaches.

SETTING

This study was conducted in 5 large home-infusion agencies in a CLABSI prevention collaborative across 14 states and the District of Columbia.

PARTICIPANTS

Staff performing home-infusion CLABSI surveillance.

METHODS

From May 2021 to May 2022, agencies implemented a home-infusion CLABSI surveillance definition, using 3 approaches to secondary bloodstream infections (BSIs): National Healthcare Safety Program (NHSN) criteria, modified NHSN criteria (only applying the 4 most common NHSN-defined secondary BSIs), and all home-infusion-onset bacteremia (HiOB). Data on all positive blood cultures were sent to an infection preventionist for validation. Surveillance staff underwent semistructured interviews focused on their perceptions of the definition 1 and 3-4 months after implementation.

RESULTS

Interrater reliability scores overall ranged from κ = 0.65 for the modified NHSN criteria to κ = 0.68 for the NHSN criteria to κ = 0.72 for the HiOB criteria. For the NHSN criteria, the agency-determined rate was 0.21 per 1,000 central-line (CL) days, and the validator-determined rate was 0.20 per 1,000 CL days. Overall, implementing a standardized definition was thought to be a positive change that would be generalizable and feasible though time-consuming and labor intensive.

CONCLUSIONS

The home-infusion CLABSI surveillance definition was valid and feasible to implement.

Artificial intelligence-based clinical decision support for liver transplant evaluation and considerations about fairness: A qualitative study

BACKGROUND

The use of large-scale data and artificial intelligence (AI) to support complex transplantation decisions is in its infancy. Transplant candidate decision-making, which relies heavily on subjective assessment (ie, high variability), provides a ripe opportunity for AI-based clinical decision support (CDS). However, AI-CDS for transplant applications must consider important concerns regarding fairness (ie, health equity). The objective of this study was to use human-centered design methods to elicit providers' perceptions of AI-CDS for liver transplant listing decisions.

METHODS

In this multicenter qualitative study conducted from December 2020 to July 2021, we performed semistructured interviews with 53 multidisciplinary liver transplant providers from 2 transplant centers. We used inductive coding and constant comparison analysis of interview data.

RESULTS

Analysis yielded 6 themes important for the design of fair AI-CDS for liver transplant listing decisions: (1) transparency in the creators behind the AI-CDS and their motivations; (2) understanding how the AI-CDS uses data to support recommendations (ie, interpretability); (3) acknowledgment that AI-CDS could mitigate emotions and biases; (4) AI-CDS as a member of the transplant team, not a replacement; (5) identifying patient resource needs; and (6) including the patient's role in the AI-CDS.

CONCLUSIONS

Overall, providers interviewed were cautiously optimistic about the potential for AI-CDS to improve clinical and equitable outcomes for patients. These findings can guide multidisciplinary developers in the design and implementation of AI-CDS that deliberately considers health equity.

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising

BACKGROUND

Our aim was to understand actions by primary care teams to improve medication safety.

METHODS

This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach.

RESULTS

Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate.

CONCLUSIONS

Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services.

Development and Validation of the Hospital-to-Home-Health Transition Quality (H3TQ) Index: A Novel Measure to Engage Patients and Home Health Providers in Evaluating Hospital-to-Home Care Transition Quality

BACKGROUND

Patients requiring skilled home health care (HH) after hospitalization are at high risk of adverse events. Human factors engineering (HFE) approaches can be useful for measure development to optimize hospital-to-home transitions.

OBJECTIVE

To describe the development, initial psychometric validation, and feasibility of the Hospital-to-Home-Health-Transition Quality (H3TQ) Index to identify patient safety risks.

METHODS

Development: A multisite, mixed-methods study at 5 HH agencies in rural and urban sites across the United States. Testing: Prospective H3TQ implementation on older adults' hospital-to-HH transitions. Populations Studied: Older adults and caregivers receiving HH services after hospital discharge, and their HH providers (nurses and rehabilitation therapists).

RESULTS

The H3TQ is a 12-item count of hospital-to-HH transitions best practices for safety that we developed through more than 180 hours of observations and more than 80 hours of interviews. The H3TQ demonstrated feasibility of use, stability, construct validity, and concurrent validity when tested on 75 transitions. The vast majority (70%) of hospital-to-HH transitions had at least one safety issue, and HH providers identified more patient safety threats than did patients/caregivers. The most frequently identified issues were unsafe home environments (32%), medication issues (29%), incomplete information (27%), and patients' lack of general understanding of care plans (27%).

CONCLUSIONS

The H3TQ is a novel measure to assess the quality of hospital-to-HH transitions and proactively identify transitions issues. Patients, caregivers, and HH providers offered valuable perspectives and should be included in safety reporting. Study findings can guide the design of interventions to optimize quality during the high-risk hospital-to-HH transition.

The need to expand the infection prevention workforce in home infusion therapy

Infection prevention and surveillance training approaches for home infusion therapy have not been well defined. We interviewed home infusion staff who perform surveillance activities about barriers to and facilitators for central line-associated bloodstream infection (CLABSI) surveillance and identified barriers to training in CLABSI surveillance. Our findings show a lack of formal surveillance training for staff. This gap can be addressed by adapting existing training resources to the home infusion setting.

Controlling the chaos: Information management in home-infusion central-line-associated bloodstream infection (CLABSI) surveillance

Objectives

Access to patient information may affect how home-infusion surveillance staff identify central-line-associated bloodstream infections (CLABSIs). We characterized information hazards in home-infusion CLABSI surveillance and identified possible strategies to mitigate information hazards.

Design

Qualitative study using semistructured interviews.

Setting and participants

The study included 21 clinical staff members involved in CLABSI surveillance at 5 large home-infusion agencies covering 13 states and the District of Columbia. Methods: Interviews were conducted by 1 researcher. Transcripts were coded by 2 researchers; consensus was reached by discussion.

Results

Data revealed the following barriers: information overload, information underload, information scatter, information conflict, and erroneous information. Respondents identified 5 strategies to mitigate information chaos: (1) engage information technology in developing reports; (2) develop streamlined processes for acquiring and sharing data among staff; (3) enable staff access to hospital electronic health records; (4) use a single, validated, home-infusion CLABSI surveillance definition; and (5) develop relationships between home-infusion surveillance staff and inpatient healthcare workers.

Conclusions

Information chaos occurs in home-infusion CLABSI surveillance and may affect the development of accurate CLABSI rates in home-infusion therapy. Implementing strategies to minimize information chaos will enhance intra- and interteam collaborations in addition to improving patient-related outcomes.

Impact of a multifaceted early mobility intervention for critically ill children - the PICU Up! trial: study protocol for a multicenter stepped-wedge cluster randomized controlled trial

BACKGROUND

Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery.

METHODS

The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery.

DISCUSSION

This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04989790. Registered on August 4, 2021.

Human-Centered Design of a Clinical Decision Support for Anemia Screening in Children with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with work processes. One solution is to use human-centered design (HCD), which designs CDSS based on identified user needs and context of use and evaluates prototypes for usefulness and usability.

OBJECTIVES

this study aimed to use HCD to design a CDSS tool called the IBD Anemia Diagnosis Tool, IADx.

METHODS

Interviews with IBD practitioners informed creation of a process map of anemia care that was used by an interdisciplinary team that used HCD principles to create a prototype CDSS. The prototype was iteratively tested with "Think Aloud" usability evaluation with clinicians as well as semi-structured interviews, a survey, and observations. Feedback was coded and informed redesign.

RESULTS

Process mapping showed that IADx should function at in-person encounters and asynchronous laboratory review. Clinicians desired full automation of clinical information acquisition such as laboratory trends and analysis such as calculation of iron deficit, less automation of clinical decision selection such as laboratory ordering, and no automation of action implementation such as signing medication orders. Providers preferred an interruptive alert over a noninterruptive reminder.

CONCLUSION

Providers preferred an interruptive alert, perhaps due to the low likelihood of noticing a noninterruptive advisory. High levels of desire for automation of information acquisition and analysis with less automation of decision selection and action may be generalizable to other CDSSs designed for chronic disease management. This underlines the ways in which CDSSs have the potential to augment rather than replace provider cognitive work.

A Predictive Decision Analytics Approach for Primary Care Operations Management: A Case Study of Double-Booking Strategy Design and Evaluation

Primary care plays a vital role for individuals and families in accessing care, keeping well, and improving quality of life. However, the complexities and uncertainties in the primary care delivery system (e.g., patient no-shows/walk-ins, staffing shortage, COVID-19 pandemic) have brought significant challenges in its operations management, which can potentially lead to poor patient outcomes and negative primary care operations (e.g., loss of productivity, inefficiency). This paper presents a decision analytics approach developed based on predictive analytics and hybrid simulation to better facilitate management of the underlying complexities and uncertainties in primary care operations. A case study was conducted in a local family medicine clinic to demonstrate the use of this approach for patient no-show management. In this case study, a patient no-show prediction model was used in conjunction with an integrated agent-based and discrete-event simulation model to design and evaluate double-booking strategies. Using the predicted patient no-show information, a prediction-based double-booking strategy was created and compared against two other strategies, namely random and designated time. Scenario-based experiments were then conducted to examine the impacts of different double-booking strategies on clinic's operational outcomes, focusing on the trade-offs between the clinic productivity (measured by daily patient throughput) and efficiency (measured by visit cycle and patient wait time for doctor). The results showed that the best productivity-efficiency balance was derived under the prediction-based double-booking strategy. The proposed hybrid decision analytics approach has the potential to better support decision-making in primary care operations management and improve the system's performance. Further, it can be generalized in the context of various healthcare settings for broader applications.

A Multisite Qualitative Analysis of Perceived Roles in Medication Safety: Older Adults' Perspectives

Older adults and caregivers play an essential role in medication safety; however, self-perception of their and health professionals' roles in medication safety is not well-understood. The objective of our study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Semi-structured qualitative interviews were held with 28 community-dwelling older adults over 65 years who took five or more prescription medications daily. Results suggest that older adults' self-perceptions of their role in medication safety varied widely. Older adults perceived that self-learning about their medications and securing them are critical to avoiding medication-related harm. Primary care providers were perceived as coordinators between older adults and specialists. Older adults expected pharmacists to inform them of any changes in the characteristics of medications to ensure medications were taken correctly. Our findings provide an in-depth analysis of older adults' perceptions and expectations of their providers' specific roles in medication safety. Educating providers and pharmacists about the role expectations of this population with complex needs can ultimately improve medication safety.

2053. The Need to Expand the Infection Prevention Workforce in Home Infusion Therapy

Background

Infection preventionists who perform surveillance for central line-associated bloodstream infections (CLABSIs) in hospitals receive training in application of rigorous surveillance definitions. However, in the home infusion setting where CLABSIs also occur, the approach for training and methods to perform surveillance has not been well defined.

Objective

In this qualitative study, we sought to characterize how home infusion surveillance staff are trained in CLABSI surveillance and to identify barriers to CLABSI surveillance in the home infusion setting.

Methods

We interviewed 21 surveillance staff members of five non-profit home infusion agencies covering portions of thirteen states and Washington, DC across the Mid-Atlantic, Northeast, and Midwest. Interview questions were developed using the Systems Engineering in Patient Safety (SEIPS) 2.0 framework. Data were analyzed both inductively and deductively by two team members. These interviews are part of a larger study, some of whose findings have been previously discussed in prior publications. Data specific to training home infusion surveillance staff in CLABSI surveillance are presented (Table 1).

Results

Many of the CLABSI surveillance staff had received no formal training in CLABSI surveillance. Instead, many either learned on the job (often from predecessors who also had not been formally trained), drew from previous clinical experience, perused online resources, or attended conferences. A lack of (1) resources for learning, (2) formal training offered by their agencies, and (3) awareness of professional development resources were identified as barriers to CLABSI surveillance training in the home infusion setting.

Conclusion

Our findings indicate a current lack of formal training in CLABSI surveillance for staff performing CLABSI surveillance in home infusion therapy. The home infusion surveillance workforce can be strengthened by providing home infusion-specific standardized training, perhaps through adaptations of resources used for training surveillance staff in other settings.

Disclosures

Sara E. Cosgrove, MD, Basilea: Member of Infection Adjudication Committee.

Multicenter study of racial and ethnic inequities in liver transplantation evaluation: Understanding mechanisms and identifying solutions

Racial and ethnic disparities persist in access to the liver transplantation (LT) waiting list; however, there is limited knowledge about underlying system-level factors that may be responsible for these disparities. Given the complex nature of LT candidate evaluation, a human factors and systems engineering approach may provide insights. We recruited participants from the LT teams (coordinators, advanced practice providers, physicians, social workers, dieticians, pharmacists, leadership) at two major LT centers. From December 2020 to July 2021, we performed ethnographic observations (participant-patient appointments, committee meetings) and semistructured interviews (N = 54 interviews, 49 observation hours). Based on findings from this multicenter, multimethod qualitative study combined with the Systems Engineering Initiative for Patient Safety 2.0 (a human factors and systems engineering model for health care), we created a conceptual framework describing how transplant work system characteristics and other external factors may improve equity in the LT evaluation process. Participant perceptions about listing disparities described external factors (e.g., structural racism, ambiguous national guidelines, national quality metrics) that permeate the LT evaluation process. Mechanisms identified included minimal transplant team diversity, implicit bias, and interpersonal racism. A lack of resources was a common theme, such as social workers, transportation assistance, non-English-language materials, and time (e.g., more time for education for patients with health literacy concerns). Because of the minimal data collection or center feedback about disparities, participants felt uncomfortable with and unadaptable to unwanted outcomes, which perpetuate disparities. We proposed transplant center-level solutions (i.e., including but not limited to training of staff on health equity) to modifiable barriers in the clinical work system that could help patient navigation, reduce disparities, and improve access to care. Our findings call for an urgent need for transplant centers, national societies, and policy makers to focus efforts on improving equity (tailored, patient-centered resources) using the science of human factors and systems engineering.

Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals

OBJECTIVES

Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach.

METHODS

Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extracted from the interview transcript, and for each concern, hazard for medication-related harms was coded and grouped by its sources according to a human factors and systems engineering model that views postdischarge ADEs as the outcome of professional and patient home work systems.

RESULTS

Thirty-eight professionals participated (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers). Hazards were classified into 6 groups, ranked by frequencies of hazards coded: (1) medication tasks related at home, (2) patient and caregiver related, (3) hospital work system related, (4) home resource related, (5) hospital professional-patient collaborative work related, and (6) external environment related. Medications most frequently cited when describing concerns included anticoagulants, insulins, and diuretics. Top coded hazard types were complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information.

CONCLUSIONS

From the perspective of hospital-based frontline health care professionals, hazards for medication-related harms during care transitions were multifactorial and represented those introduced by the hospital work system as well as defects unrecognized and unaddressed in the home work system.

Challenges and Strategies for Patient Safety in Primary Care: A Qualitative Study

Although most health care occurs in the ambulatory setting, limited research examines how providers and patients think about and enact ambulatory patient safety. This multimethod qualitative study seeks to identify perceived challenges and strategies to improve ambulatory safety from the perspectives of clinicians, staff, and patients. Data included interviews (N = 101), focus groups (N = 65), and observations of safety processes (N = 79) collected from 10 patient-centered medical homes. Key safety issues included the lack of interoperability among health information systems, clinician-patient communication failures, and challenges with medication reconciliation. Commonly cited safety strategies leveraged health information systems or involved dedicated resources (eg, providing access to social workers). Patients also identified strategies not mentioned by clinicians, emphasizing the need for their involvement in developing safety solutions. This work provides insight into safety issues of greatest concern to clinicians, staff, and patients and strategies to improve safety in the ambulatory setting.

A task analysis of central line-associated bloodstream infection (CLABSI) surveillance in home infusion therapy

BACKGROUND

Barriers for home infusion therapy central line associated bloodstream infection (CLABSI) surveillance have not been elucidated and are needed to identify how to support home infusion CLABSI surveillance. We aimed to (1) perform a goal-directed task analysis of home infusion CLABSI surveillance, and (2) describe barriers to, facilitators for, and suggested strategies for successful home infusion CLABSI surveillance.

METHODS

We conducted semi-structured interviews with team members involved in CLABSI surveillance at 5 large home infusion agencies to explore work systems used by members of the agency for home infusion CLABSI surveillance. We analyzed the transcribed interviews qualitatively for themes.

RESULTS

Twenty-one interviews revealed 8 steps for performing CLABSI surveillance in home infusion therapy. Major barriers identified included the need for training of the surveillance staff, lack of a standardized definition, inadequate information technology support, struggles communicating with hospitals, inadequate time, and insufficient clinician engagement and leadership support.

DISCUSSION

Staff performing home infusion CLABSI surveillance need health system resources, particularly leadership and front-line engagement, access to data, information technology support, training, dedicated time, and reports to perform tasks.

CONCLUSIONS

Building home infusion CLABSI surveillance programs will require support from home infusion leadership.

Implementing a Toolkit to Improve the Education of Patients on Home-based Outpatient Parenteral Antimicrobial Therapy (OPAT)

BACKGROUND

Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. This article describes the study team's experience piloting an educational toolkit for patients on home-based OPAT.

METHODS

An OPAT toolkit was developed to address barriers such as unclear communication channels, rushed instruction, safe bathing with an intravenous (IV) catheter, and lack of standardized instructions. The research team evaluated the toolkit through interviews with home infusion nurses implementing the intervention, surveys of 20 patients who received the intervention, and five observations of the home infusion nurses delivering the intervention to patients and caregivers.

RESULTS

Of surveyed patients, 90.0% were comfortable infusing medications at the time of discharge, and 80.0% with bathing with the IV catheter. While all practiced on equipment, 75.0% used the videos and the paper checklists. Almost all (95.0%) were satisfied with their training, and all were satisfied with managing their IV catheters at home. The videos were considered very helpful, particularly as reference. Overall, nurses adjusted training to patient characteristics and modified the toolkit over time. Shorter instruction forms were more helpful than longer instruction forms.

CONCLUSION

Developing a toolkit to improve the education of patients on home-based OPAT has the potential to improve the safety of and experience with home-based OPAT.

The Voice of the Patient: Patient Roles in Antibiotic Management at the Hospital-to-Home Transition

OBJECTIVE

Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition.

METHODS

We performed a qualitative study including semistructured interviews with health care workers and contextual inquiry with patients discharged home on oral antibiotics. The setting was one academic medical center and one community hospital. Participants included 37 health care workers and 16 patients. We coded interview transcripts and notes from contextual inquiry and developed themes.

RESULTS

We identified 6 themes involving barriers or strategies for antibiotic MM. We identified dissonance between participant descriptions of the ease of antibiotic MM at the hospital-to-home transition and their experience of barriers. Similarly, patients did not always recognize when they were experiencing side effects. Lack of access to follow-up care led to unnecessarily long antibiotic courses. Instructions about completing antibiotics were not routinely provided. However, patients typically did not question the need for the prescribed antibiotic.

CONCLUSIONS

There are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition. Mismatches between patient perceptions and patient experiences around antibiotic MM at the hospital-to-home transition provide opportunities for health system improvement.

A Patient Outcomes-Driven Feedback Platform for Emergency Medicine Clinicians: Human-Centered Design and Usability Evaluation of Linking Outcomes Of Patients (LOOP)

Background

The availability of patient outcomes–based feedback is limited in episodic care environments such as the emergency department. Emergency medicine (EM) clinicians set care trajectories for a majority of hospitalized patients and provide definitive care to an even larger number of those discharged into the community. EM clinicians are often unaware of the short- and long-term health outcomes of patients and how their actions may have contributed. Despite large volumes of patients and data, outcomes-driven learning that targets individual clinician experiences is meager. Integrated electronic health record (EHR) systems provide opportunity, but they do not have readily available functionality intended for outcomes-based learning.

Objective

This study sought to unlock insights from routinely collected EHR data through the development of an individualizable patient outcomes feedback platform for EM clinicians. Here, we describe the iterative development of this platform, Linking Outcomes Of Patients (LOOP), under a human-centered design framework, including structured feedback obtained from its use.

Methods

This multimodal study consisting of human-centered design studios, surveys (24 physicians), interviews (11 physicians), and a LOOP application usability evaluation (12 EM physicians for ≥30 minutes each) was performed between August 2019 and February 2021. The study spanned 3 phases: (1) conceptual development under a human-centered design framework, (2) LOOP technical platform development, and (3) usability evaluation comparing pre- and post-LOOP feedback gathering practices in the EHR.

Results

An initial human-centered design studio and EM clinician surveys revealed common themes of disconnect between EM clinicians and their patients after the encounter. Fundamental postencounter outcomes of death (15/24, 63% respondents identified as useful), escalation of care (20/24, 83%), and return to ED (16/24, 67%) were determined high yield for demonstrating proof-of-concept in our LOOP application. The studio aided the design and development of LOOP, which integrated physicians throughout the design and content iteration. A final LOOP prototype enabled usability evaluation and iterative refinement prior to launch. Usability evaluation compared to status quo (ie, pre-LOOP) feedback gathering practices demonstrated a shift across all outcomes from “not easy” to “very easy” to obtain and from “not confident” to “very confident” in estimating outcomes after using LOOP. On a scale from 0 (unlikely) to 10 (most likely), the users were very likely (9.5) to recommend LOOP to a colleague.

Conclusions

This study demonstrates the potential for human-centered design of a patient outcomes–driven feedback platform for individual EM providers. We have outlined a framework for working alongside clinicians with a multidisciplined team to develop and test a tool that augments their clinical experience and enables closed-loop learning.

Clinical Decision Support Systems to Reduce Unnecessary Clostridoides difficile Testing Across Multiple Hospitals

BACKGROUND

Inappropriate C. difficile testing has adverse consequences for the patient, hospital, and public health. Computerized Clinical Decision Supports (CCDS) in the Electronic Health Record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into the healthcare providers' (HCP) workflow, are not well understood.

METHODS

Nine academic and 6 community U.S. hospitals participated in this 2-year cohort study. CCDS (hard- or soft-stop) triggered when duplicate C. difficile test order attempted, or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incident rate ratios (IRR) and mixed effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary- and sub-nodes.

RESULTS

In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing IRR reduction was 33% (95% CI, 30-36%), and 23% (95% CI 21-25%), respectively. Two hospitals implemented a non-EMR based human intervention with IRR reduction of 21% (95% CI 15-28%). HCPs reported generally favorable experiences, and highlighted time efficiencies such as inclusion of the patients most recent laxative administration on the CCDS. Organizational factors including hierarchical cultures, and communication between HCPs caring for the same patient, impact CCDS acceptance and integration.

CONCLUSIONS

CCDS reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow, and when displayed relevant patient specific information needed for decision-making.

Association of Implementation and Social Network Factors With Patient Safety Culture in Medical Homes: A Coincidence Analysis

OBJECTIVES

The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture.

METHODS

This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture.

RESULTS

The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health.

CONCLUSIONS

Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.

Care transition of trauma patients: Processes with articulation work before and after handoff

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.

The case for wearable proximity devices to inform physical distancing among healthcare workers

Objective

Despite the importance of physical distancing in reducing SARS-CoV-2 transmission, this practice is challenging in healthcare. We piloted use of wearable proximity beacons among healthcare workers (HCWs) in an inpatient unit to highlight considerations for future use of trackable technologies in healthcare settings.

Materials and Methods

We performed a feasibility pilot study in a non-COVID adult medical unit from September 28 to October 28, 2020. HCWs wore wearable proximity beacons, and interactions defined as <6 feet for ≥5 s were recorded. Validation was performed using direct observations.

Results

A total of 6172 close proximity interactions were recorded, and with the removal of 2033 false-positive interactions, 4139 remained. The highest proportion of interactions occurred between 7:00 Am–9:00 Am. Direct observations of HCWs substantiated these findings.

Discussion

This pilot study showed that wearable beacons can be used to monitor and quantify HCW interactions in inpatient settings.

Conclusion

Technology can be used to track HCW physical distancing.

Physical distancing, or social distancing, is important in preventing COVID-19. It is hard for healthcare workers (HCWs) to physically distance at work. We tested a device (proximity beacon) that HCWs could wear to measure their distance from each other among HCWs on a medical unit. The device measured any time HCWs were within 6 feet of each other for at least 5 s. We watched HCWs who were close to each other. The devices and our observations showed that 7:00 Am—9:00 Am was the highest risk time for not physically distancing. This study shows that wearable devices can be a tool to monitor HCWs physical distancing on a hospital unit.

Perspective on reducing errors in research

Efforts to ensure research integrity has mostly focused on research misconduct. However, the complexity of research operations and processes makes research work also prone to unintentional errors. To safeguard against errors and their consequences, strategies for error reduction, detection, and mitigation can be applied to research work. Nurturing a scientific culture that encourages error disclosure and rectification is essential to reduce the negative consequences of errors. Creating repositories where errors can be reported can enable learning from errors and creation of more robust research processes.

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!

OBJECTIVES

To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU.

DESIGN

A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts.

SETTING

Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD.

SUBJECTS

Interprofessional PICU staff.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement.

CONCLUSIONS

Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

Telemedicine Expansion in Pediatric Gastroenterology in Response to COVID-19: Early Results of an International Physician Survey

The COVID-19 pandemic triggered an unprecedented expansion of telemedicine, leading to development of new workflows. We conducted a survey of telemedicine practice among pediatric gastroenterology practitioners on March 26, 2020. Responses were coded and analyzed. The survey garnered 33 responses. Most centers were 3 weeks into the implementation. The most commonly used telemedicine software was Zoom followed by FaceTime, telephone, and Epic software. Provider education was through online meetings, webinars, and tip sheets. Patient education was by nonclinical staff at the time of visit scheduling or tip sheets. A major barrier was the need for patients to enroll in an electronic portal. Two thirds of practices offered telemedicine to both new and return patients. Most sites billed based on time. This represents a record of the very early response of the pediatric gastroenterology community to the COVID-19 telemedicine expansion and can inform follow-up studies.

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.

Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing

Background

More than 28 000 people were infected with Ebola virus during the 2014–2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission.

Methods

A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing. These interventions were tested in a randomized controlled trial of 48 participants with no prior experience doffing enhanced PPE. Contamination was simulated using a fluorescent tracer slurry and fluorescent polystyrene latex spheres (PLSs). Self-contamination of scrubs and skin was measured using ultraviolet light visualization and swabbing followed by microscopy, respectively. Doffing sessions were videotaped and reviewed to score standardized teamwork behaviors.

Results

Participants in the intervention group contaminated significantly fewer body sites than those in the control group (median [interquartile range], 6 [3–8] vs 11 [6–13], P = .002). The median contamination score was lower for the intervention group than the control group when measured by ultraviolet light visualization (23.15 vs 64.45, P = .004) and PLS swabbing (72.4 vs 144.8, P = .001). The mean teamwork score was greater in the intervention group (42.2 vs 27.5, P < .001).

Conclusions

An intervention package addressing the PPE doffing task, tools, environment, and teamwork skills significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to reduce the risk of pathogen transmission.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Engaging Patients and Caregivers in a Transdisciplinary Effort to Improve Outpatient Parenteral Antimicrobial Therapy

We worked with patients, caregivers, and healthcare workers to prioritize barriers and propose solutions to outpatient parenteral antimicrobial therapy (OPAT) care. Unclear communication channels, rushed instruction, safe bathing with an intravenous catheter, and lack of standardized instructions were highly ranked barriers. Outpatient parenteral antimicrobial therapy programs should focus on mitigating barriers to OPAT care.

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients

Hospital-based care of pediatric trauma patients includes transitions between units that are critical for quality of care and patient safety. Using a macroergonomics approach, we identify work system barriers and facilitators in care transitions. We interviewed eighteen healthcare professionals involved in transitions from emergency department (ED) to operating room (OR), OR to pediatric intensive care unit (PICU) and ED to PICU. We applied the Systems Engineering Initiative for Patient Safety (SEIPS) process modeling method and identified nine dimensions of barriers and facilitators - anticipation, ED decision making, interacting with family, physical environment, role ambiguity, staffing/resources, team cognition, technology and characteristic of trauma care. For example, handoffs involving all healthcare professionals in the OR to PICU transition created a shared understanding of the patient, but sometimes included distractions. Understanding barriers and facilitators can guide future improvements, e.g., designing a team display to support team cognition of healthcare professionals in the care transitions.

Overcoming COVID-19: What can human factors and ergonomics offer?

A novel coronavirus disease, named coronavirus disease 2019 or COVID-19, which sparked an outbreak in Wuhan, China in December 2019, is now a pandemic. The rapid spread of this disease from one to more than 155 regions worldwide in 2.5 months highlights the need for better preparation to manage a pandemic. In this commentary, we describe how Human Factors and Ergonomics (HFE) can contribute to the COVID-19 pandemic response. Specifically, we provide an example of how HFE methodologies informed workflow redesigns implemented as part of COVID-19 pandemic preparations in an academic pediatric ambulatory clinic. We then identify key mechanisms and areas where HFE can contribute to and improve the effectiveness of a pandemic response: Just-in-time (JIT) training development, adapting workflows and processes, restructuring teams and tasks, developing effective mechanisms and tools for communication, engaging patient and families to follow the recommended practices (e.g., social distancing, revised hospital visitation policies), identifying and mitigating barriers to implementation of plans, and learning from failures and successes to improve both the current and future pandemic responses. We recommend integrating HFE approaches and tools across health care systems, state health organizations, and the Centers for Disease Control and Prevention (CDC) as they confront this pandemic.

Respiratory Practices in the Long-term Care Setting: A Human Factors-Based Risk Analysis

OBJECTIVE

To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach.

DESIGN

We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) identified failure modes where a subtask may be completed inappropriately; (3) prioritized each failure mode based on a risk priority scale; (4) identified contributing factors to and consequences for each of the prioritized failure modes; and (5) identified potential solutions to eliminate or mitigate risks.

SETTING

Three high-acuity LTC facilities with ventilator units across Maryland.

METHODS

The hierarchical task analysis was conducted jointly by 2 human-factors experts and an infectious disease physician based on respiratory care policies from the Centers for Disease Control and Prevention and existing policies at each LTC facility. The findings were used to guide direct observations with contextual inquiry and focus group sessions to assess safety risks for residents receiving tracheostomy care.

RESULTS

Direct observations of tracheostomy care and suctioning in the LTC setting revealed significant variations in practice. Respiratory therapists working in LTC reported lack of training and ambiguity concerning recommended procedures to reduce infection transmission in daily care. Highest risk steps identified in tracheostomy care and suctioning included hand hygiene, donning gloves, and providing intermittent suctioning as the suction catheter was withdrawn. Participants identified risk mitigation strategies targeting these high-risk failure modes that addressed contributing factors related to 5 work system components: person (knowledge and competency), task (eg, urgency or time constraints), tools and technology (eg, availability of hand sanitizer), environment (eg, communal rooms), and organization (eg, patient safety culture).

CONCLUSIONS AND IMPLICATIONS

Human factors analysis of the highest-risk steps in respiratory care activities in the LTC setting suggest several potential mitigation strategies to decrease the risk of infection transmission. Clear procedure guidelines with training are needed to reduce ambiguity and improve care in this setting. Involving frontline staff in patient safety issues using human factors principles and risk analysis may encourage participation and improve the infection prevention culture in LTC.

Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy

BACKGROUND

Complicated medical therapies traditionally performed in acute care hospitals are increasingly moving to the home, requiring patients and informal caregivers to perform complicated medical tasks. For example, in outpatient parenteral antimicrobial therapy (OPAT), patients and caregivers perform antimicrobial infusions and venous catheter care. The objective of this study was to characterize patient understanding of patient, caregiver, and health care worker roles in OPAT and barriers to fulfilling these roles, with the goal of understanding how to best support patients and their caregivers.

METHODS

A qualitative study using 40 semistructured telephone interviews and 20 contextual inquiries of patients and caregivers performing OPAT tasks was performed. Eligible participants were discharged from two academic medical centers on OPAT. Interview transcripts and notes from contextual inquiry were coded based on a human factors engineering model.

RESULTS

Four main roles are described: communicator, advocate, learner-trainer, and lay health care worker doing "high-skilled tasks." Patients and caregivers experienced role ambiguity about OPAT task performance at the time of hospital discharge. Patients noted that their health care workers experienced role ambiguity as well, particularly regarding who was managing their care. Patients and caregivers used role transitions to achieve workload management, in which patients and caregivers transitioned OPAT tasks or non-OPAT tasks from one person to another.

CONCLUSION

Clear delineation of roles in complicated home-based medical therapies and training of all who may perform these tasks could improve the safety and quality of home-based care.

1063. A Healthcare Worker-Informed Approach to the Hospital-to-Home Transition on Oral Antibiotics

Background

Improved antibiotic decision-making during the hospital-to-home transition is an important but under-addressed target for antimicrobial stewardship. This study aims to provide a healthcare worker-informed approach to characterize prescriber antibiotic decision-making and patient medication management at discharge to identify barriers to and strategies for antibiotic stewardship during the hospital-to-home transition.

Methods

Semi-structured interviews were conducted at an academic medical center with relevant stakeholders including house staff (n = 10), nurses (n = 2), nurse practitioners (n = 5), inpatient pharmacists (n = 4), and discharge coordinators (n = 2). Interviews focused on challenges to antibiotic decision-making and patient medication management at discharge. Transcripts were independently coded and analyzed by two physicians using the constant comparative method.

Results

We identified four main barriers to antibiotic decision-making at hospital discharge: (1) uncertainty over antibiotic choice (due to lack of microbiology data), (2) pressure to discharge, (3) lack of control over antibiotic decision-making (attending-led decision with little room for input), and (4) lack of awareness of cost and insurance coverage. We also identified challenges to patient medication management specific to patient education: (1) role ambiguity around who provides education and (2) lack of education to patients around side effects. To improve antibiotic decision-making, prescribers relied heavily on institutional guidelines and interaction with experts in informing antibiotic choices, and used multidisciplinary approaches to verify antibiotic cost and availability. Five strategies to improve medication management were proposed: (1) assessing patient health literacy when providing instructions, (2) an in-hospital trial of the oral antibiotic to ensure tolerance, (3) ensuring the patient leaves the hospital with the antibiotic in hand, (4) care coordination after discharge, and (5) close follow-up with prescribers after discharge.

Conclusion

Our findings identify barriers to discharge antibiotic decision-making and medication management that allow for targeted interventions to improve antibiotic decision-making during the hospital-to-home transition.

Disclosures

Sara E. Cosgrove, MD, MS, Basilea: Consultant; Theravance: Consultant.

Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial

IMPORTANCE

Patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations have high rehospitalization rates and reduced quality of life.

OBJECTIVE

To evaluate whether a hospital-initiated program that combined transition and long-term self-management support for patients hospitalized due to COPD and their family caregivers can improve outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Single-site randomized clinical trial conducted in Baltimore, Maryland, with 240 participants. Participants were patients hospitalized due to COPD, randomized to intervention or usual care, and followed up for 6 months after hospital discharge. Enrollment occurred from March 2015 to May 2016; follow-up ended in December 2016.

INTERVENTIONS

The intervention (n = 120) involved a comprehensive 3-month program to help patients and their family caregivers with long-term self-management of COPD. It was delivered by nurses with special training on supporting patients with COPD using standardized tools. Usual care (n = 120) included transition support for 30 days after discharge to ensure adherence to discharge plan and connection to outpatient care.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of COPD-related acute care events (hospitalizations and emergency department visits) per participant at 6 months. The co-primary outcome was change in participants' health-related quality of life measured by the St George's Respiratory Questionnaire (SGRQ) at 6 months after discharge (score, 0 [best] to 100 [worst]; 4-point difference is clinically meaningful).

RESULTS

Among 240 patients who were randomized (mean [SD] age, 64.9 [9.8] years; 61.7% women), 203 (85%) completed the study. The mean (SD) baseline SGRQ score was 62.3 (18.8) in the intervention group and 63.6 (17.4) in the usual care group. The mean number of COPD-related acute care events per participant at 6 months was 1.40 (95% CI, 1.01-1.79) in the intervention group vs 0.72 (95% CI, 0.45-0.97) in the usual care group (difference, 0.68 [95% CI, 0.22-1.15]; P = .004). The mean change in participants' SGRQ total score at 6 months was 2.81 in the intervention group and -2.69 in the usual care group (adjusted difference, 5.18 [95% CI, -2.15 to 12.51]; P = .11). During the study period, there were 15 deaths (intervention: 8; usual care: 7) and 339 hospitalizations (intervention: 202; usual care: 137).

CONCLUSIONS AND RELEVANCE

In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02036294.

Oncologists' Views Regarding the Role of Electronic Health Records in Care Coordination

BACKGROUND

Electronic health records (EHRs) play a significant role in complex health care processes, especially in information transfer with patients and care coordination among providers. EHRs may also generate unintended consequences, introducing new patient safety risks. To date, little investigation has been performed in oncology settings, despite the need for quality provider-patient communication and information transfer during oncology visits. In this qualitative study, we focused on oncology providers' perceptions of EHRs for supporting communication with patients and coordination of care with other providers.

METHODS

We conducted semistructured interviews with oncologists from an urban academic medical center to learn their perceptions of the use of EHRs before, during, and after clinic visits with patients. Our interview guide was developed on the basis of the work system model. We coded transcripts using inductive content analysis.

RESULTS

Data analysis yielded four main themes regarding oncologists' practices in using the EHR and perceptions about EHRs: (1) EHR use for care coordination (eg, timeliness of receiving information, SmartSet documentation); (2) EHR use in the clinic visit (eg, educating patients, using as a reinforcement tool); (3) safety hazards in care coordination associated with EHRs (eg, incomplete documentation, error propagating, no filtering mechanism to capture errors); and (4) suggestions for improvements (eg, improved SmartSet functionalities, simplification of user interface).

CONCLUSION

Current EHRs do not adequately support teamwork of oncology providers, which could lead to potential hazards in the care of patients with cancer. Redesigning EHR features that are tailored to support oncology care and addressing the concerns regarding information overload, improved organization of flagging abnormal results, and documentation-related workload are needed to minimize potential safety hazards.

Rates of and Risk Factors for Adverse Drug Events in Outpatient Parenteral Antimicrobial Therapy

Background

To better monitor patients on outpatient parenteral antimicrobial therapy (OPAT), we need an improved understanding of risk factors for and timing of OPAT-associated adverse drug events (ADEs).

Methods

We analyzed a prospective cohort of patients on OPAT discharged from 2 academic medical centers. Patients underwent chart abstraction and a telephone survey. Multivariable analyses estimated adjusted incident rate ratios (aIRR) between clinical and demographic risk factors and clinician-determined clinically significant ADEs. Descriptive data were used to present patient-reported ADEs.

Results

Of 339 patients enrolled in the study, 18.0% experienced an ADE (N = 65), of which 49 were significant (14.5%, 2.24/1000 home-OPAT days). Patients with longer courses of therapy had lower rates of ADEs compared with patients treated for 0-13 days (14-27 days: aIRR, 0.44; 95% confidence interval [CI], 0.20-0.99; at least 28 days: aIRR, 0.11; 95% CI, 0.056-0.21). Risk factors for ADEs included female gender and receipt of daptomycin or vancomycin, while treatment for uncomplicated bacteremia and empiric treatment were associated with lower rates of ADEs.

Conclusions

OPAT-related ADEs were common and often occurred within 2 weeks of hospital discharge. Patients on OPAT should be monitored more closely for ADEs, including clinical assessment and laboratory monitoring, especially within the first weeks after hospital discharge and particularly among women and patients who receive vancomycin.

Complexity of the pediatric trauma care process: Implications for multi-level awareness

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.

It's Complicated: Patient and Informal Caregiver Performance of Outpatient Parenteral Antimicrobial Therapy-Related Tasks

Outpatient parenteral antimicrobial therapy (OPAT) requires patients and caregivers to infuse antimicrobials through venous catheters (VCs) in the home. The objective of this study was to perform a patient-centered goal-directed task analysis to identify what is required for successful completion of OPAT. The authors performed 40 semi-structured patient interviews and 20 observations of patients and caregivers performing OPAT-related tasks. Six overall goals were identified: (1) understanding and developing skills in OPAT, (2) receiving supplies, (3) medication administration and VC maintenance, (4) preventing VC harm while performing activities of daily living, (5) managing when hazards lead to failures, and (6) monitoring status. The authors suggest that patients and caregivers use teach-back, take formal OPAT classes, receive visual and verbal instructions, use cognitive aids, learn how to troubleshoot, and receive clear instructions to address areas of uncertainty. Addressing these goals is essential to ensuring the safety of and positive experiences for our patients.

Evaluation of multidisciplinary collaboration in pediatric trauma care using EHR data

OBJECTIVES

The study sought to identify collaborative electronic health record (EHR) usage patterns for pediatric trauma patients and determine how the usage patterns are related to patient outcomes.

MATERIALS AND METHODS

A process mining-based network analysis was applied to EHR metadata and trauma registry data for a cohort of pediatric trauma patients with minor injuries at a Level I pediatric trauma center. The EHR metadata were processed into an event log that was segmented based on gaps in the temporal continuity of events. A usage pattern was constructed for each encounter by creating edges among functional roles that were captured within the same event log segment. These patterns were classified into groups using graph kernel and unsupervised spectral clustering methods. Demographics, clinical and network characteristics, and emergency department (ED) length of stay (LOS) of the groups were compared.

RESULTS

Three distinct usage patterns that differed by network density were discovered: fully connected (clique), partially connected, and disconnected (isolated). Compared with the fully connected pattern, encounters with the partially connected pattern had an adjusted median ED LOS that was significantly longer (242.6 [95% confidence interval, 236.9-246.0] minutes vs 295.2 [95% confidence, 289.2-297.8] minutes), more frequently seen among day shift and weekday arrivals, and involved otolaryngology, ophthalmology services, and child life specialists.

DISCUSSION

The clique-like usage pattern was associated with decreased ED LOS for the study cohort, suggesting greater degree of collaboration resulted in shorter stay.

CONCLUSIONS

Further investigation to understand and address causal factors can lead to improvement in multidisciplinary collaboration.

Reducing Three Infections Across Cardiac Surgery Programs: A Multisite Cross-Unit Collaboration

Using a pre–post design, this study examined the impact of a multifaceted program to simultaneously improve 3 health care–associated infections and patient safety culture throughout the cardiac surgery service line in 11 hospitals. Interventions included the Comprehensive Unit-based Safety Program to improve safety culture and evidence-based bundles to prevent central line–associated bloodstream infection (CLABSI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP). CLABSIs and SSIs showed a downward trend over 2 years, then the rates returned to levels similar to baseline in the third year. VAP rate changes were difficult to interpret because of the VAP definition change. Patient safety culture domain “hospital management support” showed significant improvement, but feedback and communication about errors and staffing declined. Simultaneous implementation of multiple interventions across units is challenging. The findings highlight the importance of sustainment efforts and suggest future work should anticipate both positive and negative change in safety culture dimensions.